FNP

REVIEW - AANP
Document created using Leik, Hollier and Fitzgerald – I do not own the copy rights to images, etc.

JULY 27, 2018

 PREVENTION/HEALTH PROMOTION/IMMUNIZATION

LEVEL OF PREVENTION IMMUNIZATION PEARLS SMOKING - PACK YEAR HX

Ø PRIMARY HX of Anaphylactic Immunization to avoid Number of packs-per-day (PPD)
o Goal: preventing the health problem, the reaction Multiplied by # of years smoked
most cost-effective form of healthcare Neomycin IPV, MMR, varicella
o Example: immunizations, counseling about Streptomycin, IPV, smallpox
safety, injury and disease prevention polymyxin B, neomycin 5 A’S OF SMOKING CESSATION
Ø SECONDARY Baker’s yeast Hepatitis B 1. Ask about tobacco use
o Goal: detecting disease in early, Gelatin, neomycin Varicella zoster
2. Advise to quit
asymptomatic, or preclinical state to minimize Gelatin MMR
3. Assess willingness to make a quit
its impact
o Example: screening tests, such as BP check, Previously unvaccinated adults age 19-59 with attempt
diabetes should be vaccinated against Hepatitis B 4. Assist in quit attempt
mammography, colonoscopy, ASA in hx MI
Ø TERTIARY LIVE VACCINES 5. Arrange follow-up
o Goal: minimizing negative disease induced o MMR
outcomes § Patients born before 1957 have
o Example: in established disease, adjusting likelihood of immunity due to PNEUMOCOCCAL IMMUNIZATION
therapy to avoid further target organ damage. natural infection
Ø PCV13 associated with greater
Potentially viewed as a failure of primary § Two doses 1 month apart for
those never immunized immunogenicity
prevention, support groups
o Varicella Ø PPSV23 not licensed for children
o Zostavax under 2
IMMUNIZATION PRINCIPLES o Intranasal Flu Mist Ø Indications: chronic lung disease,
Ø Community (herd immunity) Ø Avoid these with Pregnancy, immune suppression chronic cardiovascular disease,
o Immunize those who can be to protect those and with HIV (CD4 count < 200) – case by case
diabetes, chronic liver disease,
who cannot be immunized situation
Ø Rotavirus chronic alcohol abuse, smokers,
Ø Active immunity malignancy, chronic renal failure,
o Avoid with SCID (severe combined
o Resistance developed in response to an
immunodeficiency) asplenia, sickle cell,
antigen (either infection or vaccine)
immunocompromised, HIV.
Ø Passive immunity
o Immunity conferred by an antibody produced HEPATITIS B Ø PCV13 followed by PPSV23 one year
in another host (infant of mother or immune later and then again at 65
Ø Chronic Hep B can lead to hepatocellular
globulin o Exception: HIV (8 weeks
carcinoma, cirrhosis and continued infectivity
later)
Ø Childhood Hep B vaccines began in 1982
Immunize unless sending to the hospital in an ambulance Ø If PPSV23 before age 65, repeat in 5
Ø 3 dose series 0, 1, 6 months
years
Ø If not vaccinated and exposed – HBIG and series
Ø If vaccinated and exposed – single dose vaccine
 PREVENTION/HEALTH PROMOTION/IMMUNIZATION
SMALLPOX
Ø Caused by variola virus
Ø Infective droplets – contagious during fever, but
most contagious during rash
o Contagious until last scab falls off
Ø Stopped vaccinating in 1972
Ø Incubation period 7-17 days
Ø Prodromal stage – fever, malaise, headaches,
body aches
Ø Rash starts on face > arms/legs > hands/feet
o All lesions within same phase and spreads
within 24 hours
Ø Vaccination within 3 days of exposure reduces
severity
Ø Vaccinia – unique immunization method
o 2-pronged needle dipped into vaccine and
then pricks skin
POLIOVIRUS
Ø Transmission is fecal-oral
SENSITIVITY AND SPECIFICITY
Ø Sensitivity – ability of a test to detect a person
who has disease (SEN rule in)
Ø Specificity – ability of a test to detect a person
who is healthy (SPOUT – rule out)
VARICELLA
Ø Live virus; 2 dose series starting > 1 year of age
Ø Although highly protective, mild cases of chicken
pox have been associated with the disease
Ø Varicella antibody titers should be ordered on a
healthcare worker who had chicken pox as a child
Ø Varicella Zoster Immune Globulin (VZIG) is made
of pooled blood product with excellent safety
rating (given if contraindications for vaccine)
Ø Pregnant women without immunity should be
vaccinated with two doses after giving birth
Ø Varicella is transmitted via droplet
Ø Vaccination within 3-5 days of exposure has
shown benefits to reduce disease
STAGES OF CHANGE MODEL
Ø PRECONTEMPLATION
o Not interested or minimalizes
Ø CONTEMPLATION
o Considering change, looks at positive and
negative, feels “stuck”
Ø PREPARATION
o Exhibits some change behaviors, but does
not have tools to proceed
Ø ACTION
o Ready to go forward, takes concrete
steps, but no consistency
Ø MAINTENANCE/RELAPSE
o Learns to continue the change and
embraced the healthy habit
TETANUS
Ø Infection caused by Clostridium
tetani – found in soil lead to lockjaw
Ø If no previous immunity - give Tdap
followed by Td in 1 and 6 months
Ø Need vaccine every 10 years with a
single dose of Tdap in adulthood
Ø If dirty wound – BOOST if not TD in
5 years (Tdap and Immunoglobin if
no previous vaccine)
HEPATITIS A
Ø Peak infectivity occurs the 2-week
period before the onset of jaundice
or elevated liver enzymes
Ø Approximately 50% of cases have
no specific risk factors identified
Ø When traveling to developing
nations, avoid foods that are eaten
raw
Ø Administer 4-6 weeks prior to
traveling to an area where disease is
endemic
Ø Treatment is supportive
SHINGLES VACCINE
Ø Recommended for everyone except
those contraindicated
Ø Infectious until lesions dry/crusted
Ø Zostavax
o Live; One-time dose age 60
Ø Shingrix
o Non-live; 2 doses age 50
o Preferred vaccine
 PREVENTION/HEALTH PROMOTION/IMMUNIZATION

Ø Prostate Cancer
US PREVENTATIVE SERVICES TASK FORCE CANCER PREVALENCE
o Benefits of PSA screening do not
Ø Aspirin use to prevent cardiovascular disease and Ø Skin cancer is most common cancer
outweigh the disadvantages
colorectal cancer o Basal cell carcinoma
o Risk factors:
o Age 50-59 with >10% ASCVD o Melanoma highest mortality
§ Age > 50
Ø Breast Cancer Ø Men – prostate cancer
§ African ancestry
o Mammography age 50-74 (every 2 years) Ø Women – breast cancer
§ First degree relative
o Risk factors (start age 40 or BRCA1/2) Ø Gynecological
Ø Ovarian Cancer
§ Previous hx of breast cancer o Uterine/endometrial
o Routine screening not recommended
§ >2 first-degree relatives o Ovarian
o BRCA1/BRCA2 mutations – refer to
§ Early menarche, late menopause, Ø Children – acute lymphoblastic
specialist
nulliparity leukemia (ALL)
Ø Skin Cancer Counseling
§ obesity
o Recommend for those with fair skin
Ø Cervical Cancer
Ø Abdominal Aortic Aneurysm
o Age 21 – screen every 3 years
o Men age 65-75 who have smoked
o Age 30 – screen with HPV every 5 years
o One-time ultrasound MORTALITY
o Hysterectomy with removal of cervix –
Ø Lipid Disorders Ø Leading cause of death (all ages)
only need screening if hysterectomy due
o Start low – moderate statin when all: o Heart disease
to cervical cancer
§ Age 40-74 o Cancer
o Stop screening at age 65
§ CVD risk factor § Men (lung,
o Risk factors:
§ ASCVD > 10% prostate, colorectal)
§ Multiple sex partners
Ø Lung Cancer § Women (lung,
§ Younger age at onset of sex
o Smoke 30 pack-years or quit in last 15 breast, colorectal)
§ Immunosuppression and smoker
years o Chronic respiratory
Ø Colorectal Cancer
o Age 55-80 (annual screening with CT)
o Start age 50-75
§ Colonoscopy every 10 years
ADOLESCENTS
§ Flex sigmoidoscopy or CT OVARIAN CANCER
Ø Death rate for teen males is higher
colonography every 5 years Ø No recommendation for routine screening
than females
§ FOBT (3 consecutive stool Ø In postmenopausal women with palpable ovary
o Accidents (MVC most
samples) annually o Intravaginal ultrasound and CA-125
common)
§ New Cologuard Ø Strongest risk factor is BRCA1 or BRCA2
o Suicide
o Risk Factors Ø Other risk factors include age, obesity, Clomid
o Homicide
§ Familial polyposis use or endometriosis
§ First degree relative w/ colon CA Ø Prostate/testicular cancer screening not
§ Crohn’s (ulcerative colitis) recommended

DRUG -DRUG INTERACTION
Ø http://medicine.iupui.edu/clinpharm/ddis/clinical
-table/
Ø Substrates: drugs that are metabolized as substrates
by the enzyme
o CYP450 3A4 substrates: Sildenafil,
Atorvastatin, simvastatin, venlafaxine,
alprazolam
o CYP450 ↓ by 30% after age 70
Ø Inhibitors: drugs that prevent the enzyme from
metabolizing the substrates (↑ drug concentration)
o Macrolides (Clarithromycin, Erythromycin) –
can lead to substrate induced toxicity (Ex:
atorvastatin 20mg may be like 300mg)
o Antifungals (ketoconazole, fluconazole)
o Cisapride (propulsid – no longer in US)
o Cimetidine (Tagamet)
o Citalopram (Celexa)
o Grapefruit (statins, erythromycin, calcium
channel blocker, antivirals, amiodarone,
benzodiazepines, Cisapride, carbamazepine,
buspirone)
Ø Activators: drugs that increase the enzyme's ability to
metabolize the substrates (↓ drug)
o St John’s wort - antiretrovirals, contraceptives
and cyclosporine; Also lead to Serotonin
syndrome when combined with SSRI, SSNI
PHARM FACTS
Ø Pharmacokinetics – absorption, distribution,
metabolism, elimination of a drug
Ø Pharmacodynamics – biochemical and
physiological effects of drugs on the body or
disease (this does not change as a person ages)
PHARMACOLOGY
FIRST-PASS EFFECT
Ø Drug is swallowed and absorbed into small
intestine where it enters portal circulation
o Once in liver the CYP450 is responsible
for biotransformation
Ø Drugs with extensive first-pass metabolism
cannot be taken orally.
o Insulin
Ø CYP450 can be induced (increase drug
metabolism) or inhibited (slow down drug
metabolism)
o Biotransformation also includes kidneys,
GI tract and lungs
NSAIDs
Ø Avoid in heart failure, GI bleeding, kidney disease
o Inhibit prostaglandin synthesis – we
need prostaglandins to keep things
running smoothly
o Long term use – document informed
consent such as ↑ risk of MI, stroke,
emboli, GI bleed, acute renal failure
o Consider PPI, H2RA, Misoprostol
RANDOM FACTS
Ø Capsaicin cream can be used to treat pain in
trigeminal neuralgia and post herpetic neuralgia
Ø ASA irreversibly suppresses platelet function for
up to 7 days
NARROW THERAPEUTIC INDEX DRUGS
Ø Warfarin – monitor INR
o Sulfa drugs elevate INR
o Interacts with “G” herbs
o Mayonnaise and green leafy
Ø Digoxin – dig level, EKG, electrolytes
(K+, Mg+, Ca+, Creatinine)
Ø Theophylline – monitor blood levels
Ø Tegretol and Dilantin – monitor blood
levels
Ø Levothyroxine – monitor TSH
Ø Lithium – monitor blood levels, TSH
SAFETY ISSUES
Ø PPI - ↑ risk of fractures
o Prilosec interacts with warfarin
Ø TZD – cause or exacerbate CHF
Ø Bisphosphonates – erosive esophagitis
Ø Statins – do not mix with grapefruit
juice
Ø Clindamycin – high risk C. Diff
Ø Thiazide diuretics contraindication
sulfa allergy
o Chlorthalidone is longer acting
and preferred over HCTZ
Ø Spironolactone can lead to
gynecomastia
Ø DC ACEI/ARB if pregnant and are
excreted in breast milk
Ø Alpha blockers are only first-line in
makes with HTN and BPH

PRINCIPLES OF EMPIRIC ANTIMICROBIAL THERAPY
Ø Decision making process in which clinician
chooses agent based on characteristics and site of
infection
Ø What is/are the most common likely pathogen(s)
causing this infection?
Ø What bug will this antibiotic kill?
Ø Likelihood of resistant pathogen?
Ø Danger if treatment failure?
Ø What is optimal safe dose?
Ø What duration is shortest but effective?
TETRACYCLINE
Ø Gram -; Atypicals; MRSA
Ø Do not use in pregnancy or children < age 9
Ø May cause permanent discoloration of teeth and
skeletal defects if used in last half of pregnancy
Ø Treat for acne age 13-14 as all teeth have erupted
o Do not use for mild comedones – start
with OTC topicals such as salicylic acid and
benzoyl peroxide
o Try RX topicals benzamycin, Retin A and
azelaic acid cream first for 2-3 months
Ø Photosensitivity
Ø Esophageal ulcerations (swallow with full glass of
water)
Ø Take on empty stomach
Ø May decrease effectiveness of birth control pills
Ø Throw away expired pills – they degenerate and
may cause nephropathy
LINCOSAMIDE - CLINDAMYCIN
Ø Gram +, Aerobes, Anaerobes
Ø Associated with C. Diff
ANTIBIOTIC THERAPY
ANTIBIOTICS
GRAM POSITIVE
Ø Strep
Ø Staph
Ø Enterococcus
GRAM NEGATIVE
Ø H. influenzae
o Cephalosporin, Augmentin, macrolides,
resp. fluoroquinolones, doxycycline
Ø Everything else
MACROLIDES
Ø Atypical pathogens
Ø Associated with potential QT prolongation and ↑
risk of CV death
Ø Contraindicated in myasthenia gravis
Ø Drug-drug interactions (anticoagulants, digoxin,
theophylline, select statins)
Ø Erythromycin GI side effects are common
Ø Macrolide allergic: doxycycline, quinolones
CEPHALOSPORIN
st
Ø 1 generation: Gram +; Beta-lactam; Cephalexin,
Cefadroxil Group A Strep, S. aureus – not MRSA –
Keflex (pregnancy UTI, cellulitis, impetigo)
Ø 2nd generation: Gram +/- Broad spectrum –
Ceftin, Cefzil – otitis media, rhinosinusitis, CAP,
chronic bronchitis
Ø 3rd generation: Gram – with weak Gram +; Beta-
lactam; Cefixime
Ø Extended 3rd generation: Gram +/-; Beta-lactam;
Rocephin, Cefdinir – gonorrhea, PID,
pyelonephritis, otitis media
Ø Cross reactivity between PCN and cephalosporin
usually occurs with 1st generation
RISK FOR ANTIBIOTIC RESISTANCE
Ø Age <2 or >65
Ø Antibiotic use within the last month
o 3 months for pneumonia
Ø Hospitalization within 5 days
Ø Comorbidities
Ø Immunocompromised
PENICILLIN
Ø Diarrhea, C. Diff, Vaginitis, Stevens-
Johnson syndrome
Ø Avoid amoxicillin for patients with
mono (generalized rash)
Ø Dicloxacillin – mastitis & impetigo
Ø Anaphylaxis and angioedema are type
1 IgE
Ø PCN allergic: macrolides
AUGMENTIN
Ø Gram +/-, beta-lactamase. NO MRSA
Ø High-dose 3-4g/day amoxicillin needed
for drug-resistant Strep pneumoniae
(DRSP)
Ø Clavulanate as beta-lactamase
inhibitor so amoxicillin can work on H.
influenzae, M. catarrhalis
FLUOROQUINOLONES
Ø Cipro: Gram -; atypical pathogens
Ø Levaquin: Gram +/-; Atypical, DRSP
Ø Achilles Tendon rupture (esp. with
steroid use
Ø Contraindicated – less than 18,
pregnancy, breast feeding,
myasthenia gravis
Ø QT prolongation, hypoglycemia

SULFONAMIDE
Ø Gram -; MRSA; NO STREP, NO E COLI
Ø Contraindications
o G6PD anemia causes hemolysis
o Newborns and infants < 2 months
Ø HIV patients are high risk for Stevens-Johnson
MEDICATIONS THAT REQUIRE EYE EXAM
Ø Digoxin (yellow to green, blurred vision, halos if
blood level too high)
Ø Ethambutol and linezolid (optic neuropathy)
Ø Corticosteroids (cataracts, glaucoma, optic
neuritis)
Ø Fluoroquinolones (retinal detachment)
Ø Viagra, Cialis, Levitra (cataracts, blurred vision,
ischemic optic neuropathy, others)
Ø Accutane (cataracts, decreased night vision)
Ø Topamax (acute angle-closure glaucoma,
increased intracranial pressure, mydriasis)
Ø Plaquenil (neuropathy and permanent loss of
vision)
SOUTHEAST ASIAN CULTURE
Ø Vietnamese, Hmong, Filipinos
Ø Pt may have difficulty verbalizing questions about
treatment
Ø May consult family about major health decisions
Ø Will not tell provider if not compliant
Ø Would never verbalize disagreement in loud
voice – have high regard for physicians
Ø Imbalance of hot and cold (yin/yang)
Ø Male is head of house
Ø Alpha thalassemia is common in Asians, Filipino
Ø View surgery as last resort
Ø Infants and small children may wear amulet
ANTIBIOTIC THERAPY/PHARMACOLOGY
BETA-LACTAMS
Ø Penicillin – Penicillin, Amoxicillin, dicloxacillin,
ampicillin and others
Ø Cephalosporin – ceph- or cef- prefix
Ø Carbapenem – imipenem usually given with
cilastatin
Ø Monobactam – aztreonam
Ø High rate of allergic reactions
NITROFURANTOIN
Ø Urinary pathogens
METRONIDAZOLE (FLAGYL)
Ø Anaerobes
FOOD FACTS
Ø Tetracycline and dairy interact
Ø Avoid MAOI and high tyramine containing foods
(fermented foods)
Ø Eat salmon and omega-3 for heart disease; plant
sterols and stanols reduce cholesterol
Ø Collard greens are high in vitamin K
Ø Magnesium - decreases BP and dilates blood
vessels (nuts, beans, wheat, laxatives)
Ø Potassium – decreases BP – most fruits, leafy
greens and nuts
Ø Non-dairy calcium includes: tofu, spinach and
sardines
Ø Celiac Disease - Avoid gluten, wheat, rye, barley,
oats. Gluten free foods: corn, rice, potato, quinoa,
tapioca, soybeans
RANDOM HERB FACTS
Ø Echinacea – immunological effects
Ø Black cohosh, roasted soy beans – acts
similar to estrogen for some people
Ø Kava Kava - anxiety
Ø St John’s wort – depression
o interacts with oral
contraceptives, cyclosporine
and select antiretrovirals
Ø Saw Palmetto – BPH
Ø Fish oil and ginseng can cause bleeding
Ø Milk thistle – lower cholesterol, liver
problems and diabetes
VITAMIN D DEFICIENCY
Ø Vitamin D inhibits abnormal cellular
growth; encourages reabsorption and
metabolism of calcium and phosphorus;
reduces inflammation
Ø Skin exposure to sun produces greatest
values
Ø Someone taking phenytoin needs 2-5x
vitamin D
Ø Symptoms of vitamin d deficiency
o Rickets, osteomalacia, antigravity
muscle weakness
Ø 25-hydroxyvitamin D is lab measurement
Ø A child must drink 32 oz of milk daily to
receive recommended 400 IU (infants) of
daily vitamin D
Ø 600 IU for those age 1-70 including
pregnant; 800 IU > 70
Ø Darker skin tones synthesize less vitamin D
Ø Sunscreen increase risk of vitamin d
deficiency
Ø Vitamin d deficiency is common in hepatic,
renal and after gastric bypass.
Ø Vitamin D3 is preferred form
o 50,000 IU per week x 8 weeks
o 1000-2000 daily

EYE
Ø Macula – responsible for central vision
Ø Optic Disc – shaped like saucer with indentation
where cup goes (balance between intraocular and
intracranial pressure) – should be sharp with cup
to disc ratio < 0.5
Ø Veins pulsate and are prominent
Ø Papilledema – optic disc swollen with blurred
edges due to ↑ ICP; absent vein pulsations
Ø Angle closure glaucoma -deeply cupped disc –b/c
too much intraocular pressure (cup ratio > 0.5)
Ø Hypertensive Retinopathy
o Copper and silver wire arterioles (hard)
o AV nicking – artery crosses over vein
(atherosclerosis in eye)
o Flame hemorrhages
HEENT - EYES
EYE EXAM
1. Visual Acuity - with any eye complaint
o OU (both) OD (right) OS (left)
o Two-line difference between each eye
o Can miss up to 2 letters on each line
o 20/200 is considered legally blind
o By age 6 child can see 20/20
2. Slit-lamp or binocular loupe - evaluation of anterior
eye, including cornea, conjunctiva, sclera and iris
o Penlight and do 180
3. Fluorescein staining
4. Lid Eversion -
Ø Near vision – ask patient to read small print
Ø Triad of ophthalmologic emergency
o Red eye, painful eye, new-onset vision change
Ø Presbyopia – gradual, age-related loss of eyes’ ability
to accommodate stiffening of the lens; unable focus
actively on nearby objects; starts around age 40
Ø Amsler grid test – early detection of macular
degeneration
Ø Tonometry – measures IOP, glaucoma screening test
Ø If a protruding object is found – it should not be
removed
Ø Diabetic Retinopathy
o Microaneurysms
o Cotton wool spools (nerve reels dying)
o Flame hemorrhages
CATARACTS
Ø Chronic steroids, trauma, aging,
sunlight, tobacco
Ø Opacity of lens of eye which can be
central or on the sides
Ø Difficulty with glare (with headlights
when driving at night or sunlight),
halos around lights, and blurred
vision
Ø Absent red reflex
Ø Retinoblastoma – leukocoria – white
reflex
TERMINOLOGY
Ø Palpebral conjunctiva – mucosal
lining inside eyelids
Ø Bulbar conjunctiva – mucosal lining
covering eyes
Ø Hyperopia – farsighted – distance
vision intact, but near vision is blurry
Ø Myopia – nearsighted – near vision
is intact, but distance vision is blurry
Ø Xanthelasmas – yellow plaque on
the inner canthus – 50% of people
have elevated lipids
Ø Uveitis – occasionally dull painful
red eye with vision changes, pupil is
constricted, nonreactive and
irregularly shaped. Tx with pupil
dilation, corticosteroids, evaluate
underlying cause (autoimmune)

LYMPH NODES
Ø Cancerous nodes are non-tender
Ø Tender nodes indicate infection
MOUTH
Ø Gums may be red and swollen due to gingivitis or
taking Dilantin
Ø Salivary glands – parotid, submandibular and
sublingual
Ø Sialadenitis – swelling to side of face (mumps)
Ø Sialolithiasis – calculi or stone – painful lump
under tongue - ↑ fluids, moist heat, NSAIDs,
antibiotics if infected, surgery to remove stone
Ø Torus palatinus – painless bony protuberance
midline on hard palate
HEENT
CHEILOSIS
Ø Painful skin fissures and maceration at corner of mouth
o Over salivation, poorly fitting dentures,
nutritional deficiencies, lupus, autoimmune
disease, irritant dermatitis, squamous cell
carcinoma
o Remove underlying cause
o If yeast – treat with azole ointment BID
o If staph – treat with mupirocin ointment BID
o When infection clear, use barrier cream at
night
§ Zinc
§ Petroleum jelly
ORAL CANCER
Ø Ulcerated lesion with indurated margins
Ø Relatively fixed submandibular nodes
Ø Squamous cell cancer is most common form
Ø Risk factors include male gender, advanced age,
tobacco and alcohol abuse, HPV type 16
Ø Screening is recommended at every dental visit
KOPLIK SPOTS
Ø Small-sized red papules white centers inside cheeks
RED EYE COMPLAINTS
Ø Send to ophthalmology
o Change in vision
o FB sensation with inability to
keep eye open
o Photophobic
Ø Keep FB sensation, scratchy, gritty
o Pink eye
DACROCYSTITIS
Ø Infection of lacrimal sac/tear duct
usually caused by blockage
Ø Common in infants, adults > 40
Ø Thick eye discharge, pain, redness,
swelling, warmth of lower eyelid,
watery eye, excess tears
Ø Treatment: lacrimal sac massage
(downward towards mouth) 2-3
times daily, antibiotics 7-10 days
NOSE
Ø Only inferior nasal turbinates are
seen
Ø Pale, boggy, bluish nasal turbinates
are seen in allergic rhinitis
Ø Sinus cavities – frontal appear by age
5 and sphenoid by age 12
Ø Rhinitis Medicamentosa - Prolonged
use (> 3 days) of topical nasal
constrictor/decongestants
 HEENT
EAR
BACTERIA OF THE EAR Ø Bones – Malleus, incus and stapes
Ø S. pneumoniae – usually causes most significant Ø Tympanogram – test for presence of
symptoms and is least likely to resolve without fluid inside middle ear (straight line
antibiotics vs peaked shape)
o Resistance to low dose amoxicillin, Ø Pinna injuries – refer to plastics
certain cephalosporins and macrolides Ø Tragus – small cartilage flap of tissue
o Mechanism of resistance is alteration of
in front of ear
intracellular protein-binding sites
Conductive Sensorineural § Use high dose amoxicillin and Ø Ceruminosis – carbamide peroxide
Location Outer or middle ear Inner ear
select cephalosporins
Cause Sound is being Inner ear or nerve
o Risk factor is recent antibiotic use
blocked (earwax, becomes damaged
foreign objective, (advanced age, Ø H. influenza and M. catarrhalis
damaged eardrum, ototoxic o Gram negative capable of producing
serous otitis media, medications, beta lactam ring
bone abnormality – immune disorders, o High rate of spontaneous resolution
cholesteatoma) trauma) o H. influenza is most common found in
Weber Sound lateralizes to Sound lateralizes mucoid and serous middle ear infection
Result – affected ear (buzzing to unaffected ear Ø Treatment
tuning sound heard louder (buzzing sound not o No recent antibiotics
fork on in affected ear) – at all in affected § Amoxicillin high dose TID
forehead otitis media, ear- numbness) –
§ Augmentin BID
ceruminosis, Presbycusis
perforation of TM Meniere’s disease § Cefdinir
Rinne Negative (BC > AC) Normal (AC > BC) o Recent antibiotic use
Result – or positive § Augmentin BID
mastoid **can hear longer § Levofloxacin or Moxifloxacin
then front in front of ear than Ø Otitis Media with Effusion
of ear on mastoid bone o Symptomatic treatment
Treatment Often self-resolves Hearing aids or o Can last 8 weeks
post cerumen cochlear implants
impaction removal, possible options
post URI or AOM with expert
resolution. Rarely, communication
further
pharmacologic or
surgical intervention
is needed
**Temporary **Permanent
Ø Acoustic nerve or CN VIII Vestibulocochlear – Auditory
Ø Presbycusis – age related hearing loss; difficulty
appreciating content in noisy environment
 HEENT EMERGENCIES

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Fluorescein dye
Fern like lines in corneal
surface (corneal abrasions
Acute onset of severe eye pain, photophobia,
Herpes simplex are round or irregularly
tearing and blurred vision in one eye Infection permanently
(Herpes Simplex shaped)
Herpes Zoster Ophthalmicus – acute crusty rashes damages corneal
Herpes Keratitis Keratitis) or herpes Refer to ED
that follow ophthalmic branch (CN V) of epithelium – corneal
varicella zoster (Herpes
trigeminal nerve (one side forehead, eyelids and blindness
Zoster Ophthalmicus)
tip of nose) can result in blindness

Mid-dilated pupil oval

shaped. Cornea appears
cloudy. Funduscopic exam
reveals mid-dilated Ophthalmological
Elderly patient with acute onset of severe eye
cupping of optic nerve emergency
pain with redness and vision changes.
2nd leading cause of
Acute Angle- Accompanied by headache, N/V, halos around
Refer to ED blindness
Closure Glaucoma lights and decreased vision.
Risk factors: Asian
ethnicity, female gender,
Angle (door) closing in eye – pain
far-sightedness

Young adult female with new or intermittent loss

of vision of one eye alone or accompanied by
nystagmus or other abnormal eye movements.
Optic Neuritis Multiple Sclerosis (aphasia, paresthesia, abnormal gait, spasticity). Refer to neurologist
Daily fatigue upon awakening that worsens as day
goes on. Heat exacerbates symptoms. Has
recurrent episodes.
Acute onset of erythematous swollen eyelid with
Acute bacterial proptosis (bulging of eyeball) and eye pain on
More common in young
Orbital Cellulitis infection of orbital affected side. Unable to perform ROM of eyes. Refer to ED
children
contents Abnormal EOM with pain on eye movement. Hx
of recent rhinosinusitis or URI
Risk factors: myopia,
Sudden onset of shower of floaters associated with
cataract surgery,
looking through a curtain sensation with sudden
diabetic retinopathy,
Retinal Detachment flashes of light (photopsia). Associated symptoms Refer to ED
hx of retinal
include unilateral photophobia, wavy distortion of
detachment, older age,
an object.
trauma
Cauliflower like growth accompanied by foul-
smelling ear discharge. Hearing loss on affected
ear. No tympanic membrane or ossicles are visible Refer to otolaryngologist.
Keratinizing squamous
Cholesteatoma because of destruction by tumor. Hx of chronic Treated with antibiotics and surgical
epithelium
otitis media infection. Mass is not cancerous but debridement
can erode into bones of face and damage facial
nerve (CN VII)
 HEENT EMERGENCIES CONTINUED

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Raccoon eyes (periorbital ecchymosis)

and bruising behind the ear (mastoid Basilar skull fractures can cause
Battle Sign Trauma area) that appears 2-3 days after trauma. Rule out basilar or temporal bone skull fracture. intracranial hemorrhage. Refer to
Search for clear golden serous discharge ED
from ear or nose.
Clear Golden
Basilar skull Clear golden fluid discharge from Test fluid with urine dipstick – positive for glucose (plain
Fluid Discharge Refer to ED
fracture nose/ear mucous or mucopurulent drainage is negative)
from Nose/Ear

Severe sore throat with difficulty

swallowing, odynophagia (pain on
swallowing) and a “hot potato voice”
Unilateral swelling of peritonsillar area
Peritonsillar
and soft palate. Affected area is markedly Refer to ED
Abscess
swollen and appears as a bulging red
mass with uvula displaced away from
mass. Accompanied by malaise, fever
and chills.

Sore throat, fever and markedly swollen

neck (bull neck) Low grade fever,
hoarseness and dysphagia. Posterior
pharynx, tonsils, uvula and soft palate
Diphtheria Refer to ED
are coated with gray to yellow colored
pseudomembrane that is hard to
displace. Very contagious. Contact
prophylaxis required.

Sore throat, fever, muffled voice,

Hib vaccine
Epiglottitis drooling, stridor, hoarseness “hot Refer to ED
eradicated in kids
potato”, “thumb sign”
 HEENT

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Flush eye with sterile normal saline. Evert

Contact Lens-Related
eyelid to look for foreign body. Topical
Acute onset severe eye pain with tearing. Reports Keratitis – acute onset
Fluorescein dye. Linear or antibiotic trimethoprim-polymyxin B
Corneal Abrasion feeling of foreign body sensation on surface of eye. red eye, blurred vision,
round (Polytrim), Ciprofloxacin (Ciloxan),
Always ask about contacts watery eyes, photophobia,
Ofloxacin (Ocuflox) to affected eye 3-5 days.
foreign body sensation
Do not patch eye.
Abscess of hair follicle
and sebaceous gland in Hot compresses x 5-10 minutes BID – TID
Acute onset swollen, red and warm abscess on the
upper or lower lid. until drained Can cause cellulitis of
Hordeolum (Stye) upper or lower eyelid. May spontaneously rupture
Internal – May need dicloxacillin or erythromycin PO eyelid
and drain purulent exudate.
inflammation of QID
meibomian gland
Gradual onset of small superficial nodule on
upper eyelid that feels like a bead and is discrete
Chronic inflammation I&D, surgical removal or intrachalazion
Chalazion and moveable. Painless. Can slowly enlarge over
of meibomian gland corticosteroid injections.
time. If large enough, can press on cornea and
cause blurred vision.

Raised yellow to white small growth in the bulbar

Pinguecula Chronic sun exposure conjunctiva (skin covering eyeball) next to the
cornea If inflamed, refer to ophthalmologist for RX
of weak steroid eye drops only during
exacerbations. Use artificial tears as needed
Yellow triangle wedge-shaped thickening for irritation. Good quality sunglasses 100%
of conjunctiva that extends across the cornea UVA and UVB. Remove surgically if
Pterygium Chronic sun exposure on the nasal side. Surfer’s eye. Can be red or encroaches on cornea and affects vision
inflamed at times. May complain of foreign body
sensation on the eye. Non-cancerous

Coughing, sneezing,
Subconjunctival heavy lifting, vomiting, Blood trapped underneath the conjunctiva and
Watchful waiting and reassurance of patient
hemorrhage local trauma, sclera secondary to broken arterioles.
spontaneously
Refer to ophthalmologist.
Gradual onset of increased IOP greater than 22 Most common glaucoma.
Check IOP with tonometer. Normal 8 to 21
Elevated intraocular due to blockage of drainage of aqueous humor Blindness due to ischemic
(>30 is very high)
pressure inside eye; most common in elderly; usually damage to retina.
Betimol 0.5% - ↓ aqueous production
Primary Open- Risk factors: African asymptomatic during early stages. Gradual 2nd leading cause of
(beta/alpha blockers)
Angle glaucoma ancestry, Type 2 DM, change in peripheral vision then central blindness
Latanoprost – topical prostaglandin
advanced age, family vision (tunnel vision). May complain of missing Risk factors: postural
SE of med: bronchospasm, fatigue,
hx of POAG portions of words when reading. If cupping of hypotension, hx of fungal
depression, heart failure, bradycardia
optic disc– IOP is too high conjunctivitis, white race
Contraindicated asthma, COPD, heart failure
gradual damage to Asymptomatic in the early stages. Complains of
Refer to ophthalmologist. Pt is given Amsler Most common cause of
pigment of macula gradual or sudden and painless loss of central
Macular grid to check vision loss daily to weekly vision loss. Leading cause
(area of central vision) vision in one or both eyes. Straight lines become
degeneration Atrophic (dry form) or exudative (wet form) of blindness in elderly
results in severe visual distorted or curved (scotoma). More common in
– wet is responsible for 80% Risk factors: age, smoking
loss to blindness smokers
Decreased function of lacrimal and salivary
OTC tear substitute TID
Chronic autoimmune glands. Persistent daily dry eyes and mouth
Sjogren’s Syndrome Refer to ophthalmology, dentist and
disorder (xerostomia) for > 3 months. Eyes have sandy or
rheumatology
gritty sensation. Uses OTC artificial tears TID
 HEENT

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Johnsons baby shampoo with warm water.

