All diastolic murmurs are pathological. Murmurs Grades I-barely II-audible III- clearly audible. IV- first time thrill V-Steth edge VI-entire steth. EXAM
III first time audible, IV first time thrill
Fundal height 12 weeks
Fundal Height 12 weeks above symphysis pubis. EXAM
Fundus 16 weeks between symphysis pubis and umbilicus.
Fundus at 20 weeks is at umbilicus.
2 cm more of less from # of wk gestation is normal if more or less order US
3 month old infant with down syndrome, due to milk intolerance, mom started on goats milk; now has pale conjunctiva but otherwise healthy. Low HCT. What additional test would you order?
Iron, TIBC
3 months of synthroid, TSH increased, T4 normal, what do you do?
Increase Medication
3 ways to assess cognitive function in patient with signs/symptoms of memory loss
Mini mental exam
4 month old with strabismus, mom is worried……
tell her it is normal.
4 month old wont keep anything down, what is the main thing you look at?
Growth chart
6 month old closed anterior fontanel.
XRAY
Abnormal cells on PAP, what do you do next?
Refer for Colposcopy
CAGE ACRONYM
Cut down
Annoyed by criticism
Guilty about drinking
Eye opener drink
Causes of tachycardia
Fever
Anemia
Hypotension
Cranial nerves responsible for extraocular eye movements
CN 3,4,6
Definition of metabolic syndrome
cluster of conditions that increase risk of heart disease, stroke, diabetes.
diagnose trichomoniasis
wet prep
Elderly presents with atrophic vaginitis, small uterus, palpable 4×5 ovary, what do you do next?
Pelvic US
Epistaxis is most common in the area of the nose known as kiesselbachs triangle, where is this located?
Anterior septum
Definitive diagnosis of acute bacterial prostatitis
urinalysis and culture
GERD treatment
H2 is first line, give hs
Grade 3 cells on Pap, treatment?
LEEP
excision
Fingernail hematoma treatment?
drill hole and drain blood?
Increased risk of ectopic pregnancy
Salpingitis, or history of abortion, PID,
Koplick spots
Measles (rubeola). Grains of salt lesions inside mouth in Measles
Koplick spots
Measles (rubeola). Grains of salt lesions inside mouth in Measles
Legg-Calve-Perthes Disease
Avascular necrosis of the proximal femoral head
Lipid level of 1500, increased risk for?
Pancreatitis
Low HGB, Low HCT, High MCV indicates what?
Macrocytic anemia, B12 Def
Man with BPH, prostate feels on digital exam?
Enlarged, symmetrical, smooth
Man with HTN, CAD, present femoral pulses but absent pedal
Arterial Insufficiency
McMurray’s Sign
(+) palpable or audible click while extending with varus stress
Meniscus tears
Lachman’s Test
pivot shift test (ACL tear)
Newborn with foot turned in, what do you do?
refer to orthopedist
Osgood-Schlatter disease
Knee pain.
inflammation or irritation of the tibia at its point of attachment with the patellar tendon
Patient forgot to start Thanksgiving dinner and husband states she has trouble remembering tasks and trouble with organization. What is this indicative of?
Alzheimer’s
Pt has Barretts Esophagus, insurance no longer covers GI who was treating condition. Pt at FNP office wanting refill prescriptions. What do you do?
Refer to oncologist
Pt presents with rash on shoulder, erythematous maculopapular rash with center clearing and scaling?
Tinea Corporis
Pt presents with “bag of worms:, indicates?
Varicocele
Pt with atopic dermatitis, look for what other diseases?
Asthma
Pt with bleeding after menopause
endometrial biopsy, need to screen for cancer
Pt with hx of PID, increased rick for?
Infertility
Pt with HIV took high potency anti viral treatments and CD4 is >400, what does this indicate?
This is good. Want higher than 350
Pt with hx of htn and stroke, now having memory loss. What does this indicate?
Vascular dementia
Pregnant teacher with exposure to 5ths disease (SLAP CHEEK), what risk is there to the fetus?
slap cheek, PVB19, rash hands / feet Fetal death and birth defects
Quick assessment of patients fall risk? Timed Get up and Go
Timed Get up and Go
Red beefy tongue?
pernicious anemia
Rotator cuff injury presentation
disturbs sleep, arm weakness, dull ache
Shingles near eye
immediate referral to ophthalmology
Signs and symptoms of Roseola (6ths disease) ?
