FNP NR-506 LEIK EXAM TIPS Health Screening and Health Promotion GRADED A

FNP NR-506 LEIK EXAM TIPS Health Screening and Health Promotion US Health Statistics/Mortality Statistics Leading cause of death (all ages/genders): 1. Heart disease (or diseases of the heart) 2. Cancer (or malignant neoplasms) 3. Chronic lower respiratory diseases (i.e., chronic obstructive pulmonary disease [COPD]) Leading Cause of Cancer Death 1. Lung Cancer for both men and woman 2. Men – prostate & Woman- Breast 3. Colorectal Cancer for both men and woman Leading Cause of Death in Adolescents (^ in males than females) 1. Accidents /Unintentional Injuries 2. Suicide 3. Homicide Leading Cause of Death by Age Group • Birth to 12 months: • Congenital malformations (20.3%) • Ages 1 to 44 years: • Unintentional injuries • Ages 45 to 64 years: • Cancer (30.9%) • Ages 65 and older: • Heart disease (25.6%) Average Life Expectancy: 78.8 years of life Cancer Statistics Most Common Cancer: skin cancer Most Common type of skin Cancer: Basal Cell Carcinoma and Melanoma causes the majority of skin cancer related deaths. Most Common Cancer by Gender • Men – Prostate cancer (there are more cases of prostate cancer, however lung cancer is still the highest mortality cancer associated to males). • Females- Breast Cancer (there are more cases of breast cancer, however lung cancer is still the highest mortality cancer associated to females). Most Common Cancer among all children: Acute Lymphoblastic Leukemia (34% of all cancers in children). Sensitivity vs. Specificity • Sensitivity: is a good way of detecting those people who have the disease (i.e. true positive). • Specificity: is a good way of detecting those people without the disease (i.e. true negative). Top Three Cancers in Children • Leukemia (34%) • Brain and nervous system tumors (27%) • Neuroblastoma (7%) Health Promotion Aspirin Use to prevent Cardiovascular Disease or Colorectal Cancer • Begin at age 50-59 with =/ 10 % risk for cardiovascular disease (ASCVD score) Breast Cancer • Risk factors o age 50 or greater, o previous hx of breast CA, o two or more first * relatives o nulliparity, early menarche, late menopause (longer exposure to estrogen) o Obesity (adipose cells can synthesize small amounts of estrogen) • Baseline mammogram starts at 50 years of age • Repeat every 2 years from ages 50-74 years of age NOTE: Does NOT apply to those individuals with known genetic mutations (BRCA1 or 2), familial breast cancer history, history of chest radiation at a young age or previously diagnosed with high risk breast lesions, who may benefit from starting screenings at age 40. So, essentially if at high risk start screenings at age 40-49. Cervical Cancer • Risk factors o Multiple sexual partners o Younger age onset of sex o Immunosuppressed and/ or smoking individuals. Age Group Recommendations for Pap/Liquid Cytology Age 20 years or younger Do not screen (even if sexually active with multiple partners) Age 21 to 65 years Baseline at age 21 years. Screen every 3 years. Age 30 to 65 years Another option starting at age 30 years is to screen with combination of cytology plus human papillomavirus (HPV) testing every 5 years. Had hysterectomy with removal of cervix If hysterectomy with cervical removal was not due to cervica neoplasia (CIN grade 2) or cervical cancer, then can stop scre Age Group Recommendations for Pap/Liquid Cytology Women older than 65 years who had adequate prior screening Do not screen if history of adequate prior screening and is otherwise not at high risk for cervical cancer. Colorectal Cancer • Risk factors o Familial history of polyposis (multiple polyps on colon) o 1st * relative with colon cancer o Chron’s disease (ulcerative colitis) • Start at age 50-74 years of age is routine screenings • Age 76-85 years of age: against routine screening, but may have individual considerations for screening. • Screening Modalities for Colorectal Cancer o High-sensitivity fecal occult blood test (gFOBT) for three consecutive stool samples annually o Flexible sigmoidoscopy or CT colonography every 5 years o Colonoscopy every 10 years Lipid Disorders • Must be fasting for a minimum of 9 hours. • 40-74 years of age • Must have 1 or more risk factors i.e.- dyslipidemia, DM, HTN, and/ or smoking. • ASCVD of 10 % or greater Lung Cancer • Screening for individuals who smoke 30 pack-years or have quit in the past 15 years. • Age 55-80 years of life – low dose CT Prostate Cancer • Risk Factors o 50 years or older o African Ancestry o 1st * relative with prostate cancer. • Does not recommend PSA screening for prostate CA. • The benefits do NOT outweigh the disadvantages. Ovarian Cancer • Very high-risk women with BRCA1/BRCA2 mutations: Refer to specialists. If ovarian cancer screening is done, transvaginal ultrasound with serum cancer antigen (CA-125) is ordered. • Screening starts at age 30 • Some recommend BSO between age 35-40 years of life. • Who is at high risk? o Look for family history of having two or more first- to second-degree relatives with a history of ovarian cancer or a combination of ovarian cancer; women of Ashkenazi Jewish ethnicity with first-degree relative (or second-degree relatives on the same side of the family) with breast or ovarian cancer. Skin Cancer Counseling • Should occur starting at age 10-24 with fair skin. • Should avoid sunlight from 10am-to- 4 pm and use of 15 spf sunblock or higher, protective clothing, wide brim hats. No Routine Screening for the following • Ovarian cancer • Oral cancer • Prostate cancer • Testicular cancer General Recap of Screening Recommendations Vaccination Facts Hepatitis B Vaccine • Total of 3 doses with one given at birth and 4 weeks given between 1st and 2nd dose. • If patient only one dose of hep B vaccine? o Do not restart the series, just give the second dose. Then given 3rd when time permits. Influenza Vaccination • 6 months is the youngest age at which it can be given. • Most flu vaccinations are manufactures using egg-based technology. o Note: only 1.3% of children and only 0.02 % of adults have egg allergies. • Use caution with pt’s with previous reactions, history of Guillain-Barre syndrome within 6 weeks prior to previous immunization. • Live vaccine contraindications o Pregnancy o Chronic disease (i.e. COPD, Renal failure, DM, and immunosuppression). o In children on aspirin therapy ages 2-64 years of age. Tetanus Vaccines (Tdap and/ or Td) • Given every 10 years with boosters (i.e. contaminated wounds) every 5 years. • Age Implications o Infancy and younger than 7 years of age : use DTap form. o 7 years of age and older: only use Td or Tdap forms of the vaccine o All forms are given IM • Tdap can be used as a booster and substitute for Td (but only once in a lifetime) in adolescent and adults starting at 11-12 years of age. • What do you do for someone with a tetanus prone wound that has no tetanus history? o Give Td/Tdap vaccine and the tetanus immunoglobin (TIG) injection ASAP. • High risk wounds for Tetanus exposure o Puncture wounds o Wounds with devitalized tissue o Soil contaminated wounds o Crush injuries o Other injuries that are high risk for tetanus infection. • Use in caution with hx of Guillian-Barre Syndrome within 6 weeks of previous dose as well as pertussis component in individuals with progressive or unstable neurological disorder and or uncontrolled seizures. Pneumococcal Vaccinations • Pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax (50% effective): 65 years of age or older. • Pneumococcal conjugate vaccine (PCV13 or Prevnar) (85% effective) o All children less than 5 years of age o Those who are at high risk for pneumococcal disease ▪ Chronic Disease (alcoholism, DM, CSF