Inflammation of Seborrheic dermatitis –
Gently scrub eyelid margins until resolves.
eyelids associated with Itching or irritation in the eyelids (upper, lower or inflammatory Malassezia,
Blepharitis Consider erythromycin eye drops to eyelids
seborrheic dermatitis both), gritty sensation, eye redness and crusting. respond to antifungals,
2-3 times day. Warm compresses to lids 2-4
and rosacea worse in winter
times a day to soften debris
Itchy, watery, red eyes Cool compresses, artificial tears,
Allergic Rope-like yellow discharge (eosinophils), Ocular antihistamine, cromolyn, oral Medications normally
IgE mediated response
conjunctivitis chemosis, eyelid edema, allergic shiners antihistamines sting the eye temporarily

Red, irritated eye with eyelids that were “stuck Adenovirus is most
Suppurative Pseudomonas Polymyxin B plus trimethoprim,
together” – injected palpebral and bulbar common cause of viral
conjunctivitis aeruginosa levofloxacin, azithromycin
conjunctiva conjunctivitis

Itchy eyes, nose, or throat. Nasal congestion, First line: Remove or avoid allergen. Avoid 1st generation
Nose has blue-tinged or pale
IgE mediated disease rhinorrhea, postnasal drip, sneezing. Cough · Intranasal corticosteroids (down regulates antihistamines due to
boggy nasal turbinates.
due to genetic and worsens when supine. inflammatory response) takes 2-7 days sedation
Mucus clear. Posterior
Allergic rhinitis environmental · Add Astelin. (chlorpheniramine,
pharynx thick mucus with
interactions Pollens – most common seasonal allergen; dust · Cromolyn sodium TID – mast cell stabilizer diphenhydramine,
possibly cobblestoning.
“Asthma in the head” mites – most common perennial allergen; mold · Use decongestants – nasal congestion carbinoxamine,
Undereye circles.
spores – common indoor allergen · Oral antihistamines (block H1) – itch brompheniramine)
Acute onset nasal bleeding. Possible vomiting of Direct pressure. Nasal decongestants (Afrin -
Idiopathic, digitorum,
blood. Anterior nose bleeds (Kiesselbach’s oxymetazoline) – silver nitrate (ouch) Posterior nasal bleeds can
ASA, NSAIDs, cocaine,
Epistaxis plexus) are milder and more common than Apply triple antibiotic ointment or petroleum lead to severe
HTN, anticoagulants
posterior nose bleeds (Sphenopalatine or carotid jelly in front of nose with cotton swabs for a hemorrhage
place pt. at higher risk
artery) few days.
Abrupt onset sore throat, fever, headache, tender, Strep screen PCN V 500 BID-TID x 10 days Viral if cough, rhinorrhea,
Streptococcus
localized anterior cervical lymphadenopathy. Dark CENTOR Score Amoxicillin 500 BID x 10 days coryza (watery eyes).
pyogenes or Group A
pink to bright red pharynx. Tonsillar exudate • Tonsillar exudate PCN allergic: Zpak x 5 days If not treated can cause
beta Strep
yellow to green in color. Petechiae on hard palate. Ibuprofen/Tylenol rheumatic fever – rash is
(incubation is 3-5 days) • Anterior cervical
Scarlet fever or scarlatina (sandpaper-like rash) Salt water gargles, throat lozenges, drink increased risk
Strep throat M. ↑ is often common adenopathy
with strawberry tongue. Rash usually erupts on fluids Post-strep
in teenagers and adults
day 2 and often peels a few days later. • Hx of fever glomerulonephritis –
with same symptoms, • Absence of cough
Most adults do not get strep, but *** If H. influenza - Augmentin or cephalosporin proteinuria, hematuria,
but dry cough Age 3-14 +1; 15-44 0; 45+ -1
immunocompromised or those who have high If M. pneumoniae – macrolide or dk urine, RBC cast, HTN
(incubation 3 weeks) Score > 2 screen for strep
exposure due to job or lifestyle fluoroquinolone edema
Non-severe – watchful waiting; Treat with Bullous myringitis –
Non-severe: mild otalgia <
Otalgia, popping noises, muffled hearing, recent amoxicillin 80-90mg, if recent abx then blisters on red and
48hrs. or fever <102.2 in
Strep pneumoniae cold or allergies. Moderate or severe bulging of Cefdinir followed by Augmentin. (< 2 yrs. 10 bulging TM. Conductive
past 24 hours
Acute Otitis Media H. influenzae TM or new onset otorrhea not related to otitis days, 2-6= 7 days, >6 = 5-7 days) if pt. has hearing loss. Tx same as
Severe: moderate/severe
M. catarrhalis externa (OE); erythema, mild bulging of TM and mono do not give Amoxicillin – will have AOM.
otalgia, otalgia > 48 hrs. or
recent onset of ear pain morbilliform rash; tympanic membrane Expect sensation of ear
fever > 102.2
rupture with hearing loss – Refer to ENT fullness up to 8 weeks
Symptomatic tx: Saline nasal irrigation,
Secondary bacterial HPI- bacterial intranasal corticosteroids, decongestants,
Acute viral Unilateral facial pain or upper molar pain for 10 Watchful waiting: 10 days
infection usually Persistent and not mucolytics
rhinosinusitis days or longer with purulent nasal or post nasal No macrolides
following viral URI improving (>10days); fever First line: Augmentin 875/125 or
(AVRS) drip. Head congestion, fever, sore throat, cough. Treatment 5-7 days =
Strep pneumoniae Severe > 3-4 days 1000/62.5 or 2000/125 BID 5-7 days
Acute bacterial Self-treatment with OTC provide no relief efficacy, fewer
H. influenzae (common Worsening or double Allergy to PCN/Cephalosporin:
rhinosinusitis complications, better
in smokers) sickening Doxycycline 100mg BID or Levofloxacin
(ABRS) compliance
M. catarrhalis transillumination 500mg daily or Moxifloxacin 400mg daily;
Cefdinir, Ceftin, Vantin BID 5-7 days
 HEENT

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Pseudomonas External ear pain, swelling, discharge, pruritus Polymyxin B-neomycin-hydrocortisone

Physical exam, if malignant Preventative: Domeboro
aeruginosa and hearing loss. Hx of recent activities that suspension (Corticosporin Otic) 4 gtts QID x
consider CT, (boric) or alcohol and
Otitis Externa S. aureus involve swimming or getting the ear wet. Ear pain 7 days; Ofloxacin otic or Ciprofloxacin otic
radionucleotide bone scan, vinegar
Proteus spp. with manipulation of external ear or tragus. ear drops BID x 7 days. Keep water out of
gallium scan, MRI
Enterobacteriaceae Purulent green discharge. Erythematous ear canal ear. (No steroids if eardrum ruptured)
CBC: atypical lymphocytes
and lymphocytosis; LFT:
Malaise and fatigue, Fever, pharyngitis,
abnormal for several weeks;
lymphadenopathy. Hx of sore throat, enlarged Limit physical activity for 4 weeks.
Heterophile antibody Peak ages 15-24
posterior cervical nodes and fatigue for several Abd US is splenomegaly/hepatomegaly.
EBV test: Monospot +; Large 3F’s and an L
weeks. May have abdominal pain. Virus is shed Repeat US in 4 to 6 weeks. Avoid amoxicillin.
Mononucleosis (incubation is 30-50 cervical nodes; Fever, Fatigue,
through saliva Avoid close contact, kissing, sharing utensils.
days) Erythematous pharynx with Pharyngitis and
50% have splenomegaly If airway obstruction, hospitalize with high
inflamed, sometimes white Lymphadenopathy
(normal spleen is 1 x 3 x 5, weighs 7 oz and lies dose steroids
exudate; Hepatomegaly and
between 9 and 11 ribs)
splenomegaly; red
maculopapular rash
Painful shallow ulcers on soft tissue of mouth that
Magic mouthwash – liquid
Aphthous usually heal within 7-10 days
unknown diphenhydramine, viscous lidocaine and
stomatitis
glucocorticosteroid
Aphthous ulcer – canker sore

Multiple fissures and irregular smooth areas

Benign physiological looking like a topographic map. May have
Geographic tongue
variant soreness after eating or drinking acidic or hot
foods

Poor fitting dentures, Slow growing white plaque with firm to hard
Leukoplakia chewing tobacco, surface, slightly raised on tongue, floor of mouth Precancerous lesion refer
alcohol abuse or inside cheek

Largely diagnosis of
exclusion. Horizontal
nystagmus usually towards
the affected ear with rapid
Present with episodes of vertigo with a sensation correction to midline. Weber
that the room is whirling about – preceded by lateralizes to unaffected ear.
Increased pressure decreased hearing, tinnitus and feelings of Rinne’s AC>BC; performing
Meniere’s disease within endolymphatic increased pressure. Characterized by repeat pneumatic otoscopy in
system attacks that last minutes to hours and can be affected ear can elicit
related to food and drinks, mental and physical symptoms. Romberg +
stress and variations in menstrual cycle Fukuda marching step test
is positive with drift towards
affected ear. Dix-Hall Pike is
occasionally also positive
indicating BPPV
Risk factors include: use
Antihistamines such as meclizine,
of ototoxic drugs such as
antiemetics or benzodiazepines can minimize
aminoglycosides, long-
symptoms, thiazide diuretics can decrease
term high dose salicylate
pressure load in ear and prevent but not treat
use, certain cancer drugs
attacks. Corticosteroids have also been
and long-time exposure to
demonstrated to be helpful
loud noise. Can also have
Prevention: avoid ototoxic drugs, protecting
Meniere’s symptoms with
ears from loud noise and limiting sodium
certain situations but not
intake
the disease

DERMATOLOGY ASSESSMENT TIP
Ø Assess the entire patient, not simply the skin problem.
Consider whether there is transmission/contagion risk.
Ø Where did it start? (face, torso, extremities, genitals)
Ø How long have you had it?
Ø Does it itch?
Ø Is the patient otherwise well?
o Disease limited to skin such as rosacea,
keratosis pilaris, seborrheic dermatitis.
Ø Is the patient miserable, but not systemically ill?
o Itch, burning, pain – scabies or shingles
Ø Is the patient systemically ill with constitutional
symptoms (fever, fatigue, loss of appetite, unintended
weight loss, malaise)?
o Varicella, transepidermal necrosis, Lyme
disease, systemic lupus erythematosus
Ø Primary lesions only? Primary and Secondary?
o Where is oldest lesion - when did it occur?
o Where is newest lesion – when did it occur?
o Primary – result from disease process, has not
been altered by outside manipulation or tx
§ Ex: vesicle – fluid filled < 1 cm
(varicella, shingles, herpes)
o Secondary – lesion altered by tx or
progression of disease
§ Ex: Crust – raised lesion caused by
dried serum and blood remnants,
develops when vesicle ruptures
SMALLPOX
Ø “Eliminated” 1977
Ø Infection targets respiratory and oropharyngeal
surfaces. Incubation period of 2 weeks.
Ø Flu-like signs and symptoms with large nodules in
center of face, arms and legs. Symptomatic treatment
Ø Mortality rate 20-50%
Ø If vaccine given within 3-4 days postexposure, can
lessen severity of illness
SKIN/INTEGUMENTARY SYSTEM
SKIN LESIONS SKIN CANCER ASSESSMENT
Ø Annular – in a ring (Bull’s eye lesion – Lyme A – Asymmetry
disease) – central clearing B – Border irregularity
Ø Bulla – blisters > 1cm w/fluid (burn) C – Color (brown, black, red, white, blue)
Ø Clustered - lesion occurring in a group without D – Diameter >6mm (pencil eraser)
pattern (herpes) E – Evolving/Elevated (most are new)
Ø Confluent or Coalescent- multiple lesions blending
together (psoriasis vulgaris) Ø > 2 features ABCDE 100% sensitive, 98%
specific
Ø Cyst – raised, encapsulated fluid filled lesion
Ø Melanoma: dark colored moles with
(intradermal lesion)
Ø Lichenification – skin thickening usually found uneven textures – may be pruritic
over pruritic or friction areas Ø Acral lentiginous melanoma: most
Ø Linear - lesion distribution in streaks (poison ivy) common in AA/Asian. Nailbeds,
Ø Macule – flat non-palpable are of discoloration palms/feet
Ø Subungual hematoma: direct trauma to
<1cm (freckle)
nailbed causing bleeding between bed
Ø Maculopapular – both color and small papules or and finger – trephination – draining the
raised skin lesions ranging from erythematous to nailbed
bright pink
Ø Nodule – solid lesion > 0.5 – 2 cm (> 2 cm tumor)
Ø Papule – solid elevation <0.5 cm (mole)
o Smooth papule dome shaped with central PRESSURE ULCER
umbilication with white plug (molluscum
Ø Stage I: nonblanchable erythema on
contagiosum)
intact skin
Ø Patch – flat, nonpalpable area of skin discoloration
Ø Stage 2: presence of epidermal or dermal
larger than macule (vitiligo)
skin loss; can appear as intact blister
Ø Petechiae – < 1cm (thrombocytopenia)
Ø Stage 3: full-thickness skin loss with
Ø Plaque – elevated, variable shape >1cm (psoriasis)
exposure of some amount of fat, ulcer
Ø Purpura – flat, red-purple discoloration that does
has crater-like appearance
not blanch with pressure
Ø Stage 4: full-thickness skin and tissue loss;
Ø Pustule – vesicle like lesion with purulent content
would exposes muscle, bone and tendons
(impetigo)
Ø Reticular – netlike cluster
Ø Scale – raised superficial lesions that flake with
ease (dandruff)
Ø Scattered – generalized over body without specific
pattern (viral exanthem – rubella/roseola)
Ø Vesicle – clear fluid (herpes)
Ø Wheal – circumscribed area of skin edema
(urticaria)
 SKIN/INTEGUMENTARY SYSTEM

• Potency class 7 (low) to 1 (high)

• Non-folded trunk and extremities
o Triamcinolone 0.1%
o Face and body folds – Desonide or
hydrocortisone
o Palms/soles – fluocinolone or clobetasol
• Lotions < creams < gels < ointments BURN
• Creams absorb well and lack greasy texture (sting if st
Ø 1 degree – reddened easily blanched with
open wound) gentle pressure
• Ointments contain emollient (pounding form of Ø 2nd degree (partial thickness) – red, moist with
absorption) peeling borders and scattered bulla (Silvadene or
• Lotions water based and spread easily (most gentle) polysporin)
• Face greatest rate of absorption, then axilla and Ø 3rd degree (full thickness) – thickened,
genitals hypopigmented tissue
• 2gm hands, head, face, anogenital Ø Refer
• 3gm arm, anterior or posterior trunk o Face, hands, feet, genitals, major joints
• 30-60gm of topical cream for entire body o Electrical burns, lightning burns
o Partial thickness > 10% BSA
o 3rd degree any age
o Circumferential
Ø P. aeruginosa, E. coli, K. pneumoniae
 SKIN/INTEGUMENTARY SYSTEM

SKIN FINDINGS WOUNDS

o Fifth disease – maculopapular rash in lace-like pattern Ø Factors that impair wound healing
o Varicella, zoster, herpes simplex – maculopapular rashes with papules, vesicles and crust o Older age, poor nutrition, impaired immune system,
(vesicular rash on erythematous base) impaired mobility, stress, diabetes, medications (impair
o Pityriasis rosea – maculopapular rashes that are oval shaped with a herald patch (Christmas clot formation and steroids), pressure loading, smoking,
tree) secondary bacterial infection
o Seborrheic Keratosis – soft, wart-like growth on trunk ranging from light brown-black; Ø Primary healing – wound closed within 24 hours by suturing,
pasted on appearance tissue glue or butterfly strips
o Xanthelasmas – raised, yellowish plaques under brow or lids. Sign of high lipids Ø Secondary healing – would is left open and heals from bottom up
o Melasma – pregnancy mask. On upper cheeks and forehead Ø Tertiary intervention – wounds with heavy contamination or poor
o Vitiligo – hypopigmented patches of skin w/ irregular shapes vascularity (crush injuries) are best left open to heal by secondary
o Cherry angioma – benign small papules bright cherry red in color, always blanch with intention.
pressure Ø Referral – infected wounds, closed-fist injury, facial wounds with
o Lipoma – fatty cystic tumors of subcutaneous layer on neck, trunk, legs, arms risk of cosmetic damage, foreign body or embedded object, injury
o Nevi (moles) – round macules/papules varying in color and size – benign to joint capsule, electrical injuries, paint-gun or high-pressure
o Xerosis – inherited extremely dry skin of mouth and eye wounds, chemical wounds, child abuse
o Acanthosis Nigrans – velvety thickening of skin behind neck/axilla; associated with DM, Ø Do not suture wounds > 24 hours - ↑ infection risk > 12 hrs.
metabolic syndrome, obesity, and GI cancer tract Ø Tdap if last tetanus was > 5 yrs.
o Acrochordon – skin tags. Painless pedunculated outgrowths of skin are the same color. Ø Suture removal
o Candida – bright-red with satellite lesions o Face: 5-7 days
o Intertrigo – bright-red diffused rash due to bacterial infection o Scalp: 7-10 days
o Acral – on extremities o Upper extremities: 7-10 days
o Lower extremities: 10-14 days

RANDOM FACTS
o Bed bugs: do not infect the patient
LICHEN PLANUS
o Squamous cell carcinoma: sun exposed areas, lower lip common in smokers Ø Small, flat red to purple bums with
• Presents as papule, plaque, nodules, smooth, hyperkeratotic or ulcerative lesion white scales
Ø Itch – common on wrist, forearms,
• May bleed easily
ankles
• Definitive diagnosis is biopsy or excision of specimen – moles procedure?
Ø Common causes include Hepatitis C –
§ N - nodular
self-limiting
§ O - opaque
§ S – sun-exposed
§ U - ulcerating
§ N – nondistinctive borders ODE TO MRSA
o Irritant contact dermatitis – contaminated water, soaps and detergents, fiberglass, Ø ABCD
particulate dust, food products, cleaning agents, lubricants, oils, coolants, solvents, plastics, o MRSA
resins, petroleum products o Bactrim
o Allergic contact dermatitis – poison ivy, rubber, nickel, fragrances o Clindamycin
o Doxycycline
 SKIN/INTEGUMENTARY SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Can be fatal (3-9%)

high fever, chills, severe headache, n/v, Doxycycline 100mg BID for 7-14 days – can
Antibody titers to rickettsia Highest in
Dog/Wood Tick bite photophobia, myalgia, conjunctival injection, be fatal if not started on treatment within 8
Rocky Mountain Punch biopsy southeastern/south
Rickettsia rickettsii arthralgia; 2-5 days after onset - rash (petechiae) days. Remove tick by grasping closest to skin
Spotted Fever CBC, LFT, CSF central regions of US
starts on hands/feet to trunk (palmar rash) and apply steady upward pressure.
Most common Apr - Sept
Ice at time of bite. Local debridement,
Fever, chills, nausea and vomiting. Red, white and
antibiotic ointment, elevation, loose
blue sign; central blistering with surrounding gray
Brown recluse immobilization. NSAIDs Found in midwestern and
to purple discoloration at bite surrounded by
spider bite Prevention: look before putting body part southeastern US
blanched skin surrounded by large areas of
into places where spiders hide such as
redness
footwear and boxes
Expanded red rash with central clearing (bulls- Early: Doxycycline BID x 14-21d (maybe 28
NE regions of US
eye), feels hot to touch and rough texture; Enzyme immunoassay (EIA) days) (Alt: Amoxicillin or Ceftin) Avoid
Systemic infection with
Erythema Migrans Borrelia burgdorferi common areas belt line, axilla, popliteal, groin Indirect doxycycline in children due to teeth staining.
organ shutdown
(Lyme disease) (tick) FLU-LIKE symptoms immunofluorescence assay Stage 1: single painless annular lesion
Guillain-Barre
Rash appears 7-14 days after deer tick bite (IFA) Stage 2: AV heart block, Bell’s palsy
Migratory arthritis
Spontaneously resolves Stage 3: joint pain 1 yr. after infection
Death within 48 hours
sudden onset of sore throat, cough, fever, Rocephin 2G IV q12h + Vancomycin IV q12h Medical emergency –
Neisseria Meningitides Lumbar puncture: CSF
headache, stiff neck, photophobia, and changes in Hospital isolation and supportive tx REFER
Meningococcemia Gm – diplococci Blood/throat cultures
LOC Close contact prophylaxis: Rifampin BID x2d College students in dorms
Spread via respiratory CT or MRI of brain
abrupt onset of petechial to hemorrhagic rashes and meningococcal vaccine ↑ risk asplenia, sickle
cell, HIV
Varicella: Acyclovir within 24-48 hrs. of
Chickenpox: Fever, pharyngitis, malaise
Herpes-zoster Viral culture eruption (avoid ASA and NSAIDs) Herpes zoster
Pruritic vesicular lesions beginning at head
(Chickenpox or PCR for ZDV Acyclovir or Valacyclovir x 10d for initial ophthalmicus (corneal
expanding to trunk (vesicles and crust) – most
Varicella / Zoster Shingles) – spread by Vaccine: >60 outbreak and then x 7 days for flare-ups blindness) CN V -
common on thorax Shingles: lesions at various
direct contact or Tzanck smear confirms Post herpetic neuralgia: TCA, anticonvulsant, photophobia, eye pain,
stages along dermatome
inhalation shingles gabapentin, lidocaine or capsaicin cream to blurred vision
Contagious 1-2 days before rash until crusted
intact skin
A – Asymmetry
B – Border irregularity Refer to Dermatology Risk factors, family hx of
Malignant C – Color (brown, black, red, white, blue) Acral Lentiginous Melanoma – African melanoma, sun exposure,
Needs biopsy by derm.
Melanoma D – Diameter >6mm (pencil eraser) American and Asians, located on nail beds, tanning beds, lots of
E – Evolving/Elevated (most are new) palmar and plantar surfaces nevus, light skin/eyes
May be pruritic
Waxy, pearly domed nodule, usually distinct
borders with or without telangiectasia; white,
Metastatic risk low, significant tissue
light pink, brown or flesh colored. Papule, nodule Risk factors: light-colored
Basal Cell Most common skin destruction risk without treatment. Slow
with or without central erosion skin, Australian decent, sun-
Carcinoma cancer growing – common in fair skin types
PUT ON (Pearly papule, Ulcerating, exposed area
Excisional biopsy
Telangiectasia, On the face, scalp, pinnae,
Nodules, slow growing
Clinical diagnosis fluorouracil cream (5FU cream); 5%
Slow-growing; Scaling, dry, round, flesh-colored imiquimod cream, topical diclofenac gel
Pre-cancerous
lesions on skin that do not heal; usually sun- Liquid nitrogen, laser resurfacing or
Actinic Keratosis Precursor to squamous
exposed areas; sizes range from microscopic to chemical peel
cell carcinoma
several centimeters Gold standard: refer to derm for biopsy

Rare reaction to
Lesions like “bulls-eye”, erupt suddenly
medications (NSAIDs, Toxic Epidermal
Erythema Hives, blisters, petechiae, purpura, hemorrhagic
Sulfa, antiepileptic), Necrolysis (TEN) (>30%
Multiforme lesions and sloughing of epidermis. Could have
infection (herpes or of skin) allopurinol,
(Stevens-Johnson prodrome of fever with flulike symptoms 1-3 days
Mycoplasma anticonvulsants, sulfa,
syndrome) before rash appears (palmar rash)
pneumoniae) and NSAIDs
malignancies
 SKIN/INTEGUMENTARY SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

First Line: Medium potency topical Psoriatic arthritis:

Erythematous papules and plaques “fine-silvery
Chronic corticosteroid, painful red, warm and
Inherited; excessive scales” found over elbows, scalp, knees, gluteal
Koebner phenomenon – Second Line: Vitamin D derivatives swollen joints. Guttate
Psoriasis mitotic grown of folds; pitting of fingernails
scar formation in places not Topical retinoids (tazarotene), Tar psoriasis: severe form
epithelial cells Auspitz sign: Pinpoint areas of bleeding
near typical psoriasis preparations; UVB light and topical tar may resulting from Gp A strep
remain in the skin when a plaque is removed.
induce remissions **BB can exacerbate infection
Hypopigmented round macules on
Yeast - Pityrosporum Topical selenium sulfide
chest/shoulders/back; appear after skin is tanned KOH slide: hyphae & spores
Tinea Versicolor orbiculare or Ketoconazole (Nizoral) BID x 2w
from sun “spaghetti & meatballs”
Pityrosporum ovale. Oral antifungals
asymptomatic
Pruritic rash on hands, flexural folds, and neck; Skin lubricants/hydrating baths to alleviate
well-demarcated round-to-oval erythematous dryness Formation of fissures and
Atopic Dermatitis coin-shaped plaques exacerbated by stress and Topical steroids: Mild – hydrocortisone 1- risk of infection
Inherited pruritic rash Clinical diagnosis
(Eczema) environment; Starts as small vesicles that rupture 2.5% Medium – triamcinolone Triad – allergies, eczema,
leaving red, weeping lesions that become Med/High potency (Halog) x 10d asthma
lichenified and itchy Oral antihistamines for pruritis
Non-purulent: Cephalexin 500mg QID, Refer if s/s don’t resolve,
dicloxacillin QID or Clindamycin x 10 day cellulitis not responding
Strep pyogenes Infection of dermis and subcutaneous fat with
MRSA: Bactrim, Doxycycline or Clindamycin to tx, spreading quickly,
Acute cellulitis Staph Aureus heat, redness and discomfort in the region, poorly
Td booster if >5yrs DM,
(MSSA or MRSA) demarcated
**Good follow-up; 48 hrs. after initial tx. immunocompromised
Osteomyelitis, sepsis

Skin infection involving hair follicle and I & D and warm soaks
Cutaneous abscess, Staph Aureus
surrounding tissue (heat, redness and discomfort) C&S Bactrim, Doxycycline or clindamycin Bactroban for folliculitis
furuncle, carbuncle (MSSA or MRSA)
Carbuncle – multiple abscesses MSSA: Dicloxacillin or Cephalexin

Sudden onset one hot, indurated, erythema Non-purulent: Keflex or dicloxacillin

Erysipelas S. pyogenes with clear demarcation. Usually on lower legs Hospitalization for infants,
or cheeks immunocompromised

Human bite dirtiest of all

Dogs & Cats (P. Augmentin 875mg x 10d (PCN allergic: Watch for closed-fist
Cats higher risk of infection than dogs
multicoda) gram doxycycline or Bactrim + Flagyl or injury (infection of the
Rabies: skunks, raccoons, foxes, coyotes: Immune
Bite wounds negative Wound C&S clindamycin) joints)
globulin and vaccine
Humans (Eikenella Clean, no sutures, tetanus 80% cat bites become
Quarantine domestic animals for up to 10d
corrodens) Follow-up 24-48 hours infected
Bacterial infection of
Acute onset painful, large, red nodules and Mild: Chlorhexidine; Clindamycin 1% for 12
Hidradenitis axillary sebaceous
papules under one or both axilla that become C & S of drainage weeks; Tetracycline 500 BID; doxycycline or Recurrences and scars
Suppurative gland
abscessed minocycline BID for 7-10 days
Staph aureus
Nonbullous – erythematous macule evolves into Nonbullous - mupirocin ointment 2% x10d
pustule ruptures leaving honey crusted exudate. (treats select gram + organisms)
No school until 48-72
Staph Aureus Bullous – clear, yellow fluid ruptures within 1-3 Cephalexin or dicloxacillin QID x 10d
Impetigo C & S of crusts/wounds hours after treatment
Strep pyogenes days leaving a rim of red with moist base (scalded Azithromycin if PCN allergic 250 x 5d or
initiation
appearance) - deep ulcerated=ecthyma clindamycin x10d
Contagious and pruritic: worse in warm weather
 SKIN/INTEGUMENTARY SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Analgesic or NSAIDs
Painful blistering on side of finger or cuticle Acyclovir for severe infections
Herpetic whitlow HSV 1 or 2
Direct contact with cold sore or genital herpes Avoid sharing personal items, gloves, towels.
Cover skin lesion until healed
Oval plaque with central salmon-colored area and
dark red peripheral zone on anterior trunk.
None – self-limiting (6-8 weeks) Rule our secondary
Pityriasis Rosea Unknown may be viral Fine scales following skin lines: “Herald patch” or
May need something for itching syphilis
“Christmas Tree” patch
Koplik spots
Severe pruritic rash, worse at night, between webs Permethrin 5% cream to entire body – wash
of toes and fingers, axillae, waistline, groin, Wet mount of scraped rash off after 8-12h
Avoid Kwell due to
Scabies Sarcoptes scabiei breasts, butt, penis to view eggs under Treat everyone in household;
neurotoxicity
Rash appears in linear burrows – can last up to 4 microscope clothes/bedding should be washed in hot
weeks water
Capitis – head (most common)
Pedis – foot OTC topical “azole” or allylamines
Tinea Infections –
Corporis/Circinata – body KOH slide for hyphae and (terbinafine, butenafine)
ringworm yeast
Cruris – jock itch spores Gold standard: griseofulvin (baseline LFT
(Dermatophytosis)
Manuum – hands and repeat 2 weeks after initiating meds)
Barbrae – beard

Oral fluconazole 150-300mg weekly for 2-3

Onychomycosis Yellow thickening of nail – great toe most
Yeast Fungal cultures of nail months; Lamisil weekly for several weeks; Monitor LFTs
(tinea unguium) common; nail bed may separate (onycholysis)
terbinafine

Teaching –take 6-8

Mild: OTC - Neutrogena acne wash (salicylic acid 2%) plus benzoyl peroxide
Open comedones (blackheads), closed comedones weeks, put all over skin
2.5% Prescription meds: Isotretinoin (Retin-A), benzoyl peroxide with
(whiteheads), small papules and pustules Before age 13 tetracycline
erythromycin (Benzamycin) cream, clindamycin topical (Cleocin)
Inflammation of the Affects face, chest and back can stain teeth
Mod: retinoid and antibiotic tetracycline, minocycline, doxycycline (if under
sebaceous gland Mild: <20 comedones; <15 inflammatory or <30 permanently
Acne Vulgaris 13 then erythromycin, clindamycin; Oral contraceptives: combined estrogen-
High androgen levels, total Accutane category X –
progestin Yaz or Desogen
bacteria, genetics Moderate: 20-100 comedones; 15-50 females 2 forms of birth
Severe: Accutane; injections
inflammatory or 30-125 control – monitor liver
Severe: > 5 cysts lithium contributes to
Baby acne – topical erythromycin or clindamycin
acne
Rhinophyma: hyperplasia
Small acne-like papules and pustules around nose, First line: symptom control and avoidance of
of tissue at tip of nose
mouth and chin. Patient blushes easily and ocular triggers (spicy food, alcohol, sunlight)
Ocular rosacea:
Rosacea Inflammatory response symptoms (dry eyes) Metronidazole topical gel (Metrogel); Azelaic
blepharitis, conjunctival
Patient usually blonde, blue eyes “celtic gel (azelex); Low-dose tetracycline over
injection, lid margin
background” several weeks
telangiectasia
Cutaneous: begins as papule enlarges in 24-48
hour and develops eschar and necrosis. Hx of
exposure of handling animals Cutaneous: doxycycline, ciprofloxacin, levofloxacin BID 7-10 days (if
Anthrax Bacillus anthracis Pulmonary: inhaling aerosol through working bioterrorism treat for 60 days)
with animals or bioterrorism – symptoms are flu- Post exposure prophylaxis: Cipro 500 mg BID x 60 days
like with cough, chest pain with cough,
hemoptysis, dyspnea, hypoxia, shock
 CARDIOVASCULAR SYSTEM

MURMURS GRADING OF MURMURS
Ø Turbulent blood flow through great vessels or across a heart valve Ø GRADE I/VI – barely audible
Ø Timing of murmur – systole or diastole Ø GRADE II/VI – audible but faint
Ø Location of murmur – aortic or mitral Ø GRADE III/VI – moderately loud, easily heard (as loud as S1)
Ø Systolic murmurs – MR Peyton Manning AS MVP Ø GRADE IV/VI – loud, associated with a thrill
o Mitral Regurgitation- “pan systolic”/ holosystolic. Heard at
Ø GRADE V/VI – very loud, heard one corner of the stethoscope off the wall
apex, radiates to axilla, loud or high-pitched blowing (use
diaphragm) Ø GRADE VI/VI – loudest, heard without a stethoscope
o Physiologic Murmur-
§ Hemic like in severe anemia, dehydration
§ Becomes louder when lying down STETHOSCOPE
o Aortic Stenosis- second ICS to right of sternum, radiates to Ø Bell – low tones (S3, S4), mitral stenosis
neck, harsh/noisy murmur (use diaphragm) – avoid physical Ø Diaphragm – mid to high pitch tones, lung sounds, mitral regurgitation,
exertion due to ↑ risk sudden cardiac death; monitored by aortic stenosis
echo and surgical valve replacement; LVH; congenital defect in
kids; acquired could be from prior rheumatic fever; angina,
syncope, heart failure
o Mitral Valve Prolapse- mid to late systolic murmur with mid
HEART SOUNDS
systolic click
Ø Motivated Apples
Ø Diastolic murmurs – ARMS
o Motivated – systole – S1 closure of AV - mitral/tricuspid valve (lub)
o Aortic Regurgitation- high-pitched, second ICS to right of
§ M (mitral valve)
sternum blowing (use diaphragm)
§ T (tricuspid valve)
o Mitral Stenosis- low pitched, apex of heard or apical area; also
§ AV (atrioventricular valves)
called “opening snap” “crescendo” (use bell)
o Apples – diastole - S2 closure of semilunar - aortic/pulmonic valves
Ø All diastolic murmurs – abnormal
(dub)
Ø APETM (valve locations)
§ A (aortic)
o Aortic – 2nd ICS right upper border sternum
§ P (pulmonic)
o Mitral – apex or apical area of heart, PMI, 5th left IC space
§ S (semilunar)
Ø If radiates to axilla the mitral valve is closest to axilla
Ø S3 - Pathognomic for CHF; possible normal for adolescent athletes and
Ø If radiates to neck the aortic valve is closest to neck
pregnancy; possible thyrotoxicosis; always abnormal if occurs >35yo
Ø If a valve fails to open it is stenotic
“Kentucky” – best heard at pulmonic area (AKA ventricular gallop or S3
Ø When a valve fails to close it is incompetent
gallop)
Ø S4 – LVH; normal finding in some elderly; occurs late is diastole and best
heard at apex with bell (Tennessee) (atrial gallop or atrial kick); poorly
controlled HTN; unstable angina
Ø Split S2 is best heard at pulmonic area – healthy athlete
 CARDIOVASCULAR SYSTEM

ADDITIONAL PEARLES
Ø BP = HR x SV x PVR
Ø Left side of heart is higher level arterial system – right side is lower pressure thus
abnormalities in the cardiac exam are more likely to arise from left-sided heart
problems
Ø Deoxygenated: Superior vena cava → right atrium → tricuspid valve → right
ventricle → pulmonary valve → pulmonary arteries → lungs (RBCs pick up
oxygen and release carbon dioxide in alveoli) Oxygenated: pulmonary vein →
left atrium → mitral valve → left ventricle → aortic valve → body
Ø Left ventricle is most likely cardiac chamber to hypertrophy
o Left ventricular hypertrophy is common form of HTN TOD
o PMI shift (downward and lateral) common in LVH (normally heard at 5th
ICS MCL)
Ø 2nd chamber most likely to hypertrophy is left atrium
Ø Common pathologic murmurs to arise due to aging – aortic stenosis
Ø Most common regurgitate murmur – mitral regurgitation (mitral valve
incompetent – means it doesn’t close properly) which causes decreased cardiac
output
o Symptoms of low cardiac output
§ Dyspnea with exertion
§ Chest pain
§ Orthopnea (virtually never respiratory, almost always heart
failure – could be LVH and mitral regurgitation)
§ Syncope and near-syncope (when cardiac, generally caused by
aortic stenosis or hypertrophic obstructive cardiomyopathy)
§ Idiopathic hypertrophic subaortic stenosis – type of
cardiomyopathy – autosomal-dominant pattern
o Cardiac exam in mitral regurgitation (MR) includes holosystolic murmur
with blowing quality typically GR II-III/IV with predictable pattern of
radiation to the axilla
§ Holosystolic – takes up all of systole and is the same intensity
throughout systole
Ø Sudden unexpected finding on exam- how did I miss this in health history?
o Onset
o Location/radiation
FIBRINOLYSIS CONTRAINDICATION: o Duration
Ø Absolute: prior intracranial hemorrhage, cerebral vascular lesion, neoplasm, o Character
ischemic stroke in last 3 months, aortic dissection, active bleeding, intracranial or o Aggravating factors
intraspinal surgery within 2 months, severe uncontrolled HTN o Relieving factors
Ø Relative: chronic uncontrolled HTN, significant HTN on presentation, ischemic o Timing
stroke < 3 months, traumatic or prolonged CPR, major surgery within 3 weeks, o Severity
recent internal bleeding within 2-4 weeks, non-compressible vascular punctures,
pregnancy, active peptic ulcer disease, oral anticoagulant therapy

TARGET ORGAN DAMAGE:
Ø Eye: hypertensive retinopathy with risk of
blindness (silver, copper wire arterioles, AV
nicking, flame shaped hemorrhages – black
dots in visual field; papilledema)
Ø Kidney: microalbuminuria, proteinuria, ↑
creatinine, ↓ GFR, edema
Ø Cardiovascular: S3 (CHF), S4 (LVH), carotid
bruits, CAD, MI, LVH, PAD or PVD
Ø Brain: TIA, CVA
LIFESTYLE MODIFICATION FOR HTN/DYSLIPIDEMIA:
Ø Stop smoking. Reduce stress level.
Ø Weight reduction if overweight/obese
o 5-20mm hg per 10kg
Ø DASH eating plan
o Fresh fruit/veggies. ↓sodium, ↑ K+,
↑ Ca; eat fatty cold-water fish 3x/wk.
Ø Dietary sodium reduction – less than 2.4 g/day
Ø Aerobic physical activity
o 40 min / 3-4 days per week
Ø Moderation of alcohol
o Men < 2
o Women < 1
ALDOSTERONE ANTAGONIST DIURETICS
Ø MOA: blocks aldosterone so ↑ elimination of
Na+ and H20 in kidneys to conserve K+
Ø Used for HTN, CHF, hirsutism, precocious
puberty
Ø Adverse effect: Gynecomastia, hyperkalemia
Ø Avoid w/ potassium-sparing diuretics, ACEI or
K+ supplements, renal insufficiency, DM2 w/
microalbumin
Ø Spironolactone (Aldactone) Eplerenone
(Inspra)
CARIOVASCULAR SYSTEM
LOOP DIURETICS
Ø Furosemide (Lasix)
JNC-8 GUIDELINES Ø Bumetanide (Bumex)
Ø Implement lifestyle interventions Ø Inhibits sodium-potassium-chloride
Ø Set BP goal pump of kidneys (↑ UO)
o Anyone with diabetes or CKD < 140/90 Ø Electrolyte imbalance, hypokalemia,
o No diabetes or CKD
hyponatremia, hypomagnesemia
§ <60 yrs. <140/90
§ >60 yrs. <150/90
Ø Non-AA – thiazide or ACEI/ARB or CCB alone or in combination
Ø AA – thiazide or CCB alone or in combination ALPHA-1 BLOCKER “-OZIN”
Ø CKD – ACEI or ARB alone or in combination with other class Ø Used for BPH and HTN
Ø Maximize dose of 1st med or add 2nd med or start with combo Ø First dose may cause orthostatic
drug. hypotension, dizziness, postural
hypotension
Ø Give at bedtime, start low, titrate up.
Ø Terazosin (Hytrin), Tamsulosin
THIAZIDE DIURETICS (Flomax)
Ø MOA: ↓ volume, venous pressure and preload Ø Carvedilol is both alpha/beta
Ø Blacks get better results, associated with ED adrenergic antagonist
Ø Favorable effect with osteoporosis or osteopenia
Ø High dose 25mg or more - potential for negative impact on
glucose and dyslipidemia – hyperuricemia (gout), hyperglycemia BETA-BLOCKERS – “-OLOL”
Ø Monitor Na+, K+, Mg++ depletion, calcium sparing (good for
Ø MOA: block beta1 receptors in heart
osteoporosis due to lower observed fx risk)
Ø Lowers heart rate and stroke volume
Ø HCTZ (contraindicated with sensitivity to sulfa drugs)
Ø Monitor for worsening asthma, COPD
Ø DO NOT USE: heart block, bradycardia
Ø USE: MI, migraines, glaucoma, resting
CALCIUM CHANNEL BLOCKERS “-IPINE” tachycardia, angina, hyperthyroidism
Ø MOA: Systemic vasodilation, slows HR Ø Whites get better systolic control than
Ø Most potent BP controlling med on the market blacks – 4th line anti-HTN med
o DHP (doesn’t hurt pulse) (↓ BP): amlodipine Ø Used more for heart failure and not BP
o Non-DHP (↓ HR and BP a little): diltiazem, verapamil Ø Reduces effects of circulating
Ø 1st line choice in African American HTN catecholamines
Ø Causes headaches, ankle edema, bradycardia, reflex tachycardia
Ø DO NOT USE: heart block, bradycardia, CHF
Ø Avoid grapefruit, macrolides ACEI “-pril” or ARB “-sartan”
Ø Work better at night Ø MOA: Block conversion of angiotensin
I → II
Ø 1st choice in HTN with DM or renal
DIGOXIN disease
Ø Dry hacking cough, (more w/ACEI),
Ø ECG in therapeutic: prolonged PR, depressed, cupped ST segment
hyperkalemia, angioedema
Ø ECG with toxicity: AV heart block
Ø Adjust dose in renal insufficiency
Ø Patients with toxicity have anorexia
Ø AVOID in pregnancy, renal artery
Ø Drug interactions: amiodarone, diltiazem, macrolides,
stenosis, acute renal insufficiency
antifungals, cyclosporine and verapamil
 CARDIOVASCULAR SYSTEM

OVERWEIGHT/OBESITY
DYSLIPIDEMIA NIACIN
Ø Screening and detection Ø BMI – ratio of weight to height ↓ LDL 5-25%
o Lipid profile in those with cardiovascular risk (DM, o Weight (kilograms)/height (meters) ↑ HDL 15-35%
HTN, strong family hx and obesity) o Muscular patients can have falsely ↓ TG 20-50%
o 12 hours fasting elevated BMI Adverse effect: flushing (minimize by taking
§ Total cholesterol (TC) Ø Underweight < 18.5 ASA 1-hour prior), hyperglycemia,
§ Low-density lipoprotein (LDL) Ø Normal 18.5 to 24.9 hyperuricemia, upper GI distress, hepatotoxic
§ High-density lipoprotein (HDL) Ø Overweight BMI 25 to 29.9
§ Triglycerides (TC) Ø Obese BMI > 30
Ø Dietary options to ↓ LDL (5-10%) o Male: waist circumference: >40 inches
o Female: waist circumference: >35 FIBRATES
o Plant sterols – Take Control/Benecol margarine ↓ LDL 5-20%
o Oatmeal, oat bran o Waist-to-hip: 1.0 (males)
↑ HDL 10-20%
Ø Reduce intake of saturated fat and cholesterol o Waist-to-hip: 0.8 (females)
↓ TG 20-50%
o Avoid trans fat Ø Diagnosing metabolic syndrome Can cause ↑ in LDL with high TG
o Total cholesterol < 200 o 3 characteristics: abd. obesity (weight Adverse effect: dyspepsia, gallstones,
Ø Increase omega-2 fatty acids circumference), HTN, hyperlipidemia or myopathy, do not use in severe renal/hepatic
o Fish twice a week Ex: fenofibrate
↑ triglycerides and ↓ HDL (insulin
o Flaxseed, walnut, canola and soybean oils
o If CHD, take 1-gram EPA + DHA (salmon 4oz daily or insensitivity), fasting glucose > 100 or dx
fish oil supplement use) diabetes FISH OIL (OMEGA 3)
4 gram/day
↓ TG 20-30%
STATIN THERAPY Adverse effect: ↑ risk of bleeding, GI upset
High-intensity Moderate-intensity Low-intensity due to fishy taste – freeze capsules, take with
HMG-CoA INHIBITOR (STATIN) food, avoid hot beverages immediately after
Avoid in >80, Preferred if high Not recommended ↓ LDL 18-55%
impaired renal risk for adverse ↑ HDL 5-15%
function, frailty, effects ↓ TG 7-30%
multiple Baseline hepatic enzymes – no further monitoring
comorbidities, with required
SECONDARY HYPERTRIGLYCERIDEMIA
fibrate Avoid grapefruit juice with simvastatin, atorvastatin, Untreated/undertreated hypothyroidism
LDL reduction 50% LDL reduction 30- LDL reduction lovastatin Poorly controlled diabetes
49% <30% Adverse effects: rhabdomyolysis, myositis Excessive alcohol use
Atorvastatin 40-80 Atorvastatin 10-20 Pravastatin 10-20 • Risk factors for myositis (advanced age, low
Rosuvastatin 20-40 Rosuvastatin 5-10 Lovastatin 20 body weight and high-intensity statin therapy)
Simvastatin 20-40 Simvastatin 10 SELECTIVE CHOLESTEROL ABSORPTION
Pravastatin 40-80
Lovastatin 40 INHIBITOR
BILE ACID RESINS ↓ LDL 15-20%
ASCVD – high intensity ↓ LDL 15-30%
LDL > 190 – high intensity ↑ HDL 3-5%
↑ HDL 3-5% Examples: ezetimibe (Zetia)
Diabetes – moderate intensity ↑ TG if > 400
10 yr. ASCVD risk > 7.5% - moderate to high intensity Generally used as add-on (Vytorin)
Examples: cholestyramine, colestipol, colesevelam
**Not enough data of benefit > 75 Adverse effects: constipation, ↓ absorption of other
Take at night with baby ASA meds
 CARDIOVASCULAR SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Midsternal chest pain, squeezing, tightness,