Viral infection
Can result in a maculopapular rash, but up to 70% of cases proceed without the rash stage
-Usually accompanied by a high fever (41°C or 105°F) that comes on quickly and lasts up to 3 days followed by rash
-Seizures may occur during this period.
-On the fourth day, the fever disappears and the rash appears, first on chest and trunk, then less prominently on the face and limbs.
-High fever, pink flat or raised rash
Treatment for chronic alcoholism:
12 step program
Treatment for Gonorrhea?
Rocephin 250mg IMx1 plus
Azithromycin 1 gm orally x1 to cover chlamydia. , or doxy 100 mg BID x7d. Green colored vaginal discharge, friable cervix. EXAM
Report to health department
Young female want birth control, forgets to take pills, does not want to get pregnant for at least 5 years:
IUD
Basal cell cancer
Waxy, pearly, telangiectasia, ulcer center lesion
-most common type of skin cancer caused by UV exposure. Metastatic is rare
Actinic Keratosis
Scaly red to yellow located in sun exposed area
-a precancerous skin growth that occurs on sun-damaged skin
Actinic Keratosis
Numerous round dry pink to red areas. Scaly red to yellow located in sun exposed area
-a pre squamous cell carcinoma occurs on sun-damaged skin
biopsy
cryo or 5fu cream
subungual hematoma tx
Make a hole and drain the blood
Moderate acne treatment
Without inflammation: Topical retinoid
Moderate inflammation: Topical Retinoid or benzoyl peroxide or Azaleic acic ( very expensive and hard to get covered)
PLUS ADD
Oral antibiotics: doxycycline or tetracycline or minocycline- (tetracyclines has been proven most affective for inflammatory acne)
Minocycline- long term use has been linked with pseudotumor cerebri
Oral contraceptives for hormone related
Spironolactone
heart murmur with holosystolic or pan systolic
Heart mumur with mid systolic
MR – radiate axilla, 5th ICS MCL, apex,
AS – radiate neck, 2ICS right sternal border
MR ASSH
Coarctation of Aorta
COA: bounding radial and weak femoral pulse
increase blood pressure in arms, and lower pressure in lower legs.
-congenital cardiac condition characterized by a narrowing of the aorta
Murmur Grade III – VI
Loud murmur easily heard
JVD caused by
-tension pneumothorax,
-Rt. sided heart failure,
-cardiac tamponade,
-traumatic axphysia from
Increase in portal pressure(LIVER) in venous side or cor pulmonale
pt. with gradual onset of fever, hemorrhages on nail beds, painful raised red nodules, rash on palms
endocarditis , painful red spots on fingers olser’s nodes, janeway legions rash on palms and soles.
Know the difference between Peripheral Arterial Disease and Chronic Venous Insufficiency or PVD. There was question about PAD.
PAD: Absence of pulse, decrease blow flowing down, PAIN, Dx doppler or ABI<0.9, TX exercise by walking or antiplatelet,
PVD: Volume, edema, discoloration, decrease blood going up,
Chronic Bronchitis Treatment
Smoking cessation
Pulmonary rehabilitation
Pharmacologic therapy
Supplemental oxygen
TB… PPD is positive if area of induration is:
5 mm in an immunocompromised patient or close contact
10 mm in immigrant, health care workers, drug user
15 mm in a patient who lives in an area where TB is very rare.
what condition would make you order Lateral X-ray of the neck. Options include: Drooling, Unable to do ROM of the neck / stiff neck.
Croup/Epiglottitis
AV nicking (Arterioles pressing on vein of the eye)
HTN retinopathy
intraocular pressure (IOP)
Fluid pressure inside the eye; measured with tonometry
Rovsing sign
pain in the RLQ when the LLQ is palpated (indicative of appendicitis)
Pencil-like stools occur in an obstruction of what
Sigmoid descending colon
It’s a thin narrow stool and possible causes include colon cancer, diarrhea, IBS. Refer for GI colonoscopy
headache after trauma
SDH
migraine headache
-paroxysmal (sudden, periodic) attacks of mostly unilateral headache, often accompanied by disordered vision, nausea, or vomiting, lasting hours or days and caused by dilation of arteries.