leaks, asthma, chronic hepatitis). ▪ Anatomical or functional asplenia (including sickle cell disease) ▪ Immunocompromised or on medications that are immune-compromising. ▪ Malignancy or cancers of the blood. ▪ Renal Disorders ▪ History of organ or bone marrow transplant. • 65 years or older – CDC recommends giving PCV 13 first (if they never had PPSV23) then 12 months later give PPSV23 (better immunologic response is seen with this order) • In Adults less than 65 years of age who were previously vaccinated with Pneuovax 23 a booster should be given every 5 years after the initial dose. Shingles Vaccination • Risk factors for shingles o Older age (60 or ) o Immunocompromised – HIV, steroids, chemotherapy o Leukemia or lymphoma • Zoster Vaccine (Zostavax) is a LIVE vaccination. • Give at age 60 with a one time-SC even with a past history of shingles or chicken pox. • Certain anti-viral medications (acyclovir, famciclovir, valacylovir decrease the effectiveness if taken within 24 hours prior and 14 days after vaccination. • Can cause an exacerbation of asthma and polymyalgia rhematica (PMR) • Youngest age Zostavax can be given is 50 years of age. • Shingles is contagious until the lesions are dry and crusted (follow contact precautions) • NOTE: Shingles vaccine has 14 more times VZV then the varicella vaccine (Varivax) Varicella Vaccination • Varivax is a LIVE vaccine • 1st Dose: given at 12-15 months (no younger) and ADVISE woman not to get pregnant for 1 month after getting vaccination. • Reactions: Mild rash or several small chickenpox rashes can occur after vaccination (contagious, avoid immunocompromised people). • DO NOT administer to someone born in the United States before 1980 Immunizations for Health Care Workers • Td or Tdap: Give one-time dose of Tdap for all health care personnel who have not received the Tdap when due for a tetanus booster. Continue giving Td boosters every 10 years for a lifetime. • MMR: Proof of immunity is necessary (born before 1957, laboratory confirmation such as positive titers). If not vaccinated for MMR, two doses are needed (at least 28 days apart). • Varicella: Proof of immunity is necessary (positive varicella titer, documentation of two doses of varicella vaccine or diagnosis of varicella by physician/health care provider). • Hepatitis B: If incomplete hepatitis B series (fewer than three doses), complete the series (do not restart). If job involves blood or body fluids, obtain anti-HBsserological testing 1 to 2 months after dose 3. If anti-HBs is less than 10 mIU/mL, three additional doses should be administered on the regular hepatitis B schedule followed by anti-HBs testing in 1 to 2 months. • Influenza: All health care personnel should have an annual influenza shot during the fall/winter. Vaccination Clinical Pearls • TB blood tests (IGRA) are preferred method of testing of TB for people who have received BCG vaccine. • During flu season around 80-90% of all flu related deaths occur in people aged 65 years or older. Start immunizations in October. Systems Review Eye Emergency Review Herpes Keratitis • Clinical Manifestations: o Severe ACUTE onset of eye pain o Photophobia o Tearing o Blurred vision in one eye • Diagnosed: Fluorescein dye with black lamp in a dark room. (fern like lines in the corneal surface). • Can effect Cranial Nerve V –ophthalmic branch if due to shingles infection • Can cause permanent damages of the corneal epithelium. Acute Angle-Closure Glaucoma • SUDDEN blockage of aqueous humor caused by ^ IOP, resulting in ischemia and damage to CN II) Optic nerve. • Clinical Manifestations: o Acute onset of severe eye pain o Headache o Nausea and/or Vomiting o Halos around lights o Decreased vision. • Exam o Mid-dilated pupil that is OVAL shape o Fundoscopic exam shows cupping of the optic nerve. • Management: Immediate ED referral. Primary Open-Angle Glaucoma • GRADUAL onset of ^ IOP 22mmHg due to blockage of drainage inside the eye. • Clinical Manifestations: o Usually asymptomatic in early stages. o Changes in peripheral vision first then central vision. o C/O of missing portions of words when reading • Exam: If shows cupping (IOP is to high and warrants immediate ophthalmologist referral). Retinal Detachment • Clinical Manifestations: o Sudden onset of floaters associated with looking through a curtain o Sensations of sudden flashes of light (Photopsia) • Management: Refer to ED Ear, Nose, and Sinuses Review Cholesteatoma • Clinical Manifestations: o Cauliflower like growth (non-cancerous) can erode into the bones and cause nerve damage. (Cranial Nerve Vii). o Foul smelling ear discharge o Hearing loss on affected side • Exam o TM or ossicles are no longer visible o Hx of chronic otitis media infection. • Management: o Antibiotics and surgical debridement and refer to otolaryngologist. Battle Signs • Clinical Manifestations: o Bruising occurs behind the ear (mastoid area) 2-3 days after trauma occurs • Exam: o Physical exam does not show the clinical signs right away o Look for clear, golden, serous discharge from ear or nose (essentially a CSF leak through the fracture. You can test the fluid with a urine dipstick and if it is positive for glucose than its CSF fluid. Normal drainage should be negative for glucose. • Management: o R/O basilar and/ or temporal bone skull fracture b/c it can lead to intracranial hemorrhage. (Refer to ED) Pharynx Emergency’s Peritonsillar Abscess • Clinical Manifestations: o Sore throat, difficulty swallowing and/ or painful swallowing (odynophagia) o Jaw muscle spasm making it difficult to open mouth (Trismus) o “Hot Potato Voice” o malaise o Fever/chills • Exam o Unilateral swelling of the Peritonsillar area and soft palate o Markedly swollen o Bulging red mass with uvula displacement away from mass • Management: Refer to ED Diphtheria • Clinical Manifestations: o Sore Throat o Hoarseness with dysphagia o Low grade fever o Markedly swollen neck (Bull neck) o Posterior pharynx, tonsils, uvula, and soft palate are coated with gray-to yellow colored pseudomembrane • Management: o Contact Isolation: VERY contagious. o Refer to ED Head, Near, Eyes, Nose, and Throat Review (EXAM TIPS ONLY) Seasonal Allergic Rhinitis • Topical steroid nasal spray (Flonase is the 1st line defense). Uticaria • New onset is treated with Benadryl (sedating and last a few hours) or Zyrtec (last 24 hours) Mononucleosis (Acute or Reactivated) • Clinical Manifestations o Generalized maculopapular rash o Enlarged tonsils o Cryptic Exudate (white or darker color) o Sore throat o Enlarged Cervical nodes that are tender to touch. Otitis Externa • Common Pathogen – Psudomonas • Treatment for Otitis external is Cortisporin Otic Drops. Ruptured Spleen • Avoid contact sport for 4 weeks until US show resolution. Beta Blocker eye drops (Timolol) • Used to decrease intraocular pressure • Has the same contraindications as PO beta blockers. Cholesteatoma • Peri-orbital sinusitis complication that results in a cauliflower like growth accompanied by foul-smelling ear discharge. • Clinical Manifestations o No visualization of TM or ossicles • Treatment: Abx, surgical debridement and refer to EENT Penicillin allergic patients • Use Macrolides and quinolones that have gram + coverage (usually 4th generation abx) • Avoid Cephalosporin’s if patient has had a class I reaction or anaphylaxis to PCN. Learn to recognize Eye descriptions Chalazion: • Chronic inflammation of the melbomian gland (specialized sweat gland) of the eye lid • Painless and can resolves spontaneously in 2-8 weeks and/ or enlarge over time. • Often times pt’s c/o of gradual onset of small superficial nodule on the upper eyelid that feels like “bread” Pinguecula: • Yellowish to white small white