Unstable angina: crushing, heavy pressure, band-like, STEMI – transmural MI
Acute Coronary vasoconstriction, numbness/tingling left jaw/arm, diaphoresis w/ with subsequent Q waves.
Syndrome: (STEMI, nonocclusive cool/clammy skin. Pain is provoked by eating Beta-blockers, ACEI, aldosterone NSTEMI – subtotal
EKG
NSTEMI and thrombus, heavy meal or exercise. Continues to have pain or antagonists occlusion
unstable angina) inflammation or discomfort at rest; Women present with fatigue, Stable angina – pain is
infection sleep disturbance, dyspnea, anxiety, weakness, predictable.
back pain, nausea, syncope
Lungs have crackles bibasilar and S3 heart sound Monitor weight daily, Avoid ETOH, stop
MI, CAD, HTN, fluid
Congestive Heart Crackles, cough, dyspnea, dullness to percussion, smoking EF < 40% systolic failure
retention, valvular
Failure paroxysmal nocturnal dyspnea, orthopnea, non- diuretics, ACEI or ARBs, beta-blockers if (HFrEF)
abnormalities,
(Left sided) productive cough and wheezing HFrEF, aldosterone antagonist EF > 40% diastolic failure
arrhythmias
(“left = lung”) Limit sodium intake (2-3 grams) Fluid (HFpEF)
Chest x-ray, (Kerley B lines)
restriction 1.5-2 L daily
EKG, CPK, troponin, BNP,
NYHA classify degree of physical disability Meds that contribute to
MI, CAD, HTN, fluid JVD (normal < 4cm), enlarged spleen, enlarged CMP, echo
Congestive Heart Class I – no limitations heart failure: amlodipine,
retention, valvular liver causing anorexia, nausea, and abdominal
Failure Class II – activity results in fatigue, metoprolol (but they need
abnormalities, pain, lower extremity edema
(right sided) exertional dyspnea it), actos/Avandia
arrhythmias (“right = GI”)
Class III – limitation in physical activity (glitazone), NSAIDs
Class IV – symptoms at rest
Antibiotic prophylaxis is no longer
recommended for MVP, GU or GI
Fever, chills, and malaise associated with new
Recommended for:
murmur and abrupt onset CHF
Previous hx of endocarditis – dental
Gm + Viridans Subungual hemorrhages, petechiae on palate, REFER to cardiologist Valvular destruction,
Bacterial procedures, prosthetic valves – resp.
streptococcus, staph painful nodes on fingers or feet (Osler nodes), Blood cultures x 3 myocardial abscess,
Endocarditis procedures, congenital heart disease
aureus nontender red spots on palm/soles (Janeway CBC, Sed rate >20 mm/h emboli
Amoxicillin 2 grams PO Adult 1 hr. prior
lesions); fundoscopic exam Roth spots or retinal
Amoxicillin 50mg/kg 1 hr. prior
hemorrhages; hematuria
PCN allergic: Clinda 600mg, Biaxin
500mg, Keflex 2 grams,? macrolide
Abdominal ultrasound Risk factors: male > 60,
Dissecting Pulsating-type sensation in abdomen or lower
Incidentally: CXR may show smoker, uncontrolled
Abdominal Aortic back pain. Sudden onset severe chest/back pain Surgical.
widened mediastinum, HTN, white race, genetic
Aneurysm increasingly sharp and excruciating. Distended If less < 4cm monitor yearly with CT.
tracheal deviation, obliteration disease such as Marfan
abdomen with hypotension
of aortic knob syndrome
Search for underlying cause; Refer to Most common, classified
Risk factors: HTN,
cardiologist. CHA2DS2-VASC score > 2 as SVT – lead to stroke
CAD, ACS, caffeine, May be asymptomatic; 12-lead EKG
needs anticoagulants Paroxysmal AF: episodes
Cardiac nicotine, May be more than 110 bpm on palpation (if TSH, electrolytes, renal
CHF, HTN, Age > 75, Diabetes, terminate < 7 days
Arrhythmias hyperthyroidism, hemodynamically unstable – chest pain, function, 24h Holter monitor,
Stroke/TIA, Vascular disease, Age 65-74,
Atrial Fib alcohol intake, heart hypotension, heart failure, cold clammy skin, echo
Sex (female); possible CCB, BB/digoxin to INR >4-5 hold 1 dose
failure, LVH, PE, acute kidney failure with new A Fib call 911 Avoid stimulants
regulate HR and/or reduce
COPD, sleep apnea
Warfarin – A fib INR 2-3; Valves 2.5-3.5 maintenance dose

Digitalis toxicity,
Paroxysmal Abrupt onset of palpitations, rapid pulse, Vagal maneuvers, carotid massage, ice May be seen in Wolf
alcohol,
Supraventricular lightheadedness, shortness of breath and anxiety EKG water to face. If WPW or symptomatic call Parkinson White
Hyperthyroidism,
Tachycardia (PSVT) HR range from 150-250bpm 911 Syndrome
caffeine, illegal drugs

 CARDIOVASCULAR

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Apical pulse is audible even though radial pulse is

Asthma, emphysema,
no longer palpable. Measured through
tamponade,
Pulsus Paradoxus stethoscope and BP cuff. Chambers of heart are
pericarditis, cardiac
compressed causing exaggerated decrease in
effusion
systolic BP <10mmHg
Asymptomatic
Confirm 2 elevated BP on 2
Normal < 120/80
visits
Prehypertension <120-139/80-89 Hypertensive emergency diastolic BP > Angiotensin I to II: ↑
>140/90 if <60yo
Stage I 140-159/90-99 120 with N/V, CVA/TIA, subarachnoid
150/90 if >60yo and no co- vasoconstriction will ↑
Stage II >160/100 hemorrhage, MI, acute PE, acute renal
morbidities PVR; younger pts have ↑
Secondary HTN: R/O < 30; severe HTN or failure, retinopathy, papilledema, acute
Kidneys: creatinine, GFR, UA renin levels; alpha, beta
Any change in PVR or acute rise in BP (previously stable), Resistant severe low back pain (dissecting aorta)
Hypertension Endocrine: TSH, fasting blood and calcium channel
CO = change in BP HTN (3 agents); malignant HTN
glucose blockers ↓ PVR;
Renal: renal artery stenosis, polycystic kidney, CKD Isolated systolic HTN – systolic > 160
Electrolyte: K+, Na+, Ca2+ pregnancy system
Endocrine: hyperthyroidism, hyperaldosteronism caused by loss of recoil in arteries ↑ PVR
Heart: cholesterol, HDL, LDL, vascular resistance is
(HTN, low K+, normal to elevated Na+), Thiazides, CCB, and/or ACEI/ARB
triglycerides lowered due to hormones
pheochromocytoma (labile ↑ BP with
Anemia: CBC
palpitations, anxiety, sweating, severe HA)
Baseline EKG and CXR
Other causes: sleep apnea, coarctation of aorta
Stasis – prolonged
bedrest or travel, CHF
Refer
Coagulation
Wells Criteria
Thrombi developed Gradual onset of swelling on lower extremity after + Homan’s sign (33% of pt.), disorders – Factor C
Warfarin takes effect in 3-5 days
Deep Vein from stasis, trauma, prolonged sitting; painful, red, warm, swollen CBC, platelets, PT/PTT, INR, deficiency, Leiden
INR 2-3 with DVT
Thrombosis (DVT) inflammation or extremity. If PE abrupt onset chest pain, dyspnea, d-dimer, chest x-ray, EKG ↑ coagulation –
Clarithromycin ↑ effects of warfarin
coagulation dizziness, or syncope ultrasound contraceptives,
Cholestyramine ↓ effects of warfarin
pregnancy, fracture,
Direct Thrombin inhibitor (Pradaxa)
trauma, surgery,
malignancy
Inflammation of
Acute onset of indurated vein (localized redness, Indurated cordlike vein that is
Superficial superficial vein from NSAIDs, warm compresses, elevation of
swelling and tenderness). Usually located on warm and tender to touch
Thrombophlebitis trauma/secondary limb
extremities. Afebrile and normal vital signs without swelling or edema
infection (S. Aureus)
Smoking cessation, daily ambulation
Narrowing or occlusion Worsening pain on ambulation instantly relieved exercises Foot gangrene, CAD,
Check pedal and posterior
of medium to larger by rest (claudication – angina of calf muscles) Cilostazal (Pletal) – vasodilator can be carotid plaquing
Peripheral Artery tibial pulses, ABI < 0.9
arteries in lower Thin skin, hairless toes, toenails are often thick used with ASA or Plavix (caution if ↑ risk with HTN,
Disease (PAD) Doppler US flow study
extremities and discolored, possible gangrene of toes; grapefruit juice, diltiazem and omeprazole smoking, diabetes, HLD
Refer to vascular
(arterial insufficiency) decreased to absent dorsal pedal pulse taken together) Pentoxifylline (Trental) – Can lead to osteo
effect is marginal
Chronic color changes on fingertips white (pallor),
blue (cyanosis), red (reperfusion); numbness and
Avoid cold objects, cold weather and Small ulcers in
Reversible vasospasm tingling. Can last for several hours
Raynaud’s stimulants, avoid smoking fingertips/toes
of peripheral arterioles ↑ risk of autoimmune disorders: thyroid, Check distal pulses
Phenomenon CCB (Nifedipine or amlodipine) or ACEI Occurs between 15 and 45
of fingers/toes pernicious anemia, RA
Avoid vasoconstricting drugs, no BB yrs. of age
More common in females 8:1; scleroderma
secondary to Raynaud’s

 CARDIOVASCULAR

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Fatigue, palpitations, chest pain, lightheadedness Asymptomatic needs no treatment

S2 “click” – mid to late
aggravated by heavy exertion; May be MVP w/ palpitations tx with BB, avoid ↑ risk thromboemboli,
Mitral Valve systolic murmur
Systolic murmur asymptomatic; associated with pectus excavatum, caffeine, alcohol and cigarettes. Holter TIA, AF and ruptured
Prolapse Cardiac echocardiogram with
hypermobility of joints, arm span greater then monitoring can be used to determine chordae tendineae
doppler flow study
height (Marfan’s syndrome) arrhythmias
Total cholesterol:
Exercise, lose weight, eat healthy fats,
Normal: less than 200
eliminate trans fats, decrease junk food, stop
Risk factors: HTN, Borderline: 200-239
smoking, DASH diet Monitor for myalgias
premature heart High: greater than 240
disease (women < 65 HDL: greater than 40 (low HDL is generally from Fasting lipids starting at age
Target is to lower LDL first unless ↑ Consider stopping
and men < 55) DM, ↑ carb and ↓fat diet) 20 (and every 5 yrs.)
triglycerides (>500) – STATINS cholesterol at age 80 if
Hyperlipidemia dyslipidemia, low HDL, LDL: less than 100 >40 screen every 2-3 yrs.
Triglycerides are raised by alcohol and sugar symptoms, but statins are
cigarette smoking, Triglycerides: less than 150 – pancreatitis If HLD: screen at least
excellent at keeping
obesity, associated with > 1000 (if triglycerides are > 500 annually
Simvastatin interactions: grapefruit, fibrates, atherosclerosis stable so
microalbuminuria, treat triglycerides first – fenofibrate, niacin,
antifungals, macrolides, amiodarone can prevent MI or CVA
CAD, PAD lovanza) (avoid alcohol and Tylenol; could be
metabolic syndrome, DM, familial, alcohol abuse,
Statins can cause memory loss, confusion.
hyperthyroidism, kidney disease, medications
CK, urinalysis
Acute breakdown of Triad of muscle pain, weakness and dark urine
(myoglobinuria/proteinuria),
Rhabdomyolysis skeletal muscle, acute Muscle pain and aches persistent without
BUN, creatinine, potassium,
renal failure associated muscular exertion
EKG
Risk factors: obesity,
Usually asymptomatic; may have hepatomegaly Weight loss, diet diabetes, metabolic
Nonalcoholic Fatty Annual labs show increase of
If symptomatic, fatigue and malaise with RUQ Discontinue alcohol, avoid hepatotoxic drugs syndrome, HTN, certain
Liver Disease Triglyceride fat ALT and AST, negative
pain. Associated with obesity, metabolic (acetaminophen, statins) drugs
(NAFLD) deposits in liver hepatitis A, B, C.
syndrome, DM and HLD REFER GI for Liver biopsy (gold standard) Most common liver
(Fatty Liver)
***can progress to cirrhosis disease in US - #1 reason
for liver transplants
Inherited venous
defect, leg crossing, Tortuous dilated superficial veins; leg aching,
Laser venous ablation, sclerotherapy, Women are affected 2x as
Varicose Veins wearing constrictive mild edema at the end of the day and in warm
surgery much as men
garments, prolonged weather most often great saphenous vein affected
standing, heavy lifting

HEART BLOCK
Ø First Degree AV Block: prolonged PR>0.2 seconds
o If the R is far from P – FIRST DEGREE
Ø Second Degree Type I (Wenckebach): PR is progressively longer
until it drops
o Longer, Longer, Longer, drop then you have
WENCKEBACH
Ø Second Degree Type II: PR constant but drops QRS periodically
o If a QRS don’t get through, then you have MOBITZ II
Ø Third Degree: complete, no pattern between PR and QRS
o If Ps and Qs don’t agree, then you have THIRD DEGREE
 PULMONARY SYSTEM
PNEUMONIA - CURB 65 RANDOM PEARLS
Confusion of new onset Ø Pneumonia causes increased right
Blood Urea nitrogen > 19 PHYSICAL EXAM FINDINGS sided heart workload which can be a
Ø Normal chest percussion sound: resonance heart failure trigger in the older
Respiratory rate > 30 adult
Ø Lower lobes: vesicular breath sounds & upper lobes: bronchial
Blood pressure diastolic < 90 or systolic < 60 Ø Consolidation
Age 65 or older o Dullness to percussion
CLASSIFICATION
o Increased tactile fremitus (have pt. say 99)
CURB-65 Results: o Bronchial or tubular breath sounds, often with late Ø Intermittent Asthma (FEV1 > 80% P)
0-1: treat as outpatient inspiratory crackles that do not clear with cough o Symptoms < 2 days week
2: consider short stay in hospital or watch very closely as o Egophony: “eee” sounds like ah Ø Mild (FEV1>80% Predicted)
outpatient Ø Pleural inflammation o Symptoms > 2 days week,
3-5: Requires hospitalization with consideration as to o Sharp, localized pain, worse with deep breath, but not daily
whether patient needs to be in the intensive care unit. movement, cough o Night time 3-4/month
o Audible pleural friction rub (sounds similar to stepping o Minor limitation
in fresh snow) – heard on inspiration & expiration Ø Moderate (most common) 60-80%P
ASTHMA/COPD Ø Air trapping o Symptoms daily
o Hyperresonance o Night time > 1x week
COPD ASTHMA
o ↓ tactile fremitus o Some limitation
LAMA LABA ICS Ø Severe (FEV1<60% Predicted)
-ium & terol one o Wheeze (exp. first, insp. later)
o Low diaphragms o Symptoms throughout day
glycopyrrolate ide o Night time often 7x week
SABA (beta2 agonist) o ↑ AP diameter
o Extreme limitation
How often? 1-2x/wk.
More often (add)
INHALED CORTICOSTEROIDS (ICS)
Less often (drop)
Ø Preferred controller tx for persistent asthma STEP WISE
Ø Requires constant daily use for optimal effect Ø Intermittent Asthma
INHALED MUSCARINIC ANTAGONIST Low dose Medium High dose o SABA
Ø Emerging role in asthma dose Ø Step 2
Ø Well established in COPD (offer protracted duration) Beclomethasone 80-240mcg >240- >480mcg o Low dose ICS
Ø Used for prevention, not treatment (use scheduled) (QVAR) 480mcg Ø Step 3
o SAMA - Ipratropium bromide (Atrovent) Budesonide 180- >540- >1080mcg o Low dose ICS + LABA or
§ bronchodilation (Pulmicort) 540mcg 1080mcg o Medium dose ICS
o LAMA - Tiotropium bromide (Spiriva); Fluticasone (Flovent) 88-264mcg 264-440mcg >440mcg Ø Step 4
umeclidinium (Ellipta) Mometasone 100- 300-500mcg >500mcg o Medium dose ICS + LABA
Ø Anticholinergic – can contribute to worsening BPH (Asmanex) 300mcg and consider omalizumab
o If occurs switch from LAMA to LABA such as for allergies
salmeterol Ø Step 5
INHALED CORTICOSTEROIDS/LONG ACTING BETA2 AGONIST (ICS/LABA) o High dose ICS + LABA + oral
Ø Preferred controller tx for moderate to severe persistent corticosteroid and consider
asthma omalizumab for allergies
LEUKOTRIENE MODIFIER
Ø BLACK BOX: ↑death in asthma patients using LABA
Ø Additional benefit with allergic rhinitis, most often in Ø Requires consistent, daily use for optimal effect
conjunction with ICS o Budesonide + formoterol (Symbicort) PDE-4 INHIBITOR
Ø Requires consistent daily use for optimal effect o Fluticasone + salmeterol (Advair) Ø Roflumilast (can induce psychosis)
o Montelukast (Singular) o Mometasone + formoterol (Dulera) Ø Minimizes risk of COPD exacerbation
 COPD: FEV1/FVC < 70 PULMONARY SYSTEM
Ø Dramatically increases right sided heart workload

THEOPHYLLINE PNEUMOCOCCAL VACCINES

In patients with FEV1/FVC<0.70
Ø Bronchodilator Ø PPSV23
GOLD 1 Mild FEV1 > 80% predicted
Ø Used on daily set schedule o 19-64 asthma, COPD, CVD, smoker
GOLD 2 Moderate 50% < FEV1 < 80% predicted
o Age 65+
GOLD 3 Severe 30% < FEV1 < 50% predicted Ø PCV13
GOLD 4 Very severe FEV1 < 30% predicted o 19-64 with asplenia,
First Line therapy:
SPIROMETRY
immunocompromised
Ø GOLD 1-2: (don’t commonly see in clinic) Ø Obstructive dysfunction: (reduction in airflow rates)
o Age 65+
o <1 exacerbation per year o Asthma, COPD, bronchiectasis
o Low risk: SAMA or SABA prn Ø Restrictive dysfunction: (reduction of lung volume due
o High risk: LAMA or LABA set schedule to decreased lung compliance)
o Pulmonary fibrosis PULMONARY EMBOLISM
Ø GOLD 3-4:
o Pleural disease Ø Tachypnea is most common presentation
o >2 exacerbation per year
o Diaphragm obstruction
o ICS + LABA or LAMA on set schedule
Ø Not recommended during exacerbation
****LAMA + ICS with LABA (commonly used)
Ø Effective use of long-term oxygen requires at least 15 CHEST X-RAY
hours a day
Ø PA – x-ray goes through back
Ø Beta agonist – stimulant or bronchodilation
PEAK EXPIRATORY FLOW: PEF Ø AP – x-ray goes through front of chest
o (beta1 heart) (beta2 lung)
Ø PEF is based on HAG Ø Air: appears black (low density so less
Ø SABA (4 hrs.) / LABA (12 hrs.)– palpitations,
o Height absorption)
tachycardia. Use caution in HTN, angina and
o Age Ø Bones: appears white
hyperthyroidism. Avoid combining with caffeinated
o gender Ø Metals: bright white (high absorption)
drinks.
Ø Tissue: Different grayish shades (medium
Ø Anticholinergics – (prevent bronchoconstriction) -
absorption)
tropium avoid if patient has narrow-angle glaucoma,
Ø Fluid: Grayish to whitish
BPH or bladder neck obstruction COUGH
Ø Tissues visible: trachea, bronchus, aorta,
Ø Exacerbations – Corticosteroids with possible Ø How long have you coughed?
heart, lungs, pulmonary arteries,
antibiotics Ø Acute < 3 weeks
diaphragm, gastric bubbles, ribs
o Acute respiratory infection
***Unilateral finding on lung exam warrant CXR
ASTHMA o Exacerbation of COPD, asthma
***Hilar nodes require follow-up
Ø Risk factors for fatality o Pneumonia
o Hx of ED visits o PE
o Frequent use of rescue inhaler Ø Chronic > 8 weeks
o Nocturnal awakenings o Asthma CHRONIC STEROID USE
o Increased dyspnea and wheezing o GERD Ø Osteoporosis
o Respiratory viral infection o Pertussis, atypical pneumonia o Calcium with Vitamin D 1200mg for
o ACE inhibitors (begins 1-2 weeks after menopausal women
starting med) Ø Growth failure in children
PNEUMONIA o Chronic bronchitis Ø Glaucoma
Ø Young otherwise healthy – atypical pathogen o Bronchiectasis Ø Cataracts
o Macrolide or doxycycline o Lung cancer Ø Immune suppression
Ø Complicated Ø Hypothalamic-pituitary-adrenal suppression
o Fluoroquinolone
o Macrolide plus beta-lactam
PULMONARY SYSTEM
 PULMONARY SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Hx of A fib, estrogen
therapy, smoking, Sudden onset dyspnea and coughing. Cough
surgery, cancer, may be productive of pink-tinged frothy
Pulmonary Emboli
pregnancy, long bone sputum. Tachycardia, pallor and feelings of
fractures and prolonged impending doom
inactivity
Impending Tachypnea, tachycardia or bradycardia,
Cyanosis and quiet lungs. Epi stat. 911 oxygen, albuterol nebs,
Respiratory Failure cyanosis and anxiety. Patient appears
May speak in 1-2-word parenteral steroids, antihistamines and H2
- Asthmatic exhausted, fatigued, diaphoretic and uses
sentences blocker
Exacerbation accessory muscles to help with breathing.
High risk: > 2
exacerbations in last year,
FEV1 < 50%, hospitalized
Chronic cough (2 years), chronic sputum Smoking cessation, pneumonia & flu vaccine,
for COPD in past year
production, shortness of breath worse with Acute exacerbation: SABA, LABA, ICS
Spirometry FEV1/FVC **rarely see under age 40
physical exertion, progressive symptoms, Acute prednisone 40mg/day x 5-10 days
Alveolar damage from <0.70 post- Chronic bronchitis:
COPD – barrel chest, weight loss; hyperresonance upon **↑ dyspnea, ↑ sputum volume & purulence
loss of elastic recoil of bronchodilation. cough with excessive
can include chronic percussion, tactile fremitus and egophony is may need antibiotic; higher risk for Strep
lungs, exposure of Classification of severity mucous for 3+ months
bronchitis and decreased; CXR may show hyperinflation; pneumonia & H. influenzae –Augmentin
irritants determined by FEV1 for 2+ years
emphysema bullae sometimes present; coarse crackles (avoid due to GI upset) Cefdinir, macrolide
Airflow limitation CXR only when trying to
Alpha-1 antitrypsin deficiency screening (avoid due to CV risk); resp. fluoroquinolone
R/O pneumonia Complex patients with
< 45yrs (↑ tendon rupture)
co-morbidities:
** pack year smoker – COPD**
Multiple meds, drug-
drug interactions, drug-
disease interactions
Strep pneumoniae; S. pneumoniae: macrolides, doxycycline, Flu vaccine > 50yo
Sudden onset high fever w/ chills, productive Chest x-ray-lobar
H. influenzae; DRSP: high dose amoxicillin, resp. Pneumo vaccine >65yo
cough and purulent sputum (rust-colored if consolidation (note: middle
Mycoplasma; fluoroquinolones. Smokers – H.
Community- strep pneumo). c/o pleuritic chest pain w/ lobe is anterior chest by
Chlamydophila Minimum 5 days (most 5-7 days) Influenza
Acquired coughing and dyspnea nipple)
pneumonia; No comorbidities: Macrolides, S. pneumoniae affects
Pneumonia (CAP) Rhonchi, crackles or wheezing with dullness CBC: leukocytosis (>10.5)
Cystic fibrosis: doxycycline young and old
over affected lobe, ↑ tactile fremitus and look for anemia
Pseudomas aeruginosa Comorbidities: resp. fluoroquinolones, or Lung cancer can present
egophony; abnormal whispered pectoriloquy
(Gm-) macrolide plus beta-lactam as recurrent pneumonia
Fatigue w/ paroxysmal coughing that’s
Mycoplasma;
nonproductive; gradual onset starting like a ***Legionella –
Chlamydophila
Atypical cold; most continue to work/school regardless Physical, chest x-ray shows Macrolides, resp. fluoroquinolones, contaminated by inhaling
pneumonia;
Pneumonia of symptoms diffuse infiltrates, CBC doxycycline; antitussives, fluids/rest mist from a water source.
Legionella
Wheezing with diffuse crackles/rhonchi, Also accompanied by GI
rhinorrhea, erythematous throat
Sudden onset new cough that’s dry and possible Exacerbation of asthma
Symptomatic: dextromethorphan, Tessalon
Virus causing small amts sputum; frequent paroxysms of Pneumonia from
PERLES, guaifenesin, severe wheezing
Acute bronchitis inflammation of Upper coughing, possible low-grade fever, wheezing History, possible chest x-ray secondary infection
Atrovent or albuterol inhaler consider
respiratory tract and chest pain w/ cough; cough keeping him ***On rare occasion
steroids 40mg for 3-5 days
awake at night macrolide or doxycycline
Nasal swab for culture and
Cough lasting longer than 14d with 1 of 1st line: macrolides
PCR
following: paroxysmal coughing, inspiratory Chemoprophylaxis for close contacts Complications: Sinusitis,
Pertussis Bordetella pertussis Pertussis antibodies by
whooping w/o cause. Can last months. 3 stages: Respiratory precautions OM, pneumonia, fainting,
“whooping cough” bacteria (Gm -) ELISA
catarrhal, paroxysmal, convalescent. Most Antitussives, mucolytics, rest and hydration rib fractures
CBC: lymphocytosis (80%
infectious early in disease Tdap booster > 11yo
lymphocytes in WBC)

 PULMONARY SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Report to health department

Mantoux positive if induration- Risk factors: HIV,
Mantoux test: >10mm
>5mm: HIV+, recent contact, CXR w/ migrants, homeless,
QuantiFERON or T-SPOT
previous TB disease, Immunocompromised inmates and nursing
IGRA (avail w/in 24h)
Fever, anorexia, fatigue, night sweats, cough. As >10mm: immigrants, child less than 4, IV homes
Mycobacterium Sputum – early morning
Tuberculosis progresses, productive cough w/ hemoptysis drug users, health care workers, homeless; Prior BCG vaccine may
tuberculosis and collect for 3 days –
and unexplained weight loss employees of jails, nursing homes cause false positive
NAAT, C&S and AFB
>15mm: person w/o risk Ethambutol causes optic
CXR: affects upper lobes
Isoniazid (INH) 300mg daily, rifampin, neuritis – avoid if
ethambutol and pyrazinamide 3x a week abnormal vision
(check baseline liver functions)
Consider bone density for
Recurrent cough, wheeze (end expiration),
Rescue meds: SABA those on long-term
shortness of breath and/or tightness of chest
long-term control: inhaled corticosteroids steroids
due to variable airflow obstruction and
↑ FEV1 > 12% using Step-up therapy if not controlled; Treatment Goals:
bronchial hyperresponsiveness triggered by
spirometry; Acute prednisone 40-60mg/day x 3-10 days Perform normal activities
Chronic inflammation of underlying airway inflammation (predictable
Height, age, gender Written Asthma action plan; Minimal to no
Asthma bronchial tree pattern of symptoms)
PFT measures effectiveness PEAK flow is used to monitor exacerbations
Reversible disease Symptoms worse at night or with exercise, viral
of treatment and Well controlled – F/U 3-6 months Minimal use of rescue
infections or exposure to smoke
exacerbations Not well controlled 2-6 weeks inhaler (<2 days a week)
Typical early in life onset
**See all asthmatics in Sept to get on Avoid ED
Triad: wheeze, cough and chest
controlled drugs and immunizations Maintain normal PFT
tightness/SOB

Asthma COPD
X
LUNG CANCER SCREENING
Consider steroid
Ø Symptoms: first for treatment
X
o Chest discomfort, dyspnea, hemoptysis, cough
Anticholinergics are
Ø High risk patients
not usually helpful
o Age 55-74 who smoked at least 30 pack year and/or Disease is X
have quit in last 15 yrs.
progressive
o High risk smokers at age 50
NEVER!! LABA alone is safe X
Ø Current limitations include:
X Steroid alone is
o High false-positive rate safe
o Radiation exposure from multiple CT scans
X Needs rescue X
o Patient anxiety
inhaler
 WHEN TO USE INSULIN ENDOCRINE SYSTEM
All Type 1 DM patients
Basal insulin with adjustments for meals DIABETIC MEDICATIONS FOR DM
- Basal 40-50% total daily insulin
Ø Consider what therapeutic goal is? Correction of fasting glucose, postprandial glucose, action on insulin resistance, increasing
- Bolus 50-60% total daily insulin, given in
insulin availability, offloading of glucose? Hypoglycemia risk? Cost? Adverse effects?
response to carb intake post meals and
Ø BIGUANIDE – insulin sensitizer, ↓ hepatic glucose production and intestinal glucose absorption. Action on fasting &
with snacks (2 Units to 15 carbs
postprandial. Minimal to NO hypoglycemia when used alone.
Type 2 DM patients
o Metformin/Glucophage (1500-2000/day prevention)
- At time of diagnosis to achieve initial
§ A1c reduction 1-2%
glycemic control if A1c >9%
§ Contraindicated: eGFR < 45, acidosis, alcoholic, hypoxia, Active liver disease (hep C), heart failure
o Short course 2-3 weeks
• FYI – can use 1000mg daily for GFR 30-45 – don’t start them on it, but can continue
- A1c > 10%
§ ↑ B12 deficiency (after on meds > 5 yrs.) – ok to give in Stage 1 Heart Failure
- When > 2 standard agents are
§ Risk of lactic acidosis (rare)
inadequate
§ Hold if IV contrast dye testing for 48h
- Start 0.1-0.2 u/kg or 10 units
§ Side effects: diarrhea, flatulence and nausea
- Adjust 2-4 u (or 10-15%) 1-2x weekly to
Ø THIAZOLIDINEDIONE (TZD) – insulin sensitizer. Action on fasting & postprandial. Minimal to NO hypoglycemia used alone.
reach FBG goal (80-130 in am)
- If hypoglycemia – decrease by 4 units o Pioglitazone (Actos), Rosiglitazone (Avandia) – monitor ALT
(10-20%) § A1c reduction 0.7%
- If am is reached, but during the day it § Avoid heart disease/CHF, causes edema, rare risk of bladder cancer, liver toxicity, weight gain, fractures
spikes – Ø SULFONYLUREA – stimulates b-cells to secrete insulin – Action on fasting & postprandial. HYPOGLYCEMIA RISK
o Basal Plus: short acting insulin o Glipizide (Glucotrol)**preferred over glyburide in older adult, Glyburide (Diabeta) **long half-life; BEERS criteria
before biggest meal of day avoid, Glimepiride (Amaryl) - cheap
o Basal Bolus: bolus at each meal § A1c reduction 1-2%
§ Acts like basal insulin – constant insulin release (less effective after many years)
§ adjust dose in renal impairment
§ Side effects: weight gain and hypoglycemia
Ø DPP-4 INHIBITOR - ↑ insulin release, largely in response to ↑blood glucose post meal. Action largely on postprandial.
Minimal to NO hypoglycemia, expensive
o A1c reduction 0.6-1.4%
INSULINS o Sitagliptin (Januvia), Saxagliptin (Onglyza), linagliptin (Tradjenta), alogliptin (Nesina) – weight neutral, oral agents
Onset Peak Duration o Pancreatitis risk and unexplained joint aches
Rapid acting 15 min 30 min 4.5 hrs.
Ø MEGLITINIDE – minimize postprandial hyperglycemia; Repaglinide (Prandin) and Nateglinide (Starlix)
(Lispro, – 2.5
Ø GLP-1 AGONIST – ↑ insulin release, largely in response to ↑blood glucose post meal. Action largely on postprandial. Minimal
Aspart) hr.
hypoglycemia, expensive. Injection only.
Short acting 30 min 1-5 6-8 hrs. o A1c reduction 1-1.5%
(Regular) hrs. o Exenatide (Byetta, Bydureon), liraglutide (Victoza), albiglutide (Tanzeum), dulaglutide (Trulicity)
Intermediate 1 hr. 6-14 18-24 o Slows gastric emptying, leading to appetite suppression and possible weight loss
NPH hrs. hrs. o N/V, contraindicated in gastroparesis, rare pancreatitis risk, avoid in severe renal impairment or ESRD
Basal 1 hr. None 24 hrs. Ø SGLT2 INHIBITOR – lower plasma glucose by ↑ amount of glucose excreted in urine. Primarily postprandial effect.
(Lantus Levemir HYPOGLYCEMIA RISK when used with insulin and insulin secretagogues (Sulfonylurea, DPP-4 inhibitor, GLP-1 agonist)
Levemir) usually
o A1c reduction 0.7-1%
BID
o Canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance) – weight loss, lowers BP
Mixture 30 min. 4.4 24 hrs.
70/30 hrs. o ↑ risk GU infection adjust dose in renal impairment, DKA and urosepsis risk

ADDITIONAL DIABETES CONSIDERATIONS
Ø A – Aspirin (81-162 mg daily) in most, esp. men > 50
and women > 60 with DM and > 1 additional CVD
risk factor such as HTN, smoking, family hx
Ø B – BP controlled > 2 agents including ACEI/ARB and
thiazide
Ø C – Cholesterol: statin therapy > 40 or hx ACS. Goal
Lipids < 100
Creatinine (renal function): serum creatinine,
calculated GFR and urine microalbumin annually
Ø D – Diet: limit trans and saturated fat. Schedule with
dietician if needed
Dental care: reinforce
Ø E – Exercise: > 150 min/week (walking) + resistance
exercise 3x week
Eye exam: annually (diabetic retinopathy)
o Neovascularization (new growth of fragile
arterioles in retina), microaneurysms,
cotton wool spots, soft/hard exudates
Ø F – Foot exam: visually every visit & monofilament
at minimum annually
Ø G – Goals of care
SOMOGYI EFFECT
Ø Severe nocturnal hypoglycemia stimulating glucagon to be
released from the liver
Ø High FBG by 7:00a, usually due to overtreatment with
evening or bedtime insulin – more common in Type 1
Ø Diagnosed by checking glucose at 3am for 1-2 weeks
Ø Tx: Snack before bedtime or eliminate/lower bedtime
NPH/regular insulin
DAWN PHENOMENON
Ø Elevation in FBG daily early in morning from increase in
insulin resistance between 4 and 8am caused by spike in GH
and glucagon
ENDOCRINE SYSTEM
ENDOCRINE FACTS
Ø Endocrine works as negative feedback – low level of active hormone stimulates production.
Ø Hypothalamus stimulates anterior pituitary gland into producing stimulating hormones (FSH, LH, TSH) – these
hormones tell organs to produce hormones.
Ø Hypothalamus: coordinates nervous and endocrine system by sending signals, produces neurohormones that
stimulate or stop production
Ø Pituitary Gland:
Hypothalamus
TRH, GnRH, CRH, GHRH, Somatostatin
“On or Off” Switch
Released by Anterior Pituitary
TSH, FSH, LH, GH, ACTH, MSH, Prolactin, Vasopressin, and Oxytocin
Target Organs
Thyroid (TSH): T3 and T4 (thyroxine) – free or bound (no impact on metabolism)
Ovaries/Testes (FSH/LH): estrogen, progesterone, androgens, testosterone
Adrenal Cortex (ACTH): glucocorticoids, mineralocorticoids
Body (GH): somatic growth
Uterus (oxytocin): uterine contractions, bonding
Kidneys (vasopressin): blood volume
Pineal (melatonin): circadian rhythm
Breast (prolactin): milk production
Ø Posterior pituitary: secretes antidiuretic hormone and oxytocin which are made by hypothalamus and stored
and secreted by posterior pituitary
Ø Thyroid gland: uses iodine to produce T3 (huge impact on metabolism – 5x) and T4 (small changes affect TSH)
Ø Parathyroid glands: produce PTH which is responsible for calcium balance of body by regulating calcium loss
or gain from bones, kidneys and GI tract
Ø Pineal gland: pea-sized gland in brain that produces melatonin.
RANDOM OBESITY PEARLS
Ø Orlistat – take within an hour of each meal that contains fat
Ø Belviq – avoid with medications that have serotonergic effect
Ø Phentermine – teratogenic effects
Ø Serotonin is responsible for the sensation of satiety
Ø 1 pound of fat contains 3500 calories
Ø 10,000 steps is = 4-5 miles
Ø Weight loss meds: if not achieved 5% weight loss by week 12, discontinue therapy
Ø Weight loss of 10%+ yields immediate reduction in death from cardiovascular and cerebrovascular disease
Ø Bariatric surgery- most dramatic weight loss is seen in first few months, calcium absorption will be reduced,
rapid weight loss can contribute to gallstones, lifelong vitamin B12 supplementation is recommended
Ø Obesity can lead to OSA, steatohepatitis, female infertility and endometrial cancer
 ENDOCRINE SYSTEM

THYROID
HYPOTHYROID HYPERTHYROID
THYROID
SKIN Thick, dry Smooth, silky Ø Thyroid-stimulating hormone (TSH) NL 0.4-4.0 (goal 1.2)
o Evaluates hypothalamic-pituitary function
REFLEXES “hung up” patellar reflex, slow arc Hyperreflexia
§ Anterior pituitary ability to detect circulating
out, slower arc back, overall
free thyroxine
hyporeflexia
o When TSH normal, thyroid disease ruled out
MENTATION “can’t make sense, thoughts too “Can’t make sense, mind
Ø Free T4 (free thyroxine)
slow” racing”
o Unbound, metabolically active portion of thyroxine
WEIGHT CHANGE Small gain 5-10 lbs. Loss ~ 10 lbs.
o F/U test to confirm, support dx of hypo or
STOOL PATTERN Constipation Frequent, low volume,
hyperthyroidism with abnormal TSH
loose
Ø Thyroid peroxidase antibody (TPO Ab)
MENSTRUAL ISSUE Menorrhagia Oligomenorrhea o Test to help detect autoimmune thyroid disease
HEAT/COLD INTOLERANCE Easily chilled Heat intolerance o Measures antibody against peroxidase
OTHER Hypertriglyceridemia Proximal muscle weakness Ø Total T4 (total thyroxine)
Tachycardia, HTN o Reflects the total of the protein-bound and free
thyroxine
o (useless – altered with medications, clinical conditions)

THYROID NODULE TOXIC ADENOMA Untreated hypothyroidism, inadequate thyroxine dose

Ø Solitary Thyroid Nodule Ø Benign, metabolically • ↓ Free T4 = ↑ TSH
o Palpable thyroid mass > 1 cm in diameter active thyroid nodule
o 5% chance of malignancy Ø Autonomously
Untreated hyperthyroidism
functioning adenoma:
Ø Malignant Thyroid Nodule Painless thyroid nodule • ↑ Free T4 = ↓ TSH
o Hx head or neck irradiation with undetectable TSH
o Size > 4 cm Ø Drugs that affect thyroid: Lithium, amiodarone, high doses of
o Firmness, Nontender on palpation iodine, interferon-alfa, dopamine (lithium can damage thyroid)
o Relatively fixed position (non-mobile) Ø Natural thyroid contains fixed doses of T3 and T4 and has
different pharmakinetics than levothyroxine
o Persistent Nontender cervical lymphadenopathy
Ø Excessive use of levothyroxine includes bone thinning
o Dysphonia Ø Periodic routine screening is recommended with Down
HYPERPARATHYROIDISIM
o Hemoptysis Ø Common cause in Syndrome
Ø TSH, Thyroid ultrasound asymptomatic patient Ø Hypothyroidism - ↑ LDL, hyponatremia, ↑ MCV, ↑ CK
o ↑TSH – metabolically inactive (most common) with hypercalcemia
§ Fine needle aspiration biopsy (refer) Ø ↑ Calcium and PTH
Ø ↓ phosphorus
• Most cost effective
Ø ↓ potassium
o ↓TSH – metabolically active
BETA BLOCKERS
§ Nuclear med thyroid scan Ø Beta-adrenergic antagonist with beta 1 blockade
• Hot – metabolically active o 1 heart
o radioactive ablation or Ø Beta-adrenergic antagonist with beta 1 blockade
surgery o 2 lungs, 2 arms, 2 legs (tremors)
• Not hot – metabolically inactive
o Fine needle aspiration
o Cold usually cyst
 ENDOCRINE

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

↑ risk with radiation

therapy from childhood
Single thyroid nodule usually in upper half of one
cancer (Wilms tumor,
lobe, may be accompanied by enlarged cervical Occurs in women 3:1
Thyroid Cancer lymphoma,
nodes. May complain of hoarseness and Age 20-55
neuroblastoma) or low-
dysphagia.
iodine diet; family hx
of thyroid cancer

Random episodes of headache (mild to severe)

diaphoresis, tachycardia, HTN. Episodes resolve
Pheochromocytoma
spontaneously. Pt’s vitals are normal in between
attacks.

