AANP FNP Exam Study Guide 2025

Basal Cell Carcinoma - -painless, pearly, ulcerated nodule with overlying telangiectasis -found on sun areas Actinic Keratoses - -slightly rough, pink or flesh-colored lesion in sun-exposed area -pharmacological treatment: 5-fluorouracil (topical chemotherapy) -non-pharmacological treatment: chemical peel, cryotherapy, laser resurfacing Tuberculosis - I. Transmission A. Mycobacterium tuberculosis carried in airborne droplets B. Active Pulmonary or Laryngeal Tuberculosis transmitted 1. Sneeze, cough, speak, or sing II. Symptoms A. Latent Tuberculosis is asymptomatic B. Active Tuberculosis presentation often mimics cancer presentation 1. Non-specific presentation (most common) a. Fatigue b. Weight loss c. Cachexia d. Night Sweats C. Pulmonary Tuberculosis symptoms 1. Productive cough (typically 2-3 weeks) 2. Hemoptysis (uncommon) 3. Pleuritic Chest Pain 4. Dyspnea III. Signs A. Sites of Involvement 1. Primary infection: lung involvement B. Disseminated Disease IV. Management A. Latent Tuberculosis 1. Positive PPD without signs of Active Tb 2. Treatment indicated if risk of Tb Progression from latent to active disease B. Active Tuberculosis Gout - I. Pathophysiology A. *Gout occurs when Uric Acid levels exceed solubility limits* 1. Monosodium urate crystals deposit in joints, Kidney, and soft tissues 2. Crystal deposition triggers a inflammatory response from cytokines and Neutrophils 3. Joint space is irreversibly injured with ongoing attacks II. Risk Factors A. Most common 1. Obesity 2. Alcohol use (especially beer) 3. High purine diet (red meats, turkey and wild game, organ meats, seafood) 4. Drinks sweetened with high fructose corn syrup 5. Diuretic therapy including Thiazide Diuretics 6. Other risks a. Diabetes Mellitus b. Hyperlipidemia c. Hypertension d. Atherosclerosis e. Renal Insufficiency f. Myeloproliferative disease III. Symptoms A. Associated Symptoms 1. Chills 2. Fever as high as 104 F (40 C) 3. Severity: Very severe pain a. Unable to bear weight b. Too painful to put on socks c. Intollerant to light touch from blankets B. Regions Lower extremities 1. *First Metatarsophalangeal joint of great toe* (most common) a. Known as *Podagra* i. Affected in 50% of first gout attacks Mid-tarsal joints 2. Ankle Joints 3. Knee Joints C. Regions upper extremities 1. Fingers 2. Wrists 3. Elbows D. Characteristics: Joint Pain 1. Excruciating, crushing type pain 2. Timing: Joint Pain 3. Acute onset of lower extremity Joint Pain 4. Wakens patient from sleep IV. Signs A. Acute 1. Joint Inflammation 2. Erythema, tenderness and swelling at affected joint a. Pain extends well beyond joint b. Entire foot involved in some cases 3. Asymmetric joint involvement a. May only involve one side with the first attack 4. Skin over joint is tense and shiny B. Chronic 1. Gouty Tophi (develop after 10 years) a. Subcutaneous Nodules of monosodium urate crystals and lipids, proteins and mucopolysaccharides C. Chronic Arthritis 1. Chronic deposition occurs with recurrent attacks Dix-Hallpike Maneuver – Central Vertigo - I. Findings: Suggestive of central causes A. Nystagmus 1. Vertical or torsional Nystagmus (pure Horizontal Nystagmus may occur with either peripheral or central cause) 2. No Nystagmus on Horizontal Head Impulse Test 3. Persists 6 seconds after Dix-Hallpike Maneuver 4. Fixation of eyes on object does not inhibit Nystagmus 5. Requires weeks to months to resolve B. Episodes last hours to days C. Severe imbalance impairs standing and walking D. No Hearing Loss or Tinnitus in most central cases E. Acute Vestibular Syndrome (Posterior Circulation in 25% of cases) 1. Rapid onset (1 hour) of acute, persistent, continuous Vertigo or Dizziness 2. Associated with Nystagmus, Nausea or Vomiting, head motion intolerance, and gait unsteadiness