growth of the bulbar conjunctiva located next to the cornea • Due to UV light damage to collagen. Pteygium: • Yellowish triangular “WEB SHAPED” thickening of the conjunctiva that extends to the CORNEA on the nasal side. • Can be red and inflamed at times and Pt’s often c/o of foreign body sensation on the eye. Treatment for BOTH pinguecula and Pteygium • If inflamed – use weak steroid eye drops during exacerbations • Recommend good quality sunglasses • Remove surgically if encroaches cornea and affects vision. Cerumenosis • Impacted wax blocking auditory canal • Txt: OTC is carbonate peroxide (similar to hydrogen peroxide) Vision • What someone sees at 20/40 vision means that they can see at 20 feet can see what the normal person at 40 ft can see. Herpes Keratitis • Two Types o Herpes Simplex Keratitis – infection due to herpes simplex virus. (self inoculation “cold sores: or herpes whitlow) o Herpes Zoster Ophthalmicus- acute eruption of crusty rash that follows the ophthalmic branch (CN V1) of the trigeminal nerve on only one side of the forehead, eyelids, and/ or tip of nose. (ED REFFERRAL) • Clinical Manifestations: o Severe onset of eye pain o Photophobia o Tearing o Blurred vision in one eye • Diagnosed: Fluorescein dye with black lamp in a dark room. (fern like lines in the corneal surface). • Management: o Shingles form send to ED ASAP. Corneal Abrasions or Keratitis • Use fluorescein strips to diagnosis/check Papilledema- swollen optic nerve RT to ^ ICP secondary to bleeding, tumor & etc. Hypertensive Retinopathy • Copper and silver wire arterioles (caused by arteriosclerosis) • AV nicking (when arteriosclerotic arteriole crosses the retinal vein and thus causes and indentation. Retinal hemorrhages occur as well. Diabetic Retinopathy • Micro-aneurysms are caused by neovascularization (new fragile arteries in the retina that rupture and bleed). • Cotton wool spots- look like fluffy yellow-white patches on the retina. Cataracts • Opacity of the lens of the eye (central or on the sides (cortical)). • Difficulty with glare (with headlights when driving at night or sunlight) , halos around lights, blurred vision. Koplik’s Spots • Cluster of small red papules with white centers inside the checks by the lower molars that is usually indicative of Measles. Hairy Leukopenia • Elongated papilla of the tongue that is usually indicative of HIV infection that is caused by the Epstein-Barr Virus. Cheilosis • Painful skin fissure at the corners of the mouth due to excessive moisture (most common in elderly with dentures). • Secondary infections with yeast of bacteria can occur, but also multiple etiologies such as over salvation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma, and pacifier us in children. • TXT- o treat underlying cause (i.e. yeast, bacteria, use of pacifiers, or dentures no fitting correctly). o Once underlying cause is treated use barrier creams with zinc or petroleum jelly applied at night b/c there is a high rate of reoccurrence. Testing Vision • Distant vision – Snellen chart (abnormal if less than 4/6 letters correct). • Near Vision- just ask patient to read small print. • Color blindness- use Ishihara chart. • Legal Blindness- 20/200 or less or a visual field less than 20* (tunnel vision). • NOTE: by age 6 children should be 20/20 visual acuity in both eyes – use Snellen chart for them. Hearing • Weber Test: place the tuning fork midline on the forehead. o Normal- no lateralization o Abnormal – lateralization (sound is only in one ear). • Rinne Test: place the tuning fork on the mastoid process, then at the front of the ear. o Normal – Air conduction lasts longer than bone conduction (pt can hear longer in front of the ear than on the mastoid bone). o Abnormal: bone conduction last longer than air conduction. (pt can hear longer on the mastoid than in front of the ear) Exam Tips • Rinne Test o BC greater than AC is conductive hearing loss- cerumenosis or AOM o Normal finding- Air conduction last longer than bone conduction AC BC • Weber Test o Results in lateralization (an abnormal finding) to the bad/affected side with conductive hearing loss. • Both weber and Rinne test cranial nerve 8 • Lateralization – is defined by hearing sound louder on one side Types of Hearing Loss • Conductive (outer and middle ear) – any type of obstruction of the sound waves that will cause conductive hearing loss (i.e. ceruminosis, otitis externa, fluid inside the middle ear (otitis media, serous otitis media). • Sensorineural- damage of the cochlea/vestibule (presbycusis, Meniere’s Disease, CNViii or acoustic nerve damage. Also ototoxic drugs can cause damage. o Ototoxic drugs- aminoglycosides (i.e. - gentamicin, tobraymycin), erythromycin, tetracycline, high-dose aspirin, sildenafil, and stroke (usually results in permanent hearing loss). Integumentary Review Integumentary Terminology • Macule- flat non-palpable lesions ( 1 cm diameter) o Ex: freckle • Papule- palpable solid lesion less than or equal to 0.5cm in diameter. o Ex: nevi or acne. • Plaque- flattened elevated lesion with variable shape greater than 1 cm in diameter. o Ex- psoriatic lesions • Bulla- elevated superficial blister filled with serous fluid and more than 1cm in size o Example: impetigo second-degree with blisters, SJS lesions. • Vesicle- elevated superficial fluid filled skin lesions 1cm o Example: Herpetic lesions • Pustule- elevated superficial fluid filled (purulent in nature) that are less than 1 cm in diameter o Example: Acne pustules Secondary Skin Lesions • Primary- lesion that changes, complication of a primary lesions or injury • Lichenification- thickening of the epidermis with exaggeration of normal skin lines due to chronic itching (commonly seen with eczema) • Scale- flaking skin (psoriasis) • Crust- dried exudate (may be red in color usually seen in impetigo). • Ulceration- full thickness loss of skin (pressure ulcers) • Scar- permanent fibrotic changes after damage to dermis (surgical scars) • Keloids/hypertrophic Scar- overgrowth of scar tissues (^ blacks/Asians) Dermatology Terms • Acral- distal portions of the limbs in the hand or feet (acral melanoma) • Annular- ring shaped (ringworm or tinea corporis) • Exanthem- another term for cutaneous rash (seen sometimes in Lupus) • Flexural- skin flexures are body folds (eczema affect flexural folds) • Maculopapular rash- rash with color (usually pink to red) with small bumps that are raised above the skin (usually seen in viral rashes) • Nummular- round coin shaped rash (nummular eczema- nickel allergy with belts). • Purpura- bleeding into the skin (small bleeds are petechial in nature- usually seen with RMSF) and larger areas are ecchymosed or purpura usually seen with meningococcemia. • Serpiginous- shaped like snake – seen with larva migrans • Varrucous- wart like Impetigo – • Acute superficial skin infection caused by Gram (+) bacteria (Strep or Staph) and usually seen in hot environments. • Description: honey colored crust, fragile bullae, and pruritic in nature. • Management: o C&S crusts/wound if severe o Few lesions and NO bullae – Mupirocin ointment (bactroban) or fusidic acid o Clean lesions with antibacterial soap, betadine, or hibiclens then apply antibacterial to lesions o Shower/bathe daily with antibacterial soap until healed o DO NOT share towels o Do not return to daycare until 48-72 hours after treatment initiated. Measles- (Rubeola) • Viral infection also called Rubeola • Description: Koplik’s spots are small, white round spots on red base on the buccal mucosa by the rear molars. • Management: analgesics and preventative with MMR vaccine Scabies • Description: very pruritic, even more at night, Serpiginous rash between the