Sign of pituitary adenoma. Check prolactin if

Slow onset. Women may present with galactorrhea or
Hyperprolactinemia amenorrhea. Galactorrhea in both males and Serum Prolactin ↑ gynecomastia – big
females. When tumor is large enough, pt. will boobs or lactating =
complain of headaches and vision changes. prolactin
Refer to Endo for RAIU
Start on beta-blocker (propranolol, nadolol)
↓ TSH, ↑ T3/T4 to counteract tachycardia and tremors
Tachycardia, rapid weight loss, irritability, If Graves: + thyrotropin Propylthiouracil (PTU) and Methimazole ↑ incidence in women 7:1
anxious, hyperactivity, insomnia, possible HTN, receptor antibodies (TRAb). (Tapazole) shrinks gland/↓ hormone ↑ risk for RA, pernicious
Hyperthyroidism Graves’ disease most a fib or PAC, sweaty, exophthalmos, diarrhea, Thyroid peroxidase antibody production (rash, anemia, anemia, osteoporosis
(thyrotoxicosis) common cause amenorrhea, heat intolerance, fine tremors, brisk (TPO) is positive in Graves thrombocytopenia, hepatic necrosis) Thyroid storm ↓ LOC,
deep tendon reflexes, CHF. goiter and Hashimotos radioactive iodine (ablation – then need fever, abdominal pain
Thyroid Ultrasound levothyroxine)
Supplement with Calcium and Vitamin D
1200mg plus weight-bearing exercise
Use ideal body weight if pt. obese.
• Adults 1.6mcg/kg/day Levothyroxine should be
Fatigue, weight gain, cold intolerance, ↑ TSH, ↓ free T4 (normal
taken with water on an
Hashimoto’s constipation, menstrual abnormalities, alopecia or low T3) • Elderly (Start 25mcg)
empty stomach. Avoid
(autoimmune), on outer 3rd of eyebrows, may have ↑ cholesterol. • Child 4mcg/kg/day taking within 2 hours of
Hypothyroidism postpartum, and May have atrial fib. ** subclinical • ↑ by 33% in pregnancy calcium, iron, aluminum,
thyroid ablation with Myxedema may have poor thinking/memory, hypothyroidism has elevated
magnesium.
radioactive iodine hypotension, hypothermia TSH and normal free T4 & Check TSH about 8 weeks after tx Report palpitations,
Symptoms are very variable T3
nervousness, tremors
Symptoms vary and develop over months. Chronic
Primary: ↓ cortisol Corticosteroid replacement therapy
diarrhea, N/V, loss of appetite, paleness or
and sometimes AM Cortisol level Ample sodium during heavy exercise, hot
darkening of the skin with a possible patchy Glucocorticoids (Cortisol)
aldosterone produced K+, Na+, ACTH climates and GI upsets.
Addison’s Disease appearance, muscle fatigue, weakness, slow or Mineralocorticoid
by adrenal glands Abdominal CT for adrenal During crisis, an immediate injection of
sluggish movement, hypoglycemia, low BP, (Aldosterone)
Secondary: pituitary glands, MRI pituitary gland hydrocortisone is needed along with support
fainting and salt craving. During crisis,
gland is diseased for low BP
symptoms appear suddenly
Progressive weight gain and fatty tissue deposits,
↑ levels of cortisol for AM Cortisol level Taper steroids as soon as possible; Can lead
particularly around midsection and upper back, in ↑ in school work so
extended period (long Syndrome caused by tumor to heart failure or MI, osteoporosis, HTN,
the face (moon face) and between shoulders
Cushing’s term steroid use) or Urine, blood and saliva can DM, frequent infections and loss of muscle central obesity – very
(buffalo hump), Striae on abdomen, thinning
overproduction of
fragile skin that bruises easily, slow healing.
evaluate cortisol levels ***Spironolactone– treat for hirsutism (can uncush….. "
%
$
#
ACTH; pituitary tumor MRI or CT pituitary gland cause galactorrhea or gynecomastia)
Fatigue, muscle weakness, hirsutism

 ENDOCRINE SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

A1c > 6.5%

Unexplained weight loss despite eating a lot of Microvascular:
Autoimmune disorder Fasting blood glucose >126
food, ketonuria, polydipsia, polyphagia and Check A1c q3months until well-controlled retinopathy, nephropathy
B-cell destruction Random glucose >200 with
Diabetes Mellitus polyuria, blurred vision, breath has “fruity odor” Lipid profile yearly and neuropathy
results in abrupt polydipsia, polyphagia,
Type 1 ketones in urine. Usually dx in the acutely ill child Yearly urine for microalbuminuria Macrovascular:
cessation of insulin polyuria and unexplained
or younger adult (4-6 or 10-14) ACEI or ARB for HTN (helps renal system) atherosclerosis, CAD, MI
production weight loss
DKA – drowsiness, lethargy
OGTT > 200
Every visit: BP, feet, lifestyle - healthy
eating, weight control, ↑ physical activity
(150 min. week);
Insulin resistance with
<140/90 (ADA prefers <130/80) Increased risk
eventual insulin Screening ADA: Yearly: flu shots, Aspirin 81mg daily, yearly (diabetic in training)
deficiency
• Annual for BMI > 25 eye exam/dental exam, thyroid, lipid profile, A1C 5.7-6.4%
and 1+ risk factor urine microalbuminuria IFG 100-125
Risk factors: age > 45
• Everyone > 45 every 3 Set A1c goal with patient. IGT= 140-199
overweight or obese,
Few if any symptoms, usually dx during routine years if normal A1c goal: <7% for most, 6% with low risk, ***A1c 2x year in those
abdominal obesity,
screening; acanthosis nigricans (cutaneous <8% for elderly (varies with pt. attitude, risk meeting goals and
Diabetes Mellitus sedentary lifestyle,
manifestation of hyperinsulinemia) commonly A1c > 6.5% for hypoglycemia, life expectancy, shorter quarterly in those not
Type 2 family hx 1st degree
seen on groin folds, over knuckles and elbows – IFG > 126 duration with tighter control, comorbidities) meeting goals
relative, HTN,
will regress with weight loss and physical activity Random glucose >200 with Pre-prandial 80-130; Peak postprandial
HLD < 35, PCOS, hx
polydipsia, polyphagia, < 180; Bedtime 90-150 Meds that can ↑ risk of
vascular disease,
polyuria and unexplained Start with Metformin (always prescribe with Type 2 DM –
metabolic syndrome,
weight loss largest meal of day 500mg → 1000mg → glucocorticoids, HCTZ,
Hispanic, African
OGTT > 200 1500mg → 2000mg) atypical antipsychotics,
American, Asian or
Need ACEI statins
American Indian
multi drug combo such as: patient specific-
metformin, sulfonylurea (improve fasting)
add DPP4 (post meal insulin release)

Dual Therapy: Metformin Plus

Sulfonylurea TZD DPP4 SGLT2 GLP – 1

Efficacy High High Intermediate Intermediate High
Hypoglycemia Risk Moderate Low Low Low Low
Weight Gain Gain Gain Neutral Loss Loss
Side Effects Hypoglycemia Edema, CHF, Fracture Rare GU, dehydration GI
Cost Low Low High High High
Metformin unless contraindicated
A1C > 9: Consider dual therapy initially
A1C > 10-12: injectable insulin until less glucose toxic
BG > 300: injectable insulin until less glucose toxic
***Meglitinides for irregular eating schedule
DC sulfonylureas, glitazone after initiating insulin (SU plus insulin is less efficacious with more weight gain)

 GASTROINTESTINAL SYSTEM
CONSTIPATION
HEMORRHOIDS
Ø Idiopathic and functional
Ø Lifestyle factors Ø Grade I – no prolapse, Grade II – prolapse upon defecation but reduce spontaneously, Grade III –
hemorrhoids prolapse upon defecation and must be reduced manually, Grade IV – hemorrhoids are
o Immobility
prolapsed and cannot be reduced manually.
o Low-fiber diet
Ø ↑ risk excessive alcohol, chronic diarrhea or constipation, obesity, high fat, low fiber diet, prolonged
o Dehydration sitting, sedentary lifestyle, anal intercourse and loss of pelvic floor muscle tone.
o Milk intake
o Ignoring the urge to have BM
Ø Drugs contributing to constipation HEPATITIS SEROLOGY
o Iron supplements Ø IgG – produce after the infection is Gone
o Beta-blockers o Antibodies present (immune)
o Calcium channel blockers § No virus / not infected
o Antihistamines Ø IgM – antibody you make the Minute you get infected
o Anticholinergics o Acute infection – contagious
o Antipsychotics § No immunity
o Opiates Ø Hepatitis A
o Calcium-containing antacids o Fecal-contaminated food/water
Ø Treatment o Anti-HAV IgG – positive
o Bowel retraining § Immune to HAV
o Dietary changes o Anti-HAV IgM – positive
o Ingest bulk forming fiber (25-35 g/day) § Acute infection
o Increase physical activity o Anti-HAV IgM and IgG negative – no immunity, needs immunization
o Increase fluid intake (8-10 glasses) Ø Hepatitis B
o Consider laxatives o HBsAg – (surface antigen) screening for Hep B
§ Positive – has virus on board
o Anti-HBs (surface antibody)– positive
ANAL FISSURE § Antibodies present / immune
Ø Ulcer or tear of anus, most often posteriorly o Anti-HBc (totally Hep B core antibody) ***rotten to the core***
Ø Severe anal pain (razor blades) with bowel o IGM anti-HBc
movements lasting hours after the BM – pain leads Ø Hepatitis C
to constipation and drops of blood when wiping o Injection drug use
Ø Risk factors include constipation, diarrhea, o Anti-HCV – screening for Hep C (? Exposure – if negative order HCV RNA)
childbirth, anal sex § If positive – order HCV RNA or PCR to r/o chronic infection
Ø Primary treatment is to prevent constipation - ↑ • If positive RNA/PCR has Hep. C – refer
dietary fiber, laxative (mineral oil – avoid long term o Screen those born from 1945-1965
use due to inability to absorb A, D, E, K vitamins), Ø Hepatitis D
sitz bath, cool compresses. If these measures fail o Requires presence of Hep. B. Can be acute/chronic
NTG, Botox, surgical sphincterotomy o Infection of B/D increases risk for cirrhosis and liver damage
Ø
 GASTROINTESTINAL SYSTEM RANDOM INFO
Ø Prolonged PPI Usage

o Vitamin B12, calcium,
ABDOMINAL MANEUVERS (POSITIVE IN APPENDICITIS) ABDOMINAL MANEUVERS magnesium, iron
Ø Psoas/Iliopsoas (supine) – Flex hip 90° have pt. Ø Markle Test (heel jar) – malabsorption, possible ↑ fx
push against resistance and to straighten leg o Raise heels then drop suddenly or jump. and C. diff risk

Positive if pain is elicited or pt. refuses due Ø Partial obstruction plus chronic low
to pain. volume bleeding
Ø Involuntary Guarding o Esophageal Stricture
o Abd. Muscles reflexively become tense o Esophagitis
when palpated o Esophageal Cancer
Ø Rebound tenderness/Blumberg § Needs endoscopy
Ø Obturator sign (supine) – Internal rotate right hip
o Abdominal pain worse when palpating Ø Bowel obstruction – abdominal pain
full ROM. + pain with movement/flexion of the hip
hand releases suddenly associated with dilated loop of bowel
Ø Murphy’s maneuver – Press deeply RUQ under and tinkling bowel sounds. KUB – ileus.
costal border during inspiration. Mid-inspiratory Refer
arrest + finding Ø Ileus – absent bowel sounds – KUB
Ø Cullen’s sign – edema and blue discoloration Ø Gilbert’s Disease - ↑ Bilirubin only
around umbilicus Ø Acute abdominal pain LUQ for 60
Ø Grey Turner’s sign – blue discoloration on flanks minutes - EKG
Ø Rosving’s sign – Deep palpation of LLQ = pain RLQ that may indicate retroperitoneal hemorrhage

LFT’S
Ø Aspartate Aminotransferase – (AST) (SGOT) present in liver, heart, muscle, kidney and lung
Ø Alanine Aminotransferase – (ALT) (SGPT) found mainly in liver; + liver inflammation – more specific
for hepatic inflammation
o If both AST and ALT elevated
§ ALT > AST – (liver) think hepatitis
§ AST > ALT - (Acetaminophen, Statins, Tequila)
Ø AST/ALT Ratio
Ø McBurney’s point – Area between superior iliac o 2.0+ = alcohol abuse
crest and umbilicus in RLQ o 1-2 = ETOH, liver disease
o <1 = fatty liver disease
Ø Serum GGT – elevated in liver abuse and acute pancreatitis; sensitive for alcohol abuse
Ø Alkaline Phosphatase – (ALP) enzyme derived from bone, liver, gallbladder, kidneys, GI and
placenta. ↑ levels seen during growth spurts; healing fractures, osteomalacia, bone malignancy,
vitamin d deficiency, Paget’s, bone cancer
o Expect elevation in pregnancy and kids
Ø Albumin – liver makes albumin
Ø
 GASTROINTESTINAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Acute onset periumbilical pain steadily CT with contrast Peak age 10-30
worsening over 12-24h. Pain localizes at **Abd US can be used in myelocytes/metamyelocytes
Inflammatory disease
McBurney’s point with rebound and guarding, (immature neutrophils) –
Acute Appendicitis caused by infection or younger thinner people REFER
anorexia. Psoas and obturator signs + ominous marker in life-
obstruction Left shift: ↑ WBC, ↑
If ruptures, have guarding, rebound, and board threatening infection found
neutrophils, ↑ Bands
like abdomen. in appendiceal rupture
Severe RUQ or epigastric pain constant with 2- Risk factors: fair, fat, 40
Inflammation of 3 minutes of increased pain (colicky pain) can Cholelithiasis – stones, no
Elevated AST, ALT and ALP Gut rest with clear liquids
Acute Cholecystitis gallbladder nearly always occur w/in 1h of consuming fatty meals. Pain inflammation
RUQ abdominal US - HIDA REFER to Surgery
caused by gallstones can radiate to right shoulder, N/V, anorexia, Collins – pain radiating to
intermittent fever, + Murphy’s sign right shoulder
Risk factors: ↑ age,
constipation, low dietary
Fever, anorexia, nausea, cramping, LLQ pain. Ciprofloxacin + Metronidazole 10-14d
CBC shows leukocytosis w/ fiber intake, obesity, lack of
Infected diverticula - Blumberg’s sign; Acute abdomen rebound, or
neutrophilia Bands signal exercise, NSAIDs, family
Acute (diverticulosis most Rovsing +, board like abdomen. Levaquin + Flagyl
severe bacterial infection; hx, connective tissue
Diverticulitis common in sigmoid Diverticulosis – exam normal High fiber diet
FOBT + if bleeding disorder, Complications:
colon) 33% of population will develop diverticulosis Follow-up in 48-72h
CT scan definitive scan Sepsis, Ileus, SBO,
by age 50 If worsens refer to ER
hemorrhage, perforation,
fistula, death
Acute onset fever, N/V associated with rapid ↑ serum amylase, lipase and Ileus, sepsis, shock, multi-
onset severe abdominal pain radiating to trypsin; ↑ AST and ALT, organ failure
Drug use, Alcohol abuse,
mid-back with bloating. Guarding and GGT, bilirubin, leukocytosis; **Risk factors for
Acute Pancreatitis gallstones, elevated REFER
tenderness over epigastric region on exam. + abdominal ultrasound and pancreatic CA include
triglycerides, infections
Cullen’s sign and Grey-Turner’s sign **rocks CT chronic pancreatitis,
back and forth to relieve pain Triglycerides > 800 ↑ risk tobacco use, DM
Severe watery diarrhea 10-15 stools a day w/
Clostridium lower abdominal pain, cramping and fever. CBC w/ leukocytosis Metronidazole (Flagyl), avoid
difficile Colitis Symptoms appear 5-10d after antibiotic (>15,000) antimotility agents and opiates,
(C-diff) initiation (clindamycin, quinolones, Stool assay for C-diff increase fluid intake
cephalosporins and PCNs)
Colonoscopy age 50 (repeat Screen everyone with these questions: ↑ risk factors >50 yrs.;
Asymptomatic until advanced disease. Vague
every 10 yrs. unless polyps) Have you ever had colorectal cancer multiple polyps or
adenocarcinomas GI symptoms, changes in bowel habits, stool or
<40 assess cancer risk; FOBT (CRC) or adenomatous polyp (AP)? inflammatory bowel disease
Colon Cancer 3rd leading cause of bloody stool. Heme-positive stool, dark tarry
annually ever year; Inflammatory bowel disease? Family (diet in high fat, red meat
cancer deaths in US stool, mass on abdominal palpation. May have
Cologuard every 3 yrs. member with CRC or AP? and low calcium may
hx of polyps
If CRC - Surgery, chemo and radiation contribute
fever, malaise and mild weight loss,
↑ CRP, ESR, Leukocytosis ↑ risk of toxic megacolon
Inflammatory bowel periumbilical to RLQ pain. May palpate tender Lactulose intolerance is common. Stop
Anemia (chronic disease, B12 and colon cancer; risk of
disease affecting mouth abdominal mass. Remission and relapses are smoking. Gut rest. Oral
deficiency) development of lymphoma
Crohn’s Disease to anus common. If ileum involved, diarrhea without aminosalicylates sulfasalazine and
WBCs in stool especially when treated
(Inflammation affects blood or mucous. If colon involved bloody mesalamine (better tolerated). Flagyl
Cobblestone mucosal pattern with azathioprine. More
entire intestine wall) diarrhea with mucus. Fistula formation and and Cipro. Immune modulators
on endoscopy – skin lesions common in Jews
anal disease.
bloody diarrhea with mucus. Severe
“squeezing” cramping pain located on left side
Inflammatory disease of abdomen with bloating and gas exacerbated ↑ CRP, ESR, Leukocytosis Oral aminosalicylates sulfasalazine and
affecting colon/rectum by food. Relapses characterized by fever, Anemia mesalamine (better tolerated) ↑ risk of toxic megacolon
Ulcerative Colitis
(Inflammation affects anorexia, weight loss and fatigue. Accompanied WBCs in stool Corticosteroids. No antibiotics due to and colon cancer
mucosa) by arthralgias and arthritis that affects large risk of C. Diff. Immune modulators
joints, sacrum and ankylosing spondylitis. May
have IDA or anemia of chronic disease
 GASTROINTESTINAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Gastrin secretion stimulating high acid

Zollinger-Ellison Gastrinoma on pancreas production of stomach. Develops ulcers in
Fasting gastrin levels
Syndrome or stomach stomach and duodenum. Epigastric to mid-
abdominal pain; stools may be tarry colored

First line treatment is lifestyle changes Chronic GERD may

Gastric contents Chronic heartburn over time with large/fatty
regurgitate from stomach meals worsening when supine. Recurrent dry
to esophagus due to cough, chronic pharyngitis, and hoarseness.
GERD reduction in LES tone, Self-tx w/ OTC antacids and H2 blockers. May
irritation of esophageal be due to chronic NSAID use, aspirin, or alcohol
mucosa, ↑ gastric ***Anyone with GERD x 10 yrs. should be
secretion referred to GI to R/O Barrett’s
Intermittent episodes of moderate to severe
cramping in lower abdomen, especially LLQ.
Irritable Bowel Disorder of colon Bloating with flatulence. Relief after defecation.
Syndrome (IBS) (spastic colon) Stools range from diarrhea to constipation.
Exacerbations/remissions. Commonly
exacerbated by stress.
Intermittent epigastric pain, burning/gnawing
Erosive Gastritis H. pylori; Too much
pain. Pain worse with eating, tender at
(Gastric Ulcer) stress, alcohol or NSAIDs
epigastrium
Episodic epigastric pain, burning/gnawing pain.
Pain relieved by food or antacids with recurrent
Duodenal Ulcer H. pylori
2-3 hours after meals. Awakens at 1-2am with
symptoms
fatigue, nausea, anorexia, malaise, abdominal
pain, dark colored urine, clay stools and joint
pain for several days. Skin and sclera have a
yellow tinge. Tenderness over liver with
A: Fecal/oral percussion and deep palpation. ↑ ALT/AST up
B: sexual; mother to to 10x normal. Remove and treat cause. Avoid
Viral Hepatitis child; blood transfusion hepatotoxic agents such as Tylenol, alcohol and
C: IV drug abuse, blood statins. Treatment is supportive
transfusion
Periodic monitoring for alpha-fetoprotein to
look for hepatoma (hepatocellular carcinoma)
May have aversion to smoking
(avoid eating 3-4 hours before bedtime, result in Barrett’s
dietary changes and weight loss) avoid esophagus ↑ risk of
triggers (mints, chocolate, alcohol, ASA, squamous cell cancer –
NSAIDs, caffeine, carbonated beverages) (followed by GI –
HPI – Clinical Dx Stop smoking. Evaluate meds: BB, CCB, lifetime PPI with
Endoscopy when dysphagia, alpha agonist, estrogen, progesterone. endoscopic biopsy
odynophagia, unintended 2nd line: Can combine lifestyle changes annually – 6 months)
weight loss, hematemesis, with antacids or H2 blockers (prn up
melena, chest pain or choking to 12 hours), if no relief: ***CCB – blocks calcium
PPI once a day, before the 1st meal of day and ↓ electoral
(long term therapy associated with hip conductivity – smooth
fx, pneumonia, C Diff.; wean off due to muscle relaxer which ↓
rebound) – If no relief after 4-8 weeks, LES and increases GERD
refer to GI
Abdominal exam tenderness
in lower quadrants Increase fiber, avoid gas producing
R/O bacterial infections foods: beans, onions, cabbage, high-
ROME III criteria: recurrent fructose corn syrup. Antispasmodics. If
More commonly affects
discomfort 3 days/month in constipation based – trial fiber
females
last 3 months with 2+ supplements, Miralax. If diarrhea-based
Discomfort relieved by take Imodium before regularly
defecation, change in stool scheduled meals. Decrease life stress
form or appearance
H. pylori negative: Stop NSAIDs, (if Sudden abruption of
Worrisome symptoms:
needs NSAIDs add PPI or misopristol). medication can cause
dysphagia, early satiety and
Stop alcohol. Stop smoking. Stress rebound worsening
weight loss
management. Lifestyle changes with H2 symptoms
H. pylori stool antigen test or blockers the step up to PPI.
urea breath test H. pylori positive: triple therapy More common H. pylori
(no serological H. pylori Clarithromycin + Amoxicillin + is transmitted oral/fecal
because will test positive if omeprazole and oral/oral
ever infected) (Flagyl if allergic to Amoxicillin) x 14 d
Reportable to public health department
Hep A: Asymptomatic; Hep A symptoms start about 28 days after exposure; Post-exposure and not
vaccinated (age 1-40, give HAV) if >40 give IG within 2 weeks of exposure; avoid oral contraceptives to
avoid cholestasis; avoid alcohol. Avoid working in food-related jobs for 1 week after onset of infection
Hep B: acute, self-limiting or chronic infection. Tx: first-line agents pegylated interferon alfa (PEG-
IFN-a), entecavir (ETV), and tenofovir disoproxil fumarate (TDF) – Offer vaccine to those born before
1986 - cannot get vaccine if anaphylaxis to baker’s yeast. Post-exposure and vaccinated give HBV, if in
the process of vaccination series, give HBIG and complete series. Unvaccinated should receive HBIG
and start vaccine series within 24 hours of exposure if possible
Hep C: approximately 75-85% of people who will become infected will develop chronic infection.
Most common cause of liver cancer and liver transplantation. Screen adults from 1945-1965 Tx:
administer antivirals such as ledipasvir-sofosbuvir (Harvoni), ribavirin, and pegylated interferon alpha
2a/2b

CEREBELLAR SYSTEM
Ø Romberg Test – stand
with arms/hands straight
on each side and with feet
together. Have eyes
closed; Positive if
excessive swaying or
imbalance
(Proprioception)
Ø Tandem test – have pt.
walk straight line in
normal gait. Instruct to
walk in straight line with
one foot in front of the
other. Positive if loose
balance, falling, or unable
to walk straight
NEUROLOGICAL MANEUVERS
Ø Kernig’s sign – flex pt.
hips one at a time,
attempt to straighten leg
while keeping hip flexed
at 90°
Ø Brudzinski’s sign –
passively flex/bend
patient’s neck toward
chest. Positive if patient
flexes hip and knee to
relive pressure and pain
Ø Nuchal rigidity – tell
patient to touch chest
with chin. Inability to
touch chest secondary to
pain is positive.
NERVOUS SYSTEM
CEREBELLAR TESTING
Coordination (Diadochokinesia)
Ø Rapid alternative movement:
patient to place lower arms on top
of each thigh and move them
alternating between supination
and pronation positions
Ø Heel-to-shin testing: patient in
supine position with extended
legs. Patient to place the left heel
on the right knee and then move it
down the shin – repeat w/ right
heel on left leg
Sensory
Ø Vibration, Sharp-dull touch,
temperature
Stereognosis – recognizes familiar
object w/ sense of touch
Graphesthesia – identify figures
“written” on skin
Motor
Ø Gait – observe normal gait; check
leg muscles for atrophy
Ø Pronator drift test – stretch out
arms w/ palms facing up, eyes
closed. Observe for 5-10 seconds
for drifting of arms.
Ø Reflexes –
o Quads (Knee-jerk)
o Achilles (ankle-jerk)
o Plantar (Babinski)
CRANIAL NERVE TRICKS
Ø Cranial nerves responsible for extraocular eye movements?
o 3, 4, 6 – make the eyes do tricks
CRANIAL NERVES
** Some Say Marry Money But My
Brother Says Big Brains Matter More
(Sensory, Motor, Both)
I (S) – Olfactory smell (one nose)
II (S) – Optic visual acuity, visual field,
fundoscopy (2 eyes)
III (M) – Oculomotor
upward/medial/downward
movements of eye (need CN 3 to look
up)
IV (M) – Trochlear eyes down and in
V (B) – Trigeminal touch forehead and
cheeks clench teeth
VI (M) – Abducens eyes look side to
side
VII (B) – Facial crease forehead, close
eyes tight, puff out cheeks and smile
real big
VIII (S)– Vestibulocochlear/Acoustic,
hearing, equilibrium (2 ears sitting on
top of each other, Rinne and Weber)
IX (B) – Glossopharyngeal speech (gag
reflex)
X (B) – Vagus digestion, defecation,
slowed heart rate (need CN10 to stick
out tongue)
XI (M) – Accessory Spinal shoulder
shrug
XII (M) – Hypoglossal stick out their
tongue
3 MINUTE NEURO EXAM:
- Stand with eyes closed: Romberg
- With eyes open: Tandem gait
- Walk on tip toes (power test of
plantar flexion)
- Walk on heels (power test of
dorsiflexion)
- With eyes closed Pronator Drift
followed by finger to nose test
- With eyes open: play the piano
(pyramidal function)
- Rapid taping or alternative
movements
- Close eyes tightly (CN VII)
- Open eyes – observe pupillary
reflex (CN II, III)
- Smile (CN VII)
- Stick out tongue (CN XII)
- Rapid tongue movements
(pseudobulbar palsy)
- Visual fields by confrontation (CN II)
- Eye movements (CN III, IV & VI)
- Babinski
- Fundoscopy
 NERVOUS SYSTEM

Headache Symptoms
Migraine without aura Throbbing pain behind one
eye, photophobia, N/V
phonophobia, last 4-72 hr.
Migraine with aura Preceding symptoms plus
scotoma, lights, halos,
last 4-72 hr.
Trigeminal neuralgia (CN V) Intense and very brief, sharp
stabbing pain, one cheek
Cluster Severe “ice-pick” piercing pain
behind one eye and temple;
with tearing, rhinorrhea,
ptosis and miosis on one side
(Horner’s syndrome)
Temporal arteritis (giant cell Unilateral pain, temporal area
arteritis) with scalp tenderness, skin
over artery is indurated,
tender, warm and reddened;
amaurosis fugax (temporary
blindness)
Muscle tension Bilateral “band-like” pain,
continuous dull pain, may last
all day; may be accompanied
by spasm of trapezius muscle
MIGRAINES
Aggravating Factors
Red wine, MSG, aspartame,
menstruation, stress
Foods high in triptans.
Teenage to middle-age
females
Cold food, cold air, talking,
touch, chewing, older adults
and elderly Check serum levels
Occurs at same time daily in
clusters for week
to months;
middle aged males
polymyalgia
Medical urgency;
rheumatica (up to 50%); older
adults and elderly
Stress
Adults
Acute Treatment
Ice pack on forehead, rest in
dark quiet room
Triptans, Tigan suppositories
Carbamazepine (Tegretol) or
phenytoin (Dilantin)
100% oxygen at 12 LPM
Intranasal 4% lidocaine
Refer to ED or
ophthalmologist
Lab: ESR
High dose steroids
NSAIDs, Tylenol, hot
bath/shower, massage, etc.
Prophylaxis
TCAs
Episodic migraine (<14 days
per month)
Beta-blockers
Tegretol or Dilantin
Watch for drug interactions
May become suicidal
Spontaneous resolution
ETOH can trigger
Permanent blindness;
temporal artery biopsy is gold
standard
Stress reduction, yoga,
massage, biofeedback

HEADACHE TREATMENT COMMON DRUGS: CONCUSSION

Ø ACUTE TREATMENT: Ø Headache, loss of memory,
Ø NSAIDs – GI pain/bleeding/ulceration, renal damage, ↑ BP in HTN confusion, dizziness, ringing in
Ø Triptans – Nausea/Acute MI; use with caution in cardiovascular co-morbidities, not within 24 hours of ergot; not ears, N/V
within 14 days of MAOI Ø Must pass protocol to return to
Ø Analgesics – Tylenol; hepatic damage, prophylaxis – must be taken daily to work play
Ø PROPHYLAXIS: Ø Risk for subdural hematoma if
Ø Tricyclic Antidepressants – Elavil or imipramine at ½ strength; sedation, dry mouth, confusion in elderly hit head
Ø Beta-blockers – propranolol or atenolol daily; contraindicated in 2nd or 3rd degree heart block, asthma, COPD,
bradycardia
Ø Antiseizure medications – Topamax – requires titration; should not be prescribed in a hx of kidney stones
 NERVOUS SYSTEM

BRAIN DAMAGE:
HEADACHES Ø Apraxia: difficulty performing purposeful movements
PRIMARY SECONDARY
Ø Broca’s aphasia: “nonfluent aphasia” Pt comprehends speech and can read, but has difficulty with
Not associated Associated with motor aspect of speech – word salad

with any other or caused by Ø Wernicke’s aphasia: “fluent aphasia” Pt has difficulty with comprehension but has no problem with
diseases other conditions speaking. Reading and writing can be impaired.
Migraine, Tumor, Ø Frontal lobe damage: (intelligence, personality) dementia, memory loss, difficulty to learn
tension-type, intracranial
cluster bleeding, ↑ICP,
meds like NTG,
meningitis, giant HEADACHE EVALUATION: MINI-MENTAL STATE EXAM (MMSE):
**more common cell arteritis Ø History - Orientation
o Where does it hurt? - Short term memory - Recite 3
Red Flag Headaches:
o Characteristics? unrelated words
Systemic symptoms: o Patient appearance (lights out, fetal position vs - Attention and calculation

- Fever, unintended weight loss reading iPad) Spell “world” backwards or
- Secondary HA Risk factors: HIV, malignancy, o Duration subtract 7 starting at 100
pregnancy, anticoagulation, HTN o Associated symptoms - Recall – ask to repeat the words
Neurological signs, symptoms: Ø Exam – physical including
fundoscopic and neuro exam - Write sentence
- Newly acquired symptoms, confusion, impaired o BP, pulse - Copy design
alertness or consciousness, nuchal rigidity, HTN, o Palpate head,
neck, shoulders, spine - While speaking, look for aphasia
papilledema, CN dysfunction o Bruits (impairment in language
o Acceptable abnormalities include Ø If you are 35+ and develop a new headache – you bought resulting in difficulty speaking)
Photophobia & phonophobia an expensive test
- Unequal pupil size Ø notes should reflect:
If ordering imaging
o Red flag headache HEADACHE DIFFERENTIAL:
Onset: sudden, abrupt or split-second “thunderclap”
headache (subarachnoid) onset with exertion, sex, o Change in pattern, frequency or severity of HA - Nasal stuffiness: sinusitis
o Worsening of HA despite therapy - Jaw claudication, fever, visual
cough ↑ICP
o Unexplained neuro symptoms loss, pain in temple: temporal
Older >50 or < 5 years
o Headache always on the same side arteritis***
Previous headache history - Visual field defect: Optic pathway
o Onset of HA with exertion, cough, intercourse
- Less worrisome if have had HA before lesion (pituitary tumor)
o New onset > 50 yrs.
- “worst headache of my life” – r/o subarachnoid - Blurred vision on bending head:
o HA associated with fever, stiff neck, papilledema,
cognitive impairment or personality change intracranial lesion
Rule-Out: - Headache with N/V: tumor
- Subarachnoid or acute subdural Unilateral vision loss: optic
-
- Leaking aneurysm MINI COG: neuritis
- Bacterial meningitis Ø Three-word recognition
- Sweating, tachycardia:
- Increased ICP Ø Clock drawing (normal or abnormal) pheochromocytoma
- Brain abscess or tumor Ø Three-word recall - Transient visual changes:
Ø Dementia if score 0-2. No dementia if >3 pseudotumor cerebrii***
Ø
 NERVOUS SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Report to Health Department.

Infants: Ampicillin or 3rd gen.
Lumbar puncture: CSF large
High fever, severe headache, stiff neck and cephalosporin
WBC, ↑ protein, ↓ glucose
Strep pneumonia meningmus. Rapid changes in mental status. Adults: 3rd gen. cephalosporin +
Acute bacterial CT/MRI
Neisseria meningitides Purple-colored petechial rash w/ N/V and Chloramphenicol Fatal if not treated
meningitis CBC, CMP, Coags, Blood
Haemophilus influenza photophobia. Worsening symptoms to lethargy, >50: amoxicillin + 3rd gen. cephalosporin
culture x 2
confusion and coma Prophylaxis of close contacts with
Gram stain and C&S of CSF
rifampin or ceftriaxone

Mean age dx 72
Acute onset headache located on one temple,
Refer to ophthalmologist or ED Permanent blindness
usually in older adult; induration, redness,
Biopsy is definitive test ***women more likely
Temporal arteritis Autoimmune vasculitis cordlike temporal artery accompanied w/ scalp Elevated ESR
High-dose steroids 40-60mg daily (Add than men
(Giant cell arteritis) of temporal artery tenderness. Abrupt visual changes and/or Elevated CRP
PPI to prevent ulcer and possibly Pt’s with polymyalgia
transient blindness (amaurosis fugax). Some
bisphosphonate for bone health) rheumatica are at very
people may also complain of jaw pain.
high risk 30%
Embolic: Acute onset stuttering/speech changes, 911 – Assess ABCs
Blacks, Hispanics and
Embolic or one-sided facial weakness, hemiparesis Risk factors – A fib and HTN; aneurysm,
Stroke (CVA) Indians have ↑
hemorrhagic Hemorrhagic: May have poorly controlled HTN anticoagulants, stimulants, sickle cell,
prevalence
and severe headache, N/V, and nuchal rigidity diabetes, oral contraception, smoking.