4-12 hours,
abortive triptans
prophylaxis propranolol, TCA amitriptyline, anticonvulsants topiramate
Vitamin B12
Folate shares a close relationship with this other B Vitamin.
Vitamin B12
Cognitive deficits, glossitis, pernicious anemia,
Folate shares a close relationship with this other B Vitamin.
88/yr. old patient in for follow up secondary. She’s been treated with Tylenol for Joint arthritis. Her SED rate was checked after 6 weeks of treatment and it was 28. Normal range is from something to 25. How would you treat the pt.
be changed to NSAID, SED rate is a sign of inflammation
Which medication causes low sperm count for a patient
SSRI
grandiosity
Exaggerated belief in or claims about one’s importance or identity.
Bipolor
ADHD
A behavioral problem characterized by short attention span, restless movement, and impaired learning capacity.
pt. pap’s smear noted with Low Grade Squamous Intraepithelial Lesions and High Grade Squamous Epithelia Lesion noted on the report, what should NP do?
HPV test if not done. Refer for colposcopy
Chlamydia trachomatis
Doxycycline (+ ceftriaxone for gonorrhea coinfection)
Genital warts treatment
Cryotherapy
OR
Podophyllotoxin cream –
OR
Imiquimod (Aldara cream)
HIV pt. with antiviral and CD4 count still less than 200. What should NP tell the pt.
tell the pt. that he is qualified to be diagnosed with AIDS according to CDC
Most common cause of death in children
motor vehicle
Tanner 2
Tanner 2- female breast bud areola develops Male testes scrotum start to enlarge, scrotum gets darker
Tanner 4
Tanner 4- female nipples and areola become elevated from breast, secondary mound Male penis grows wider grows in length, darker scrotum
pt. expericieng memory loss, and increase in confusion and she has a history of stroke, HTN, What type of Alzheimer.
vascular dementia
presbycusis
a gradual loss of sensorineural hearing that occurs as the body ages
a pregnant female at slightly above symphysis pubic and Fundal height is 32cm (above the umbilical). What should be done
Ultrasound
Romberg test
cerebellar
-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed
-expected finding: client should be able to stand with minimal swaying for at least 5 seconds
Direct Coombs test
r/o bilirubin
preeclampsia treatment
bed rest, laying on her side
Molluscum contagiosum treatment
Currettage, liquid nitrogen
pyloric stenosis
non bilious vomiting, olive like firm mass palpated on right upper quadrant
horizontal nystagmus that stops when eye is close to midline in a college student
Ménière’s disease ?
Nystagmus test
the involuntary jerking of the eyes as a person gazes to the side
eating, painful lump noted on the jaw that comes and go.
sialolithiasis).
Etopic Pregnancy: Risk Factors
Previous ectopic pregnancy
Prior fallopian tube surgery
Previous pelvic or abdominal surgery
Certain sexually transmitted infections (STIs)
Pelvic inflammatory disease
Endometriosis
cigarette smoking
age older than 35 years
history of infertility
use of assisted reproductive technology, such as in vitro fertilization (IVF)
Which among the list can cause increase in respiration
Options include (low oxygen, high oxygen, hypercapnia, hypocapnia)?
Which among the list can cause increase in respiration
hypercapnia
Osteoporosis Risk Factors (ACCESS)
A-lcohol Use
C-orticosteroid Use
C-alcium low
E-strogen low
S-moking
S-edentary lifestyle/s
ACCESS leads to OSTEOPOROSIS
to prevent fracture in a pt. with low vitamin d hydroxyl, high TSH and low Hct
VITAMIN D 600-800, CALCIUM 1000-1200.
OSTEOPOROSIS BONE ABSORPTION EXCEED BONE FORMATION.
LOW TSH= Hyperthyroidism- BONE DEMINERALIZATION.