finger/toes, waist, axilla, and /or penis. Scarlet Fever • Description: sandpaper rash with sore throat (strep throat) Tinea Versicolor • Description: hypo-pigmented round to oval macular rash that is usually on the upper back/shoulders (not itchy) Pityriasis Rosea • Description: “Christmas tree” pattern rash that is usually seen on cleavage lines. • Herald patch is also seen and this appears initially. Molluscum Contagiosum • Description: smooth papules 1 mm size that are usually dome-shaped with central umbilication with a white plug. Erythema Migrans (Lyme Disease) • Description: (bulls eye target lesions) Red like target lesions that grow in size with some degree of central clearing (early stages of Lyme Disease) • Common locations: belt line, axillary area, behind the knees, and in the groin. Meningococcemia • Clinical Manifestations o Description: purple colored to dark red painful lesions all over the body o high fever o HE o LOC changes • Treatment: Give Rifampin prophylaxis for close contacts. • Management: Aerosol Droplet precautions Rocky Mountain Spotted Fever • Clinical Manifestations o Description: red spot like rashes that first break out on the hand/palm/wrist and on the feet/sole/ankles accompanied with o Acute sudden onset high fever, severe headache, and myalgia • TXT: 1st line is Doxy Skin and Integumentary System Exam TIPS only Differentiate between contact dermatitis and atopic dermatitis Atopic Dermatitis: (Eczema) • Extremely pruritus rash located on hands, flexural folds, neck and exacerbated by stress. • Clinical Manifestations o Starts as multiple vesicles that rupture, leaving painful, bright red, weepy lesions that eventually become lickenfield from chronic itching. • NOTE: Familial history of atopy is usually present. Contact Dermatitis: • Inflammatory skin reaction due to external irritants. • Description o Can be single lesion or generalized rash. o Can follow a pattern or have asymmetric distribution. Scabies • Rash that is very pruritic at night and located on the inter-digital webs and/ or penis are scabies UNTIL proven otherwise • Treat close contacts • Wash linens and clothes in hot water. Human dog/ cat Bite • Preferred txt is Augmentin Hydranitis Suppurativa • Bacterial infection of the sebaceous glands in the axilla or groin by S. Aureous. • Usually becomes chronic. • TXT: Drainage and ABX Psoriasis • Inherited skin disorder that produces fine , silvery white scales (also called “fine scales”) accompanied with pitted fingernails and toe nails. • Clinical Manifestations: • Koebner phenomenon • Auspitz Sign • TXT: Steroids, Psoralens (tar-derived topical) and antimetabolite (methotrexate). RMSF • Petechial rash that starts on hands and feet and then spreads and appears on the 3 day after onset of • Clinical Manifestations o high fever o Severe headache o Myalgia, o Red eyes o N/V o Arthralgia • TXT: Doxy Meningococcemia • Clinical Manifestations: Sudden onset of sore throat, cough, fever, HE, stiff neck, photophobia, change in LOC, and a petechial to hemorrhagic rash (pink to purple) in the axillae, flanks, wrists, and ankles • High risk for pt’s living in Dorms • Management: Droplet precautions • TXT: Rifampin prophylaxis for those in close contacts Erythema Migrans (Lyme Disease) • Bull’s eye rash that usually appears within 7-14 days after deer tick bit. Rash it hot to touch, and rough texture. • TXT: doxy Rosacea • Chronic inflammatory skin disorder that can produce acne like papules and pustules around the nose, mouth, and chin. • Usually have fair skin color at baseline. • TXT: topical Metronidazole gel Acne • Mild acne is only treated with topicals. Pityriassis Rosea • Herald’s Patch Post-Herpectic Neuralgia • Prophylaxis is TCA’s Differentiate erysipelas vs. other cellulitis Erysipelas • Cellulitis only involving the upper dermis and superficial lymphatic’s that is usually caused by A. Streptococcus. • CLUE: Any cellulitis questions often involve pt’s being barefoot. Cardiovascular EXAM tips • Advise all HTN Pt’s to DECREASE NA+ intake. • How to decrease triglycerides o Reduce intake of simple carbohydrates, junk foots, and fried foods. o Excessively high triglycerides (500) lower triglycerides first with niacin or fibrate before treating high cholesterol and LDL levels o High Triglycerides increase the risk of Pancreatitis o Niacin and Fibrates are best agents to decrease triglycerides. • How to increase HDL o Increase aerobic-type exercises and take niacin • Dietary Sources o Magnesium: dried beans, whole grains, and nuts o Potassium: most fruits and vegetables o Calcium: low fat dairy o Omega 3: salmon, anchovies, flaxseed oil • ASCVD score of 7.5 or start on high-intensity statins o Atorvastatin 40-80 mg o Crestor 20-40 mg • Murmurs (Only 2-3 questions) o Systolic: MR PM AS MVP • Only systolic murmurs radiate 1. Mitral Regurgitation to the axilla 2. Aortic stenosis to the neck. o Diastolic: AR MS • Mitral Murmurs: o Located on the apex of the heart or apical area o On the 5th ICS on L side of the sternum medial to the mid-clavicular line • Heart Sounds o S3- is a sign for HF o S4- LVH (Sounds like Tennessee) and 1st place the thrill is felt. o Split S2 is best heard at the pulmonic area. AAA • Must be R/O in older male who has a pulsatile abdominal mass that is 3cm in width. Cardiac Rhythms – no strips will be on test, just signs and symptoms. • Atrial Fibrillation o Sudden onset of palpitations, weakness, dizziness, dyspnea, rapid and irregular heart rate, and possible syncopal episodes. • Paroxysmal Atrial tachycardia o Abrupt onset of palpitations, rapid pulse, lightheadedness, SOB, and anxiety. HR can range from 150-250. (Common in Dig toxicity). o TXT: Valsalva maneuvers and cold water. • Pulsus Paradoxus o BP and stethoscope when a radial pulse is no longer palpated. • Anterior STEMI (anterior wall MI) o Most common and serious type of MI o EKG changes- ST elevation in leads V2 to V4 and Q waves and wide QRS complex resemble tombstones. • PSVT and AF causes o ETOH, hyperthyroidism, stimulants (theophylline, decongestants, and cocaine, as well as HD). JNC Antihypertensive guidelines • Consider chlorthalidone or indapamide versus HCTZ b/c longer half life. Eye Findings • Hypertensive Retinopathy: copper and silver wire arterioles and AV nicking • Diabetic Retinopathy: neovascularization, microaneurysms, hard exudates, and cotton wool spots. Isolated systolic HTN: low dose thiazide diuretics or CCB (long acting dihydropyridine). Orthostatic Hypotension – sitting and standing BP ACEI’s or ARB’s- use for DM, CKD, and HF. • 1st line medication for stable HF • Caution with use of ACEI’s/ARB’s in combination with thiazide - ^ K+. • Bilateral renal artery stenosis will precipitate acute renal failure. Thiazide Diuretics • Causes hyperglycemia, hyperuricemia, and hypertriglyceremia. • 1st line txt for woman with HRT and osteopenia/osteoporosis b/c it slows down the loss of Calcium from the bone and helps stimulates osteoclasts. Potassium Sparing Diuretics • Spironolactone- causes gynecomastia • Use in caution in combination with ACEI due to risk for ^ K+ and • Don’t give to pt’s with bilateral renal artery stenosis. • Should be given to woman with osteopenia/osteoporosis b/c it helps decrease bone loss by decreasing calcium loss and ^ stimulation of osteoclasts. Calcium Channel Blockers • Used to treat Raynaud’s Alpha Blockers • Only 1st line txt for HTN when pre-existing BPH condition. Statins • May cause memory loss confusion, cognitive effect that are reversible. • Pt’s with simvastatin and lovastatin should avoid grapefruit juice and do NOT mix with macrolides. • Complications o Rhabdomyolysis – muscles pain usually located on the valves, thighs, lower