History of head trauma and HA with gradual

bleed between dura cognitive impairment (apathy, somnolence,
Chronic subdural
and subarachnoid confusion)
hematoma (SDH)
membrane More common in elderly & those on
anticoagulation or ASA therapy
Sudden onset HA “worst HA ever” w/
photophobia, N/V, meningeal irritation Sentinel headache – can
Subarachnoid
Head trauma (+Brudzinski and Kernig signs), decline in LOC. occur a few up to 20 days
hemorrhage (SAH)
Elderly – fall before event.
Younger – MVC
Migraine without aura
• HA last 4-72 hrs.;
• has 2 characteristics
(unilateral pulsating Contraindications for
Gradual onset throbbing headache behind one eye quality, mod to severe Rest in dark room w/ ice; avoid triggers triptans: ischemic heart
gradually worsening over several hours; intensity, aggravated by (MSG, chocolate, ripened cheese, disease, CVA, TIA, HTN,
photophobia and phonophobia. May last 2-3 days routine activity) fermented foods, alcohol, caffeine, sleep diabetes, obese, male >
and become bilateral if not treated • has one of the following changes, stress, menses, skipping meals, 40, HLD; ↑ risk of
Aura can be paresthesia, seeing halos, metallic (Nausea and/or odors, bright light, change in weather) serotonin syndrome with
taste, hyperosmia, Scotomas (blind spots in visual Vomiting, photophobia or SSRI or SNRI; Do not
Migraine (with or
field) etc. phonophobia) Abortive tx: triptans, NSAIDs, start within 2 weeks of
w/o aura)
Positive family history and being female increases antiemetics MAOI use; Do not
• 5 or more attacks
risk factors. In children, migraines can present as Prophylactic tx: beta-blockers, TCAs, combine with ergots
abdominal pain. • no other reason for HA anticonvulsants (avoid if hx of kidney ***Avoid use of combined
Migraine with aura stones) estrogen-progestin oral
***Note motion sickness and migraines come • 2 attacks with aura contraceptive in migraine
from same gene • Visual, sensory, motor (Butterbur, feverfew and magnesium) with aura due to stroke
reversible risk
• Develops over 5-20 min;
HA w/in 60 min.
 Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Basilar or
Focal neurological finding with stroke-like s/s.
hemiplegic Avoid estrogen agents
resembles TIA.
migraine

Bilateral morning stiffness and aching of High risk of developing

Polymyalgia ↑ ESR Symptoms usually respond quick to oral
shoulders, neck, hips, and torso (difficulty putting temporal arteritis
Rheumatica (PMR) ↑ CRP steroids
on bra) More common > 50

Unilateral facial pain following one of the

branches of the trigeminal nerve. Pain usually
located close to the nasal border and the cheeks
Trigeminal triggered by chewing, eating cold foods or cold air MRI/CT to r/o tumor/artery High doses anticonvulsants
Compression of CN V More common in women
Neuralgia (Tic lasting few seconds pressing on nerve or Multiple carbamazepine (Tegretol) or phenytoin
root by artery or tumor and peaks in 60’s
Douloureux) Type I: extreme, shock-like facial pain lasting 2 Sclerosis (Dilantin); muscle relaxants, gabapentin
minutes to 2 hours
Type II: constant, aching, burning facial pain of
lower intensity
Dysfunction of CN VII High dose corticosteroids x 10 days (wean) Corneal ulceration,
Facial paralysis progressing rapidly within 24h, HPI - R/O CVA, TIA, mastoid
Viral infection, Acyclovir (Zovirax) if herpes suspected permanent neurological
difficulty chewing and swallowing food on same infection, bone fx, Lyme
Bell’s Palsy autoimmune or Protect cornea from drying and ulceration sequelae or facial
side, unable to fully close eyelids and tear disease and tumor
pressure from w/ lubricant. Patch eye at night to close weakness if prolonged
production may stop
tumor/blood vessel with eyelid. case
Abrupt one-sided headache marked by recurrent
episodes of brief “ice-pick” pain behind one eye w/ High dose oxygen (100% 12LPM for 15
High risk for suicide
Cluster headache Idiopathic tearing and clear rhinitis. May have Ptosis minutes), sumatriptan (Imitrex)
More men > women
Happens several times a day, may resolve May take verapamil for prophylaxis
spontaneously
Headache that is “bandlike” or “squeezing”, dull
and constant; may follow tensing of neck muscles NSAIDs, OTC analgesics + caffeine Narcotics and butalbital
Emotional/psychic
Tension headaches and last several days (Excedrin), stress reduction and avoid are habit forming and ↑
stress
Prevention: yoga, tai chi, exercise, regular triggers rebound headaches
eating/sleep schedule, counseling

Overuse of abortive
Daily headaches w/ irritability, depression and Discontinue medicines or gradually taper
Rebound headache medicines, NSAIDS,
insomnia off
aspirin, narcotics

Refer to ED - Consider hospitalization

within 24-48 hrs.:
Abrupt onset difficulty speaking, unilateral
Focal ischemia – brain, Patient’s first TIA – or TIA > 1 hour; ↑
Transient Ischemic hemiparesis, dizziness, vertigo, weakness and CT/MRI within 24 hrs. of Up to 20% will have
spinal cord, retinal risk cardiac emboli – A fib; Symptomatic
Attack (TIA) poor balance. Slurred speech (aphasia). The episode stroke within 90 days
ischemia internal carotid stenosis >50%;
longer the episode, the higher the risk of damage.
hypercoagulable state; crescendo TIA;
High ABCD2 score

Gradual onset of numbness and tingling on Tinel’s sign – tap anterior

thumb, index finger and middle finger affecting wrist briskly. + if “pins and Primary prevention – limit time spent
Factors that ↑ risk are
hand grip. Acroparethesia – awakening at night needles” sensation with activities, ensure proper breaks and
Carpal Tunnel median nerve repetitive motion,
with numbness and burning pain in fingers. Phalen’s sign – full flexion of encourage toning and stretching exercises
Syndrome (CTS) compression hypothyroidism,
Problems lifting objects w/ affected hand. Hx wrist for 60 sec. + if tingling of Elevation, application of volar splint in
pregnancy and obesity
occupation or hobby involving frequent wrist median nerve neutral position SLE
movement EMG and nerve conduction
 NERVOUS SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Symptom of vestibular dysfunction, Spinning, Benign Paroxysmal Positional Vertigo:

swaying, tilting, N&V, postural instability. Single brief, recurrent, symptoms are
episode or recurrent If you can get the patient to reproducible, attributed to calcium debris
Peripheral etiology: involves the vestibular focus on an object and get the in semicircular canals; Dix-Hallpike
Vertigo NOT DIAGNOSIS system; severe N/V, recurrent < 1 minute vertigo to stop, without maneuver; change in position precipitates
Central etiology: involves the brainstem or shifting gaze – you can keep symptoms
cerebellum – prolonged nystagmus, them. Otherwise refer Tx with antihistamines like meclizine &
impaired gait/mobility, single episode Dramamine or Benzos like alprazolam or
lasting minutes to hours lorazepam and TIME
Symmetrical, burning, weakness and sensory loss,
variable course, rapid progression, lower Risk factors: diabetes and
Polyneuropathy
extremity more common with symptoms distal to alcohol abuse
the trunk
Parkinson’s – chronic progressive; average age of 70; tremor at rest, pill rolling tremor, bradykinesia and rigidity.
• Levodopa first line treatment – refer
Tremors
Essential Tremor – most common; familial (50% autosomal dominant trait); more common with aging, bilateral action
tremor of hands, forearms, head, voice, chin and lip tremor – tremor in legs in unusual.
• Betablocker

Immune mediated,
Young adult with abnormal limb sensation, visual
inflammatory,
Multiple Sclerosis loss, motor symptoms, diplopia, gait disturbance, MRI Refer to neurology
demyelinating disease
acute motor symptoms
of CNS

Normal or abnormal
cognition?
Dementia, delirium or Declining cognitive function need safety
depression? assessments:
Insidious; decline in complex attention, executive MMSE: <24 suggestive • Driving
function, learning memory, perceptual motor, dementia
• Financial capacity Most common cause is
social cognition. Medications that impair
Dementia Decline in cognition • Wandering Alzheimer disease
Cognitive deficits must be severe enough to cognition: analgesic,
• Living alone followed by Lewy bodies.
interfere with function and independence anticholinergic, psychotropic,
sedative-hypnotics Caregiver burnout, polypharmacy, family
CBC, CMP, B12, folate, conflict over decision making, risk of
TSH, UA, RPR, HIV, CT injury, elder abuse
and/or MRI
Screen for depression
Sundowning – occurs in
Prescription meds,
delirium and dementia.
substance abuse, drug-
Starting at dusk, the
drug interaction,
Reversible, temporary process. Duration is usually patient becomes agitated,
abrupt drug
brief (hours to days). Pt may be excitable, Remove and or treat illness, infection or confused and combative
Delirium withdrawal, preexisting
irritable, combative, short attention span, metabolic derangement and symptoms resolve in
medical condition,
memory loss and disorientation. the morning. Avoid dark,
infections, electrolyte
quiet spaces. Use radio,
imbalance, heart
do not move furniture or
failure, renal failure
décor.

 HEMATOLOGICAL SYSTEM
HOW BLOOD CELLS MADE
Ø RBC, WBC, Platelets come from Stem cell
Ø Infection HEMOGRAM EVALUATION IN ANEMIA MICROCYTIC ANEMIAS

o Bacterial or allergic Ø What are hematocrit, hemoglobin, and RBC values? Ø Low MCV; Low MCHC
§ Neutrophil - infection o Normally hemoglobin to hematocrit ratio 1:3 o Thalassemia
§ Eosinophil – allergic reaction o Iron-deficiency
§ 10 = 30%
§ Lead poisoning
§ Basophil - anaphylaxis § 12 = 36% o Anemia of chronic disease
o Viral § 15 = 45%
§ Lymphocyte o Severe dehydration causes elevated MACROCYTIC ANEMIAS
o Tissue damage Ø Low H/H; High MCV
hematocrit
§ Monocyte o B12 deficiency
o Testosterone = more RBC (hence male have
o Folic acid deficiency
Ø When poly/lymph close = viral higher hematocrit values) § Impaired liver
Ø When poly/lymph far = bacterial Ø What is the RBC size? § Thyroid hypo-function
Ø Pt should look like labs. o RBC size is same size during life § Reticulocytosis
o MCV (cytic = size)
§ Microcytic <80 Ø Drug induced Macrocytosis without
anemia
§ Normocytic 80-96
HOW BLOOD CELLS MADE
ANEMIA o (ETOH >5 drinks in men > 3 drinks
§ Macrocytic > 96 in women; carbamazepine, valproic
Ø RBC, WBC,ofPlatelets
Complex signs andcome from Stem cell
symptoms
o In evolving microcytic anemia acid, phenytoin; malabsorption,
Ø Infection
o ↓RBC, ↓ hemoglobin, ↓hematocrit
§ As MCV ↓ RDW ↑ zidovudine (reversible, but meds
Ø Acute Bacterial
o blood or allergic in primary care)
loss (uncommon outweigh the risks – DC ETOH –
o In evolving macrocytic anemia
Ø Chronic blood loss (common -ininfection
§ Neutrophil primary care) heavy alcohol intake has swollen
§ As MCV ↑ RDW ↑
o Erosive Eosinophil
§ gastritis, – allergic reaction
menorrhagia, GI malignancy cells) Hgb, Hct, RBC, MCHC, RDW)
Ø What is the RBC hemoglobin content?
§
o Leads to IDA Basophil - anaphylaxis normal with ↑ MCV
o MCH or MCHC (chromic = color)
o Viral
Ø Reduced RBC production (sick bone marrow)
o Normochromic: 31-37
o Vitamin Lymphocyte
§ B12, folic acid, iron deficiency, anemia
o Hypochromic: <31 LABS
o Tissue damage
of chronic disease, bone marrow suppression,
Ø What is RDW (RBC distribution width)? Ø Serum iron – measure of iron in circulation
§ Monocyte
reduced erythropoietin production (chronic Ø Serum ferritin – < 15 (iron in storage)
o Index of variation in RBC size
renal failure) – select medications (PPI, o Chronic smokers, COPD, high
o Abnormal = > 0.15 proportion (15%)
metformin) altitudes
§ New cells differ in size
Ø Premature destruction (uncommon) o Hct more than 48% women and
§ Early indicator of evolving microcytic 52% men
o Shortened RBC lifespan (90-120 days normal)
or macrocytic anemia o Hbg more than 16.5 women and
o Sickle cell anemia, thalassemia, hemolytic
Ø What is reticulocyte percentage? 18.5 men
G6PD deficiency Ø Reticulocyte count – indicates ability of
o Body attempts to correct anemia
Ø In a person with normal bone marrow production, bone marrow to produce RBCs
o Normal 1-2%
supplementing the deficient substance will cause H/H Ø TIBC – total iron binding capacity
o Response to anemia is >2%
to increase in 1-2 weeks and normalize within 4-8 o TIBC is ↑ when iron ↓
o Reticulocytopenia - Low means body cannot
weeks o TIBC is ↓ when iron ↑
fix the anemia Ø High Altitude stress – low barometric
pressure causes reduction in arterial PO2
 HERBAL MEDICATIONS WITH INCREASED BLEEDING RISK HEMATOLOGICAL SYSTEM
HEMOGLOBIN
Ø Ginseng
Ø Electrophoresis gold standard
Ø Gingko
RBC TESTING o Sickle cell anemia
Ø Fish oil
Hemoglobin 14-18 (males) o Thalassemia
12-16 (females) Ø Secondary polycythemia
Hematocrit 40-50% (males) o Chronic smokers, COPD, high
EFFECT ON H/H altitudes
36-45% (females)
MCV (average size of RBC) o Hct more than 48% women and
COPD ↑ 52% men
< 80 microcytic
Chronic kidney disease ↓ 80-100 normocytic o Hbg more than 16.5 women and
Hypertension N/A > 100 macrocytic 18.5 men
DM with A1c 13.8 ↓ MCHC (average color of RBC) Ø High Altitude stress – low barometric
(↓ IDA, thalassemia) pressure causes reduction in arterial PO2
Aspirin use N/A o CAD, CHF, sickle cell ↑ risk
31-37 normochromic
Testosterone use ↑ MCH (indirect measure of color) complications
Resident of Denver, CO ↑ (↓ IDA, thalassemia)
84 years old ↓ 25-35

Nobody likes my educational background

Meds that worsen anemia: ARB and ACEI in TIBC (capacity to seat iron – Iron count ↑ TIBC ↓) WBC TESTING
Hemoglobin
250-410 Normal
patients with CKD, diabetes, CHF, HTN Ø Electrophoresis gold standard5.0-10.0 x 10
↑ IDA
Ø Neutrophils 55-70%
Normal thalassemia, vitamin B12 o Sickle cell anemia
(AKA poly or segs) ****bands young Neut.
deficiency and folate deficiency o Thalassemia Bands > 6% (shift L)
Serum Ferritin (stored form of iron) **sensitive IDA
THALASSEMIA IDA 20-400 Lymphocytes
Ø Secondary polycythemia 20-40%
abnormal Hgb electrophoresis Normal ↓ IDA (virus)
o Chronic smokers, COPD, high altitudes
↓ MCV, MCH ↓ Normal to high thalassemia Ø Monocytes 2-8%
o Hct more than 48% women and 52% men
(debris)
Normal RDW ↑ Serum Iron 50-175
Normal/↑ Serum Fe ↓ ↓ IDA Ø Eosinophils
o Hbg more than 16.5 1-4%
women and 18.5 men
Normal TIBC ↑ RDW (variability in size) Ø (allergens, parasites,
High Altitude stress worms, pressure
– low barometric wheezes,
causes
> 15% measure variability weird diseases)
Normal Serum ferritin ↓ reduction in arterial PO2
↑IDA, Thalassemia Ø Basophils .5-1%
Asia, Ethnic any Reticulocytes (immature – RBC survive 120 days)
Mediterranean, ***Alpha thalassemia Anaphylaxis not fully understood
.5-2.5% Ø Leukocytosis (WBC > 10) – anticipated
North Africa, (Asians) Reticulocytosis (occurs w/ bone marrow stimulation) response in bacterial infections.
Middle East ↑ supplementation with iron, Ø Neutrophilia – elevated neutrophils
CBC, then iron studies, then Hgb electrophoresis folate, B12, after acute bleeding, Ø Lymphocytosis – elevated lymphocytes
hemolysis, leukemia, Ø Monocytosis - elevated monocytes
erythropoietin (EPO) Ø Eosinophilia – elevated eosinophils
HEMORRHAGE Poikilocytosis (peripheral smear) (shape) IDA Ø Basophilia – elevated basophils
Ø Blood loss of 15% or more. Anisocytosis (variable size RBCs)
o Orthostatic hypotension Serum Folate 3.1-17.5
o Signs and symptoms of shock ↓ macrocytic anemia
B12 250
↓ macrocytic anemia
 HEMATOLOGICAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

African Americans have

Neutropenia Fever, sore throat, oral thrush ANC less than 1500
lower ANC

Gradual onset symmetrical peripheral neuropathy MCV > 100

Nerve damage (? Reverse
numbness, ataxia, loss of vibration and position Peripheral smear has
Most common cause pernicious anemia if < 6 months)
Vit. B12 Deficiency Deficiency in B12 sense, impaired memory and dementia. macroovalocytes, megaloblasts
Replace B12 Advise vegans to take
Stocking glove neuropathy, pale conjunctiva; and multisegmented
supplements
systolic murmur, beefy red tongue neutrophils

Night sweats, fevers, and pain with ingestion of

Hodgkin’s Cancer of beta ↑ incidence age 20-40 or
alcoholic drinks; pruritus and painless enlarged
Lymphoma lymphocytes >60 males, white
lymph nodes (neck), anorexia and weight loss;

Non-Hodgkin’s Cancer of lymphocytes night sweats, fever, weight loss, generalized

Prognosis is poor >65 years
Lymphoma and killer cells lymphadenopathy (painless)

Fatigue, weakness and bone pain usually located

Poor prognosis
Multiple Myeloma Cancer of plasma cells in back or chest; proteinuria with Bence-jones more common in elderly
proteins; hypercalcemia, normocytic anemia;

Asymptomatic until platelets lower than 100,000; If bleeding - Check

easy bruising, bleeding gums, spontaneous Get better management of underlying medications ASA,
nosebleeds, hematuria disease. NSAIDs, Warfarin, SSRI,
Platelet count of less
Thrombocytopenia Bruising on distal lower and upper extremities is Or diagnose the occult disease or illness. steroids. Check CBC,
than 150,000
usually related to physical activity. Petechiae, Red blood cell life span is shortened from PT/PTT and R/O
purpura, large hematomas not accompanied by 100-120 days to 60-90 days coagulation disorders
other symptoms are suspicious.
↓ Hgb Iron rich foods – red meat, beans, green Avoid iron supplement w/
↓ Hct leafy vegetables, whole grains; antacids, dairy products,
Most common type of anemia in childhood,
↓ Serum Fe *Need 150-200mg elemental iron daily. levothyroxine, quinolones
pregnancy and women during reproductive years.
↓Serum ferritin Ferrous Sulfate 325mg PO TID take with or tetracyclines.
Asymptomatic. Weakness, headache, irritability,
↓MCV (microcytic) OJ on empty stomach (65mg elemental Serum iron is a drug level
Deficiency in iron- skin pallor, fatigue, exercise intolerance, glossitis
↓MCH (hypochromic) iron per tablet) – recheck in 4-6 weeks. that fluctuates
Iron Deficiency most common cause (red beefy tongue), angular cheilitis, cravings for
↑TIBC (Rule of thumb Hct ↑ 3 pts. and Hgb ↑ 1 SE: constipation, black
Anemia chronic low volume pica. May cause spoon shaped nails, systolic
↑RDW > 15% (if <15% old) pt. – if not improved check reticulocyte colored stools, upset
blood loss murmurs, tachycardia, CHF, exacerbation of co-
Anisocytosis count for possible bone marrow problem). stomach
morbid
Poikilocytosis Treat for 3-6 months to replace iron Store iron away from
**common in alcoholic, NSAID users, females
Most iron is obtained from stores. children due to toxicity
with heavy menses, vegans
recycled iron content from Once anemia corrected = Ferritin for Angular cheilitis – fungal
aged red blood cells estimation of iron stores infection. Tx with nystatin
Hgb ↓ 12 women; ↓ 13 men
Normocytic, normochromic Treatment aimed at control of underlying
Anemia of Chronic ↓ renal EPO Most common type of anemia in elderly followed
anemia, reticulocytopenia disease or diagnosing the occult disease or
Disease production by IDA and then pernicious anemia.
Check serum ferritin, TIBC, illness
vitamin B12 and folate

 HEMATOLOGICAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

If someone comes up
↓ Hgb positive screen the family
Majority asymptomatic. Discovered due to Diagnostic test: Hemoglobin
↓ Hct At risk ethnic groups
abnormal CBC results revealing electrophoresis
↑ RBC Alpha thalassemia:
microcytic/hypochromic RBCs Beta-thalassemia (abnormal) IDA, normal
Genetic producing ↓ MCV Asian, African ancestry
Thalassemia Minor (Blood smear: microcytosis, anisocytosis,
abnormal Hgb ↓ MCHC (AAA)
***Cooley’s anemia is Beta Thalassemia Major – poikilocytosis)
Normal RDW Beta thalassemia:
transfusion dependent anemia (found early in Do not treat thalassemia
Normal to ↑ ferritin and iron African, Mediterranean,
infancy) Genetic counseling prior to pregnancy
Normal TIBC Middle Eastern
(more common in US)
Destruction of stem CBC w/ diff
Bone marrow production slows or stops Pancytopenia
cells inside bone Platelet county
Aplastic Anemia Fatigue, weakness, pale color, tachycardia and Refer to hematologist (leukopenia, anemia,
marrow (radiation, Bone marrow biopsy (gold
systolic murmur; neutropenia, thrombocytopenia thrombocytopenia)
drug, viral infection) standard)
Vitamin B12 deficiency
(pernicious anemia,
B12/folate levels; B12 levels Dietary deficiency may > 5 years to occur gastric disease, infections,
may be normal in 5% of B12 sources: foods of animal origin (meat, antacids and metformin)
Autoimmune causing patients with B12 deficiency poultry, eggs, milk, cheese) Nerve damage from
destruction of parietal Gradual onset of paresthesia on feet/hands, Antiparietal and anti-intrinsic B12 via injections or nasal spray (1000mcg chronic B12 deficiency
Pernicious anemia cells; gastrectomy, pallor, glossitis; numbness/tingling extremities, factor (IF) antibody test + per week for 4 weeks then monthly for a ↑ incidence in older
vegans, alcoholics, neuropathy, diff fine motor skills 24h urine for methylmalonic lifetime) women
bowel disease acid, homocysteine level Oral 1000-2000mg daily 2-3x ↑ gastric cancer
elevated, peripheral blood Multivitamin with iron since IDA **All dementia or
smear (macrocytosis) commonly coexist patients with
neuropathy need B12
levels checked
Elderly, infants,
alcoholics, overcooked
Body’s supply last 2-3 months vegetables, low citrus
Macrocytic normochromic,
Inadequate dietary Anemia, tired, fatigue, pallor, reddened sore Lifestyle changes (dietary – leafy green intake, malabsorption
Folic acid peripheral smear –
intake causing damage tongue, glossitis, unexplained weakness, possible vegetables, grains, beef, liver) (gluten). Drugs that
deficiency macroovalocytes
to DNA or RBCs tachycardia, palpitations, angina or heart failure. PO folic acid 1-5 mg/day interfere: Phenytoin
folate levels <4
Pregnancy 400 mcg daily (Dilantin), sulfa,
metformin, methotrexate,
zidovudine
Refer to hematologist, Sickle cell disease is
Genetic hemolytic Most asymptomatic; extreme anemia, frequent CBC 1 out of 500 African
part of newborn screening; autosomal
anemia; variations in sickling episodes w/ pain, ischemic necrosis of Sickledex – screening Americans in US have
recessive (if each parent trait – one
RBC – sickle shaped bones or skin, renal/liver dysfunction, priapism, Electrophoresis – gold sickle cell anemia
Sickle cell anemia of four will have disease) prenatal
and insufficient of hemolytic episodes, hyposplenism, frequent standard ↑ risk Strep pneumo, H.
screening available as early as 8-10 weeks
oxygen carrying infections – highly susceptible to infection. If Mean Hgb 8.0 influenzae due to
via chorionic villus sampling or
capacity fever give prophylactic PCN up to age 5 RBC live 17 vs. 120 days hyposplenia
amniocentesis

 MUSCULOSKELETAL SYSTEM

ORTHOPEDIC MANEUVERS SHOULDER
Ø Drawer Sign – knee instability/torn ligaments Ø Impingement Syndrome – hand at or above level
of shoulder begins to be painful in lateral
shoulder area; reaching into pantry to get can;
reaching up in closet. – Painful Arc Test

Ø McMurray’s test – “click” on manipulation of knee with rotation of ankle; injury to medial meniscus tear

Ø Rotator Cuff Tear – lateral deltoid pain; pain and

weakness, loss of strength in external rotation or
abduction – usually disturbs sleep
Ø Lachman’s sign – Ø Adhesive capsulitis (Frozen Shoulder) – anterior
Ø Collateral ligaments – positive finding increase
suggest ACL damage; more sensitive than drawer test shoulder pain; joint stiffness, measurable loss of
laxity of damaged knee. Valgus stress – MCL; Varus
movement in external rotation and abduction;
stress test – LCL (Varus and Lateral) common in diabetes
Ø AC OA – AC joint tenderness; osteophytes, joint
space narrowing
Ø Extrinsic shoulder pain
o Cervical nerve root compression
• ROM of neck –
precipitate pain? If yes;
then neck problem -
Spurling
o Myocardial ischemia; Splenic injury;
Ø Spurling Test Ectopic pregnancy

Ø Finkelsteins’s test – De Quervain’s

tenosynovitis from inflammation of the
tendon at base of the thumb. Pain w/ ulnar
deviation
 EXERCISE AND INJURIES MUSCULOSKELETAL
Ø Do not exercise the first 48 hours OTTAWA RULES (SPRAINS)
Ø Use cold for first 48 hours Ø Grade 1 – mild – slight stretching and
Ø RICE LOW BACK PAIN
Ø Usually due to soft tissue inflammation, sciatica, damage to ligament, stable joint. Able
Ø After 48 hours
o Isometric exercises sprains, muscle spasms or herniated discs (usually to bear weight and ambulate
L4, L5 to S1 because hinge in back) (C6-C7) Ø Grade 2 – moderate – partial tearing
Ø 90% of cases resolve within 1 month of ligament. Ecchymoses, moderate
TENDONITIS Ø Risk factors: ↑ age, overactivity, obesity, DJD swelling, pain to palpation, weight
Ø Microtears on tendons causing inflammation and pain Ø Most complain of stiffness, spasm, ↓ ROM bearing painful. Mild/mod joint
o Repetitive microtrauma, overuse or strain Ø Early lumbar radiculopathy – loss of DTR instability. Consider x-ray/referral
o Gradual onset Ø Further evaluation if:
Ø Grade 3 – complete rupture of
o Acute pain with firm pressure applied to tendon o Hx of significant trauma; infection
o Suspect cancer metastases
ligaments and joint instability –
o ↓ ROM caused by stiffness and discomfort
§ >50 with new onset back pain inability to bear weight after injury,
o RICE
Ø Supraspinatus tendonitis – cuff tendonitis. Shoulder pain o Suspect spinal fracture (osteoporosis or inability to ambulate at least 4 steps,
with certain movements such as elevation and abduction chronic steroid use); Spinal stenosis (R/O tenderness over posterior edge of
(reaching to the back pocket). Click when raise arm above ankylosing spondylitis); Symptoms malleolus; severe bruising/pain, resists
head. Local point tenderness located on anterior area of worsen despite treatment foot motion
shoulder Ø Loss of posterior tibial reflex (L5)
o Contributors – swimming, throwing a football, Ø Loss of Achilles tendon reflex (L5 to S1)
pitching baseball, raking, washing cars or windows Ø MRI
o Bursitis is common Ø Treatment depends on etiology RA vs OA
Ø Epicondylitis – elbow pain o Uncomplicated – NSAIDs, warm packs for Characteristic RA OA
o Lateral epicondylitis (Tennis Elbow) muscle spasms; Primary joint Hands; Weight
§ Gradual onset pain on outside of the § Muscle relaxants affected metacarpo- bearing,
elbow radiating to forearms. Overuse § After acute phase abdominal
phalangeal carpometa-
injury Pain worsens w/ twisting/grasping and core-strengthening
§ Avoid bedrest due to
carpal, DIP
movements (opening jars, shaking
hands); may have decreased hand grip deconditioning Heberden’s Absent Usually
strength; pain with wrist extension Ø Spinal stenosis – pain improved when sitting Nodes present
o Medical epicondylitis (Golfer’s Elbow) down or leaning over Joint Soft, warm, Bony and
§ Gradual onset of pain in medial area of Ø Bulging disc – feels better when standing Description tender hard
elbow; high risk baseball, bowlers, Ø Complications – cauda equina syndrome Labs: RF, Positive negative
golfers; may have decreased hand grip Ø Inspect, palpate, reflexes, strength, sensation, CCP, ESR,
strength gait, straight leg raise = radiculopathy CRP
§ 95% recover without surgery Ø Waddell’s sign – overreaction during exam
o Rest and keep joints moving
o Complications – ulnar nerve neuropathy –
numbness tingling of little finger and lateral side of
ring finger with weakness of the hand.
§ Permanent “claw hand” BENIGN VARIANTS
§ Tx with TCA, gabapentin, phenytoin and Ø Genu recurvatum – hyperextension or backwards
pain meds curvature of knees
Ø Tenosynovitis – Wrist tendonitis - ↓ ROM, swelling and Ø Genu valgum – knock-knees
muscle weakness o “gum stuck between knees”
Ø Genu varum – bowlegs
 MUSCULOSKELETAL
SPORTS PARTICIPATION EVALUATION FIBROMYALGIA
Ø Cardiovascular evaluation is an important component of sports Ø Mechanism unknown
physical RANDOM PEARLES Ø 4-7x more common in women
o < 35 yrs. are mostly caused by cardiac malformations Ø Pathological fracture – may be related to Ø More common in patients with
§ Hypertrophic cardiomyopathy osteosarcoma or osteoporosis autoimmune disease
o >35 yrs. are atherosclerotic CAD Ø Stress fracture – overuse injury of bone Ø Widespread body aches, fatigue and
o Cardiovascular hx should include: o Take 6 weeks to heal cognitive changes
§ Prior occurrence chest pain/discomfort, Ø DeQuervain’s Tenosynovitis – dorsal thumb pain Ø Diagnosis involves identifying multiple
syncope o Use fingers a lot tender points throughout body 11/18
§ SOB or fatigue with exercise Ø Contusion – bone injured but didn’t break o Apply enough pressure so
§ Hx of heart murmur or elevated BP Ø Strain – injury to muscle that nailbeds blanch
§ Family hx premature death, cardiovascular Ø Sprain – injury to ligament Ø Physical activity aimed at ↑ flexibility
disease <50 yrs. of age Ø Cauda Equida syndrome – compression of spinal Ø Trigger point injection may be helpful
o Cardiovascular physical examination cord Ø Acetaminophen, NSAIDs, Trazodone,
§ Precordial auscultation supine and standing Ø Vitamin D is recommended for all adults > 50 antidepressants, antiepileptics
§ Assessment of femoral artery pulses to rule out Ø Risk factors for ankle sprain include:
coarctation of aorta o Poor conditioning
§ BP sitting and standing o Inappropriate footwear
Ø HTN – avoid beta-adrenergic antagonist because of ability to o Lack of warm-up period prior to
blunt normal increase in heart rate; avoid diuretic if possible due exercising
to ↑ risk of dehydration
Ø Physiological murmur is ok – eval by cardiology
Ø Aortic Stenosis – play varies with degree TYPES OF SCANS
Ø Mitral Stenosis – play varies with degree § X-rays – bone fractures/damage, OA, metal, dense
Ø Mitral regurgitation – mitral valve incompetency – regurgitation objects
from left ventricle to left atria; commonly caused by rheumatic § MRI – gold standard for injuries to cartilage,
fever, endocarditis, calcific annulus, rheumatic heart disease, meniscus, tendons and ligaments
some mitral stenosis is usually present – play varies with degree o No metal, pacemakers, aneurysm clips ORTHO TERMINOLOGY
of mitral regurgitation and ventricular chamber enlargement § CT – costs less than MRI, views structures likes Ø Abduction (varus) – movement away
Ø Mitral Valve Prolapse – most common valvular heart problem – masses, trauma, fractures, bleeding. Forms 3-D from body
common in pectus excavatum; ok to play if absence of symptoms picture Ø Adduction (valgum) – movement
of activity intolerance toward the body
Ø Hypertrophic cardiomyopathy – disease of cardiac muscle – can Hook Test – Biceps Tear – MRI
lead to sudden cardiac death; mid-systolic murmur that gets
louder with standing
Ø Those with ICD should be aware of risk
Ø Septal/Atrial Defect – if repaired with little residual dysfunction,
full sports is allowed; if no repair then degree should be assessed
on individual basis; easily fatigued is a sign of atrial septal defect;
child presentation can range from entirely well to heart failure
Ø A still murmur has a buzzing quality
Ø S2 split is occasionally found in uncorrected atrial septal defect
Ø Sinus Arrythmia should be encouraged to play
Ø Down syndrome needs cervical spine x-ray prior to sports (AAI)
 MUSCULOSKELETAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Pain on palpation of “snuffbox” area, pain on axial

Navicular Fracture Fall with outstretched x-ray initially may be Splint wrist (thumb spica splint) refer to Avascular necrosis
loading of thumb; pain worse when gripping or
(Scaphoid) hand normal; repeat in 2weeks hand surgeon and nonunion
squeezing

Fracture of distal
Colles Fracture “dinner fork” fracture. Most common type fracture
radius from fall
Hip Pain Location Diagnostic Consideration
Lateral, aggravated by
Sudden onset on-sided hip pain. If mild may be able Trochanteric bursitis More common in
direct pressure
to bear weight. If displaced, inability to walk or bear Pain with use, better with elderly 1-year
Hip Fracture Falls Structural joint problem, OA
weight on affected hip. Severe hip pain with external rest mortality rate from
rotation of the hip/let and leg shortening Constant pain, especially at Infectious, inflammatory, 12-37%
night neoplastic
Depends on degree of injury and structures i.e.:
Anterior hip/groin pain Hip joint: OA, etc.
nerves, blood vessels, organs. Ecchymosis and May cause internal
High-energy trauma Posterior hip pain SI joint, LBP
Pelvic Fracture swelling in lower abdomen, hip, groin, scrotum. hemorrhage - life-
(MVC)
Bladder/fecal incontinence, vaginal/rectal bleeding, threatening
hematuria, numbness.

Acute onset saddle anesthesia, bladder/fecal

Surgical emergency
Cauda Equina incontinence. Bilateral leg numbness and weakness,
Refer to ED
Syndrome pressure on sacral nerve root causing
Needs spinal decompression
inflammatory/ischemic changes to nerves.