F. Positive HiNTs Exam Criteria (at least 1 of 3 positive) are suggestive of cerebellar CVA or Brainstem CVA (100% sensitive, 96% specific) 1. Normal Horizontal Head Impulse Test (no saccade/correction on head rotation) OR 2. Nystagmus that changes direction (or Vertical Nystagmus or torsional Nystagmus) OR 3. Skew Deviation on Alternate Eye Cover Test in which uncovered eye demonstrates quick vertical gaze corrections III. Causes: Central Vertigo A. Non-Vascular Central Causes of Vertigo (CN 8 or CNS) 1. Tumor a. Acoustic Neuroma (Vestibular Schwannoma) b. Infratentorial ependymoma c. Brainstem glioma d. Medulloblastoma e. Neurofibromatosis 2. Migraine Headache 3. Multiple Sclerosis B. Vascular disease related transient cerebral anoxia 1. Specific anoxia to vertebrobasilar system a. Vessel specific i. Brainstem Infarct (associated with Hearing Loss) 1. Anterior Inferior Cerebellar Artery Infarction 2. Anterior Vestibular Artery Infarction ii. Brainstem Infarct (no Hearing Loss) 1. Posterior Inferior Cerebellar Artery infarction 2. Labyrinthine Artery Infarction b. Precipitating conditions i. Arteriosclerosis ii. Hypertension iii. Anemia iv. Atrial Fibrillation C. Other Causes 1. Postural Hypotension 2. Syncope Peripheral Vertigo - I. Findings: Suggestive of peripheral causes A. Pathognomonic for peripheral cause 1. Sudden onset with brief episodes often on awakening 2. Rotary Illusion with Nausea, Vomiting B. Nystagmus 1. Combined horizontal and torsional Nystagmus 2. Persists 5-20 seconds after Dix-Hallpike Maneuver 3. Fixation of eyes on object inhibits Nystagmus C. Moderate imbalance D. Nausea or Vomiting E. Associated findings 1. Hearing Loss 2. Tinnitus F. Tullio's Phenomenon 1. Nystagmus and Vertigo provoked by loud sounds II. Causes: Common (Peripheral Vertigo) A. Acute Vestibular Neuronitis B. Benign Paroxysmal Positional Vertigo C. Meniere's Disease III. Causes: Other (Peripheral Vertigo) A. Ear Infections 1. Serous Otitis Media 2. Chronic Otitis Media 3. Otitis Externa 4. Mastoiditis B. Other infections 1. Herpes Zoster Oticus (Ramsay Hunt Syndrome) 2. Acute Labyrinthitis (uncommon) a. Not synonymous with Vestibular Neuritis i. Labyrinthitis is much less common than neuritis ii. Labyrinthitis causes permanent Hearing Loss b. Types i. Viral Labyrinthitis ii. Bacterial Labyrinthitis (Rare) C. Structural disorder 1. Cholesteatoma 2. Perilymphatic Fistula 3. Otosclerosis D. Trauma 1. Temporal Bone Fracture 2. Labyrinthine Concussion Reiter's Syndrome – Perihepatitis - Spontaneous Abortions - When there is vaginal bleeding and cramping but the cervix remains closed it is a threatened abortion. It is possible in this case that the pregnancy can be salvaged. In an inevitable abortion the cervix is dilated. In a complete abortion the placenta and fetus are expelled completely. In an incomplete abortion placental products remain in the uterus and the cervix remains dilated. Addison's Disease – Cushing's Disease – Myocardial Infarction – Fosamax - Patients taking aledronate are instructed to take the medication when they get up in the morning, 30 minutes before eating and with a full glass of water. They should be instructed to remain upright to avoid esophageal irritation. If they take this medication with food, it will reduce the bioavailability by 40%. Taking alendronate with coffee or orange juice will reduce bioavailabiliy by 60%. Hyperlipidemia Medications - The expected outcomes of the preceding medications are as follows: Lipitor: LDL: 20-60% decrease HDL: 5-15% increase Triglyceride: 10-40% decrease Gemfibrozil: LDL: 5-15% decrease HDL: 14-20% increase Triglyceride: 20- 50% decrease Nicotinic acid: LDL: 10-25% decrease HDL: 15-35% increase Triglyceride: 20-50% decrease Colestipol: LDL: 10-20% decrease HDL: 3-5% increase Triglyceride: May increase Trochanteric Bursitis - I. Definition A. Inflammation of bursa overlying hip greater trochanter II. Symptoms A. Pain overlying greater trochanter B. May radiate into knee or ankle or into buttock C. Night pain occurs if lying on affected side D. Palliative and provocative factors 1. Worse when standing from seated or lying position 2. Improves initially on walking 3. Worse again after walking for 30 minutes III. Signs A. Point tenderness over lateral greater trochanter of hip B. Symptoms reproduced on hip adduction C. Adduction and internal rotation may also provoke IV. Management A. NSAIDs B. Modify activity C. Trochanteric Bursa Injection Marfan Syndrome - I. Etiology A. Defect in gene coding for fibrillin structure B. Connective tissue defect affecting multiple systems 1. Musculoskeletal disease 2. Ocular disease 3. Cardiac disease II. Signs A. Body habitus 1. *Tall (Height exceeds 95th percentile for age)* 2. *Extremely slender build* B. Cardiovascular signs and conditions 1. Mitral Valve Prolapse 2. Aortic root dilatation 3. Myocardial Infarction 4. Aortic Insufficiency 5. Congestive Heart Failure 6. Subacute Bacterial Endocarditis 7. Aortic Dissection C. Musculoskeletal signs and conditions 1. Arachnodactyly (Spider fingers) 2. *Pectus deformity (Pigeon Breast or Funnel Breast)* 3. High narrow Palate 4. Arm Span exceeds height 5. Leg length exceeds trunk length 6. Hyperextensible joints and ligaments 7. Pes planus 8. Hammer toes 9. Vertebral Column deformities (e.g. Kyphoscoliosis) 10. Inguinal Hernia 11. Striae Distensae D. Ocular signs and conditions 1. Upward ectopia lentis 2. Myopia 3. Iridodonesis 4. Glaucoma 5. Retinal Detachment III. Labs A. Homocystinuria IV. Radiology A. Echocardiogram 1. Enlarged aortic root B. Chest XRay 1. Deformed aorta and pulmonary artery Korsakoff's Syndrome - I. Causes A. Untreated Thiamine deficiency from Alcoholism II. Pathophysiology A. Follows Wernicke's Encephalopathy B. Lesions develop in mammillary bodies and Thalamus III. Signs A. Severe Short Term Memory loss B. Intact Immediate Memory C. Confabulation IV. Management A. Thiamine (See Wernicke's Encephalopathy) V. Prognosis A. Life-long Impairment B. Improvement in 75% of patients with treatment II. Symptoms A. Hematemesis (vomiting fresh blood) follows episode of Retching or Vomiting III. Signs A. Melena (black, tarry stool) B. Shock IV. Diagnosis A. Endoscopy (EGD) 1. Mucosal tear directly visualized V. Management A. Generally heals spontaneously within several days B. Endoscopy for cauterization if needed C. Surgery rarely required Mallory Weiss Syndrome - I. Pathophysiology A. Severe Retching results in tear in esophageal mucosa B. Lesion occurs near esophagogastric junction Idiopathic Thrombocytopenia Purpura (ITP) Pathophysiology A. IgG Antibody develops against platelet membrane antigen B. Acute Idiopathic Thrombocytopenic Purpura 1. Acute onset follows Viral Exanthem or viral Infection 2. Occurs in otherwise healthy patients C. Chronic Idiopathic Thrombocytopenic Purpura 1. Insidious onset in patient with immune disorder 2. More common onset in teenage girls II. Signs and Symptoms A. Purpura B. Bleeding complications 1. Associated with severe Thrombocytopenia (Platelet Count 30,000 per uL) C. Mild Splenomegaly in 5 to 10% of cases D. Absent signs 1. No fever, lethargy, pallor or weight loss 2. No bone or Joint Pain 3. No Lymphadenopathy 4. No Hepatomegaly III. Management: First-Line Management A. Corticosteroids 1. Indicated for severe Thrombocytopenia a. Typically indicated with Platelet Count 50,000 per uL (especially 30,000 per uL) 2. Platelets increase within a week of starting Corticosteroids - I. 3. Dosing a. Methylprednisolone 30 ml/kg/day over 20-30 min up to 1 g/day IV OR b. Prednisone 1-1.5 mg/kg orally daily B. Intravenous