back, and/ or shoulders. Urine will be dark. R/O if any c/o of of the above s/s. INR • Goal INR is 2-3 for A. Fib o If between 4.01-4.99 hold one dose and do NOT give vit. K • Major bleeding suspected check INR, PTT, and PT b/c INR can be normal. • Coumadin is category X New York Heart Association Class II Heart Disease (Functional Capacity Ratings) • Ordinary physical activity results in fatigue, exertional dyspnea. Risk Factors for DVT’s o Birth control, pregnancy, bone fractures , trauma, surgery, and malignancy. Raynaud’s Phenomenon • Reversible vasospasm of the peripheral arterioles on the fingers and toes with unknown cause, but strongly associated with autoimmune disorders (especially scleroderma). • Description: Color ranges from white (palor), blue (cyanosis), to red (reperfusion). • TXT- CCB’s Bacterial Endocarditis • Bacteria Pathogen- gram (+) viridans streptococcus and S. Aureus • Clinical Manifestations: o fever, chills, malaise, o subunal hemorrhages (splinter hemorrhages on nail bed) o Janeway lesions- red macules palms/soles that NOT Painful. o Osler’s nodes- painful violaceous nodes found mostly on the pads of the fingers, toes, thenar eminence. o Some pt’s have heart murmur. Metabolic Syndrome • Metabolic syndrome is a cluster of symptoms. o Abdominal obesity ( 40 inches in men and 35 in females). o HTN o HLD o Fasting glucose 100 o ^ triglycerides 150 o Decreased HDL 40 Nonalcoholic Fatty Liver Disease (NAFLD) – usually asymptomatic • Caused by triglyceride fat deposits in the hepatocytes of the liver. • Risk Factors: obesity, DM, metabolic syndrome, HTN, drug induced. Overweight • BMI of 27 • 1st line txt is lifestyle modifications with diet. Pulmonary System Exam Tips COPD • 1st line txt is either SABA or short acting anticholinergics (Atrovent). If poor response with 1 single agents add second agent, so if on SABA add short acting anticholinergic (Ipratropium (Atrovent). • If short acting meds are not controlling symptoms next step is to start pt on a LABA or a LAMA (salmeterol or formoterol), but can continue with SABA as needed. • Only txt to prolong life – supplemental oxygen. • COPD smoker with PNA- cause is most likely Haemophilus influenza, so when you pick an antibiotic choose one that has coverage for both Haemophilus influenza and Streptococcus Pneumoniae. • Do NOT use LABA for rescue inhaler. Rescue Inhalers- Short acting B2 Agonist (Albuterol and Xopenex. Bacterial Pneumonia (Community Acquired Pneumonia) • 1st cause is Streptococcus Pneumoniae & 2nd is Haemophilus influenzae • Clinical Manifestations • Acute onset with high fever, chills, productive cough (mucous green to rust color), pleuritic chest pain with and/ or without cough. • Lung Sounds- crackles, decreased breath sounds, dull • Diagnostic • CXR- lobar infiltrates. Outpatient CAP- based on S/S and CXR, do not order phlegm for C&S or CBC. Atypical Pneumonia (Walking Pneumonia) • Mycoplasma is most common and Chlamydia • Clinical Manifestations o Gradual onset, low grade fever, HE, sore throat, cough, and sometimes rash o Lung sounds- wheezing • Diagnostics o CXR- interstitial to patchy infiltrates • Usually seen in young adults. o Depending on the stage of the disease and hydration status CXR may result in normal during the early stages of bacterial PNA (lobar PNA). Pertussis / Whopping cough • Coughing illness that last at LEAST 14 days and up to months that is usually caused by Bordetella Pertussis bacteria. • Clinical Manifestations • Excessive barking cough, inspiratory whooping without apparent cause. • Has 3 stages • TXT: Macrolides (Azithromycin), antitussives, mucolytic, rest, hydration , and small frequent meals. • NOTE: Suspect pertussis in a “healthy adult with no fever who has been coughing for more than 2-3 weeks, especially if they were treated with a abx that was not a macrolide and is getting worse. However, r/o PNA 1st. Acute Bronchitis • TXT- NO abx • Treatment is symptomatic based, so increase fluids, rest, smoking cessation, dextromethorphan, Tessalon perles, inhalers, and possible steroid Medrol dose pack. TB • PPD 10 suggestive of TB, but if there is 9.5 and c/ o of symptoms this is suggestive of TB • Never txt with fewer than 2-3 drugs. • Pt’s with HIV with CD4 count 500 or pt’s who are taking tumor necrosis factor antagonists or biologics are at ^ risk for TB. • Can use TB skin test during pregnancy. • Younger children ^ likelihood then older adults to develop life threatening TB. Peak Expiratory Flow Rate (PEFR or PEF) • Measures effectiveness of treatment, worsening of symptoms. • Based on ht, age, gender (HAG) High dose inhaled corticosteroids • Can cause osteoporosis, mild growth retardation in children, glaucoma, cataracts, immune suppression, hypothalamic-pituitary adrenal suppression. Asthmatics • 1st line txt for SEVERE asthmatic exacerbation is adrenaline injection • Must always have a rescue inhaler (short acting B2 agonist) Long term Corticosteroids • Can increase risk for PNA Mucolytic • best option is hydration b/c it thins secretions. Lung Cancer • Can present as recurrent PNA due to mass blocking bronchioles. Asthma pg. 218……………… Endocrine Exam Tips Subclinical Hypothyroidism • TSH is elevated and there is a normal T4 level. • Do not treat, but recheck the TSH in 6 months. • Many patients with subclinical hypothyroidism will eventually develop overt hypothyroidism Hypothyroidism - Elevated TSH • TSH 5.0 workup is needed for hypothyroidism. • Order TSH, free T4, and T3. • Alopecia of outer 1/3 of eye brow and myxedema are symptoms of hypothyroidism. Radioactive Iodine Treatment • Results in hypothyroidism for life, so will need Synthroid for life. Hyperthyroidism (Graves Disease) • If TSH is suppressed (0.1mU/L) workup is needed to r/o hyperthyroidism. • All hyperthyroidism pt’s should be referred to and Endocrinologist ASAP. • Lid lag is very common in Graves disease. Subclinical Hyperthyroidism • At increase risk for bone issues (osteopenia/osteoporosis), cardiac (A.Fib) complications. • NOTE: new onset A-fib check TSH level Levothyroxine (Synthroid) • Is a form of synthetic T4 • Goal TSH is 1.0-4.0 mU/L for thyroid hormone replacement supplementation. • Start elderly patients at low dose Synthroid of 12.5-25mcg/day and gradually increase b/c this avoids adverse cardiac issues often seen with elderly. (i.e. palpitations, angina, MI). • Check TSH every 6-8 weeks (do not due it earlier than 6 weeks) to monitor effectiveness of medication. If TSH is 0.5 to 5.0 mU/L it is within normal limits. • Have pt crush Synthroid tablet with teeth inside mouth before swallowing with water for better absorption. Alternative Thyroid medications • Armour Thyroid tablets – desiccated thyroid glands of pigs with contain natural T3 and T4 for hypothyroidism DMII • 1st line treatment is then Metformin (Glucophage) • IF pt on 500mg daily of metformin and A1C is 7 increase dose to 500mg BID. • If A1C is still 7 increase to 1,000mg BID (max dose). • If taking maximum dose of Metformin several drug classes with metformin can be used. • Glipizide (Glucotrol XL) 5 mg PO daily (note max dose is 20mg PO daily) • Pioglitazone (Actos) • If pt is unable to tolerate Metformin and A1C is 9 or then start on basal insulin of maximum dose of Glipizide 20mg or pioglitazone (Actos) • Bariatric surgery can result in remission of DMII for obese pt’s. Chronic amenorrhea and hyper metabolism results in osteoporosis • Supplement with calcium with vid D 1,200 mg daily and engage in weight bearing exercises. Diabetic Retinopathy • Neovascularization (new growth of fragile arterioles in retina), Micro-aneurysms (dot and blot hemorrhages due to neovascularization), Cotton wool spots or soft exudates, and hard exudates