More common in
RICE – Stop activity for several weeks
Overuse resulting in Recurrent shin pain in one or both legs that runners and those
Medial Tibial Stress Cold packs during acute exacerbation for
microtears and becomes more severe over time. Pain along inner X-ray will not show stress with flat feet.
Syndrome or 20 minutes several times a day
inflammation of border of tibia and occurs during and after exercise. fx. Recommend bone scan Female athlete
Fracture (Shin Use cushioned soles
muscles, bones and Mild swelling and focal area of tenderness painful or MRI triad: amenorrhea,
Splints) Stretch before exercise and start at lower
tendons on palpation may suggest fx eating disorder,
intensity
osteoporosis

x-ray to r/o fractures, spurs ↑ risk with obesity,

Plantar foot pain, unilateral or bilateral, worsened
Microtears of plantar NSAIDs, Naproxen, diclofenac gel, diabetes, aerobic
Plantar Fasciitis by walking or weight bearing. worse in morning
fascia orthotics, stretching. Refer to podiatry exercise, flat feet,
or with prolonged walking
prolonged standing

Inflammation of digital Mulder test (MTP

Weeks of plantar foot pain worsened by walking ↑ risk with high
nerve of the foot squeeze) - grasp 1st/5th
(esp. high heels or tight narrow shoes); pain has Avoid narrow/high shoes, use forefoot heeled shoes, tight
Morton’s Neuroma between 3rd and 4th metatarsal and squeeze.
numbness/burning located between 3rd/4th pad, well-padded shoes. Refer to podiatry shoes, obesity,
metatarsal Positive if click along with
metatarsals on forefoot. “pebble-like” nodule dancers and runners
(nerve tumor) patient report of pain
Goals: Relieve pain, preserve joint
mobility and function, minimalize Large weight bearing
Gradual onset: early-morning joint stiffness w/
x-ray- joint effusion, disability and protect joint joints (hips and
inactivity. Short duration (<15 min). pain w/
osteophytes and joint space PT/exercise – weight bearing; weight loss knees) and hands are
Degenerative Joint overuse, swelling, tender to palpation. DIP
Damage of articular narrowing if appropriate, Acetaminophen then most commonly
Disease common, May be unilateral – absence of systemic
covered cartilage r/o osteoporosis w/ bone- NSAIDs; diclofenac gel to area, capsaicin affected
(Osteoarthritis) symptoms; pain awakens at night
density testing cream; steroid injection on inflamed joint Risk factors ↑ age,
Heberden’s nodes (nodules on DIP)
Glucosamine and chondroitin – overuse of joints,
Bouchard’s nodes (nodules on PIP)
mechanism unknown, QT prolongation. family hx
AAAOS cannot recommend use
 MUSCULSKELETAL SYSTEM

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Maculopapular butterfly shaped rash on middle of

face (malar rash)- most evident after exposure to Refer to rheumatology Characterized by
ANA
Systemic Lupus sun; nonpruritic thick scaly red rashes on sun- Topical and oral steroids, Plaquenil, remissions and relapses;
↑ ESR
erythematosus Autoimmune exposed areas (discoid rash); fatigue, oral ulcers, methotrexate, biologics (DMARDs) more common in women
anemia in 20’s, 30’s
(SLE) gastritis, chronic inflammatory disease affects Education: avoid sun 10am-4pm
U/A (+) for proteinuria Mild form cutaneous
skin, joints, kidneys, lungs, nervous system and Use nonfluorescent light bulbs
serous membranes lupus erythematous;
↑risk miscarriage
Gradual onset, fatigue, low-grade fever, body Symmetrical joint involvement
Uveitis (eye pain with
aches, myalgia, peripheral, polyarthritis >3 and present for 6 weeks; ↑
conjunctival injection –
Autoimmune; multiple fingers/hands/wrist/ankles/feet/shoulders. ESR, CBC mild Refer rheumatology
Rheumatoid no purulent drainage),
joint inflammation and Morning stiffness last longer than 1-hour (longer microcytic/normocytic NSAIDs, steroids, DMARD, antitumor
Arthritis scleritis, pericarditis,
damage than DJDs) w/ painful, warm and swollen joints. anemia, rheumatoid factor necrosis (Humira, Enbrel)
malignancies
“sausage joints” – Swan neck deformities; positive, anti-CCP, radiographs
Peak age 20-40
Bouchard’s nodes space narrowing
First goal – provide pain relief Joint destruction
Painful, hot, red and swollen metatarsophalangeal Tophi on ears/joints; ↑uric
Indomethacin/Anaprox – colchicine More common in middle
Uric acid crystals joint of great toe (podagra). Limping from severe acid level (test 2 weeks after
Do not start allopurinol in acute phase aged men 30+; obesity
Gout within joints (great toe pain, hx or previous attack. Precipitated by attack); ↑ ESR
(worsens); however, if patient already on Pseudogout – calcium
or fingers) alcohol, meats or seafood; meds that contribute Gold standard – joint allopurinol, do not discontinue pyrophosphate dihydrate,
include aspirin, diuretics, cyclosporine and niacin aspiration Allopurinol/Probenecid for maintenance linked with parathyroid
Chronic c/o back pain (>3 mon) worse in upper Anterior uveitis (eye pain
back. Joint pain worse at night; low-grade fever, Refer to rheumatology with conjunctival
↑ESR, CRP, RF negative,
Ankylosing Inflammatory disorder fatigue, chest pain w/ respiration, long-term NSAIDs (injure GI by blocking COX-1 and injection – no purulent
“bamboo spine” on spinal
Spondylitis affecting spine stiffness improving with activity, some buttocks COX-2 resulting in ↓ prostaglandins) drainage), aortitis, fusing
radiograph
pain, loss of ROM, Uveitis/eye If uveitis refer to ophthalmology of spine w/ ROM
irritation/photosensitivity loss/spinal stenosis
Locking of knee, popping or giving out. Some McMurray then ask patient to RICE, joint effusion may be present, but
patients are unable to fully extend affected knee. squat; Apley grinding test; aspirate only if no improvement in 2-4
Meniscus Tear (of Trauma or overuse
Patient may limp. Complains of knee pain and ↓ ROM weeks; Crutches and knee immobilizer;
knee) (twisting of knee)
difficulty walking and bending the knee. Some x-ray but meniscus will not straight leg raises help strengthen quads
complain of joint line pain show up; MRI Refer to ortho

Active patient complains of “ball-like” mass

Clinical presentation RICE, NSAIDs, large bursae can be
Bursitis (Ruptured Rupture of bursa behind knee, may be asymptomatic. If cyst
MRI drained
baker’s cyst) behind knee ruptures will cause inflammatory reaction like
r/o septic joint If cloudy fluid, C&S to r/o sepsis
cellulitis of area (redness, swelling, tenderness)

Inflammatory
Can develop gradually with symptoms that last for Serum amyloid A; Soluble
condition resulting in
years or have more rapid progression and interleukin 2 receptor; ACE Often self-limiting; NSAIDs;
production of Adults 20-40; women and
resolution of disease. Fever, fatigue, anorexia and Glycoprotein KL-6; Corticosteroids orally, cream, inhaled
Sarcoidosis noncaseating African Americans more
arthralgias, rash, lesions, color change, nodule Hypercalcemia; Hypercalciuria Plaquenil, DMARDs
granulomas common
formation under skin, blurred vision, eye pain, Chest x-ray; CT chest; PFT; Lung transplant
predominately lungs,
severe redness and sensitivity to light biopsy
lymph nodes, eyes, skin
2+, with at least one musculoskeletal:
With diarrhea affects genders NSAIDs, systemic corticosteroids, tumor Often seen days to weeks
asymmetrical oligoarthrtitis, predominately lower
Reactive arthritis equally; with urethritis (male necrosis factor blocker (etanercept or after diarrhea caused by
Acute nonpurulent extremity, sausage shaped finger (dactylitis); toe
(formerly Reiter dominance) with HLA-B27 infliximab); Urethritis treated with Shigella, Salmonella or
arthritis or heel pain; cervicitis, prostatitis, acute diarrhea
Syndrome) positive; culture of joints doxycycline x 7 days or azithromycin Campylobacter or
within one month, conjunctivitis or uveitis, genital
negative single dose Chlamydia
ulceration, urethritis; joint pain knee/ankle/feet
 COMMON SSRIS (listed from most to least energizing)
First line tx for major depression, OCD,
anxiety and premenstrual disorder
Ø Fluoxetine (Prozac) longest ½ life
INCREASED RISK OF SUICIDAL THINKING IN THOSE LESS THAN 24 YEARS
(interacts with coumadin)
Ø Sertraline (Zoloft)
Ø Citalopram (Celexa) few drug interactions,
QT prolongation (max dose 20 elderly)
Ø Escitalopram (Lexapro)
Ø Paroxetine (Paxil) shortest ½ life (lots
drug interaction and sedating – Erectile
Dysfunction and anticholinergic effects)
Best effect on lifting and smoothing mood
***Can induce mania w/ bipolar. Do NOT
combine with MAOIs
***40% chance sexual adverse effects
COMMON SNRIS
Ø Venlafaxine (Effexor) ↑ BP
Ø Duloxetine (Cymbalta) neuropathy (avoid in
alcohol users)
Ø Desvenlafaxine (Prestiq)
Best effect on lifting and smoothing mood plus
increase focus
***40% chance sexual adverse effects
SDRI
Ø Bupropion (Wellbutrin) avoid seizures/bulimia
Ø Usually used as add-on to SSRI
Best effect on improving mood with insufficient
response with SSRI
***20% chance sexual adverse effects
TCA
Ø Not first line for depression
Ø Postherpetic neuralgia, stress incontinence
Ø Avoid if ↑ risk for suicide
Ø Overdose = fatal cardiac, neurological effects,
Ø SE = Anticholinergic, hypotension, conduction
arrhythmia, glaucoma, BPH, confusion
Ø Migraine prophylaxis
Ø Imipramine, amitriptyline and nortriptyline
Ø Avoid in CV disease, elderly (BEERS)
PSYCHOSOCIAL MENTAL HEALTH
DEPRESSION SYMPTOMS
Ø S – Sleep – insomnia or hypersomnia
Ø I – Interest– less interest in activities,
irritability (anhedonia)
Ø G – Guilt – worthlessness or inappropriate
guilt
Ø E – Energy – fatigues
Ø C – Concentration – diminished
Ø A – Appetite – weight change, loss or gain
Ø P – Psychomotor – agitation or
retardation
Ø S – Suicide – recurrent/obsessive
thoughts
Ø M – Mood – depressed mood, tearful
Major depression: > 5 symptoms
Minor depression: 2-5 symptoms
r/o hypothyroidism, anemia, autoimmune,
B12 def.
S/S in teens: failing grades, acting out,
avoiding socialization, moodiness.
ANTIDEPRESSANT DISCONTINUATION
Ø SSRI, SNRI, TCA > 6 months then discontinued.
Typically, last < 7 days. Taper over 6 weeks to
reduce symptoms. Bothersome, not life
threatening.
Ø F – Flu-like symptoms
Ø I – Insomnia
Ø N – Nausea
Ø I – Imbalance (dizziness, difficult coordination)
Ø S – Sensory disturbance
Ø H – Hyperarousal (anxiety/agitation)
Ø H – Headache
ANXIETY SYMPTOMS
Ø W – Worry
Ø A– Anxiety
Ø T – Tension in muscles
Ø C – Concentration difficulty
Ø H – Hyperarousal or irritability
Ø E – Energy loss
Ø R – Restless
Ø S – Sleep disturbance
Ø > 3 of the following occurring on most days > 6
months
TREATMENT GOALS ANXIETY/DEPRESSION
Ø Remission of symptoms for > 4-5 months aimed at
elimination and restorative health
o Most often achieved with psychologic,
social services and medications
o Slowly taper off meds
Ø Consider longer-term therapy if > 2nd episode
QUESTIONS TO ASK PRIOR TO RX
Ø What are the most bothersome symptoms?
Ø What meds will help with these symptoms?
ANXIOLYTICS
Ø Benzodiazepines (use long acting to avoid abuse)
o ↓ dose by 25% each week when dc
Ø Buspirone (BuSpar) -low abuse potential
o Potentially helpful if taken 3x daily for 6
weeks or longer (useless as prn & for sleep)
MAOI
Ø Food and drug interactions
Ø Phenelzine (Nardil) and tranylcypromine (Parnate)
Ø Do not combine with SSRI, TCA, triptans
Ø Elevates BP and risk of stroke when used with
fermented foods such as beer, wine, cheese

ALCOHOL SCREENING
Ø C: Do you feel the need to cut down?
Ø A: Are you annoyed when your
friends/spouse comment about your
drinking?
Ø G: Do you feel guilty about your drinking?
Ø E: Do you need to drink early in the
morning?
Ø Positive response to 2/4 is highly
suggestive of alcohol abuse
Ø Anyone feeling compelled to drink no
matter what the consequences is
addicted
ANTIPYSCHOTICS SIDE EFFECTS
Ø Pill rolling, shuffling gait, bradykinesia
Ø Extrapyramidal symptoms:
o Akinesia - inability to initiate
movement
o Akathisia - strong inner feeling to
move, unable to stay still
o Bradykinesia - slowness in
movement when initiating
activities that require successive
steps such as buttoning a shirt
o Tardive dyskinesia - involuntary
movements of lips (smacking),
tongue, face, trunk and
extremities
Ø Increased risk of obesity, Type 2 DM,
hyperlipidemia, metabolic syndrome and
hypothyroidism
PSYCHOSOCIAL MENTAL HEALTH
SUICIDE ALTERNATIVE MEDS FOR DEPRESSION
Ø Males represent nearly 80% of all completed Ø St. John’s wort
suicides. o Interacts with SSRI, TCA, MAOI
Ø Females attempt suicide 2-3 times more often. o ↓ Digoxin effectiveness
Ø Highest rate of completed suicide is found in o ↓ effectiveness of birth control
elderly males (75+). Ø 5-HTP, L-tryptophan
Ø Inquiring about suicidal ideation DOES NOT lead o Interacts with SSRI, MAOI,
to suicide. dextromethorphan, Triptans
Ø Risk Factors: Ø Omega-3 fatty acids
o Older people who have lost a spouse o No major drug interactions
o Plan involving gun or lethal weapon o High doses may ↑ risk of bleeding
o Hx of attempted suicide o Stop 1 week before surgery
o Mental illness: bipolar, depression Ø Folate and vitamin B6
o Hx of sexual, emotional or physical abuse Ø Exercise, yoga, massage, guided imagery,
o Terminal illness, chronic illness, pain acupuncture, light therapy
o Significant loss Ø Kava-Kava and valerian root are both used for
o Bipolar is higher risk during depressive anxiety and insomnia. Do not mix with benzos,
episode hypnotics or any CNS depressants
Ø 3 important questions:
o Are you thinking of hurting yourself?
o If yes, do you have a plan?
o If yes, do you have the means?
Ø Imminent risk MOOD
o Immediate psychiatric referral, inpatient Ø Monoamine System
hospitalization o Serotonin (5-HT)
Ø Elevated risk but not imminent § Well being
o Aggressive treatment § Calm
§ ↓ impulsivity
§ ↓ sex drive
SEROTONIN RECEPTOR SITES § ↓ aggression
Ø 5-HT1A – antidepressant § ↑ appetite
Ø 5-HT1C, 5-HT2C – cerebral spinal fluid o Dopamine
production § Make you worry
Ø 5-HT1D – antimigraine effect (anti=defense) § ↑ vigilance
Ø 5-HT2 – agitation, anxiety, panic (2 stressed) § ↑ motivation
Ø 5-HT3 – nausea, diarrhea (3 GI N/V/D) o Norepinephrine
§ Enhance concentration
§ Enhance ambition
§ Enhance productivity
 PSYCHOSOCIAL MENTAL HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Type 1: classic manic episode: labile

Medications:
moods, euphoria, talkativeness, flight of ideas,
Lithium (adverse effects kidney and thyroid)
grandiosity and less need for sleep; increased
Anticonvulsants (valproate, carbamazepine)
Strong genetic energy/activity, disinhibition. May have High risk for suicide
Bipolar Disorder Peak onset in 20s Antipsychotics (treat manic episodes)
component psychotic episodes. ↑ rates of substance abuse during depression phase
Benzodiazepines (insomnia, agitation,
Type 2: hypomanic episode – hypomanic
anxiety)
disorder, absence of mania and major
depression
High levels of Acute onset high fever, muscular rigidity, ↑ risk if combining medications SSRI,
Acute Serotonin serotonin from new mental status changes, hyperreflexia, Acute onset with rapid MAOI, TCAs
Life-threatening
Syndrome drugs or dosage uncontrolled shivering, dilated pupils, progression. If switching medications wait a minimum of
change tachycardia, diarrhea 2 weeks.
Antipsychotics affect dopamine in brain.
Malignant neuroleptic Sudden onset high fever, muscular rigidity,
Idiopathic Life-threatening
syndrome changes in mental status, fluctuating BP and
urinary incontinence
USPTF recommends
Must include depresses moor If patient is harm to self or others, refer to
Sleep, interest, guilt, energy, concentration, screening every adult for
or loss of interest or pleasure psychiatric hospital. “Baker Act” – 3 days
appetite, agitation, suicide, mood depression
Major: > 5 symptoms involuntary detention for evaluation and
(generally, complain of headache, back pain, Comorbidities: anxiety,
Minor: 2-5 symptoms treatment of those at high risk.
chronic pain, “tired all the time” with consistent PTSD, OCD, ADHD,
R/O hypothyroidism, anemia, Screening tools – Beck Depression inventory,
30-40% genetic early morning wakening) oppositional defiant
Depression autoimmune, vitamin B12 PHQ9
60-70% life events disorder, alcohol and
CBC, CMP, TSH, Folate, B12, Cognitive Behavioral Therapy
Seasonal affective disorder – common in winter drug disorders
UA, UDS (EKG if giving SSRI 1st line – 4-12 weeks to take effect
(exercise and SSRI) St John’s Wort interacts
something to prolong QT TCA prior to bedtime due to sedation (avoid
with oral contraceptives,
interval) TCA with suicidal) If sexual dysfunction,
↑ risk for suicide in older men cyclosporine and select
consider adding Wellbutrin
antiretrovirals
Refer to AA, Al-Anon family groups
Benzos such as Librium, Valium –
Dietary Guidelines: Women 1 drink per day; GGT – lone elevation sign of
antipsychotics if needed (Haldol).
Men 2 drinks per day – women metabolize abuse
Avoid RX for potential abuse such as
alcohol 50% slower than men AST/ALT ratio – 2:1 Levels > 0.8% for driving
Compulsive desire to narcotics or alcohol (cough syrup)
Binge drinking: Men 5+ drinks, women 4+ ALT more specific for liver Beer – 12 oz
drink despite Lorazepam if treating alcohol withdrawal and
Alcoholism Acute delirium tremors – sudden onset AST found liver, cardiac, Wine 5 oz
personal, financial and hepatic dysfunction; clonidine for tremor and
confusion, delusions, auditory, tactile or visual kidneys, lungs and skeletal Liquor 1.5 oz
social consequences tachycardia
hallucinations, tachycardia, HTN, tremors, muscle
Disulfiram (Antabuse) – causes N/V,
picking, grand mal seizures MCV > 100 due to folate
headache
Peak symptoms within 24-36 hours after deficiency
Naltrexone (Vivitrol); acamprosate
alcohol is discontinued
(Campral) – decreases alcohol cravings

Complication from
Neurological disorder - hypotension, visual High dose parenteral vitamins, especially can lead to Wernicke
Korsakoff’s syndrome chronic alcohol abuse
impairment and coma; mental confusion, thiamine (vit. B1) Encephalopathy
(Wernicke-Korsakoff) (thiamine – vitamin
ataxia, stupor. (B1 is sugar for the brain)
B1)

Problems with acquiring and learning new

Chronic thiamine information (antegrade amnesia) and retrieving
Korsakoff’s amnesic
deficiency damaging old information (retrograde amnesia). Permanent due to thiamine deficiency
syndrome
brain permanently confabulation, disorientation, attention deficits,
visual impairment
 PSYCHOSOCIAL MENTAL HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Sleep hygiene (regular time, avoid caffeine,

Refer to sleep lab (polysomnography is gold
standard for sleep apnea)
Antihistamines (careful w/ Benadryl in
elderly)
Benzo hypnotics:
Short acting: Alprazolam, Triazolam,
Midazolam
Intermediate acting: Lorazepam, temazepam Risk factors: depression,
Primary – not caused by
Long acting: Diazepam, clonazepam, anxiety, GERD, female,
disease or environment
chlordiazepoxide illicit drug use,
Circadian rhythm Secondary – caused by
(Halcion and temazepam are more sedating) musculoskeletal illness,
disorders, psychic disease or environment
7-8 hours of sleep is the ideal amount. Difficulty Non-Benzo hypnotics: adverse effects pain, chronic health
issues, mental illness, Short term – less than 3
falling asleep or waking up during night too include agitation, hallucinations, nightmares, problems, shift work,
Insomnia OSA, RLS, months, pain, stress, grief
early and unable to go back to sleep; daytime suicidal ideations. Awakening and cannot alcohol, caffeine and
environmental factors, Chronic – at least 3 months,
drowsiness, fatigue, headache, irritability, recall event. nicotine. (certain
certain medications, occurs at least 3 nights per
difficulty concentrating Zolpidem (Ambien) – sleep onset or inability medications – SSRI,
idiopathic. week
to stay asleep cardiac, BP, allergy and
Eszopiclone (Lunesta) – sleep onset or steroids can cause
inability to stay asleep insomnia)
Ramelteon (Rozerem) – sleep onset insomnia
(melatonin agonist)
Complementary: Kava-Kava, Valerian root
(do not give to children or lactating/pregnant
& do not mix with benzos or hypnotics),
Melatonin, Chamomile tea, meditation, yoga,
Tai-Chi, acupuncture, regular exercise (avoid
4 hours prior to bedtime)
Refer to psychiatrist
Delusions and paranoia (disorganized speech
Use of typical antipsychotics can increase
and behavior). Hallucinations are common
sudden death
(usually auditory) with loss of ego boundaries;
Schizophrenia Antipsychotics can prolong QT intervals Onset is usually 16-30’s
flat and restricted affect with poor social skills,
(EKG needed) and can cause torsade de
ability to plan and organize day-to-day
pointes – clozapine, thioridazine,
activities (executive skills) are poor
ziprasidone, haloperidol and others
Onset usually during
Secretive, perfectionistic and self-absorbed. DSM V: adolescence
Marked weight loss (BMI <18.5), lanugo on • Inability or refusal to Osteopenia/osteoporosis
SSRI 1st line
face, back, shoulders, amenorrhea for 3 mon or maintain body weight at due to prolonged
Wellbutrin contraindicated– increases
Irrational longer, abdominal distention with or above minimum estrogen depletion from
seizure threshold
preoccupation with hepatomegaly, cheilosis, oral and gum disease, normal weight for age amenorrhea and low
intense fear of gaining coarse dry skin, hypotension with bradycardia and height calcium intake,
Anorexia Nervosa Chvostek’s sign – contract of facial
weight with distorted and hypothermia • Intense fear of gaining peripheral edema due to
muscles when facial nerve is tapped briskly –
perception of body If purging - loss of dental enamel. Engage in weight and becoming fat low albumin from low
associated with hypocalcemia which could
shape and weight severe food restriction or binge eating and despite low body weight protein intake, cardiac
further develop to tetany
purging. Some use laxatives, vomiting and • Disturbance in complications –
excessive daily exercise. perception of body arrhythmia,
Onset teens to early 20’s weight and shape cardiomyopathy,
hypokalemia

 PSYCHOSOCIAL MENTAL HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

DSM V:
• Eating excessing
amount of food in 2
hours Binge eating is lack of
• Person feels lack of control over amount and
Secretive disease. Problems with erosion of
control over eating type of food 2+ times per
lingual surface of upper teeth due to excessive
• Recurrent compensatory week for 6 months.
exposure to gastric contents during vomiting. Cognitive behavior and pharmacological
Bulimia Nervosa behavior to prevent Accompanied by distress,
Hypokalemia caused by laxative and diuretic therapy. SSRIs – but NOT Wellbutrin
excessive weight gain self-anger, shame and
use is common. Pt is typically of average to
such as vomiting, frustration because of
slightly above average weight.
excessive exercise, purging. Pt is usually
laxative or diuretic obese.
abuse or fasting
• Occurs once per week
for at least 3 months
First line treatment is SSRI such as
Flashbacks, nightmares, intrusive thoughts, paroxetine and sertraline. Therapeutic trial of Comorbidities such as
Combat/war, sexual
avoidance of reminders of trauma, agoraphobia, Assessment tools such as 6-8 weeks to determine effectiveness. depression, anxiety,
PTSD assault, MI, stroke,
sleep disturbance and hypervigilance, feelings PTSD checklist Mirtazapine for sleep. Cognitive behavioral antisocial disorder and
ICU stay
of detachment therapy, Eye movement desensitization and substance abuse is higher
reprocessing (EMDR).
Benzos – limited duration, addiction concern
behavioral treatment and SSRI to kick in and
GAD – excessive worry then wean off Benzo Herbs: Kava-kava,
Situational, Phobias, Panic disorder occurs more in women than men
Anxiety occurs on more days than not GAD – SSRI, SNRI, buspirone valerian root and passion
OCD, Generalized with agoraphobia
for 6 months Panic disorder – SSRI, SNRI, TCA, BB, flower
MAOI
OCD – SSRI, SNRI, TCA

Factitious disorder imposed on self. Patient Munchausen syndrome

Munchausen
falsifies symptoms and or injures self-seeking by proxy (makes the
Syndrome
medical treatment. child sick)

TOBACCO CESSATION
Ø Nicotine gum use: Chew and park – chew gum slowly until nicotine taste appears and then park next to cheeks until the taste disappears. Repeat pattern
several times and discard after 30 minutes of use
Ø Nicotine patches – do not use with other nicotine products. Nicotine overdose can cause acute MI, HTN, agitation.
Ø Bupropion (Zyban) decreases cravings to smoke. Patients can still smoke while on medication. Individually eventually loses desire to quit. Contraindications
include seizures, anorexia/bulimia, abrupt cessation of alcohol, benzos, stroke and brain tumor. Can increase risk of suicide.
Ø Varenicline (Chantix) – 12 weeks. Advise to quit within 1-4 weeks. Avoid prescribing to mentally unstable or hx suicide. Pilots and air traffic controllers are not
allowed to take medication.
 PSYCHOSOCIAL MENTAL HEALTH
ABUSE
Ø Physical, emotional and sexual abuse, economic abuse, material
exploitation
o Can happen at any age (↑ risk with pregnancy)
o Pattern of injury is inconsistent with story
Ø Factors that increase likelihood of abuse
o Increased stress
o Alcohol and drug abuse
o Personal hx of abuse, family hx of abuse
o Major loss
o Social isolation
o Pregnancy
o Elderly (especially those who are frail with dementia)
Ø Physical Exam
o Another health care provider should be in the room during exam
o Interview with abuser and then without
o Collect visual evidence, photos, use ruler. Document in direct
quotes.
o Look for spiral fx, multiple healing fx, burns, welts, etc.
o Look for signs of neglect
o Develop a safety plan with partner abuse
o STD testing
Ø State things objectively, do not be judgmental
Ø Abuser is typically dominant in conversation
Ø BATHE
o Background – how are things at home? Work? Anything changed?
o Affect, anxiety – how do you feel about home life? Work? School?
Life in general?
o Trouble – What worries you the most?
o Handling – how are you handling the problems?
o Empathy – that sounds difficult
Ø SOAP
o Support – Normalize but do not minimalize. What support do you
have?
o Objectivity – Watch your reactions to the story.
o Acceptance – personal acceptance
§ Acknowledge patient priorities
o Present focus
§ Focus on present, negotiate contract
DSM CRITERIA FOR SUBSTANCE ABUSE DISORDER
Ø Require 2 or more of the following within past 12 months
Ø Substance use in larger amounts over longer period than intended
Ø Desire to cut down or has tried unsuccessfully in the past
Ø Excessive time spent obtaining substance, using substance or
recovering from substance
Ø Craving or a strong desire to use
Ø Inability to maintain major role obligations
Ø Continued substance use despite recurrent social or interpersonal
problems related to substance use
Ø Substance use in potentially hazardous positions
Ø Important social, occupational or recreational activities are given up
or reduced due to substance use
Ø Tolerance
o Needing more to get same effect
o Diminished effect with same amount
Ø Withdrawal
o Set of characteristic withdrawal symptoms
o Same or other substances taken to avoid withdrawal
RANDOM SUBSTANCE ABUSE FACTS
Ø Often have underlying mood disorder
Ø Young adults (18-25) are most likely to misuse RX meds
Ø Chronic used of marijuana can lead to COPD
Ø Alternative to methadone is buprenorphine plus naloxone
Ø Hyperthermia and racing heart is potentially life threatening with
MDMA (ecstasy or Molly)
 RENAL

KIDNEYS KIDNEY FUNCTION CHRONIC KIDNEY DISEASE
Ø Body’s regulator of fluids Ø Serum Creatinine – when renal function ↓ creatinine ↑ Ø Common electrolyte disorders include
Ø Water is reabsorbed by antidiuretic hormone and Creatinine affected by age (less sensitive in elderly), hypernatremia, hypercalcemia and
aldosterone gender (higher in males), ethnicity (high with African hyperkalemia
Ø Excrete water-soluble waste (creatinine, urea, uric acid) background), muscle mass Ø Increase in creatinine from 1-2
Ø Produce erythropoietin (stimulates bone marrow to Male 0.7 to 1.3 indicates a 50% loss in renal function
produce more RBC), renin, bradykinin, prostaglandins and Female 0.6 to 1.1 Ø Creatinine clearance usually

calcitriol/vitamin D3 Ø Estimated Glomerular Filtration Rate (eGFR) approximates eGFR
Ø Average UO is 1500 mL eGFR “estimated value” – more damaged the kidneys, the Ø Creatinine is best described as a
Ø Oliguria < 400 mL day lower the eGFR. Best if patient does not eat meat 12 product related to skeletal muscle
Ø Right kidney sits lower than left due to liver displacement hours before test and is less reliable with drastic changes metabolism
in muscle mass, pregnancy and acute renal failure Ø Common causes include DM,
normal eGFR > 90 recurrent pyelonephritis, polycystic
URINALYSIS Stage 2 eGFR 60-89 kidney disease
Ø Epithelial Cells – large amounts indicate contamination; a Stage 3a eGFR 45-59 Ø Persistent proteinuria is commonly
few are normal Stage 3b eGFR 30-44 found in early development of CKD
Ø Leukocytes – normal WBCs in urine <10 Stage 4 eGFR 15-30 Ø ACEI can limit the progression of some
o Leukocyte esterase Stage 5 eGFR < 15 renal disease by reducing efferent
o Pyuria (presence of leukocytes) in males is always Ø Blood Urea Nitrogen – elevation may be caused by acute arteriolar resistance
abnormal renal failure, high-protein diet, hemolysis, CHF or drugs Ø Objective findings in
Ø Urine for Culture and Sensitivity (waste product of protein from foods eaten, dehydration glomerulonephritis include edema,
o >100,000 will also elevate BUN) RBC cast and proteinuria
Ø Red Blood Cells Ø BUN-to-Creatinine Ratio – evaluate dehydration, Ø Anemia: Normocytic, normochromic
o <5 is normal hypovolemia, acute renal failure anemia with low retic count
Ø Protein Ø Erythropoiesis is recommended with
o Indicates kidney damage CKD and Hgb < 10
o Urine dipstick detects albumin not microalbumin Ø Dialysis and transplant discussion at
KIDNEYS
(Bence-Jones proteins) Stage 4 CKD
Ø Prerenal azotemia – most common cause of acute renal
Ø Nitrites Ø Some meds that affect kidneys –
failure, kidneys are hypoperfused – which leads to acute
o Indicative of infection Allopurinol, antibiotics, digoxin,
tubular necrosis. Caused by ↓ circulating volume such as
Ø Cast lithium, gabapentin, H2 blockers, anti-
dehydration and acute blood loss; ↓ CO such as heart
o Hyaline cast are normal arrythmias
failure; excessive sequestering of fluids as in burns
o WBC cast may be seen with infection
Ø Postrenal azotemia – obstruction to urine flow and is
o RBC cast and proteinuria are diagnostic of
uncommon cause of renal failure. Such as
glomerulonephritis
glomerulonephritis
 RENAL

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

CVA tenderness
Uncomplicated may treat as outpatient
E. Coli, Klebsiella spp. High fever, chills, dysuria, frequency, and UA – large leukocytes,
Cipro BID x 7 days or Levaquin daily
Pyelonephritis Proteus mirabilis unilateral flank pain (described as deep ache) N/V hematuria, WBC cast and
Rocephin 1 gram + Augmentin BID x 14
May have had recent UTI proteinuria
days
Urine C&S
Decreased blood flow
Abrupt onset of oliguria, edema and weight gain
to kidneys; damage to ↑ creatinine
Acute renal failure (fluid retention). Complains of lethargy, nausea Hydrate
kidneys; urine blockage ↓ GFR
and loss of appetite. Rapid ↓ in renal function
in kidney
Preferred therapy for nonmuscular-
Painless hematuria (microscopic or gross). May UA – microscopic hematuria is Risk factors: Elderly > 50;
invasive bladder cancer without evidence
appear at the end of voiding. Dysuria, frequency, the primary finding in 20% of male (73 years), smoker,
Long term use with of metastasis is transurethral resection
Bladder cancer nocturia (not related to UTI). Advanced disease individuals with bladder CA occupational exposure to
pioglitazone with intravesical chemotherapy. Despite
may complain of lower abdominal or pelvic pain, Urine C&S textile dyes and heavy
successful initial therapy, local recurrence
perineal pain, low-back pain or bone pain. Urine for cytology metals
is common
Cancer, infection, renal
calculi, coagulopathy,
UA
glomerular disease,
Gross hematuria if urine is pink, red, brown or If infection: Urine C&S
Hematuria hydronephrosis,
blood clots are present. If malignancy: Urine for
polycystic kidneys,
cytology
trauma, medications,
BPH, exercise induced
UA moderate to large
leukocytes, +/- nitrites, few Uncomplicated: Bactrim DS BID x 3 days; For men do prostate exam
RBC (inflammation) (sulfa allergic/resistance) Nitrofurantoin Only treat pregnant
C&S > 100,000 (Macrobid) 100mg BID x 5 days women with
Frequency, burning, urgency, dysuria, hematuria,
Ciprofloxacin (Cipro) 250mg PO BID – no asymptomatic bacteriuria
E. Coli, Klebsiella spp. foul-smelling urine, nocturia, lower abd. /back
UTI never normal in male – fluoroquinolones in pregnancy or <18yo UTI in pregnant women
Urinary Tract Staph. Saprophyticus, pain – NO FEVER
R/O other causes. Pyridium – leaves it orange (avoid in liver and children <3 are more
Infection (Cystitis) Proteus mirabilis Risk factors: female, pregnancy, hx of UTI, DM,
3 or more UTI in 1 year in disease) likely to progress to
failure to void after sex, spermicide use, low fluid
females – R/O other causes Complicated: Keflex, Cipro 500mg BID or pyelonephritis
intake, poor hygiene, catheterization
Levaquin 750 daily for 7-10 days
***nitrates are normal in ***Nitrofurantoin contraindicated with Renal and bladder sono
urine, nitrites can indicate renal insufficiency for UTI infants
infection
Severe colicky pain that comes in waves. Patient
Risk factors: family hx of
cannot sit still. Pain builds in intensity, lessens Toradol injection
Majority made of stones, gout, bariatric
and disappears. Associated with N/V. May have Increase fluids, strain urine
calcium oxalate; surgery, high doses
Nephrolithiasis gross or microscopic hematuria Avoid high-oxalate foods: rhubarb,
Struvite stones are vitamin C
(Urolithiasis) Stones in upper urethra or renal pelvis may cause spinach, beets, chocolate, tea and meats
found in those with hx Meds that cause kidneys
flank pain and tenderness whereas stones in lower Consider alpha blocker
of kidney infection stones: HCTZ,
urethra may cause pain radiating to testicle or Refer urology
topiramate, indinavir
labia. Both can cause abdominal pain
Acute is often self-limiting. Manage Risk factors include
UA ↑ Protein, RBCs, renal cast underlying cause and protect kidneys – infection: bacterial
Inflammation of antihypertensives, antimicrobials, endocarditis, immune
Pink or cola colored urine due to hematuria, ↑ Creatinine and BUN
glomeruli in kidney. systemic corticosteroids and immune disease: Goodpasture’s
Glomerulonephritis foamy due to proteinuria, HTN, edema of face, CT scan or kidney sono
Occurs 1-2 weeks s/p suppressants. Plasmapheresis, dialysis syndrome, SLE, or
hands, feet and abdomen, possible anemia Confirmatory diagnosis is with
bacterial infection If left untreated, can lead to kidney failure, vasculitis: polyarteritis or
Kidney biopsy HTN, electrolyte disorders and nephrotic Wegener’s
syndrome granulomatosis
 WOMEN’S HEALTH

RANDOM GU URINARY INCONTINENCE
Normal healthy women of reproductive
age Types Definition Management Age
Ø Discharge – white, clear, flocculent (1/2 to 1 tsp Stress incontinence Associated with lifting, Pelvic floor exercises, Peak 45-49 yrs.
daily) laughing, sneezing, bending decongestant?
Ø Normal pH – 3.8-4.2 Overflow incontinence Frequent dribbling; due to Identify & treat underlying Older men
blockage of flow cause (BPH, MS, spinal cord
injury)
If test positive for STI then also recommend Urge incontinence Reports of strong sensation of Antimuscarinic Older women
o Syphilis, HIV and Hep B testing needing to void. “overactive (oxybutynin/Ditropan) or
bladder” – detrusor instability TCA (imipramine), Kegels
Friable cervix – brisk bleeding with cleaning with Functional incontinence Often occurs in presence of Bedside commode, raised
cotton swab mobility problems toilet seats with handles,
o Increased chance to acquire STI physical therapy for
strengthening and gait
Mixed incontinence Stress and urge incontinence Kegels
Normal findings on pelvic exam in older woman
o Flattening of vaginal rugae
Treatable Causes of urinary incontinence:
o Scant white vaginal discharge
D – Delirium
o Should not be able to palpate ovary
I – Infection (UTI)
A – Atrophic urethritis and vaginitis
P – Pharmaceuticals (diuretics, others)
E – Excessive urine output (heart failure, hyperglycemia due to undetected or poorly-controlled DM)
R – Restricted mobility
S – Stool impaction

Risk factors: obesity, pregnancy, vaginal delivery, menopause, age and diabetes.
Some foods have diuretic effects: tea, caffeine, alcohol, carbonated drinks, citrus fruits, spicy foods

URINARY INCONTINENCE
Ø During gynecological exam, instruct patient to cough (↑ intra-abdominal pressure so herniation is visible)
Ø Herniation of bladder (cystocele) – bulging anterior vaginal wall – refer for pessary placement, surgery
Ø Herniation of rectum (rectocele) – bulging posterior vaginal wall – feeling of rectal fullness, possible fecal
incontinence – Kegels, avoid straining during bowel movement, treat constipation – refer for pessary
placement, surgery
Ø Uterine prolapse – cervix descends midline into vagina; feeling that something is falling in vagina, low back pain
– avoid heavy lifting; refer for pessary or surgery
Ø Enterocele – small bowel slips into area between uterus and posterior wall of vagina. Pulling sensation inside
pelvis, pelvic pressure or pain, low-back pain, dyspareunia
 BREAST CANCER WOMEN’S HEALTH CERVICAL CANCER
Ø BRCA (breast cancer susceptibility gene) Ø Pap smears start at age 21 every 3 years until 29
Ø Age 30 – pap with HPV every 5 years otherwise
Ø High risk
CERVIX every 3 years
o Family history of breast cancer (before 50)
Ø Cervical ectropion – looks like bright-red bumpy Ø Stop screening age 65 if negative hx for 15-20 yrs.
o Breast cancer triple-negative (before 60)
tissue with irregular surface on cervical surface Ø Hysterectomy with removal of cervix not due to
o Ovarian or other gynecological cancer
around os – benign and more friable. It is cancer – can stop screening
o ↓ parity, early menarche, late menopause
common with women taking birth control. It can Ø Specimen is satisfactory if both squamous epithelial
Ø Men with BRCA genes are higher risk of breast and
change in size, shape or disappear over time. cells and endocervical cells are present
prostate cancer
Sample the transformation zone Ø Atypical Squamous Cells of Undetermined
Ø Refer high risk to breast specialist
(squamocolumnar junction) when performing Significance (ASC-US)
Ø Screened using MRI and mammogram – screen 10
pap. Border of brighter red ectropion and o <20 yrs. repeat 1 year
years earlier than when family member diagnosed
smother surface of cervix – area where abnormal o 21-24 – repeat pap in 1 year
Ø More common among Ashkenazi Jews
cells are more likely to grow o 25-29 – reflex HPV and pap in 1 year
o 30+ if HPV + colposcopy, if HPV – repeat co-
UTERINE FIBROIDS
testing in 3 years
Ø Uterine fibroids (uterine leiomyoma or myoma) can
Ø Atypical Glandular Cells – (endometrial cells)
enlarge the uterus. Symptoms include heavy bleeding
premalignant or malignancy – endometrial biopsy
(menorrhagia), pelvic pain or cramping and bleeding
Ø Low-Grade Squamous Intraepithelial Lesions (LSIL)
between periods.
o 21-24 – repeat pap in 1 year
Ø Usually benign but can be malignant and cause
o 25-29 – colposcopy with cervical biopsy
uterine cancer (leiomyosarcoma)
o 30+ if HPV + colposcopy with cervical
biopsy, if HPV – repeat in 12 months or
MENSTRUAL CYCLE colposcopy
Ø Follicular Phase (Days 1 to 14) – estrogen is the Ø High-Grade Squamous Intraepithelial Lesions (HSIL)
predominant hormone – stimulates development and o 21-24 – colposcopy with cervical biopsy
growth of endometrial lining. FSH from anterior o 25+ refer for immediate excisional
pituitary stimulates the follicles into producing treatment (LEEP) or cervical conization
estrogen Ø HPV 16 and 18 cause 70% cervical cancer
Ø Midcycle (Day 14): Ovulatory Phase – LH secreted by Ø Vaccinate with Gardasil
anterior pituitary gland which induces ovulation
Ø Luteal Phase (Days 14 to 28) – progesterone
predominant hormone RANDOM PEARLES
Ø Sex 1-2 days prior to ovulation offers greatest chance Ø During puberty it is common for both girls and boys to
of pregnancy have asymmetrical breasts, gynecomastia
Ø Palpable ovary after menopause – intravaginal
ultrasound and rule out ovarian cancer
RANDOM TESTING Ø Primary Amenorrhea - Lack of menses by age 15 w/
Ø Tzanck smear – herpetic infections – lg. nuclei secondary sexual characteristics, Refer to OB –
Ø Gram stain – Neisseria gonorrhea, rarely used
secondary to pituitary, hypothalamus etc.
Ø Whiff test – for BV
Ø KOH – fungal infections