NEED CALCIUM for BONE GROWTH
Carotid bruit
abnormal flow of blood through the carotid artery
Carotid bruit
abnormal flow of blood through the carotid artery due to atherosclerotic disease
Common causes of GERD
risk factors- alcohol, anticholinergic, CCB, chocolate peppermint, fatty, spicy, citrus foods, hormones, obesity, pregnancy, smoking, theophylline, exacerbated by CCB verapamil
Common causes of GERD
risk factors-
alcohol,
anticholinergic,
CCB, BB
chocolate peppermint, fatty, spicy, citrus foods,
hormones,
obesity,
pregnancy,
smoking,
theophylline
Zeprexa. What lab and intervention to put in place
CAUSES ELEVATED LIPDS, GLUCOSE, WEIGHT
monitor CBC for low WBC
weight- BMI q 3m
b/p, mental status, lips, prolactin, glucose
Weber test
Sensorineural loss Weber test(top of head) no laterization, normal finding, does not lateralize to either ear, bilateral hearing loss, if hear better in left ear, right sensorineural loss
Weber test
Sensorineural loss Weber test (top of head) no laterization- normal, does not lateralize to either ear- bilateral hearing loss, if hear better in left ear, right sensorineural loss.
SUN- sensorial lateralize unaffected ear
CAFFE- Conductive lateralize to affected ear
Assessment on patient with ascites
Dullness
Assessment on patient with ascites
Dullness to percussion
Varus Stress Test
application of a lateral force to the medial aspect of a joint in an attempt to create a gap in the lateral joint line, thereby testing the stability of the lateral aspect of the joint
LCL
Varus Stress Test
TEST LCL (lateral-vaRus)
McMurrays- Meniscus CLICK
application of a lateral force to the medial aspect of a joint in an attempt to create a gap in the lateral joint line, thereby testing the stability of the lateral aspect of the joint
LCL
German Measles (Rubella)
Pink, papular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik spots.
patient with IOP of 32mmHg, what do you expect during fundoscopic exam
patient with IOP of 32mmHg, what do you expect during fundoscopic exam
increase cup-to-disc ratio
retinal hemorrhage
optic nerve asymmetry and pallor
measured w tonometry
BPH and urge incontinence
anticholinergics/oxybutynin, impamine/tricyclic/antidepressant
Anticholinergic- can’t think or blink, can’t see (Increase eye pressure) or pee, can’t spit or shit, SADCCUB sedation, anorexia, dry mouth confusion, constipation, urinary retention, BPH
BPH and urge incontinence
TX anticholinergics/oxybutynin,
impamine/tricyclic antidepressant
seasonal affective disorder (SAD)
a mood disorder caused by the body’s reaction to low levels of sunlight in the winter months
intussusception
telescoping obstruction of the intestines, cuts off blood supply, fatal, sudden loud crying, comes/goes, vomiting, blood/mucus mixed with stool, SAUSAGE LIKE
MASS
intussusception
telescoping obstruction of the intestines, cuts off blood supply, fatal, sudden loud crying, comes/goes, vomiting, blood/mucus mixed with stool, SAUSAGE LIKE
MASS CURRENT JELLY STOOL
IBS (irritable bowel syndrome)
An intestinal disorder causing pain in the belly, gas, diarrhea, and constipation.
due to Small intestinal bacterial overgrowth, or SIBO
IBS (irritable bowel syndrome)
SS pain in the belly, gas, diarrhea, and constipation. Pencil like stool.
Caused by: Small intestinal bacterial overgrowth, or SIBO
TX fiber, avoid gas foods, antispasmodics, decrease life stress
Osteoporosis treatment
TX first line is bisphosphonates alendronate, Fosamax, calcium500 mg, vitamin d thru food and supplementation, testosterone, wt bearing exercise
Osteopenia- increase calcium dark green vegetables, salmon, sardines, soy and OJ
Hormone (estrogen) replacement therapy (HRT) slows bone loss
Natural progesterone cream prompts new bone growth
Statins increase bone mineral density
Osteoporosis treatment
TX BIOPHOSPHATES alendronate, Fosamax, CALCIUM 500 mg, vitamin D food and supplementation, testosterone, WT BEARING EXERCISE
CAUCASIAN and ASIAN affected most
RISK PPI, STATIN, STEROIDS, THYROID,
Osteopenia- increase calcium dark green vegetables, salmon, sardines, soy and OJ
Hormone (estrogen) replacement therapy (HRT) slows bone loss
Natural progesterone cream prompts new bone growth
BONE DENSITY >2.5
Retinoblastoma
white reflection in child’s pupil
for staph aureus infection (skin) with pus
MRSA- TX Bactrim or tetracyclines?