occur • Screening o DMI- start screening at age 10 o DMII- start screening at age: refer to ophthalmologist shortly after diagnosis then exam exams needed every 6-12 months. Hypertensive Retinopathy • Silver wire/copper wire arterioles, AV nicking occur Pioglitazone (Actos) • Can cause water retention, which may precipitate CHF, so contraindicated in pt’s with history of HF or NYHA class III or IV (moderate to severe CHF). Insulin Pumps • Must disconnect with swimming, showering, bathing and with certain sports (wrestling). Microvascular Complications of DM • Retinopathy • Nephropathy • Neuropathy Macrovascular Complications of DM • CAD • PAD • Stroke Charcot’s Foot – very common in DM • Condition causing weakening of the bones in the foot that occur in people who have severe nerve damage (neuropathy) Diabetics At and increase risk for cataracts and glaucoma Gastrointestinal Review Gastrointestinal Danger Signs Acute Appendicitis: pain at McBurney’s Point with positive psoas and obutrator signs Acute Cholecystitis: Murphy’s maneuver Acute Diverticulitis: Rovsing’s Sign with board-like abdomen with leukocytosis and neutrophilia and a shift to the left. Acute Pancreatitis: Cullen’s Sign (blue discoloration around umbilicus) & Grey-Turner’s Sign (blue discoloration on the flanks). Also may have ileus and show signs of shock. Clostridium Difficile Colitis: severe watery diarrhea from 10-15 stools a day. Usually appears 5- 10 days after the start of antibiotics. Especially common with clindamycin, fluoroquinolones, cephalosporin, and PCN”s. Colon Cancer • Gradual onset with very vague symptoms, • Clinical Manifestations: o Iron-deficiency anemia, change in bowel habits, bloody stools, heme-positive stools, dark-tarry stool, and mass on abdominal palpation. Crohn’s disease and Ulcerative Colitis. Crohn’s Disease: • Form of inflammatory bowel disease that affects any part of the GI tract from mouth (canker sores are common) small –large intestine, rectum, and anus. If ileum is involved there is watery diarrhea without blood of mucus. • Fistula formation and anal disease only occurs with CD and NOT with UC. Also may palpate a tender palpable mass. • Increased risk for colon CA, lymphoma, and toxic megacolon (especially in pt’s treated with Azathioprine. McBurney’s Point: • The name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (navel). This point roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum. • Positive in Appendicitis Psoas/Iliopsoas (supine position) • RLQ abdominal pain that occurs when the hips are flexed at a 90* angle then have the patient push against the examiners hand to try and straighten the leg. • Positive in Appendicitis Obturator Sign • Positive if inward rotation of the hip causes RLQ abdominal pain. Rotate right hip through full range of motion. Positive sign is pain with the movement or flexion of the hip. • Positive in Appendicitis Rovsing’s Sign (supine position) • Deep palpation of the left lower quadrant of the abdomen that results in pain to the RLQ. • (+) in Appendicitis Markle Test (Heel Jar) • Instruct patient to raise heels and then drop them suddenly. An alternative is to ask the patient to jump in place. Positive if pain is elicited or if patient refuses to perform because of pain. Involuntary Guarding : With abdominal palpation, the abdominal muscles reflexively become tense or board-like. Barrett’s Esophagus • Precancer to esophageal cancer • Diagnosed by upper endoscopy with biopsy. Lifestyle Modifications • Avoid mints and caffeine? – WHY???? Cullen’s Sign • Edema and bruising of the subcutaneous tissue around the umbilicus Nervous System LEIK EXAM TIPS Danger Signs with headaches • Abrupt onset of severe headache “Thunderclap headache” • “Worst headache of my life” • First onset of headache at age 50 • Sudden onset of HE after coughing, exertion, straining, or sex (i.e. exertional headache) • Sudden change in LOC • Focal neurological signs (i.e. unequal pupil size). • HE with papilledema (i.e. can be secondary to “ Worst Case List” Below o Subarachnoid hemorrhage or acute subdural hemorrhage. o Leaking aneurysm o Bacterial Meningitis o Increased ICP o Brain Abscess o Brain Tumor Acute Bacterial Meningitis • Clinical Manifestations o Acute onset of high fever o Severe headache o Stiff neck o Meningismus – symptoms related to inflammation of the meninges. o Class purple colored petechial rash o Nausea/vomiting o Photophobia o Can lead to lethargy, confusion, and / or coma • NOTE: Bacterial Meningitis is REPORTABLE Temporal Arteritis (Giant cell Arteritis) • Clinical Manifestations o Acute onset of headache located on one temple on an older adult o Affected temple is indurated, reddened, and cord like that is tender to touch. o Scalp tenderness o Abrupt onset of visual disturbances and/ or transient blindness of the affected eye (amaurosis fogax). o Jaw pain or jaw claudication • Labs o ^ ESR o ^ CRP • High Risk: patients with Polymyalgia rhematica ^ risk to develop this. Acute/Narrow Angle Glaucoma • Clinical Manifestations o Acute onset of headaches behind the eye accompanied with eye pain, blurred vision, nausea/vomiting. o Cornea looks hazy and the affected pupil is dilated midway. • Risk Factor: more common in older adults • Management: ED Neurological Testing Cerebellar Testing: Romberg Test (cerebellar testing): tell the patient to stand with arms/hands straight on each side with the feet together, and then instruct the patient to close both eyes while standing in the same position and observe. ▪ Positive Test: excessive swaying, patient falls, keeps feet far apart to maintain balance. Tandem Gait (cerebellar testing): Tell pt to walk a straight line in normal gait, and then instruct the patient to walk a straight line with one foot in front of the other. • Positive Test: test is positive if unable to perform tandem walking, loses balance, and falls Kernig’s Sign: Flex the patient’s hip one at a time, then attempt to straighten the leg while keeping the hip flexed at 90 *. • Positive- there is resistance to leg straightening b/c of painful hamstrings (this would be due to inflammation of lumbar nerve roots and / or c/o of back pain. Brudzinski: Passively flex/bend the patient’s neck toward the chest. • Positive Test: pt’s reflexively flexes the hip and knee to relieve pressure and pain (this is due to inflammation of the lumbar nerves) . Nuchal Rigidity: Have the pt touch chest with chin. • Positive finding is the inability to touch the chest secondary to pain Reflexes : Graded from 0-4+ • 0- Normal • 1+ Low Response • 2+ Normal or Average Response • 3+ Brisker than the average • 4+ Very Brisk Response Neurological Terminology Diadochokinesia- Coordination Stereognosis- ability to recognize familiar objects though sense and touch ONLY Graphesthesia- ability to identify figures written on the skin EXAM TIPS Cranial Nerves Mnemonic: On, On, On, They, Traveled, And, Found, Voldemort, Guarding, Very, Special, Horcruxes NOTE: Cranial nerves are listed by number only. 1. Olfactory Nerve (I) 2. Optic Nerve (II) 3. Oculomotor Nerve (III) 4. Trochlear Nerve (IV) 5. Trigeminal Nerve (V) 6. Abducens Nerve (VI 7. Facial Nerve (VII) 8. Vestibulocochlear Nerve (VIII) 9. Glossopharyngeal Nerve (IX) 10. Vagus Nerve (X) 11. Spinal Accessory Nerve (XI) 12. Hypoglossal Nerve (XII) Herpes Zoster Infection (Shingles) • Affects cranial nerve V, the ophthalmic branch which can result in corneal blindness. • NOTE: if there is a rash at tip of nose and the temple area, you must r/o shingles infection of the trigeminal nerve. Acute Bacterial Meningitis • An acute bacterial infection of the leptomeninges that cover the brain and spinal cord. • Pathogens: Streptococcus