ORAL CONTRACEPTIVES
Ø Combined oral contraceptives
o Monophasic pills (Loestrin FE) – 21 active pills;
placebo (iron) last 7d
o Biphasic (Ortho-Novum) – two progesterone
doses
o Triphasic (Ortho tri-cyclin) - 21 active pills;
placebo last 7d. Hormones weekly. 3 varies.
Good for acne
o Extended Cycle (Seasonale) – 84 days active pill
w/ 7 free days. 4 periods per yr. – breakthrough
bleeding
o Ethinyl Estradiol/Drospirenone (Yaz)
drospirenone as progesterin; great for acne,
PCOS, hirsutism, PMDD. High risk for
DT/hyperkalemia. Must check K+ levels if on
ACEI/ARB/K+ sparing diuretic - ↑ risk blood
clots, CVA, CAD
o Low dose pills contain 20 to 25 mcg of ethinyl
estradiol
Ø Progestin-Only
o Safe for breastfeeding, “minipill”
o Take pill at same time each day
o If taken late > 3 hours or miss dose, use
condoms
o Micronor – 28 days of progestin. Start taking on
day 1 of menstrual cycle
Ø New prescriptions
o Can be started after ruling out pregnancy
o “Quick Start” – start on day prescribed
o “Sunday Start” – first pill on first Sunday after
period – will avoid periods on weekends
o “Day One Start” – first pill on first day of
menstrual cycle (provides best protection)
o Follow-up in 2-3 months to check BP, side
effects
Ø Advantages (After 5 years of use)
o ↓ ovarian and endometrial cancer
o ↓ Dysmenorrhea and cramps ↓ prostaglandins
o ↓ endometriosis
o ↓ acne and hirsutism (↓ androgen)
o ↓ ovarian cyst (suppress ovulation)
o ↓ heavy/irregular periods thus decreasing IDA
WOMEN’S HEALTH OTHER METHODS
ORAL CONTRACEPTIVE CONTRAINDICATIONS
§ Absolute contraindications
§ “My CUPLETS” 10yrs
o Migraines with focal neurological aura
or >35 migraines without aura
o CAD/CVA
o Undiagnosed genital bleeding
o Pregnant
o Liver disease or tumor
o Estrogen-dependent tumor
o Thrombus/emboli – factor V Leiden
o Smoker 35 or older
§ Relative contraindications
o Migraines 35+
o Smoker < 35
o Fracture/cast on lower extremity
o Hypertension
ORAL CONTRACEPTIVE PROBLEMS
Ø Unscheduled bleeding (spotting)
Ø Menstrual cramps
o Mefenamic acid (Ponstel), Aleve, Advil,
Anaprox
Ø Menorrhagia – heavy bleeding
Ø Missing pills
o Missed 1 day – take 2 now and continue
o Missed 2 days – take 2 pills for 2 days
and finish pack (use condoms for
current cycle)
Ø Drug interactions – anticonvulsants, antifungals,
St. John’s wort, PCN, Tetracyclines, Rifampin
Ø Thromboembolic Warning signs: ACHES
o Abdominal pain
o Chest pain
o Headaches
o Eye problems (vision changes)
o Severe leg pain
Ø IUD – risk for infection, perforation, heavy
bleeding
o ParaGard – copper-bearing; effective
o Mirena – levonorgestrel hormone;
effective 5 yrs. little more effective
than Paragard (Skyla) - smaller
Ø Depo-Provera (6% failure rate) – injections q3
month, start within 5 days of cycle. Recommend
calcium with vitamin D and weight-bearing
exercise. Avoid >2 years. Risk for
osteopenia/porosis. Avoid if anorexic/bulimic.
May delay return of fertility – do not use if wish
to become pregnant in 12 months. Does not
interact with Dilantin
Ø Diaphragm w/ gel (13% failure rate) – after
insertion, the cervix should be smoothly
covered. Leave in for 6-8h. Add spermicide w/
every act of intercourse. Cervical cap can be
work for up to 72h - ↑risk UTI and TSS
Ø Condoms (18% failure rate)
Ø NuvaRing (9% failure rate) leave inside for
3weeks
Ø Patch (9% failure rate)- risk of VTE
Ø Implants (<1% failure rate) – may take 1yr to
ovulate after removal, weight gain. Norplant
good for 5yr, Nexplanon 3yr
EMERGENCY CONTRACEPTION
§ r/o pregnancy
§ effective up to 72h after unprotected sex
§ most effect within first 24h
§ inhibits ovulation, slows sperm and ovum
transport
§ Plan B – progesterone only (89% effective): take
1st dose now, 2nd dose 12h later. If vomits tablet
within 1 hour – repeat dose
§ Ulipristal – inhibits embryo transplantation-
approved for up to 5 days after intercourse
§ Return if no menses w/in 3 weeks

 WOMEN’S HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Middle-age or older female with painless mass Screening – ACS age 45 then Screening: BRCA
feels hard and irregular. Mass attached to skin yearly; USPSTF age 50 then standardized
and tissue (immobile) RUQ of breast most every 2 years questionnaire such as
Breast mass/CA Refer to surgeon
common location (tail of spence). Skin changes: < 30 start with ultrasound FHS-7 (if BRCA gene
dimpling, retraction, peau d’orange “orange peel”, Diagnostic Mammogram positive – consider
blood discharge, nipple displacement Breast biopsy referral for counseling)
Older female c/o chronic scaly red-colored rash,
Paget’s disease of like eczema, on nipple that does not heal; itching,
breast (Ductal skin lesion slowly gets larger and includes
carcinoma in Situ) crusting, ulceration and/or bleeding. Spreads to
areola
Acute onset red, swollen, warm area in breast of
Aggressive form of CA
Inflammatory younger women. Mimics mastitis. No distinct
More common in African
breast cancer lump. Acute onset, skin may be pitted or appear
American
bruised.
Risk factors: family hx,
Vague symptoms: abdominal bloating,
BRCA, endometriosis,
5th most common CA in discomfort, low-back pain, pelvic pain, urinary BRCA 1/BRCA 2 screening
Ovarian cancer >55, early menstruation,
women frequency, constipation. usually metastasized by starts at age 30
nulliparous, obesity, late
diagnosis
menopause, infertility,
Sexually active, amenorrhoeic or light to scant
bleeding, one sided lower abdominal/pelvic pain
Quantitative HCG – should Leading cause death 1st
Ectopic pregnancy 6-8 weeks after LMP w/ cramping worsening when supine or with
double 24-72 hours trimester of pregnancy
jarring. May refer to right shoulder, hx PID, tubal
ligation, or previous ectopic
Bilateral breast tenderness and lumps up to
Avoid caffeine
2weeks prior to menses, resolving w/ menses. No
Fibrocystic disease Vitamin E and evening primrose capsules
masses, skin changes, nipple discharge, or nodes
daily. Wear bras with good support
on physical exam
Presents teenage years; hirsutism, acne, Transvag. ultrasound Low-dose oral contraceptives,
Hormonal ↑ Risk for DM2,
oligomenorrhea, amenorrhea, dark hair on face, ↑ serum testosterone, DHEA, spironolactone to control hirsutism,
abnormality, infertility, hyperlipidemia, metabolic
Polycystic Ovarian cheek, beard areas, acanthosis nigricans, androstenedione, FSH is Provera 5-10mg daily for 10-14 days
excessive androgen syndrome, endometrial
Syndrome (PCOS) mood/mental health problems normal or low, FBS and OGTT (repeat every 1-2 months), metformin to
production, insulin hyperplasia, obesity, OSA,
Rotterdam Criteria (2 of 3): Oligomenorrhea, are abnormal; induce menses, weight loss
resistance CAD, breast CA
hyperandrogenism and cystic ovaries
Weight-bearing exercises (yoga, calcium w/ Vit D
(1200/800mg), Bisphosphonates: 1st line ↑
BMD and inhibits bone reabsorption (potent
“Skinny white woman who smokes and drinks” – esophageal irritant, take with full glass of water Long term
Affects women and men while sitting or standing and do not lay down for bisphosphate tx
Common fx sites include femur, forearm, 30 minutes) Fosamax (alendronate), Actonel has been
vertebrae; ↑ risk with chronic steroid use, hx of DXA scan: T-score < -2.5
(risedronate), Selective Estrogen Receptor associated with
(Osteopenia: -1.0 to -2.4)
Loss of bone density anorexia or bulimia, long term PPI use, gastric Modulator – block estrogen receptors. Good for atypical fx. – give
Osteoporosis Repeat DXA in 1-2 yrs. if on
from estrogen def. bypass, celiac disease, hyperthyroidism, postmenopausal women with osteoporosis who for 5 years and
meds otherwise in 2-5 yrs.
ankylosing spondylitis, Caucasian and Asian also need breast cancer prophylaxis. ↑ risk DVT, then take break.
women. Lifestyle risk factors - ↓ Calcium, vitamin endometrial cancer, strokes and PE. Evista Use of calcitonin
D, inadequate physical activity, alcohol (raloxifene) after menopause. Parathyroid has ↑ risk of
consumption (3+ per day), ↑ caffeine, smoking hormone (PTH) Analog – Forteo; Miacalcin and malignancy
Calcitriol – weak compared to bisphosphonate.
Low calcium diet and monitor for hypercalcemia,
hypercalciuria and renal insufficiency.
 WOMEN’S HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Wet smear: clue cells,

Thin, homogenous, white, gray, copious milk-like
few WBC; Whiff test – Metronidazole (Flagyl) BID x 7 days,
Overgrowth of discharge. Unpleasant “fish-like” odor worse after Clue cell = mature squamous
Bacterial Vaginosis KOH applied to sample Clindamycin cream, Not STD, no partner
anaerobic bacteria in intercourse. Exam shows light gray discharge epithelial cell with numerous
(BV) – smells fishy treatment needed
vagina coating on vaginal walls. – does not cause bacteria noted on cell borders
Alkaline vaginal pH Abstain from sex until treatment complete
inflammation
>4.5
-azole antifungal, oral fluconazole (Diflucan),
Wet smear – or vaginal miconazole (Monistat),
Candida albicans yeast White curdy cottage cheese-like vaginal discharge pseudohyphae and Clotrimazole (Gyne-Lotrimin), Terconazole ↑ Risk with HIV, those on
Candida Vaginitis
in vulva/vagina c/o severe pruritus, swelling and redness. spores, budding yeast (Terazol-3) cream; If patient on antibiotic antibiotics, diabetics
w/ large # WBC daily yogurt or lactobacillus pills;
complicated case butoconazole

Pap smear shows topical estrogen cream is symptomatic or

Vaginal dryness, itching, pain w intercourse. less atrophic changes recurrent UTI (oral estrogen as solo
Atrophic Vaginitis Estrogen deficiency
rugae, pale color, may bleed on physical exam Elevated FSH/LH intervention is likely inadequate)
pH > 5.0 Osphena (non-estrogen)

Primary – pain improving w/ menses, N/V,

diarrhea, back pain, starts as teen & improves w/
Excessive
age and NSAIDs Good history, physical NSAIDs; if secondary treat cause; exercise, Vaginal bleeding post-
prostaglandins
Dysmenorrhea Secondary – after 35yo, abnormal bleeding, exam esp. pelvic, check heat to area. menopause – endometrial
Most common GYN
non-midline pain worsens w/ time (most STDs, fibroids, Oral contraceptives biopsy for CA
problem
commonly as endometriosis) – pain with
intercourse
Structural
Polyps > 30 years
Adenomyosis > 30
Leiomyoma/Fibroids > 30
Post-menopausal bleeding > 12 months since Malignancy/Hyperplasia >40
Abnormal Uterine Non-Structural
LMP – refer to OBGYN r/o cancer
Bleeding (AUB)
PALM-COEIN Coagulopathy any age
Ovulatory Dysfunction any age
Endometrial Disorder any age
Iatrogenic Medications any age
Not classified
Hormonal Therapy – contains ¼ or less
amount estrogen as COC. May preserve bone
density, but contributes to endometrial,
breast cancer and CAD; use lowest dose
possible, if hysterectomy – add progestin
component is to minimize endometrial
↑ LH & FSH hyperplasia. Estradiol 1mg provides relief in
No naturally occurring Hot flashes, night sweats, symptoms typically 4 weeks vs. low dose 8-12 weeks. Low dose is
↓ testosterone
Menopause menstrual period for 12 occur the week before menses. Estrogen receptors better tolerated Perimenopause 40-45
↓ estradiol
months are found in highest concentration in the vagina Estrogen receptor modulator therapy: Evista
↓ progesterone – osteoporosis risk is reduced
Other options: venlafaxine, sertraline,
gabapentin, paroxetine
Phytoestrogens include red clover, ginseng,
black cohosh, yam, and soy products
High dose vitamin E (800 IU)
 PREGNANCY PREGNANCY SIGNS OF PREGNANCY
Ø Zygote → Blastocyte → Embryo → fetus Ø Positive signs
PREGNANCY
Ø Naegele’s rule: NUTRITION o Palpation of fetus by health care provider
o Subtract 3 months from first day of LMP, o Ultrasound and visualization of fetus
Ø Additional 300 kcal/d
add 7 days = 40 weeks (280 days) Ø Lactation 500 kcal/d o Fetal Heart Tones auscultated
Ø 1st trimester ultrasound – crown-rump
§ 10-12 weeks doppler
Ø Calcium 1000-1500 mg/d
measurement (with 7-day error) Ø Folic acid 0.4-1 mg/d (green leafy veg, cereal) § 20+ fetoscope/stethoscope
Ø 2nd trimester ultrasound – using multiple fetal Ø Probable signs
measurements (with 10-14-day error) o Goodell’s sign (4 weeks) – cervical softening
Weight Gain:
Ø Uterine size, etc.: o Chadwick’s sign (6-8 weeks) – blue color o
BMI Total Weight
o Nongravid – lemon Gain cervix and vagina
o 8 weeks – orange Underweight <18.5 28 – 40 o Hegar’s sign (6-8 weeks) softening uterine
o 10 weeks – baseball (? Doppler heart) Normal weight 18.5 – 24.9 25 – 35 isthmus
o 12 weeks – above symphysis pubis Overweight 25.0 – 29.9 15 – 25 o Enlarged uterus
§ grapefruit (FHT doppler) Obese >30 11 – 20 o Ballottement – when fetus is pushed, it can
o 16 weeks – between symphysis pubis and be felt to bounce back by tapping the
umbilicus Ø Twins: ↑ weight gain (37-54lbs) palpating fingers inside vagina
o 16-18 weeks – quickening (feeling baby Ø After delivery – loss of 20-30lbs in first few weeks o Urine HCG (because also can present in
move) Ø Avoid soft cheese, uncooked meats, raw milk molar pregnancy and ovarian cancer)
o 20 weeks – at umbilicus (FHT stethoscope) Ø Do not eat raw shellfish or raw oysters (Vibrio Ø Presumptive signs
o 20-36 weeks – about 1 cm about vulnifucus infection) o Amenorrhea
symphysis pubis +/- 1 cm Ø Be careful with cold cuts, uncooked hot dogs and o N/V
o At term – fundus height dropped deli meats (Liesteria monocytogenes) o Breast changes
Ø If uterus is smaller than expected (IUGR) Ø Regular coffee 8 oz. o Fatigue
Ø Most weight is gained in 3rd trimester (about 1-2 o Urinary frequency
lbs. per week) o Slight increase in body temperature
RISK FOR ECTOPIC
o “Quickening” – mother feels baby’s
Ø Hx of salpingitis movements for 1st time (16 weeks)
Ø Prior ectopic pregnancy ASYMPTOMATIC BACTERIURIA
Ø Hx of tubal surgery
Ø Always treat (asymptomatic 3, symptomatic 7)
Ø Assisted reproduction RANDOM PEARLES
Ø Macrobid BID x 5-7 days
Ø Hx of infertility
Ø Augmentin BID 3-7 days Ø Zika – cleft palate, highest risk in 1st trimester
Ø Cigarette smoking
Ø Amoxicillin BID 3-7 days Ø Schedule of visits
Ø Progestin use
Ø Cephalexin BID 3-7 days o Every 4 weeks until 28 weeks
Ø Current IUD use
Ø Avoid nitrofurantoin and sulfa drugs near term, o Every 2 weeks until 36 weeks
Ø Previous cervicitis or PID
during labor and during delivery – contraindicated o Every week until delivery
Ø Tubal ligation failure
in neonates Ø Drugs can pass placental barrier <500 daltons, unable
Consider if hcg > 1500 and us fails to show pregnancy
Ø ↑ hyperbilirubinemia → kernicterus to pass at >1000 daltons
Methotrexate or surgical
Ø UTI in pregnancy is complicated UTI Ø Pregnancy with asthma – bronchospasm in 36-40 wk.
 LABS
Ø UA every visit
Ø Alkaline phosphatase always ↑ due to bones
Ø Leukocytosis with neutrophilia is normal
Ø Alpha-Fetoprotein (AFP) – check 16 -20 weeks
o Low – order triple screen to evaluate for
Down syndrome
o High – r/o neural tube defects or
multiple gestation ↑ sono
Ø Triple Screen Test (AFP, beta HCG, estriol serum)
Ø Quad – triple + inhibin A (hormone by placenta)
o Down syndrome
Ø Amniocentesis –gold standard for genetic
disorder is fetal chromosomes/DNA
(spontaneous fetal loss 1-400)
Ø Tay-Sachs disease (neurologic, common Jews)
Ø Cystic Fibrosis (white)
Ø Sickle cell trait (blacks)
Ø 1st prenatal – document HCG
o Pap, GC/chlamydia
o Rubella, varicella, rubeola
o Syphilis, HIV, HBsAg, consider HCV
o CBC, blood type, antibody screen
o TSH if being treated
Ø 16-20 weeks
o Quad marker/screen
Ø 24-28 weeks
o Screen for gestational DM
Ø 28-32 weeks
o STI
o RhoGAM if indicated (Rh -)
Ø 32-36 weeks
o Fetal presentation
o Kick counts
Ø 35-37 weeks
o Group B strep culture
o Positive – pen G 5 million IV followed by
2.5-3 million Q4 until delivery
Ø 40-42 week
o Vaginal exam to assess cervical ripeness
PREGNANCY
DRUGS IN PREGNANCY
PHYSIOLOGICAL CHANGES Ø Category A –
Ø Heart is shifted anteriorly and towards left o Vitamin A, Levothyroxine
Ø Heartrate ↑ 15-20 BPM Ø Category B – SAFE
Ø Heart sounds are louder, S3 is common, splitting o PCN, Cephalosporin, macrolides,
of S2 may be heard acetaminophen, Pulmicort, Maalox,
Ø Systolic ejection murmur (II/IV) heard over Colace, methyldopa (check LFT –
pulmonary and tricuspid area discontinue with jaundice, abnormal LFT
Ø CO ↑ 30-50% (↑ preload), ↓ SVR and BP (↓ or unexplained fever), CCB (Procardia),
afterload) BB (labetalol), insulin
Ø Plasma volume ↑ 50% Ø Category C – Probably SAFE
Ø Physiological anemia o Sulfa in 3rd trimester, Clarithromycin,
Ø Uterus compresses vena cava (orthostatic HTN) NSAIDs (premature closure of ductus)
Ø Hypercoagulable state Ø Category D – May NOT be safe
Ø Basal rales that disappear with coughing o ACE/ARB, quinolone, tetracycline,
Ø No change in FEV1 but ↓ total lung capacity Tegretol, Depakote, fluoxetine,
Ø Constipation, heartburn paroxetine
Ø ↑ melanocyte-stimulating hormone causing linea Ø Category X – NOT Safe
nigra (dark line from down abdomen) and nipples o Accutane, Thalidomide, statins, Proscar,
and areola darken misoprostol, Evista
Ø Chloasma (melasma) – blotchy Ø Teratogens – alcohol (FAS), aminoglycosides
hyperpigmentation on forehead, cheeks, nose (deaf), cigarettes (IUGR), cocaine (CVA),
and upper lip – more common in dark skin, due isotretinoin, lithium (cardiac defects), gestational
to ↑ estrogen level diabetes (LGA, neural tube defects)
Ø Striae gravidarum
Ø Telogen effluvium (hair loss) – during postpartum RANDOM PEARLES
Ø Kidney size ↑ - GFR ↑ due to ↑CO and renal
Ø Cat litter or raw/undercooked meat can cause
blood flow
toxoplasmosis
Ø Nasal congestion, epistasis due to ↑ blood flow
Ø Smoking (IUGR) and alcohol are contraindicated
Ø Varicose veins
Ø Do not use hot tubs, saunas or expose oneself to
Ø Peripheral edema
excessive heat
Ø Progesterone, CCBs relaxes esophageal sphincter
and contributes to heartburn
OBSTETRIC HISTORY
Ø Uterine involution – uterine contractions for 2-3
Ø Gravida
days after birth. Soft boggy uterus with heavy
Ø Term
vaginal bleeding is atony (inadequate
Ø Preterm
contraction). Involution takes about 6 weeks.
Ø Abortion
Breastfeeding speeds this up.
Ø Living
Ø Edwards trisomy 18
 PREGNANCY

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Late third trimester pregnancy with sudden onset ↑ Risk with HTN,
Placental Abruption
vaginal bleeding accompanied by contracted CBC, PT/PTT, Type Deliver fetus; severe case can cause preeclampsia/eclampsia,
(Abruptio
uterus, painful. Hard abdomen, rigid uterus. Up and Cross, Rh, sono hemorrhage cocaine use or hx of abruptio
Placentae)
to 20% do not have vaginal bleeding placentae
Bedrest. Mag sulfate for cramping. If mild,
Multipara late 2nd to 3rd trimester with new onset uterus will reimplant. No vaginal or rectal ↑ risk hx., C-section, multipara,
Placenta Previa painless bleeding worsened by intercourse. Soft, stimulation. If cervical dilation or older age, smoking, fibroids,
nontender uterus. hemorrhaging, fetus is delivered via C- cocaine
section
Primigravida in late 3rd trimester (>34 weeks);
Triad: HTN,
sudden onset recurrent headaches, visual
proteinuria and edema
Unknown – risk factors: abnormalities (blurred vision, scotomas) and
> 20 weeks
primigravida, pitting edema. Edema easity seen on face/eyes HTN before 20 weeks is HTN –
BP > 140/90 Delivery – can occur up to 4 weeks after
Preeclampsia multipara, > 35, and fingers. Sudden rapid weight gain in 1-2 days. may be able to get off meds
Proteinuria 0.3 gram delivery
obesity, prior hx., HTN New onset RUQ pain, BP > 140/90 with urine during 1st and 2nd trimester
in 24 hours
or kidney disease protein 1+, oliguria. N/V are worrisome for
Edema face, eyes,
encephalopathy. Can start at 20 weeks. If
hands
seizures, Eclampsia.
↑AST, ALT, lactate
HELLP (Hemolysis,
Serious but rare dehyrogenase
Elevated Liver Signs and symptoms of preeclampsia that present
complication of Total Bili > 1.2 Multipara > 25
Enzymes, and Low suddenly
preeclampsia/eclampsia Platelets <100,000
Platelets)
↓ H/H
RhoGAM (anti-D immune globulin) made
Maternal immune system produces antibodies from pooled IgG antibodies. If not given, this
against Rh-positive blood if not given RhoGAM. Coombs: detects Rh will result in fetal hemolysis in future
Rh-negative mother
Rh-incompatibility Give for all pregnancies of Rh-negative mothers – antibodies (indirect) pregnancies. ↓ risk by destroying fetal Rh+
with Rh-positive fetus
even if they terminate in miscarriage, abortion, and infant (direct) RBC that have crossed placenta
ectopic etc. RhoGAM 300mcg IM – first dose 28 weeks
2nd dose within 72 hours of delivery
One-Step Method – 75 g OGTT –
fasting (8 hrs.) >92
1 hour >180
2 hours >153
Screen at first visit if
Two Step Method – 50 g OGTT (not fast)
high risk otherwise
Associated with higher rates of neural tube Check plasma glucose at 1 hour (if > 140 –
screen at 24-28 weeks
defects, congenital heart disease, birth trauma order 100 g OGTT –
(shoulder dystocia), preeclampsia, hydramnios, Fasting (8 hrs.) > 95
Diabetes in 1st
Gestational macrosomia, fetal organomegaly and neonatal 1 hour > 180
trimester = Type 2 Higher risk for Type 2 diabetes
Diabetes hypoglycemia. Risk factors – hx, obesity, Asian, 2 hours > 155
diabetes
Native American, Pacific islander, black, 3 hours > 140
Hispanic, infant > 9lbs, older than 35 Glycemic targets –
Test 6-12 weeks
Preprandial 95 or less
postpartum and every
1 hour < 140
3 years afterwards
2 hours < 120
A1C goal: 6-6.5%
Lifestyle measures → insulin, glyburide,
metformin

 SEXUALLY TRANSMITTED DISEASES

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Prophylaxis if CD4 <200: Bactrim daily; If

Hairy leukoplakia of tongue (caused by Epstein- allergic: Dapsone, atovaquone, aerosolized
Barr virus of tongue), recurrent candidiasis, pentamidine AIDS = CD4 < 200
thrush, fever, weight loss, diarrhea, cough, ELISA – screening Pregnancy – start Zidovudine (AZT) Toxoplasma gondii
shortness of breath, Kaposi’s sarcoma; symptoms Western blot – Confirmatory ASAP; Newborns start within 6-12 hours (protozoa) CD4<100
HIV-1 most common develop within 2-4 weeks for HIV antibodies of delivery Bactrim daily; headaches,
strain in US HIV PCR if both + Best sign of treatment is ↓ viral load blurred vision, confusion
HIV
Attacks CD4 T- Normal CD4 count 500-1500 Pneumocystis jirovecii causes most deaths Avoid: cat litter,
lymphocytes in people with HIV uncooked pork/beef, bird
It can take 3-12 weeks for HIV Tenofovir disoproxil fumarate – UA every stool, turtles/amphibians,
antibody test to detect HIV 6 months - nephrotoxic; Zidovudine – gardening
CBC (bone marrow suppression)
If exposed PEP – start ASAP
PrEP reduces HIV transmission 90%
Petechial or pustular skin lesions of hands/soles;
swollen, red, tender joints in one large joint
Disseminated Refer – Ceftriaxone 1-gram IM or IV every
(knee). May have s/s STD, pharyngitis w/ green
Gonococcal disease 24 hours
purulent throat exudates not responding to
antibiotics
Azithromycin 1G, Doxycycline 100mg x7d
NAAT test for pharynx/rectal Treat sexual partners – Azithromycin 1G
Asymptomatic. Most common STD in US;
samples; GenProbe for Test of cure only for pregnant women 3w Leads to PID (PID has +
Chlamydia Atypical bacteria Samples from urine, cervix, urethra, fallopian
cervix/urethra after completion with Azith or Amox. chandelier’s test)
trachomatis Incubation 7-14 days tubes, oral and rectal sites. Can occur in
Friable cervix with yellow Complicated: Rocephin 250mg IM + Most common < 25
endometrium
discharge doxycycline PO BID x 14 days with or
without Flagyl PO BID x 14 days
Purulent green-colored vaginal/penile discharge;
NAAT test for pharynx/rectal Ceftriaxone 250mg IM (Rocephin) + IF GC + always co-treat
Gm- diplococci exam shows discharge on cervix which may bleed.
Neisseria samples; GenProbe for Azithromycin 1-gram PO (if allergic for chlamydia even if test
bacteria May be asymptomatic, Cervicitis, urethritis,
gonorrhoeae cervix/urethra Gemifloxacin 320mg PO + azithromycin 1- negative
Incubation 1-5 days pharyngitis, Bartholin gland abscess, salpingitis,
gram PO) Incubation 1-5d
epididymitis/prostatitis
Risk: men with men, HIV
infection.
Primary – painless chancre with most contagious during
lymphadenopathy that last 3 weeks. Heals secondary stage
spontaneously (Chancre should start healing 3-7 Primary: Benzathine PCN G 2.4mil x False positive RPR:
days after injection if treated) 1dose or doxycycline for allergy. If latent pregnancy, Lyme disease,
Secondary – ***most contagious nonpruritic RPR or VDRL for screening syphilis administer weekly x 3 weeks autoimmune disease,
Treponema pallidum
skin rash, involving palms and soles, mucous (nontreponemal test) (Genital) chronic or acute disease
Syphilis (spirochete)
membranes. Fever, lymphadenopathy, sore confirm w/ FTA-ABS Recheck RPR 6-12 months
2-4-week incubation
throat, patchy hair loss, headaches, weight loss, (treponemal test) Treat partners and test for HIV/STDs Jarisch-Herxheimer
condyloma lata Refer to infectious disease if latent or Reaction – acute febrile
Latent – variable tertiary reaction during first 24
Tertiary – neurosyphilis, gumma, aneurysms, hours of treatment. Acute
valve damage onset fever, chills, HA,
myalgias. Supportive
treatment.
Treat as complicated
Chlamydial and/or
Fitz-Hughes-Curtis gonorrheal/chlamydial infection
gonococcal infection of Symptoms of PID complaining of RUQ abdominal
Syndrome Liver function normal Rocephin 250mg IM + doxycycline PO
liver capsule causing pain and tenderness on palpation
(Perihepatitis) BID x 14 days with or without Flagyl PO
scarring
BID x 14 days
 SEXUALLY TRANSMITTED DISEASES

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Mostly in males. Presents w/ history of

Immune mediated
chlamydia c/o red, swollen joints that
reaction secondary to
come and go (migratory arthritis) “I
Reiter’s syndrome infection with Supportive - NSAIDs
can’t see (conjunctivitis), pee
bacteria (chlamydia)
(urethritis), or climb up a tree
that resolves
(migratory arthritis”
Imiquimod (Aldara) 5% cream –
leave on 6-10h 3x a week;
Condyloma Soft flesh-colored pedunculated, flat, or Podofilox (Condylox) cream 2x
Acuminata; HPV popular growths. day x 3 days – hold for 4 days and Prevent with Gardasil – give at age 11 and 12
Pap smear, colposcopy
Verruca Vulgaris (malignancy 16, 18) Appear as white-colored skin on cervical repeat, if pregnant liquid nitrogen, carcinogenic
(genital warts) surface after swabbing w/ acetic acid bichloracetic or trichloroacetic
acid wash in office

Acyclovir (Zovirax), Famciclovir

Prodromal itching, burning and tingling
(Famvir), Valacyclovir (Valtrex)
at site. Sudden onset groups of small
Herpes viral culture or Episodic: Famciclovir/Zovirax r/o syphilis and HSV
Herpes Simplex HSV-1 oral mucosa vesicles on erythemic base, easily
RPR assay Suppressive treatment: Even when asymptomatic, virus sheds 10% of the
1&2 HSV-2 genital ruptures and painful; can last 2-4 weeks
Tzanck smear (old test) Acyclovir/Famciclovir time
Can travel oral, genital, and intact skin
Suppressive therapy decreased
via asymptomatic transmission
reoccurrences by 70-80%
Found at site in inoculation with
Azithromycin, ciprofloxacin and
vesicular-form to pustular form lesion
Gm – Haemophilus Culture for H. ducreyi ceftriaxone; Lifestyle changes:
Chancroid creating a painful, soft ulcer with
ducreyi (sensitivity <80%) condoms, limit partners, STI/HIV
necrotic base. Multiple lesions are
testing, Hep. vaccines
usually found

Symptoms occur 1-4 weeks after contact;

vesicular or ulcerative lesion on external Doxycycline and erythromycin
Lymphogranuloma
C. Trachomatis genitalia progressing to inguinal PCR assay Lifestyle changes: limit partners,
Venereum
lymphadenitis or buboes which fuse, STI testing, Hep vaccines
then drain

N. gonorrhoeae, C.
Irritating voiding symptoms, fever, Ceftriaxone 250mg PO plus
Pelvic trachomatis,
abdominal pain, cervical motion doxycycline 100 mg BID x 14 days
inflammatory bacteroides, ↑ risk for ectopic pregnancy and/or infertility
tenderness, adnexal tenderness, vaginal with or without metronidazole
disease Enterobacteriaceae,
discharge. 500mg PO BID x 14 days
streptococci
Metronidazole (Flagyl) 2gram PO
Exam: “strawberry”
Dysuria, bubbly itching, vulvovaginal or tinidazole 2gram PO or 500mg
Trichomonas cervix w/ some bleeding
irritation, yellow-green vaginal PO BID x 7 days. Abstain from
Trichomoniasis Vaginalis Protozoan Wet smear: motile
discharge, occasionally frothy. alcohol use until treatment
parasite w/ flagella protozoa flagella and
complete. Treat sexual partner;
large # WBC
avoid sex until treatment complete
Screening:
Annual screening < 25 for sexually active Chlamydia and gonorrhea
HIV: annual testing for syphilis, chlamydia and gonorrhea
Men having sex with men: annual screening chlamydia and gonorrhea, pharyngeal gonorrhea, HIV, syphilis and HBsAg
Pregnant women: HIV, chlamydia, gonorrhea, syphilis HBsAg at initial prenatal visit
 MEN’S HEALTH

PROSTATE GLAND RANDOM PEARLES
Normal prostate
Firm, smooth, Firm as pressing Ø Sperm produced in seminiferous tubules of testes
(See A below) nontender in on tip of your Ø Sperm require about 3 months to mature (stored in epididymis until mature)
nose Ø Production of testosterone is stimulated by release of luteinizing hormone
Acute prostatitis Tender, boggy, Firm as pressing Ø Spermatogenesis is stimulated by testosterone and follicle-stimulating hormone
indurated in over your
Ø Transillumination for evaluating testicular swelling, mass, bleeding or cryptorchidism
cheekbone
o Hydrocele will transilluminate
BPH firm, smooth Firm as pressing
(See B-F below) symmetrically in on tip of your o Tumor and varicocele (bag of worms) will not transilluminate
enlarged nose Ø Postrenal azotemia – can be due to prolonged urinary obstruction leading to hydronephrosis and
Prostate cancer Asymmetric, Usually malignant compromised renal failure
Nodular, hard, lesions not Ø Only scrotal edema and no pain – assess for generalized weakness and refer to urology
nontender palpable until
disease is
advanced
Produces PSA
 MEN’S HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Sickle cell, drugs for

Priapism ED, cocaine, Prolonged and painful erection for several hours Surgical emergency
quadriplegia

More common in whites

Teen to young adult c/o nodule, sensation of 15-35 yrs. Rare in African
Ultrasound for solid mass
heaviness, testicle larger than other. One testicle Refer to urology for biopsy and Americans.
Testicular cancer Gold standard: testicular
heavier, may palpate hard fixed nodule. Usually management Cryptorchidism
biopsy
asymptomatic until metastasis (undescended testes) ↑
risk of cancer
Painless, hard fixed nodule, asymmetrical
Asymmetric, hard, Refer to urologist PSA > 4.0 for all or Average age > 71 Risk
enlargement on prostate gland on older male.
nodular prostate. PSA > 4.0 PSA > 2.5 if high risk factors: African
New onset ED low back pain, rectal area.
Biopsy of prostatic tissue Antiandrogens: Finasteride (Proscar) American, Jamaicans,
2nd most common Discomfort with voiding, weaker stream, nocturia.
Prostate Cancer PSA looks good when taking Hormone blockers (Lupron) obesity.
cancer in men May be asymptomatic.
Flomax; Prostate shrinks Proscar teratogenic (don’t
(temporarily) while on Proscar USPSTF does not recommend screening touch w/ bare hands –
↑ PSA with prostate infection, ejaculation,
so PSA must be doubled asymptomatic DRE/PSA affects male fetus)
cycling, enlarged prostate gland
Appendix teste is round,
Torsion of Infarction/necrosis of School age; complains abrupt onset blue-colored small pedunculated
Appendix Testis appendix testis mass on testicular surface resembling “blue-dot”. Refer to ED polyp-like structure
(blue dot sign) NOT Testicular Torsion Blue dot caused by infarction and necrosis attached to testicular
surface

Hernia Inguinal – on exam Surgical repair

Lifestyle changes: ↓ caffeine, alcohol,

Rectal exam – firm, smooth fluids before bed, avoid diuretics
LUTS – lower urinary tract symptoms. Nocturia,
symmetrically enlarged Alpha-adrenergic antagonist - Terazosin
difficulty starting stream, weakened stream,
Non-cancerous prostate gland (Hytrin), Tamsulosin (Flomax) – monitor
dribbling, feelings of incomplete emptying, Seen in 50% of men > 50
BPH enlargement of for orthostatic hypotension (take at
urinary retention 80% men > 70
prostate gland PSA level should be doubled bedtime)- Finasteride; Refer to urology;
Prostate size does not correlate well with severity
with Flomax and Proscar to Avoid: antihistamines, decongestants,
of symptoms
reflect true PSA caffeine; amitriptyline. Herb: saw
palmetto may improve symptoms

Chronic > 6 weeks of Hx of acute UTI or may be asymptomatic. Several Trimethoprim-sulfamethoxazole

Prostate feels normal to
Chronic Bacterial infection of prostate weeks suprapubic or perineal discomfort w/ (Bactrim), if sensitive, give ofloxacin or
palpation; UA normal
Prostatitis caused most commonly irritative voiding symptoms, dysuria, nocturia, levofloxacin
Culture
by E. coli and Proteus frequency Treat 4-6 weeks

Sudden onset high fever, chills w/ suprapubic

<35: ceftriaxone and doxycycline
and/or perineal pain; pain radiating to back or Enlarged, boggy (could be
Bacterial infection E. >35: ciprofloxacin or Levaquin for 6 weeks Vigorous palpation of
rectum w/ dysuria, frequency, nocturia and firm), warm and tender
Acute Prostatitis coli and Proteus or antipyretics, NSAIDs, stool softeners w/o infected prostate can
cloudy urine. “hurts when bottom hits chair or prostate
STD laxative, sitz bath, hydration. Should see cause septicemia and pain
ride in car” CBC, UA, C&S
improvement within 2-6 days
When you had BM, did it hurt?

 MEN’S HEALTH

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Abrupt onset extremely painful and swollen red Loss of cremasteric reflex (testicle
Most common between
scrotum. Frequent has N/V, affected testicle elevated toward body with urologic emergency
Spermatic cord 10-20; more common
Testicular Torsion located higher and closer to body than stroking inner thigh) 6h window for survival >85%
becomes twisted with bell clapper
unaffected testicle. Left side more often affected UA Orchiopexy to prevent recurrence
deformity
Ultrasound (done in ED)
Acute or chronic swollen red scrotum that’s
CBC, UA, C&S, + Prehn’s sign
painful w/ unilateral testicular tenderness and <35 -Doxycycline x 10d Infertility is possible post
Inflammation (relief of pain with scrotal
Epididymitis discharge. Scrotum is swollen and erythematous >35 – Ofloxacin or levofloxacin x 10d infection due to scarring
(can be infectious) elevation) + Cremasteric reflex
w/ induration of the posterior epididymis, s/s NSAIDs, scrotal support/elevation of vas deferens
Check for STI
UTI; most common when people sit too long
Vascular insufficiency Phosphodiesterase 5 inhibitor – take
(diabetes, HTN), Viagra on empty stomach
Concomitant nitrates,
Erectile neuropathy, Inability to have an erection firm enough to Viagra or Levitra – take prior to sex
caution alpha-blockers,
dysfunction medications (SSRI, perform sexual intercourse Cialis – take within 36 hours of sex
recent MI, post CVA
BB), smoking, alcohol, May cause headache, flushing, dizziness,
hypogonadism hypotension, nasal congestion, priapism

Penile pain primarily occurring during erection.

palpable nodules (fibrotic plaques) and crooked
Peyronie’s disease Inflammation Refer to urology
penile erection
May resolve spontaneously or worsen over time

Inflammation of glans penis, more common in

uncircumcised men, DM, or
Balanitis Candida infection immunocompromised males
OTC azole creams
Treat partner

Foreskin cannot be pushed back from glans

Phimosis Edema
penis. Usually seen in neonates

Scrotal ultrasound
Varicose veins in scrotal sac (“Bag of worms”) –
Treatment if causing pain, atrophy
Abnormally dilated only present in standing position. New onset can May have decreased
Varicocele or infertility includes -surgery or
spermatic vein signal testicular tumor or mass impeding venous sperm count
percutaneous embolization
drainage; may have recurrent scrotal pain
Scrotal support can help

Non-communicating
Collection of serous fluid that causes painless
Underlying cause may Scrotal ultrasound disappears within 1st year
Hydrocele scrotal swelling, easily recognized by
be hernia Refer to urologist of life – scrotum will look
transillumination
like deflated balloon.