Immune globulin (IV IG) 1. Dose: 1 g/kg/day for 2-3 days C. Rituximab (Rituxan) IV. Management: Emergent management A. Indications for urgent or emergent management (uncommon) 1. Serious Hemorrhage 2. Urgent or emergent surgery required B. Treatment 1. Platelet Transfusion at dosing 2-3 fold greater than usual dose Hidradenitis Suppurativa - Hidradenitis Suppurativa is a bacterial infection of the sebaceous glands of the axilla (or groin) by Gram-positive Staphylococcus aureus. It is marked by flare-ups and resolution. It can be confirmed by a C&S of the purulent discharge. I. Pathophysiology A. Inflammation of the Apocrine Sweat Glands II. Symptoms A. Pain, itching, burning and erythema in area involved III. Signs A. Characteristic 1. Early: Inflammatory Nodule or abscess 2. Later a. Sinus tract formation b. Fibrosis c. Bridge scarring d. Hypertrophic Scar or Keloid e. Contractures f. Comedones B. Distribution 1. Axilla (more common in women) 2. Anogenital area (more common in men) 3. Breasts 4. Extension onto back and buttocks IV. Management: Mild (Single Nodules with minimal pain) A. Avoid exposure to heat and humidity B. Avoid shaving if it causes irritation C. Avoid synthetic tight fitting clothes D. Use antibacterial soaps or hibiclens E. Weight loss F. Apply warm compresses to affected area V. Management: Moderate (Recurrent Nodules, pain, abscesses) A. Antibiotics for 2 months or more 1. Axillary involvement a. Dicloxacillin b. Erythromycin c. Tetracycline d. Clindamycin Topically (Cleocin-T) 2. Anogenital involvement a. Augmentin or other broad spectrum antibiotic B. Other options 1. Oral Contraceptives (high Estrogen, low androgen) 2. Accutane 0.5 to 1 mg/kg PO daily a. Used before surgery 3. Corticosteroids (variable efficacy) a. Prednisone 70 mg tapered over 14 days b. Intralesional triamcinolone 4. Cryotherapy VI. Management: Late (abscesses, sinuses, scarring) A. Referral to Dermatology B. Extensive surgical excision of lesions Infant Reflexes I. Reflexes A. Foot 1. Stroke Inner Sole (Grasp) a. Toes curl around ("grasp") examiner's finger 2. Stroke Outer Sole (Babinski) a. Toes spread, great toe dorsiflexion B. Walking Reflex 1. Hold baby up with one hand across chest 2. As feet touch ground, baby makes walking motion ("stepping") C. Rooting Reflex 1. Touch newborn on either side of cheek 2. Baby turns to find Breast 3. Sucking Mechanism on finger is divided into 3 steps: a. Front of Tongue laps on finger b. Back of Tongue massages middle of the finger c. Esophagus pulls on tip of finger D. Tonic Neck (Fencing) Reflex 1. If the Babies' head is rotated leftward a. The left arm (face side) stretches into extension b. The right arm flexes up above head 2. Opposite reaction if head is rotated rightward E. Moro Reflex (Startle Reflex) 1. Hold supine infant by arms a few inches above bed a. Gently drop infant back to elicit startle 2. Baby throws Arms out in extension and baby grimaces F. Hand-to-Mouth (Babkin) Reflex 1. Stroke newborns cheek or put finger in babies palm - The fencing reflex (tonic neck reflex) is done by turning the head to one side with the jaw over the shoulder. This should cause the arm and leg on the side where the head is turned to extend and the arm and leg on the opposite side to flex. Nodes on Interphalangeal Joints - Bouchard's nodes are bony nodules on the proximal interphalangeal joints. Heberden's nodes are bony nodules on the distal interphalangeal joints. 