Pneumoniae, Neisseria meningitides, Haemophilus influenza (the later two being of a gram (-) origin. • Clinical Manifestations o Acute onset of high fever o Severe headaches o Stiff neck (nuchal rigidity) o Rapid changes in mental status and LOC : Confusion, lethargy, and/ or stupor. o Photophobia o Nausea and/ or Vomiting • Bacterial meningitis is a reportable disease to the local health department. • Labs o LP- CSF contains large number of WBC’s, elevated protein, and low glucose levels. (usually CSF is cloudy, but a definitive diagnosis is made from bacteria that is isolated from the CSF). o Elevated opening pressure (need CT or MRI) o CBC with differential, CMP, Coagulation factors, platlets, and blood cultures X2 • Treatment o Infants: Ampicillin or 3rd generation cephalosporin o Adults: 3rd generation cephalosporin plus chloramphenicol o 50y/o: Amoxicillin plus 3rd generation cephalosporin. o Prophylaxis: close contacts should be treated with rifampin or ceftriaxone. • Prevention: immunization with pneumococcal vaccination has shown to decrease occurrence. • Complications: o Pt’s who recover usually have permanent neurologic sequelae. o Elderly pt’s have increase mortality rate due to presence of comorbid conditions. Migraine headaches with Aura: • Aura may present as scotomas (blind spots on visual fields) or flashing light that precede a headache. • Increase risk for patients with positive family history and being female (3:1) • Infants- migraines may present as abdominal pain. • Clinical Manifestations: o Gradual onset of bad throbbing headache behind on eye that gradually worsens over several hours. o Photophobia (sensitivity to light) o Phonophobia (sensitivity to noise) o Nausea, and/ or vomiting o Can last anywhere from 2-3 days and may become bilateral if it is not treated. • Treatment o Neurological exam o Rest in quiet, darkened room, with ice pack to head o Nausea: drink ginger ale or chew dry toast. o Avoid heavy fatty meals o Triggers ▪ Avoid precipitating foods ▪ Monosodium glutamate (MSG), Chinese food, chocolate, nitrates/Nitrites (usually found in hot dogs, lunch meat, and / or sausage). ▪ Red wines, beer, and caffeine ▪ Sleep changes, stress, barometric weather changes. ▪ Odor triggers: tobacco smoke, perfumes, and/ or strong odors. ▪ Visual triggers: strobe lights, sunlights, and/ or glares. Treatment of Migraines Abortive: Immitrex (see below) and NSAID’s Sumatriptan (Imitrex) • FIRST: must r/o cardiac disease • Do not use if history of ischemia heart disease (MI, angina), CVA/TIA, uncontrolled HTN or hemiplegic migraine) causes stroke like symptoms to one side) . • S/E: flushing, tingling, chest/neck/sinus/jaw discomfort • Implications: must have first dose supervised (especially if pt’s have risk factors for cardiac disease o Risk factor for Cardiac disease: DM, Obese, males 40 y/o, high lipids o Consider EKG monitoring for these pt’s. • Drug Interactions: o Increased risk for serotonin syndrome if combined with SSRI or SNRI’s (Duloxetine/Cymbalta, Venlafaxine/Effexor. o Do not start within 2 weeks of taking and MAOI o Do not combine with ergots or within 24 hours of ergots use (ergotamine/caffeine or Cefergot NSAID’s, Analgesics, and / or Narcotics • Extra Strength Tylenol, Codeine and/ or Hydrocodone Ergotamine/Caffeine (Cafergot • Ergot alkaloids are potent vasoconstrictors. • Do NOT mix with other vasoconstrictors (triptans, decongestants • S/E: nausea (main one) • Drug interactions: Don’t give within 14 days of an MAOI’s Anti-Emetics • Trimethobenzamide (Tigan) : given IM suppository, and/ or PO • Reglan: increase peristalsis in the duodenum and jejunum. Prophylactic Treatment • Beta Blockers: Propranolol (Inderal) daily or BID • TCA’s: Amitriptyline (Elavil) at HS o Other TCA”s used : Desipramine (Norpramin) Imipramine (Tofranil) Notriptyline (Pamelor). • Other drug classes o Anticonvulsants (Valproate, Topiramate, Gabapentin, (Neurotin) o NOTE: Topiramate should be d/c if pt has a history of kidney stones. Contraindications for Vasoconstriction Drugs • CVD, angina, MI, PAD, CVA/TIA, HLD, males 40 y/o, menopausal females, uncontrolled HTN, as well as c/o of complex migraine (basilar / hemiplegic in nature). Basilar or Hemiplegic Migraines • Focal neurological findings with stroke-like symptoms. Often resembles TIA. • These pt’s are at higher risk for stroke, • Avoid giving estrogens or any agents that promoting clot formation. Temporal Arteritis (Giant Cell Arteritis) • A systemic inflammatory disorder (vasculitis) occurs with an acute onset of unilateral headache that is located on the temple that is associated with temporal artery inflammation. • Mean age of diagnosis is 72 y/o • Visual loss is not uncommon and occur in 15-20 % of patients (despite availability of steroids. • Clinical manifestations: o Headache along the temple with marked scalp tenderness on the same side. o Presence of indurated cord-like temporal artery that is warm and tender. o Jaw claudication (pain with chewing that is relieved when the pt stops chewing. o Visual symptoms: Amaurosis fugax (transient monocular loss of vision) or partial visual field defect and/or blindness. o Low grade fever o Fatigue • Labs o ESR/ sedimentation rate : often reaches 100 mm/hr or more ▪ Normal Range: MEN: 0-22mm/hr WOMAN: 0-29 mm/hr o CRP: will be elevated • Treatment o Refer to ophthalmologist or ED stat o Temporal artery biopsy is gold standard and is done by ophthalmologist of surgeon. o High dose prednisone for several weeks, and referral to rheumatology specialist for management. Polymyalgia Rheumatic (PMR) • VERY high risk for developing Temporal Arteritis, so educate pt’s on how to recognize the symptoms of temporal arteritis. • Clinical Manifestations: o Bilateral joint stiffness and aching (lasting 30 minutes or longer) commonly in the AM). Located in the shoulders, neck, hips, and/or torso. o Commonly causing issues with putting on clothes, /bra, having difficulty getting up from bed and/ or chair. • Risk Factors o Females 50 y/o or greater • Treatment: o Symptoms usually respond well to PO steroids. Trigeminal Neuralgia • Trigeminal nerve has 3 divisions (ophthalmic, V1, Maxillary (V2), and Mandiublar (V3) and is caused by compression of the nerve root by an artery or tumor. • Clinical Manifestations: o unilateral facial pain that follows one of the branches of the trigeminal nerve. o Pain close to the nasal border and checks. • Different Types o Type 1: extreme shock-like facial pain lasting from second to 2 minutes per episode) o Type 2: constant, aching, burning facial pain of low intensitiy, • More common in Woman and peaks in their 60’s. • Treatment: o Anticonvulsants: Carbamazepine (Tegretol) or Phenytoin (Dilantin) o Muscle Relaxants are effective when combined with Anticonvulsants ▪ Oxcarbazepine (Trileptal) used at 1st line defense drug b/c less S/E’s. ▪ Gabapentin and topiramate are also used. o CT/ MRI: scan to r/o tumor or artery pressing on nerve or Multiple sclerosis. Bell’s Palsy • Abrupt onset of unilateral facial paralysis due to dysfunction of the motor branch of the facial nerve (CNVII). Facial paralysis can progress rapidly in 24hours. • Etiology: viral infection, autoimmune process, or pressure form tumor or blood vessel. • CM: o one side of face paralyzed, o difficulty chewing or swallowing on the same side. o Unable to fully close eyelid. • Treatment Plan: o R/ O stroke, TIA, mastoid infections, bone fx, Lyme disease and/ or tumor o Corticoidsteroids at high doses X 10 days then weaning off o Acyclovir if herpes simplex suspected. o Protect cornea from drying and ulceration with eye lubricants in AM and lubricating ointments at HS. Nervous System Exam Tips Carpel Tunnel