hyperparathyroidism
high calcium
Hyperthyroidism treatment
methimazole, PTU-propylthiouracil (preferred in pregnancy)
Radioactive iodine, Beta blockers
Mammography Screening
-Age 45 – 54 yearly mammogram
-55 and older every 2 years
Fifth’s Disease (Erythema Infectiosum)
B19: lytic infection, respiratory transmission
Sx: flushed rash/fever in kids
Px: fever, get better in a week
pt has AOM but has hives on Amoxicillin and N/V with erythromycin, what meds to give
TREATMENT: Amoxicillin (first line), then Augmentin, Omnicef, Ceftin, Levaquin. If your patient is only PCN allergic do azithromycin or clarithromycin.
chlamydia in pregnancy
Azithromycin 1 gm PO x1 or Amoxicillin 500 mg PO TID x7d. Test of cure 3 weeks after completion of treatment (PREGO). EXAM
papilledema
optic disc swollen w/ blurred edges due to increased ICP EXAM
actinic keratoses
Precursor to squamous cell carcinoma. “numerous dry round and pink to red lesions” with a rough and scaly texture. Does not heal. Slow growing in sun exposed areas. Diagnosis: BIOPSY Golden Standard. Treatment: Sm. (cryotherapy), Lrg. (5-FU cream)- which causes ur skin to ooze, crust, scab, redness EXAM
Allergic Conjunctivitis
“stringy; increased tearing” PO antihistamines. Type I sensitivity. Typically bilateral. Rhinitis and allergic shiner.
COPD
COPD- Gold 1-2- SABA or SAMA ON EXAM.BASCIALLY ANTICHOLINERGIC FIRST LINE FOR COPD ON EXAM
Gold 1-2 that are poor controlled- LAMA or LABA. May use SABA for rescue.
Gold 3-4 LAMA first line. If poor use LAMA plus LABA. Alternative is LABA + ICS.
Gold 3-4- refer
SABA- Albuterol, levoalbuterol (terol)
LABA- Formeterol, salmeterol (Terol)
SAMA- Atrovent Ipatropium (tropium)
LAMA- Spiriva Tiotroium (tropium)
COPD long term is OXYGEN
CN IX Glossopharyngeal
- Shoulder shrug/ ROMBERG test EXAM
CN V Trigeminal
Herpes. CORNEAL ABRASION. EXAM
CN VIII Vestibulocochlear
ears 8 EXAM
CN VII Facial
BELLS EXAM
ACEI contraindicated
pregnancy
Safe to give varicella/MMR
Do not give <12 mo. EXAM QUESTION
Acne Vulgaris
common acne. Retin-A, acne worsens 4-6 weeks if no improvement in 8-12 weeks increase dose or add erythromycin, benzoyl peroxide.