2. Baby will bring his fist to mouth and suck a finger G. Swimmer's (Gallant) Response 1. Hold baby prone while supporting belly with hand a. Stroke along one side of babies' spine 2. Baby flexes whole body toward the stroked side Prostatic Disease Herbal Remedies - Pertussis – Baker Cyst – Koplik Spots - They are small, white spots (often on a reddened background) that occur on the inside of the cheeks early in the course of *measles*. Salter-Harris Fractures - Fractures through a growth plate; therefore, they are unique to pediatric patients. These fractures are categorized according to the involvement of the physis, metaphysis, and epiphysis. The classification of the injuries is important, because it affects patient treatment and provides clues to possible long-term complications. Pernicious Anemia (B12 Deficiency) - A. Symptoms: 1. Initial: Generalized Weakness, Paresthesias 2. Next: Leg Stiffness, Ataxia 3. Late: Memory Impairment, Personality Change, Depressed Mood B. Signs: (Mnemonic: "The 5 P's") 1. Pancytopenia (decrease in all blood cell lines) 2. Peripheral Neuropathy 3. Posterior Spinal Column Neuropathy (Dorsal Column Degeneration, Decreased proprioception, Decreased Vibration Sense, Ataxia, Hyporeflexia {e.g. Decreased Ankle Jerk}) 4. Pyramidal Tract Signs 5. Papillary Atrophy of Tongue (Atrophic Glossitis) *red, beefy tongue* C. Labs: 1. CBC a. MCV 100 (macrocytic) b. Leukopenia (decreased white blood cells) c. Thrombocytopenia (decreased platelets) 2. Serum B12 a. Megaloblastosis (oval macrocytes) D. Risk Factors: 1. Strict Vegetarian 2. History of Gastrectomy (Gastric Bypass Surgery) 3. Recent History of Malabsorption (Diarrhea) E. B12 Food Sources 1. Organ Meat a. Liver 2. Dairy Products 3. Fortified Cereal 4. Shellfish a. Clam Iron Deficiency Anemia - A. Symptoms: 1. Fatigue 2. Generalized Weakness 3. Dyspnea on Exertion 4. Lightheadedness B. Signs: 1. Pale Conjunctiva or Mucous Membranes 2. Pallor at Nail Beds 3. Tachycardia 4. Melena (dark, tarry stool) 5. Hematochezia (grossly bloody stool) C. Labs: 1. CBC a. MCV 75 (microcytic) 2. Iron Studies a. Serum Ferritin b. TIBC c. Serum Iron D. Risk Factors: 1. Vegetarian 2. Gastrointestinal Disease E. Iron Food Sources: 1. Red Meat 2. Green Leafy Veggies 3. Dried Fruit 4. Nuts 5. Iron-Fortified Cereal F. Associated Symptoms: 1. Generalized Pruritis (itching) 2. Restless Leg Syndrome (crawling feeling in legs) 3. Glossitis (inflammation of tongue) 4. Angular Cheilitis (cracking at corners of mouth) G. Treatment: 1. Iron Supplement a. Iron absorption decreased 40% when taken with meals - *do not take with meals* b. Antacids or proton-pump inhibitor use will decrease iron absorption c. *Vitamin C aids in the absorption of iron - orange juice* McMurray's Test - I. Indication A. Evaluation for *Knee Meniscus* Injury II. Interpretation: Positive Test Suggests Meniscal Injury A. *"Click" heard or palpated on above maneuvers*. B. Joint line tenderness on palpation. Lachman's Test - I. Indications A. Assessment for *Anterior Cruciate Ligament (ACL)* Rupture II. Interpretation: Positive Test for ACL Rupture A. Lax endpoints on anterior translation Rotator Cuff Injury - I. Symptoms A. Characteristics 1. Lateral arm without radiation beyond elbow 2. *Associated with arm weakness* B. Timing 1. *Night pain interferes with sleep* C. Provocative 1. Exacerbated by throwing motion 2. Overhead work II. Initial Visit A. Evaluation 1. Shoulder Exam 2. *Shoulder Xray* B. Conservative Therapy 1. Modify Activity 2. Start Physical Therapy and Encourage Early Shoulder Mobilization 3. NSAIDS Pancreatitis - I. Causes A. Adult common causes 1. Alcohol Abuse (35% of cases) 2. Cholelithiasis (40% of cases) II. Symptoms A. Abdominal Pain 1. Pancreatitis may be painful in some cases 2. Mid-Epigastric Pain, Left Upper Quadrant Abdominal 3. Pain or Periumbilical Abdominal Pain 4. Radiation into the chest or mid-back 5. Worse with eating and drinking (especially fatty foods) and in supine position 6. Boring pain that starts episodically and advances to become constant III. Signs A. General 1. Low Grade Fever B. Abdominal 1. Abdominal tenderness and guarding in the