Syndrome • Cause: by activities that require repetitive wrist/ hand motion usually due to median nerve compression due to swelling of the carpal tunnel • Both hands are affected in 50% of pt’s. • Risk Factors: o hypothyroidism, pregnancy, and/ or obesity, as well as adults who use repetitive wrist/ hand movements in his/her job. • Clinical Manifestations: o Gradual onset (over weeks to months) o Numbness and/ or Tingling (Parathesias) on the thumb, index finger, and middle finger area. o Hand grip is weaker on the affected side. o Chronic/Severe cases involve atrophy of the thenar eminence (group of muscles on the palm of the hand at the base of the thumb (usually a LATE SIGN). • Tinel’s Sign o Tap anterior wrist briskly o Positive Finding: “Pins and needles’ sensation of the median nerve over the hand after lightly percussing the wrist. • Phalen’s Sign o Engage in full flexion of wrist for 60 seconds o Positive Finding: tingling sensation of the median nerve over the hand evoked by passive flexion of the wrist for 1 minute. Cluster Headache • Idiopathic and severe one sided headache that is marked by recurrent episodes of brief “ice prick” (lacerating pain) located behind one eye that is accompanied by tearing and clear rhinitis. • Clinical manifestations: o Abrupt onset may get agitated during headache episode. o Attack happens several times a day. o Resolves spontaneously, but may return in the future in some pt’s/ o More common in adults in 30’s-40’s . o Autominc Symptoms – tearing , clear nasal discharge. o Ptosis (dropping eyelid) . • Treatment o High-dose 02 (don’t give to pt’s with COPD) o Imitrex by IM or intranasal o Prophylaxis: verapamil PO daily • Complication: highest risk of suicide for males. Alternative Headache Remedy • Butterburr and Feverfew ****Headaches: with the exception of muscle tension headaches all headache questions seen on exam are unilateral. *** Muscle Tension Headaches • Emotional/psychic stress in some pt’s cause the muscles of the scalp and neck to become chronically tense. This is a bilateral headache. • Clinical Manifestation o Band-like headache that feels like someone is “squeezing their head” o Pain is dull and constant and often accompanied by tensing of the neck muscles. o May last several days. o Pt c/ o of increased stress in life. • Treatments o NSAID’s (Naproxen (BID) or Motrin 800 mg QID or analgesics (APAP or aspirin) o Narcotics and Butalbital are habit forming and increase risk for rebound HE’s o Combination of OTC analgesics/ aspirin plus caffeine (Anacin, Excedrin). o Stress reduction therapy: yoga, tai chi, regular exercise, gradually reduce and stop caffeine, follow regular sleep patterns, and/ or therapy with counselor. TIPS • Muscle Tension: Causes band like head pain that may last for a few days. • Migraine: presents with throbbing, nausea, photophobia, and phonophobia. • Cluster: only HE accompanied by tearing and nasal congestion, a. severe pain is being one eye/one side of face b. Occurs several times a day. c. Spontaneously resolves d. More common in middle aged males. Trigeminal Neuralgia (Tic douloureux) – • Pain on one side of face/cheek that is precipitated by talking, chewing, cold food, and/ or cold air on affected area. Temporal Arteritis: • Indurated temporal artery , pain felt behind eye/scalp. • NOTE: if untreated may lead to blindness. Hematological System Review Tips Acute Hemorrhage • Blood loss of 15% or higher usually results in orthostatic hypotension. The initial H/H during acute blood loss will not shop anything abnormalities till 24 hours after the onset of the hemorrhage. Bone marrow responds by releasing immature RBC’s (reticulocytosis). Neutropenia • Defined as an absolute neutrophil count (ANC) of less than 1,500/mm3 • NOTE: African American may have a lower ANC count that is benign in nature. Meaning that the bone marrow aspirate is normal. Vitamin B 12 Deficiency • Gradual onset of of symmetrical peripheral neuropathy starting in the feet and/ or arms. • Clinical Manifestations: o Numbness o Ataxia (positive Romberg’s test) o Loss of vibration and position sense o Impaired memory (in severe cases Dementia) o Peripheral smear shows macroovalocytes, some megablasts, and multisegmented neutrophils ( usually having more than 5-6 lobes. Hodgkins Lymphoma • Cancer of the beta lymphocytes (B-Cells) • Clinical manifestations: o Night sweats o Fever o Pain with ingestions of ETOH drinks o Generalized pruritus with painless enlarged lymph nodes neck) o Anorexia and/ or weight loss • Risk Factors: o Higher occurrence in young adults (20-40), older adults 60, Males, and Caucasian in ethnicity. Non-Hodgkins Lymphoma • Cancer of the B lymphocytes and killer cells • Clinical Manifestations: o Night sweats and Fever o Weight loss o Generalized lymphadenopathy (painless) • Risk Factors: usually occurs in older adults 65 years of age Multiple Myeloma • Cancer of the plasma cells • Clinical Manifestations: o Fatigue and/ or weakness o Bone pain that usually located in the back or chest. o Proteinuria – occurs with presence of Bence-Jones protein. o Hypercalcemia o Normocytic anemia • Risk Factors: more common in older adults. Thrombocytopenia • Defined at plts less than 150,000, but note s/s usually don’t occur till less than 100,000. • CM: easy bruising, bleeding gums, spontaneous nose bleeds and/ or hematuria. Exam Tips • Screening Test for Anemia: CBC b/c H/H • Thalassemia and Sickle Cell are diagnosed via electrophoresis. • Mean Corpuscular Volume (MCV): 80-100 • Mean corpuscular Hgb Concentration (MCHC) : 31-37 – refers to color ex. hypochromic Total Iron-Binding Capacity (TIBC): • Measures the available transferrin that is left unbound to the iron. Transferrin is used to transport iron in the body, so if it is elevated there is not enough iron to transport it. (i.e. iron deficiency anemia). Serum Ferritin: • Normal 20-40. • Stored form of iron that is produced in the intestines and correlates to iron storage status in the health adult. NOTE: most sensitive test for iron-deficiency anemia. Patient’s with chronic illness and/ or autoimmune disease have higher risk of normocytic anemia. Thalassemia vs. Iron Deficiency Anemia Thalassemia: • Genetic disorder in which the bone marrow produces abnormal hemoglobin. Usually occurs in Mediterranean, North Africa, Middle East , Southeast Asia (Chinese, Cambodians, Filipinos, and/ or Thai people. • Diagnosis: electrophoresis • Diagnostic Test: o MCV: Decreased (microcytic) o MCHC: Decreased (Hypochromic o Ferritin: levels are normal to high o TIBC: Normal or borderline Iron Deficiency Anemia • Diagnosis: labs • Diagnostic Test o Ferritin/Serum Iron: Markedly Decreased o TIBC: increased o RDW: increased o MCV: Decreased (microcytic) o MCHC: Decreased (Hypochromic) • TIPS o If there is a MCV of 76, the next stop would be to order a TIBC, Ferritin, serum iron. ▪ NOTE: if ferritin / iron levels are low then the patient has iron deficiency, but if these tests are normal then it would be Thalassemia. o Order both vitamin B12 and folate levels when MCV is greater than 100 even if no neurological symptoms are present. Taking Iron • Ferrous Sulfate- is the best absorbed iron supplementation (OTC) • Must wait 4 hours after ingestion of antacids to take iron pill • Drug Interactions o Tetracycline antibiotics, levothyroxine, and Bisphosphonates decrease the effectiveness, so pt’s must take iron 2 hours before or after the above listed medications. • Failure to respond to treatment: may be a sign of continuous blood loss, misdiagnosis (i.e. thalassemia instead of iron deficiency anemia) and/ or malabsorption (Celiac disease). o Iron Poisoning: very serious in children (especially 6 years of age) ma