 ELDERLY

DELIRIUM VS DEMENTIA DELIRIUM ETIOLOGY
DELIRIUM DEMENTIA Ø Drugs – when any medication is added, or dose adjusted. (Anticholinergics, TCA,
Sudden state of rapid Slowly developing antihistamines, antipsychotics, opioids, opiates, benzodiazepines, alcohol, etc.)
changes in brain impairment of
function reflected in intellectual or cognitive Ø Emotional – mood disturbances, loss
confusion, change in function that is Electrolyte disorder (hyponatremia)
cognition, activity and progressive and Ø Low PO2 – CAP, COPD, MI, Pulmonary edema
LOC interferes with normal Lack of drugs
functioning
Etiology Acute underlying cause Variety of causes Ø Infection – UTI, CAP
such as acute illness Ø Retention of urine or feces
Onset Abrupt, over hours to Insidious that cannot be Reduced sensory input (blindness, deafness, darkness, change in surroundings)
days. related to a precise date,
Ø Ictal or post ictal state
gradual change in
mental status. Ø Undernutrition – protein/calorie malnutrition, vitamin B12 or folate deficiency,
Memory Impaired but variable Memory loss, especially dehydration
recall for recent events Ø Metabolic – diabetes, thyroid,
Duration Hours to days Months to years
MI
Reversible Usually reversible Chronically progressive
and irreversible Ø Subdural hematoma
Sleep disturbance Disturbed sleep-wake Disturbed sleep-wake
cycle with hour-to-hour cycle but lacks hour-to-
INTERVENTION
variability often worse as hour variability, often Ø Assess those at greatest risk
day progresses day-night reversal Ø Treat underlying condition
Psychomotor Usually a change, None until late in
hyperkinetic, hypoactive disease
or mixed. None in DEMENTIA ETIOLOGY
almost 15% Ø Alzheimer-type 50-80% (loss of executive functioning)
Perceptual Disturbances Yes, including None until later in the
Ø Vascular dementia - 20% (memory loss after stroke)
hallucinations disease
Ø Parkinson disease – 5%
Speech Incoherent, confused In early stages
with inappropriate Ø Misc. – HIV, dialysis encephalopathy, neurosyphilis, normal pressure
words hydrocephalus, Pick’s disease, Lewy body disease, frontotemporal dementia

CANCER IN OLDER ADULTS

Ø Cancer with highest mortality: lung and bronchial cancer (both genders) – most common risk factor – smoking; non-small cell lung carcinoma (90%) – if presents in clinic with
cough etc. CXR, then CT scan, gold standard is positive lung biopsy. Baseline labs include CBC, FOBT, chemistry panel, UA. Refer to pulmonary for bronchoscopy and tumor
biopsy. USPSTF recommends annual screening with CT (age 55-80) with 30 pack yr. smoking hx and currently smoke or quit within past 15 yrs.
Ø Cancer with 2nd highest mortality: colorectal cancer – about 20% have distant metastases at time of presentation – risk factors – advancing age, inflammatory bowel disease,
or family hx of colorectal cancer, colonic polyps, lack of regular physical exercise, high-fat diet, low fiber diet, obesity. If presents with change in bowel habits, CBC, FOBT,
chemistry panel, UA and refer to GI. At age 50 start with baseline colonoscopy (repeat every 10 yrs.); sigmoidoscopy every 5 yrs., Cologuard every 3 yrs. for low risk, or FOBT
annually.
 ELDERLY

STANDARDS FOR ALZHEIMER CARE
Ø To slow the decline in dementia
o Vitamin E 1000U BID or
o Selegiline 5mg BID
Ø Mild to moderate stage disease
o Cholinesterase inhibitors
§ Donepezil (Aricept)
§ Rivastigmine (Exelon)
§ Galantamine (Razadyne)
o Clear minor benefits
Ø More advanced dementia
o N-methyl-D-aspartate receptor
antagonist memantine (Namenda)
Ø Treat agitation and depression
Ø Consider non-AD related reasons for behavioral
issues
o Pain, infection
Ø If environmental manipulation fails
o Psychotropic (risperidone)
ELDER ABUSE
Ø Presence of bruising, skin tears, lacerations and
fractures that are poorly explained
Ø Presence of sexually transmitted disease, vaginal
and/or rectal bleeding, bruises on breast are
indicators of possible sexual abuse
Ø Malnutrition, poor hygiene, and pressure injuries
Ø Screen for abuse and financial exploitation
Ø Interview alone:
o Do you feel safe where you live?
o Who handles your checkbook and
finances?
o Who prepares your meals?
ELDERLY PEARLS
Ø Top 3 leading cause of death > 65
o Heart disease (MI, heart failure,
arrhythmia)
o Cancer (lung and colorectal)
o Chronic lower respiratory disease
(COPD)
Ø Fasting growing age is 85+
Ø Young old is considered 65 to 74
Ø Any unexplained iron-deficiency anemia who is
older, male or postmenopausal should be
referred for colonoscopy
Ø If chemistry shows ↑ calcium or alkaline
phosphatase, indicative of cancerous metastasis
of bone
Ø Depression is very common in dementia
Ø Cholinesterase inhibitor side effects include
nausea and diarrhea
Ø Syncope
Ø Dizziness
Ø Vertigo
ACTIVITIES OF DAILY LIVING
Ø Ability to feed self
Ø Ability to manage bowel and bladder elimination
Ø Personal hygiene and grooming
Ø INSTRUMENTAL ACTIVITES OF DAILY LIVING
o Grocery shopping
o Housework
o Managing finances
o Using telephone
o Driving a car
MEDS TO AVOID IN ELDERLY
Ø Anticholinergic Effects
o Tricyclic antidepressants
o Overactive bladder medications
o First generation antihistamines
o Dry as a bone (dry mouth/eyes)
o Red as a beet (flushing)
o Mad as a hatter (confusion)
o Hot as a hare (hyperthermia)
o Can’t see (vision changes)
o Can’t pee (urinary retention)
o Can’t spit (dry mouth)
o Can’t shit (constipation)
Ø Significant risk of orthostatic hypotension
o Tricyclic antidepressants
Ø Increase in fall and fracture
o Sleep medications
Ø Potential to promote fluid retention
o NSAIDs
Ø Increased risk for hyponatremia
o SSRI
o Start elderly on SSRI and recheck in one
month (esp. those taking thiazides)
Ø Use in caution with BPH, narrow-angle glaucoma
and preexisting heart disease.
ASSESS FOR FALL RISK
Ø Timed Get up and Go
 ELDERLY
BODY AND METABOLIC CHANGES
Ø Skin and Hair – atrophies, less elasticity due to less subdermal fat and collagen.
Fragile and slower to heal. Xerosis (dry skin) due to ↓ sebaceous and sweat
gland activity (↑ risk dehydration, heat stroke). ↓ in vitamin D synthesis. Fewer
melanocytes which contributes to gray hair.
o Seborrheic keratoses – soft wart-like skin that appear pasted on; found
mostly on back; color can range from tan, brown to black; benign
o Senile Purpura – bright colored patches with well demarcated edges.
o Lentigines – “liver spots” tan to brown colored macules on dorsum of
forearms and hands.
o Stasis Dermatitis – due to chronic edema
o Senile Actinic Keratosis – secondary to sun exposure with potential for
malignancy (precursor to squamous cell cancer)
Ø Nails – growth slows and become brittle, yellow and thicker with longitudinal
ridges.
Ø Mouth – hyposmia – decline in sense of smell
BODY AND METABOLIC CHANGES
Ø Eyes – presbyopia – loss of elasticity of lenses and difficulty in focusing on
objects up close. Onset mid 40’s – reading glasses. Need more illumination,
increased sensitivity to glare, washing out of colors.
o Arcus Senilis – opaque gray to white ring in margin of cornea or on
periphery of iris, develops gradually and not associates with visual
changes. Caused by deposit of cholesterol and fat. If less than 40 –
chest fasting lipids.
o Cataracts – cloudiness and opaque lens of eye. Gradual onset with
decreased night vision. Red reflex disappears. Most common cause of
blindness in developing countries.
o Macular degeneration – loss of central field of vision. Most common
cause of blindness in US.
Ø Ears – presbycusis (sensorineural hearing loss) – high frequency hearing loss.
Starts about age 50. Prevent by using ear protection when exposed to loud noise
Ø Heart – elongation and tortuosity (twisting) of arteries. Thickened intimal layer
of arterioles and arteriosclerosis result in ↑ BP due to vascular resistance. Mitral
and aortic valves may contain calcium deposits.
o Baroreceptors are less sensitive to changes in position. Maximum heart
rate decreases. ↑ risk orthostatic hypotension. S4 can be normal
finding. Left ventricle hypertrophies.
Ø Lungs – Total lung capacity remains the same. FVC and FEV1 ↓ with age.
Residual volume ↑ with age due to ↓ in lung and chest wall compliance. Chest
wall becomes stiffer and diaphragm is less efficient.
o Mucociliary clearance is less efficient. Response to hypoxia and
hypercapnia decrease. More common to see decreased breath sounds
and crackles in bases without disease (improve after asking patient to
cough). ↑ AP diameter
Ø Liver – Size and mass decrease due to atrophy. Fat deposits are more common.
ALT, AST, alkaline phosphatase is not significantly changed. Metabolic clearance
of drugs is slowed. LDL and cholesterol levels ↑ with age.
 ELDERLY
BODY AND METABOLIC CHANGES
Ø Renal – Size and mass decrease
after age 50. At age 40, the GFR starts to
decrease. Up to 30% of renal function is lost by age 70. Renal clearance of drugs
is less efficient. Serum creatinine is less reliable indicator of kidney function due
to ↓ muscle mass, creatine production and creatinine clearance. Kidney
damage from NSAIDs is much higher and renin-angiotensin levels are lower.
Ø Genitourinary – Residual urine ↑. Postmenopausal women urethra becomes
thinner and shorts the ability of the urinary sphincter to close tightly. Urinary
incontinence is 2-3 times more common in women. Erectile dysfunction affects
40% of men age 40 and 70% of men age 70.
Ø Musculoskeletal – older adults can lose 1-3 inches of height due to thin bone
loss. Compression fractures are a sign of osteoporosis. Stiffness in the morning
that improves with activity is a sign of osteoarthritis (degenerative joint
disease). Fat mass ↑ as muscle mass and muscle strength ↓. Bone resorption is
more rapid in women than men 4:1. Fractures heal more slowly due to ↓
osteoblasts (build new bone) while osteoclast break down bone.
Ø Gastrointestinal – receding gums and dry mouth are common. ↓ sensitivity of
taste buds results in ↓ appetite. ↓ efficiency in absorbing folic acid, B12 and
calcium by small intestine. Delayed gastric emptying. ↑ risk gastritis and GI
damage from ↓ prostaglandin production. Constipation is more common as
colon transit time is longer. Fecal incontinence is common due to drug side
effects and disease. Laxative abuse is more common.
Ø Endocrine – minor atrophy of pancreas. ↑ levels of insulin with mild peripheral
insulin resistance. Changes in circadian rhythm hormonal secretions can cause
changes in sleep patterns.
Ø Sex Hormones – testes are active the entire life cycle. Less DHEA and
testosterone are produced. Estrogen and progesterone production ↓ in
menopause.
Ø Immune system – older adults are less likely to present with fever. ↓ antibody
response to vaccines. Immune system is less active. Cellular immunity (T-
lymphocytes, macrophages and cytokines) is affected more by aging than
humoral immunity (B-lymphocytes and antibody production).
Ø Hematological – no change in RBC life span, blood volume or circulating
lymphocytes. ↑ risk of thrombi and emboli ↑ platelet responsiveness. ↑ risk of
iron and folate-deficiency anemia due to GI tract ↓ absorption of B12 and
folate.
BODY AND METABOLIC CHANGES
Ø Neurological – differences in ability to differentiate color, papillary response
and decreased corneal reflex. ↓ gag reflex. Deep tendon reflex may be brisk or
absent. Neurological testing may be impaired by medications, causing slower
response times. Benign essential tremor is common.
Ø Pharmacological – drug clearance is impaired by renal impairment, less efficient
liver, delayed gastric emptying, ↑ gastric pH, ↓serum albumin (affects
coumadin and Dilantin - ↓ dose), and higher ratio of fat to muscle. ↑ sensitivity
to benzo and anticholinergic (hypnotics, TCA, antihistamine and antipsychotic).
Rate of absorption is changed. ↓ beta-2 receptor sites. ↓ ability to conserve
sodium.
NEUROCOGNITIVE FINDINGS
Ø Abulia: loss of motivation or desire to do task, indifference to social norms
Ø Akathisia: intense need to move due to severe feelings of restlessness
Ø Akinesia: reduce voluntary muscle movement
Ø Amnesia: memory loss, anterograde amnesia is memory loss of recent events
(occurs during disease); retrograde amnesia is memory loss of events in the past
(before the onset of disease)
Ø Anomia: problems recalling words or names
Ø Aphasia: difficulty using (speech) and/or understanding language; can include
difficulty with speaking, comprehension and written language
Ø Apraxia: difficulty with or inability to remember learned motor skill
Ø Astereognosis: inability to recognize familiar objects placed in the palm
Ø Ataxia: difficulty coordinating voluntary movement
Ø Broca’s aphasia: ability to speak is intact but ability to comprehend language is
lost
Ø Confabulation: “lying” or fabrication of events due to inability to remember the
event
Ø Dyskinesia: abnormal involuntary muscle rigidity
Ø Dystonia: involuntary repetitive muscle movements resulting in abnormal
movements and postures (continuous muscle spasm)
 ELDERLY

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Risk factors are

extreme New onset or sudden ↑ in number of floaters or
nearsightedness, hx of specks on the visual field, flashes of light and Treated with laser surgery or cryopexy Can lead to blindness if it
Retinal Detachment
cataract surgery, and sensation that a curtain is covering part of the (freezing) is not treated.
family or personal hx visual field.
or retinal detachment
Temporal headache (one sided) with tenderness
Temporal Arteritis or induration over temporal artery; may be
(Giant Cell accompanied by sudden visual loss in one eye Screening test is ESR Can lead to blindness
Arteritis) (amaurosis fugax). Scalp tenderness on affected
side.

Older adult with acute onset severe eye pain,

Call 911
Acute Angle- severe headache, N/V. Eye is reddened with
Tonometry is done to measure intra-
Closure Glaucoma profuse tearing. Complains of blurred vision and
ocular pressure
halos around lights.

Sudden onset of neurological dysfunction that

worsens with hours. Blurred vision, slurred
TIA is temporary episode
CVA speech, one-sided upper and/or lower extremity
that last 24 hours.
weakness, hemianopsia, confusion. Signs and
symptoms are dependent upon location of infarct.

Small rough pink to reddish lesions that do not

Sun-exposure – Cryotherapy. Large numbers with wider
heal. Located in sun exposed areas such as cheeks,
Actinic Keratosis precursor of Squamous distribution are treated with 5-fluorouracil
nose, back of neck, arms, chest. More common in
cell carcinoma cream.
light skinned individuals.

Major cause of morbidity

Acute onset limping, guarding and/or inability or
and mortality in the
difficulty with weight bearing on the affected side.
Hx of osteoporosis or elderly. 20% of elderly
Fracture of Hips New onset of hip pain; may be referred to the knee
osteopenia with hip fractures die
or groin. Unequal leg length. Affected leg is
from complications
abducted (turned away from body)
(pneumonia)
Unexplained iron deficiency, anemia, blood on
rectum, hematochezia, melena, abdominal pain or
change in bowel habits. Tenesmus (feeling of
Colorectal cancer Refer to GI
incomplete defecation), rectal pain, diminished
caliber stools (ribbon like or pencil like
stools – indicated issue - descending colon)

Atypical presentation is common. May be afebrile.

Pneumonia, sepsis,
Severe bacterial WBC can be normal. Sudden decline in mental
Pyelonephritis, Most common is UTI
infections status, new onset of urine/bowl incontinence,
bacterial endocarditis
falling, inability to perform ADL, loss of appetite.

Cancer of bone marrow that affects plasma cells of

immune system. Found in mostly older adults.
CBC, FOBT, chemistry panel,
Multiple Myeloma African descent has 2-3x higher incidence than Refer to hematologist
UA.
whites. Presents with bone pain and generalized
weakness

 ELDERLY

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Most lethal cancer. Most

AST, ALT, alkaline people already have
Weight loss, anorexia, jaundice, weakness Refer to GI surgeon for Whipple
Pancreatic Cancer phosphatase, bilirubin, lipase metastasis by the time of
(asthenia) and abdominal pain. procedure.
and amylase diagnosis. 5 yr. survival
rate is 8.2%
Rare before 60. ↓ in acetylcholine production. Most common cause of MMSE 10-26 (mild to moderate) –
Aphasia – difficulty verbalizing dementia followed by vascular Donepezil, rivastigmine, galantamine,
Gingko biloba- may help
Apraxia – difficulty with gross motor dementia Namenda
Alzheimer’s with memory (do not mix
movements such as walking MMSE < 17: add Namenda
with ASA or warfarin)
Agnosia – inability to recognize familiar people Difficulty with executive MMSE < 10: continue Namenda or
or objects functioning, judgement. discontinue. Add vitamin E 2,000 IU
First line: Carbidopa-levodopa (Sinemet)
Progressive neurodegenerative disease – start low Sinemet 25/100 (1/2 tab) PO
↓dopamine receptors. Tremors (worse at rest), BID to TID with meals. Titrate up slowly.
muscular rigidity, and bradykinesia. Pill rolling, Do not discontinue abruptly Treatment for tardive
cogwheel rigidity, walks with shuffling gait, poor Others: Dopamine agonist - dyskinesia (EPS):
Parkinson’s Check vitamin B12
balance and falls often. Anxiety, depression, Bromocriptine (Parlodel) or pramipexole Benztropine (Cogentin)
excessive daytime sleepiness. Difficulty with (Mirapex) – can cause impulsive behavior; Amantadine (Symmetrel)
executive function (making plans, decisions, task). MAO-B inhibitor: Selegiline (Eldepryl)
Seborrheic dermatitis common increased risk of serotonin syndrome or
rasagiline (Azilect)
Propranolol 60-320 mg per day –
contraindicated: Asthma, COPD, 2nd-3rd
Usually seen in arms or hands and progress to Postural tremor (not a
Essential Tremor degree heart block, bradycardia
head. Tremors may get worse with anxiety. resting tremor)
Primidone (mysoline) at bedtime
Refer to neurologist

BEERS LIST CRITERIA

Drug Class Drugs to Avoid
Antihistamines Benadryl, chlorpheniramine
Benzodiazepines Short-intermediate: Xanax, Ativan, Halcion (long acting – Valium, Klonopin)
Antipsychotics Thioridazine (mellaril), mesoridazine (serentil)
Atypical antipsychotics Seroquel, Zyprexa – Monitor BMI, Lipids, TSH, glucose
Tricyclic antidepressants Elavil, Tofranil, doxepin
Cardiac drugs Orthostatic hypotension
Alpha-blockers Terazosin, clonidine, higher risk hypotension
Sulfonylureas Glyburide, chlorpropamide
NSAIDs High risk of GI bleed
Mineral oil, PPI Aspiration pneumonia, ↑ risk C Diff in hospital, ↓ absorption Ca, Mg
Ambien, Lunesta Adverse effects with minimal improvement in sleep
Antispasmodics Bentyl, scopolamine, belladonna
Other Reglan (except for gastroparesis); Insulin sliding scale
 NEONATE PEDIATRICS
DEVELOPMENT
Best vision 8-12” (breast to mom’s eyes)
Ø REFLEXES Ø 2 months
Ø Bluish scleral tint regardless of ethnicity
Ø Moro reflex – throwing out arms and legs followed o From tummy can lift self-up on 2 arms
Ø Light sensitive eyes o Responds 2 sounds
by pulling them back into body following sudden
Ø Defensive blink present at birth
movement or loud noise (gone by 16 weeks) o Smiles when smiled 2
Ø Visual preference for human face Ø 4 months
Ø Palmar grasp – grasp object placed in palm (gone by
Ø Hears high-pitched voices best
2-3 months) o Reaches 4 a toy or other object
Ø Reacts to cry of other neonates o Smiles 4 fun
Ø Babinski reflex – stroking of sole of foot elicits
Ø Well-developed sense of smell
fanning of toes (gone by 6 months) o Rolls from tummy to back
Ø Makes 6 wet diapers per day Ø 6 months
Ø Parachute reflex – arching of back and head raises
Ø Breastfed make around 4 stools per day
when placed on stomach (last until 12 mos.) o Looks like the number 6 when sitting up
Ø Newborns often lose up to 10% of birth weight in o Rolls from back to tummy and back
Ø Tonic neck reflex – when stimulating the back, the
the first week of life, but are back up to birth
trunk and hips move toward side of stimulus (gone Ø 8 months
weight by week 2 o Once able to sit up child can transfer
by 9 months)
Ø Stepping reflex – walking motion made with legs objects from hand to hand
DISCIPLINE and feet when held upright and feet touching the Ø 12 months
ground (appears 3-4 months and reappears at 12-24 o Walking
Ø Time Out – short term isolation to decrease
months) Ø 18 months
undesirable behavior; sits in safe special place
Ø Rooting reflex – turning of head and sucking when o Can name single word objects
uninteresting and only used for time out; use
cheek is stroked (gone by 6-12 months) o Acts like an 18-yr. old by coping work
timer
that adults do
o Can start at 18-24 months
o Says no
o Remains in time out for 1 min for every
Ø 2 years
year of life SPEECH MILESTONES TOOTH ERUPTION o Speaks in 2-word sentences
Ø 16-18 months Ø Incisors first to erupt o Follows 2 step commands
RANDOM PEARLS o 16-25% Ø Upper central incisors 8- o Builds a 2-block tower
Ø Multi-system disease affecting skin, lymph etc. Ø 19-21 months 12 months o Can walk up 2nd floor with help
typically viral o 50% Ø Lower central incisors 6- Ø 3 years
Ø Birth weight doubles at 6 months and triples 12 Ø 2-2.5 years 10 months o Rides a tricycle
months o 75% Ø If no teeth by 12mon then o Speaks in 3-word sentences
Ø Screen for autism at 18 and 24 months Ø 3-4 years consult dentist o Can draw a circle
Ø Age appropriately resist exam o 100% Ø Molars are 1st permanent o Builds a 3-block tower
o Foreskin is not easily retracted until
about 3 yrs. of age
DEVELOPMENTAL RED FLAGS
Ø 4 years
Ø 6 months – no big smiles or other warm, joyful expressions o Copies a cross
Ø 9 months – no back-and-forth sharing of sounds, smiles or other facial expressions o Draws a person with 3 body parts
Ø 12 months – lack of response to name, no babbling or baby talk, no pointing, showing, reaching or waving
Ø 16 months – no spoken words
Ø 24 months – no meaningful two-word phrases that do not involve imitating or repeating

OFFICE VISIT NUTRITION
Ø 2-3 days after birth
o Assess for jaundice
o Breastfeeding
o Weight change
o Status of newborn screening
o Maternal well-being
o Infant care teaching
Ø 1 week
o Gaining weight
o Elimination patterns
o Sleep/wake cycle
o Parent-infant interaction
o Review status of newborn screen
o Milia, port wine stain, nevus simplex
(stork bite), Mongolian spot
o Fontanels – posterior close 3 months;
anterior close at 9-18 months
o Eyes – hypertelorism (eyes far apart),
often cross until 2 months
o Low set ears may indicate kidney issue
o Hearing problem – interventions by 6
months
o Clavicles – palpate both – if broken,
move infant as single unit
o Palpate femoral pulses – coarctation of
aorta
o Umbilical cord – silver nitrate stick
o Genitalia
o Fat pads on infant feet can resemble -
Pes Planus (flat feet)
o Spine - Look for neural tube defect. If
tuft of hair - sono
Ø Hyperbilirubinemia - > 5
o Immature liver cannot get rid of bilirubin
fast enough; breakdown of RBC; Bili
deposited under skin. Concerns for
kernicterus
PEDIATRICS
DIABETIC SCREENING IN KIDS
Ø Breastfeeding up to 6 months Ø Overweight or obese plus 2 additional risk
Ø Delay complementary foods until 4-6 months factors
o Single ingredient – iron rich rice cereal o Family hx of T2DM in 1st/2nd degree
o Cow’s milk at 12 months
relative
Ø Vitamin D for breastfed babies
o Race/ethnicity (Native American,
African American, Latino, Asian
American, Pacific Islander)
ASSESSMENT
o Acanthosis nigricans, HTN,
Ø Eyes – red reflex, visual acuity
dyslipidemia, PCOS, small for
o Amblyopia – loss of vision; most
gestational age
common vision problem in kids
o Maternal hx of DM or gestational
o Corneal light reflex and cover/uncover
DM
o Strabismus – refer at 3 months ophthal.
o 20/20 at age 6 Ø Initiate testing at age 10 or onset of puberty
Ø Ears – assess for speech delay (Tanner 2) – every 3 years.
Ø Heart – murmurs common and rate decreases as Ø Treat dyslipidemia in kids with weight loss
heart grows
Metarsus Adductus
o BP at age 3
Ø GI – umbilical hernia easily reducible
Ø Musculoskeletal – assess dysplasia of hip
o Barlow – femoral head toward butt
o Ortolani
o Galeazzi – hip dysplasia
o Club foot – talipes equinovarus - ortho
o Metatarsus adductus
o Can you move
feet to midline?
o If yes – instruct
parents to move
10x with diaper
changes
o If not- ortho
Club Foot
 PEDIATRICS
ASSESSMENT
Ø Musculoskeletal
ADOLESCENCE
o Scoliosis – risk greatest during puberty
Ø Identity vs Role Confusion
o 10-degree curvature of spine
Ø Early (10-14)
o Adams forward bend
o Egocentric! Concrete thinking with early
o Scoliosis series (full length PA/Lateral)
moral struggles, progression of sexual
o More curvature at a young age indicates
identity, body image
worse problem
o Emotional separation from parents,
identify as a person, peer identification,
early exploration of harmful health
behaviors such as substance abuse;
engage in risky behavior – wear seatbelts
Ø Middle (15-17)
o Peer groups more important than you.
Increased abstract thinking, “bullet proof”,
growing verbal abilities, identification of
law with morality, start fervent ideology
(religious, political) – black and white
thinkers
o Increasing emotional separation from
parents, strong peer identification,
increased health risk – smoking, alcohol,
early educational and vocational plans
Ø Late (18-21)
VOMITING o Complex abstract thinker increased
Ø For all kids with vomiting – look at weight and impulse control, further development of
growth chart personal identity, development or
o Rehydrate with pedialyte rejection of religious and political ideology
o Development of social autonomy,
increasingly complex intimate
relationships, development of vocational
capability and financial independence
TANNER STAGING
Ø Tanner 1: looks like a baby
Ø Tanner 2: thelarche (breast budding), testes
and scrotum start to enlarge; pubarche
(onset of sparse pubic hair)
o General rule breast budding to first
menses (2 years)
o Official start of puberty
Ø Tanner 3: onset of growth spurt (tallest
finger)
o penis lengthens
o breast enlargement – one mound
o gynecomastia can be seen here
o pseudogynecomastia - overweight
Ø Tanner 4: female menstruating
o Most girls hit adult height 1 yr. after
starting menses
o Areola elevated from breast
(secondary mound)
o Penis widens, and testes are larger
with darker scrotal skin & more
rugae
Ø Tanner 5: full adult
Ø Tanner 2-4 Boys: Balls→Long→Wide
Ø Tanner 2-4 Girls: Boobs – bud → 1 → 2
Ø Normal onset puberty Girl 8-13
Ø Early onset puberty before age 7-8
(idiopathic – refer pedi endo) - > 13 nutrition
with low weight (eating disorders, gymnast,
genetic)
Ø Normal onset puberty Male 9-14
o Refer pedi endo for early onset
 PEDIATRICS

LIVE IMMUNIZATIONS
IMMUNIZATIONS
Ø Spacing of Vaccines Ø Must replicate to reproduce immunity – run fever and/or rash
o 4 days before due is ok – 5 days prior is INVALID Ø Avoid before age 1
Ø Hepatitis A Ø MMR
o Universally recommended age 1 o 12-15 months and age 4-6
o 2 dose series at least 6 months apart Ø Varicella
Ø Hepatitis B o 12-18 months and age 4-6
o 3 dose series: 0, 1-2 months, 6 months o If given at age 13 or later, 2 doses are required at least 1 month apart
Ø DTaP (< 7 years) – minimum age 6 weeks o Contraindicated if allergic to neomycin or gelatin
o #1 at 2 months Ø Must wait 28 days between live vaccines
o #2 at 4 months
o #3 at 6 months
o #4 at 15-18 months
ADVERSE REACTIONS TO IMMUNIZATIONS
o #5 at 4-6 years Ø Local (redness), systemic (fever) or allergic
Ø Tdap > 7 years Ø Syncope with HPV, MCV4 and Tdap
o 11-12
o Td booster every 10 years
o Every pregnancy 3rd trimester RULES ABOUT NODES
Ø Hib Ø 10mm is enlarged
o 2, 4, 6 and 12-15 months Ø Exceptions
o For unvaccinated 15+ months administer only one dose o Epitrochlear > 5mm
Ø Pneumococcal vaccine (PCV13) o Inguinal > 15mm
o 2, 4, 6 and 12-15 months o Cervical > 20mm
o Vulnerable populations also get PCV23
Ø Polio (IPV only)
o 2, 4, 6-18 months and age 4-6
o Contraindicated for allergies to neomycin, streptomycin or polymyxin B
o No more oral polio due to live vaccine
Ø Flu vaccine
o Every year
Ø Meningococcal Conjugate vaccine (MCV4)
o All children age 11-12
o BOOSTER age 16
Ø HPV-9
o Age 9-14 – 2 dose series at 0 and 6-12 months
o Avoid in pregnancy, ok if breastfeeding
 DEHYDRATION PEDIATRICS
Mild Moderate Severe
Pulse Normal Rapid Rapid and weak CONGENITAL HEART DISEASE
BP Normal Normal to low Ø Innocent Murmur Clues:
low
o Grade < 2
Respiration Normal Deep, ↑ Deep, ↑ rate
rate o Softer when sitting than when supine
Mucosa Sticky Dry Parched o Not holosystolic
Anterior fontanel Normal Sunken Very sunken o Minimal radiation
Eyes Normal Sunken Very sunken o Musical or vibratory quality
Skin turgor Normal Reduced Tenting
Ø Pathologic Murmur Clues:
Skin Normal Cool Cool, mottled
Urine output Normal Reduced None o Grade > 3
Systemic signs Thirsty Irritable Lethargy o Holosystolic
Can they hold fluids down? o Max intensity at LUSB
o Harsh or blowing
o Systolic clicks
UNDESCENDED TESTES o Diastolic murmur
Ø ↑ risk of testicular cancer o ↑ intensity in upright position
Ø Cryptorchidism – undescended o Gallop rhythm
Ø Retractile testes – moves between scrotum and o Friction rub
inguinal ring
Ø Refer if not descended by 6 months

PINWORMS
Ø Enterobiasis
Ø Scotch tape test in the morning to look for eggs
o Worms come out at night and lay eggs in anal
area
o Check several days in a row since females do
not lay eggs every day
Ø Usually happens 4-8 weeks after exposure
Ø Treat with Albendazole
Ø
 PEDIATRICS

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Physiologic jaundice
Physiologic jaundice
occurs after 24 hours of
occurs in absence of Usually seen in face and progress caudally to
Prevention: encourage breastfeeding every life
Jaundice liver disease; jaundice trunk and extremities
2-3 hours daily Jaundice within first 24
arise from problems
hours of life typically
with liver
involves liver problems
Breast milk production in the absence of lactation,
Some cultures think this is a curse so be
Maternal hormonal usual onset day 3-4 of life. Breast engorgement
Galactorrhea sure to ask how if this has any effect on the
influences will resolve without intervention within first 2
family.
months of life.

Chlamydial Oral erythromycin x 2 weeks due to

Signs and symptoms 5-14 days post exposure.
(inclusion) Exposure to Chlamydia pneumonia risk
Bilateral lid swelling, chemosis, mucoid drainage
conjunctivitis Prevention: 3rd trimester STI screening

Fever, sore throat, malaise, nasal discharge,

Notifiable condition – droplet
diffuse maculopapular rash lasting about 3 days.
Rubella (German transmission – public health dictates
Posterior cervical and postauricular Lab confirmation of serum
measles, 3-day Rubella virus when child goes back to school Teratogenic virus
lymphadenopathy beginning 5-10 days prior to rubella IgM
measles) Mask patient until she gets home
onset and present during rash; arthralgia in about
Prevention with MMR vaccine
25%
Fever, nasal discharge, cough, coryza, generalized
lymphadenopathy, conjunctivitis (clear copious
discharge), photophobia – Koplik spots, Lab confirmation of serum Notifiable condition
Rubeola (measles) Rubeola virus
pharyngitis, maculopapular rash 3-4 days rubeola IgM Prevention with MMR vaccine
and may coalesce to generalized
erythema, starts on head and neck

High fever for 2-4 days followed by

Usually around 7-13
Roseola Infantum HPV 6 maculopapular rash on body (body pink – roses Self-limiting
months
are pink)– face not affected

Erythema Parvovirus B19 – “slapped cheek” rash; lacy, maculopapular When can child go back to
Infectiosum spread through resp. Significant risk of miscarriage in pregnant mother Self-limiting daycare – fever free for 24
“Fifth disease” secretions if exposed particularly in 1st trimester hours

Fever, malaise, sore mouth, anorexia; 1-2 days Do not confuse with
Hand, foot and
Coxsackie A Virus later, lesions; can also cause conjunctivitis and Prevent dehydration – resolves in 2-3 days herpangina – sores in
mouth disease
pharyngitis; last 2-7 days mouth

Fever for 5 days plus bilateral conjunctival

CBC, ESR or CRP, ALT/AST,
injection, polymorphous, macular rash, Refer for IV immune globulin
Vasculitis of coronary UA, throat culture, Echo More common in male
Kawasaki Disease inflammatory changes of lips and oral cavity High dose aspirin
arteries ↑platelets (poor man sed than females
(strawberry tongue), cervical lymphadenopathy, Aspirin daily for 2 months
rate)
edema or desquamation of hands and feet

 PEDIATRICS

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Fever, shaggy purple white exudative

Often associates with
pharyngitis, malaise, marked diffuse
teenagers and adults
lymphadenopathy, hepatic and splenic Monospot (heterophil If pt. has mono do not give Amoxicillin –
Mononucleosis Epstein Barr virus because they are more
tenderness with occasional enlargement; antibody test) will have morbilliform rash
symptomatic than young
maculopapular rash in 20% (rare petechial
children
rash)
Depletion of birth iron
Lead toxicity
stores, initiation of
Microcytic, hypochromic, masquerades as IDA –
Iron deficiency anemia lower-iron diet in later Most common in ages 12-30 months
elevated RDW abdominal pain, fatigue,
infancy, early toddler
irritability
stage

Supportive, systemic corticosteroid

Croup
Viral Barky cough with or without stridor therapy – Decadron (one dose due to ½
(laryngotracheobronchitis)
life of 72 hours)

FB in nose may present

Mechanical
Foreign body Inspiratory stridor CXR 2 view Removal, referral to ED with unilateral purulent
obstruction
drainage

Hot potato voice, difficulty swallowing, trismus Airway maintenance, ED, ENT consult,
Peritonsillar abscess Bacterial and contralateral uvula deviation; possible antimicrobial therapy, inpatient
stridor admission, surgical intervention

Adult with dysphagia and drooling; stridor,

Acute epiglottitis H. influenzae Airway maintenance, ED, ENT consult,
hoarseness, sore throat, fever, “thumb sign”

Supportive therapy – hydration, oxygen

Fever, cough, ↑ RR, Happy wheezer; 3 months
Bronchiolitis Virus - RSV (no bronchodilators, no steroids) Typically affects < 1 yr.
to 3 years; wheeze may persist up to 3 weeks
Prevent with synagis (only a few qualify)

Asymptomatic abdominal mass that extends

↑ risk in black female,
Wilms tumor nephroblastoma from flank to midline. Light palpation to avoid ultrasound
peak age 2-3
rupture

Laxatives for initial cleansing daily until More common in males.

Underlying problem is usually constipation. normal stools (MiraLAX). Behavior Feel safe going to
Encopresis Involuntary stooling Intestines are full of stool – child loses changes (sit for 5 minutes 2-3x daily bathroom at school?
sensation to defecate after meals to establish normal BM). Females – investigate
Dietary changes: fiber, fluids sexual abuse

 PEDIATRICS

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Hyperactivity, Impulsivity and inattention Document > 6 symptoms of inattention Do not confuse with
Symptoms must be present
Use rating scale (Child behavior checklist, someone who has
prior to age 12 years;
Combined: meets criteria of BOTH inattention Conners’ rating scales, Vanderbilt ADHD sensitivity to
ADHD symptoms last > 6 months;
and hyperactivity/impulsivity rating scales, others) decongestants;
Be evident in 2 different
Predominantly inattentive If co-morbidities are present – refer hyperthyroidism;
settings (school and home)
Predominately hyperactivity/impulsivity Commonly treated with Schedule 2 meds pinworms

Same as adults except:

Disease of Most common chronic
Asthma Same as adults Leukotriene receptor – Singular (1 in 3)
inflammation disorder in children
Nebulizer or spacer

Commonly viral
Chest x-ray High dose amoxicillin 90 mg/kg/day
Pneumonia If bacteria – Strep Most sensitive finding is ↑ respiratory rate
CBC
pneumo

Excessive loss of sodium through sweat (cannot

Multisystem disease –
transport sodium and chloride – making mucous
pulmonary, GI, sweat
Cystic Fibrosis Autosomal recessive thick and tenacious); Recurrent sinus and Sweat test
glands
pulmonary infections, mucous can block ducts of
European descent
pancreas and cause weight loss and greasy stools
↓ WBC
↓ H/H
Fever in the evening, bruising, bleeding, frequent ↓ Platelets
Most common age 2-8
Most common form of nosebleeds, bone pain, recurrent infections, Peripheral smear: malignant
Leukemia ALL – 77%
cancer lymphadenopathy, fatigue, poor appetite, cells
AML – 11%
hepatosplenomegaly. Failure of bone marrow Bone marrow: infiltration with
blast cells

Narrowing of pyloric
Differential diagnosis: GERD, milk
sphincter due to Projectile vomiting, first-born males, nonbilious Typically occurs at 4-6
Pyloric Stenosis ultrasound protein intolerance, intestinal obstruction
hypertrophy of pyloric vomiting. Olive like mass palpated in RUQ weeks;
Surgery
muscle

Red flags: choking with eating, Usually preventative measures – continue

Frequent regurgitation in absence of anything coughing with eating, forceful to breast feed, place supine to sleep, small
Gastroesophageal LES immature to 9-12 pathological; occurs 30+ times in healthy infant – vomiting, GI bleed, poor frequent, thickened feedings, consider
reflux (GER) months irritability during a reflux episode indicated weight gain, refusal to feed, non-cow’s milk protein formula for 1-2
GERD rather than GER constipation or diarrhea, weeks, soy-based formula, 1-2-week trial
abdominal tenderness, fever of hypoallergenic formula

Sudden onset intermittent, crampy, progressive

abdominal pain – acts normal between painful Barium enema
Intussusception Intestinal obstruction KUB, ultrasound Typically, less than age 2
episode. Cries and pulls knees up to chest. Current Possible surgical correction
jelly stools, sausage shaped mass

 PEDIATRICS

Name Cause Signs/Symptoms Diagnostics Treatments Concerns

Trendelenburg’s (stand on
Legg-Calve Perthes Avascular necrosis of Ages 3-12
Limp; pain to hip and/or knee affected side causes pelvic tilt) Refer to ortho
Disease proximal femoral head Affects males > females
Hip x-ray (AP and frog leg)

Slipped Capital Trendelenburg’s (stand on

Femoral head slips out Several weeks or months of hip/knee pain with Refer to ortho – surgical repair with
Femoral Epiphysis affected side causes pelvic tilt) Common in adolescents
of hip joint intermittent limp internal fixator
(SCFE) Hip x-ray (AP and frog leg)

Males: Large forehead, ears, prominent jaw,

tendency to avoid eye contact, large testicles
(macroorchidism) large body habitus, hx of Most common known
Fragile X syndrome Blood testing for carrier state
learning and behavioral differences cause of autism
Females: less common with fewer prominent
findings

Klinefelter Low testicular volume, hip and breast

syndrome XXY enlargement, infertility. Mostly developmental Blood testing for carrier state
male issues, most commonly language impairment

Short stature (less than 5 ft.) wide, webbed neck,

broad, shield-shaped chest, absent menses,
Turner syndrome infertility; born without ovaries, high narrow Blood testing available; High
XO arched palate, retrognathia, low-set ears, edema rate of pregnancy loss
of hands and feet – mosaic Turner’s have milder
features

Osgood Schlatter Disease
Common in growth spurt
Tx: Rest, activity as
Tolerated; RICE