upper quadrants 2. Peritoneal signs may be present (e.g. abdominal rigidity or Rebound Tenderness) 3. Bowel sounds decreased 4. Palpable upper abdominal mass 5. Cullen's Sign (periumbilical discoloration with subcutaneous Ecchymosis and edema) 6. Grey Turner's Sign (flank discoloration with Ecchymosis) IV. Labs A. Approach 1. Consider obtaining Serum Amylase and serum Lipase simultaneously on initial evaluation a. *Expect Serum Amylase and Lipase to be increased in Pancreatitis* (question diagnosis if only 1 increased) b. Serum Lipase to amylase ratio 4 (and especially 5) strongly suggests Alcoholic Pancreatitis B. Fasting Triglycerides 1. *Hypertriglyceridemia (1500)* Cullen's Sign - Blue discoloration from subcutaneous *ecchymosis and edema in periumbilical area*. Subungual Hematoma - I. Causes A. Crush injury to nail II. Symptoms A. Severe, throbbing digital pain III. Signs A. Discoloration of nail B. Tip of digit swollen and tender IV. Management: *Drainage (Nail Trephination)* Grey Turner's Sign - Discoloration at the *flank with blue-red-purple or green-brown ecchymosis*. Results from tissue catabolism of hemoglobin. A. Contraindications 1. Phalanx Fracture 2. Nail Bed Laceration 3. Large Subungual Hematomas (50% of nail) a. Requires Nail Bed Laceration suturing B. Technique 1. *Gently drill 2-3 small holes into nail* a. Number 11 blade or b. Spin 18 gauge needle between fingers or c. *Heated paper clip* Serum Creatinine - I. Pathophysiology A. Increases by 1.0-1.5 mg/dl/day if no Renal Function B. Often unchanged until 25-50% of Renal Function lost C. Doubled Serum Creatinine implies 50% Renal Function II. Increased Serum Creatinine A. *Renal Insufficiency* B. *Decreased renal perfusion* C. Urinary Tract Infections D. Skeletal muscle Trauma or Rhabdomyolysis E. Ketonemia F. Diabetic Ketoacidosis G. Creatine Supplementation 15-20 grams per day 1. May increase Serum Creatinine over 2.0 H. Medications (Inhibit tubular secretion of Creatinine) 1. Aminoglycosides 2. Cephalosporins a. Cefoxitin b. Cephalothin 5. Hydantoin 6. Diuretics 7. Methyldopa 8. Cimetidine 9. Trimethoprim III. Decreased Serum Creatinine A. *Decreased muscle mass* B. Pregnancy Trichomonal Vaginitis - I. Etiology A. Protozoan infection II. Symptoms A. Asymptomatic in 25-44% of women B. Copious, yellow-green or grayish-green Vaginal Discharge (variably present) 1. Fishy odor to discharge (variably present) 2. Frothy discharge (Carbon dioxide bubbles) C. Vulvar and vaginal Pruritus with irritation and edema D. Dysuria (20%) III. Signs A. Vulvar edema and erythema B. Tender vaginal or vulvar ulcerations C. *Strawberry Cervix* (2-3% of cases) 1. Punctate Hemorrhages or Petechiae 2. Telangiectasia IV. Labs A. Vaginal pH 5.0 B. *KOH Preparation* 1. Sniff Test positive a. Fishy odor to discharge when KOH added (often negative) C. *Wet preparation* (from vaginal vault, not endocervix) 1. Read slide immediately a. Motility wanes quickly, over minutes b. Trichomonad shape morphs from pear-shaped to round with slide drying 2. Motile pear shaped Trichomonads with flagella exiting from tapering end (70%) a. Twice the size of White Blood Cells (WBC) V. Treatment A. General 1. Treat Sexual Partner also a. Metronidazole 500 mg orally twice daily for 7 days is most effective for male partners b. Avoid treatment in first trimester of pregnancy c. Avoid intravaginal preparations of Metronidazole or Tinidazole due to low cure rates B. Non-Pregnant, Non-Lactating Patient 1. *Metronidazole (Flagyl) 2 g orally for 1 dose (preferred)* or 2. Metronidazole (Flagyl) 250 mg PO three times daily for 7 days or 3. Metronidazole (Flagyl) 500 mg PO twice daily for 7 days or 4. Tinidazole (Tindamax) 2 grams orally for 1 dose a. Teratogenic, Category D (do not use if any risk of pregnancy) Bacterial Endocarditis