Acne Rosacea
- chronic small acne like papules/pustules around nose mouth chin. TREATMENT- Metrogel, Azelex. Low dose tetracycline. Clindamycin. EXAM
Cataracts
is on EXAM in elderly night vision issues. Opaque
Kawasaki disease
- acute high fever, enlarged lymph. BRIGHT RED RASH, conjunctivitis, dry cracked lips, strawberry tongue, Swollen hands, feet, AFTER the fever resides the rash PEELS on hands/feet. Treated with high dose aspirin and gamma globulin. This is TOXIC and VASCULAR, think blood clots, heart problems etc. Treat: high dose aspirin. EXAM
Erythema migrans
Erythema Migraines- (stage 1 Lyme) Target bulls-eye, usually appears in 7-14 days POST bitten tick. Rash is hot to touch with rough texture, flu like symptoms. DX: B. Burgdorferi via ELISA, confirm with western blot. Increased ESR. TREATMENT: Less than 7 Amoxicillin or cefuroxime axetil. Older than 7 Doxycycline. EXAM
Rocky Mountain Spotted Fever
Inc. fever, chills, N/v, photophobia, myalgia, arthralgias THEN 2-5 days later you develop a petechial rash on forearms, ankles, wrists, that spreads towards trunk and becomes generalized. Think rocky NC/OK/AK/TN/MO. DX: PCR essay with Rickessetti Antigen TREATMENT- doxycycline. EXAM
Addison’s
Addison’s- deficient in cortisol (think low sodium, blood sugar, but Increase K. You must give cortisol. (Diagnosis Plasma Cortisol <5 mcg/dl @ 0800.) EXAM
rheumatoid arthritis
Early morning stiffness, sausage joints. Symmetrical involvement. Longer stiffness than OA. Joint space narrowing. Pain, warm, tender, swollen, things. TREAT: NSAIDS, steroids, DMARDS, TNF. Only has BOUCHARDS, SWAN NECK IS DESCRIPTION ON EXAM
Osteoarthritis
Large weight bearing joints. Early morning stiffness with inactivity. Has both nodes. FIRST LINE Acetaminophen. EXERCISE: Isometric exercises for knee OA. Non-weight bearing, like biking, swimming, stationary bike. EXAM
Osteoporosis
OSTEOPOROSIS = WEIGHT BEARING- walking, lifting weights etc. bones are forced against gravity. EXAM
Fibromyalgia polymyalgia
Fibro- 11/18 points. Widespread pain for at least three months. EXAM. polymyalgia Tx prednisone 12 months. Must taper off. RISK for Temporal arteritis, DX BX, elevated ESR
Serotonin syndrome
Acute Serotonin Syndrome- Dilated pupils, high fever, muscular rigidity, mental status changes, hyperreflexes, clonus, uncontrolled shivery. You get this from SSRI, MAOIs, TCA. Could be potentially life threatening. EXAM
Fundal Height
Fundal Height 12 weeks above symphysis pubis. EXAM TOPICS
Fundus 16 weeks between symphysis pubis and umbilicus.
Fundus at 20 weeks is at umbilicus.
2 cm more of less from # of wk gestation is normal if more or less order US.
Psoriasis
Psoriasis- Inherited. Pruritic erythematous plaques, fine silvery-white scales with pitted fingernails. Scalp, elbows, knees, sacrum, intergluteal folds.
(Koebner phenomenon- new psoriatic plaques form over skin trauma)
(Auspitz sign- pinpoint bleeding when plaques are removed).
TREATMENT: Topical steroids, Tar preps (mild). For (severe) do anti-TNF, or immunologic.
D
Dacrocystitis
Darcryotosis lacrimal sac, rub down towards mouth. If think secondary infection abx. EXAM how it presents.
Acne Rosacea
Acne Rosacea- chronic small acne like papules/pustules around nose mouth chin. TREATMENT- Metrogel, Azelex. Low dose tetracycline. EXAM
Parathyroid hormone
PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract. EXAM
Diabetic Retinopathy
Diabetic Retinopathy-Cotton wool spots (moderate retinopathy), micro-aneurysms. ALSO RETINAL HEMORRHAGES ON CENTER OF EYE APPEAR ORANGE RED
HTN Retinopathy
Hypertensive Retinopathy- Copper/silver wire arterioles. AV nicking(mild retinopathy). Retinal Hemorrhages. EXAM
Wilms Tumor
Wilms tumor (Nephroblastoma)- Not painful. Asymptomatic abd mass does NOT cross the midline. 2-3 y. o.d. do not palpate. Do ABD US. PUNT. Think Nephro doesn’t cross. Stays where kidney is. EXAM
Primary Amenorrhea
Primary amenorrhea: NO menarche by 15 y. with or w/o secondary sex characteristics.
Aphthous stomatitis
Cancer sores. Aphthous stomatitis: painful shallow ulcers heal 7-10 days. Magic mouthwash.
Temporal arteritis
Temporal arteritis- one temple indurated cord like gold stand. Biopsy. Abrupt visual changes blindness, inc. ESR. CPR. Most have POLYMYALGIA RHEUMATICA. Treat high dose steroids.
Atopic Dermatitis (eczema)
Inherited. Extremely itchy. On flexural folds, neck, hands. Inc. IgE. “small vesicles that rupture leaving painful, bright-red, weepy lesions” they become lichenified from itching. First line: Topical steroids. Avoid hot water/soaps. PO antihistamines. EXAM
Tinea Corporis
ring like itchy rash, slowly enlarge central clearing”-Treatment: most respond to topical antifungals, if severe do oral Lamisil. EXAM AZOLE ending
Cellulitis
Deep dermis poor demarcated low legs. EXAM/ MULTIPLE QUESTIONS. DVT RISK, DM WITH CELLULITIS WATCH FOR OSTEOMYLITIS.
Erysipelas
Group A strep, painful, Upper dermis, clear demarcated, cheeks, shins.
TREATMENT- Dicloxacillin QID x10d. Cephalexin, Clinda. PCN ALLERGY? Do Azithro x5d.
MRSA TREATMENT: Bactrim, doxy, mino, clinda. If sulfa allergy do not use Bactrim.
Varicella Zoster
“contagious 48 h. before, until all lesions crusted over” low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “initially on trunk, then scalp and face” TREATMENT supportive, antihistamines, acyclovir 20mg/kg 5xd. If given first 24 hours works best. EXAM
Impetigo
Impetigo-Gram positive. Itchy pink-red lesions, evolve into vesiculopustules that rupture. If bullous-large blisters. Severe- Keflex, dicloxacillin. PCN Allergic-Azithro, clinda. If NO BULLAE- Bactroban. EXAM
Scarlet fever- scarlantina
“sandpaper textured-pink rash with sore throat” strawberry tongue, rash starts on head and neck, spreads to trunk. The skin THEN desquamates. EXAM
Lichen planus
LICHEN PLANUS: SMALL FLAT TOPPED, RED TO PURPLE BUMPS THAT MAY HAVE WHITE SCALES/FLAKES.. WHISPY GREY WHITE STREAKS CALLED WICHHAMS STRIAE. INNER WRISTS FOREARMS, AND ANKLES. IF ON SCALP CAUSE HAIR LOSS. Causes hep C, medications, contact with chemicals. EXAM
Spider bite
fever chills, n/v, located arms, upper legs, or the trunk. Biten area becomes swollen, red, and tender, and blisters appear within 24-48 hours. Necrotic in center, which kills the tissue. Ice packs to wound and cold inactivates the toxin, tx like cellulitis of the skin, abx ointment at first, watch etc. Exam
Pityoris rosea
Pityoris rosea itchy, herald patch, xmas tree pattern, rash hands soles/feet think to test for secondary syphilis RPR then VDRL are screening, then dx FTA-ABS. EXAM
Corneal abrasion
Corneal Abrasions- Round/Irregular. Was on EXAM.
Acute Angle Closure Glaucoma
acute/severe halos, cupping optic nerve, cloudy cornea, mid-dilated oval pupil. ER STAT. EXAM
Conductive
Conductive: Lateralization to bad ear. Rinne- BC > AC.
Rinne (1st mastoid, 2 front of ear, time each area).
Weber: Tunning fork midline. CN 8 (acoustic). EXAM
Koplik spots
Koplik Spots- “clusters sm. Size red papules w/ white centers in the buccal mucosa by lower molars”. Rubeolla. Fever, conjunctivitis, coryza, cough (3c). Morbiliform rash. EXAM
Sensorineural
Sensorineural: Lateralization to good ear. Rinne- AC > BC.
OME
Ear pressure, popping, muffled hearing, chronic allergic rhinitis, sterile serious fluid is trapped in the middle ear. TM should NOT BED RED. TM may bulge or retract. TREATMENT: Oral decongestants, steroid nasal spray, treat like allergies. Usually Painless. Weber- Lateralization to affected ear. Rhinne- BC > AC. PRECEDES OR USUALLY FOLLOWS AOM. SUPPORTIVE CARE AND WAIT 3 MOS SOMEX. EXAM
Presbycusis
sensorineural loss without lateralization. Involves the inner ear. Symmetrical progressive. Human speech lost first. AGING ADULT EXAM
OE
Otitis Externa (swimmers ear)- Pseudomonas aeruginosa. (other- S. aureus). External ear pain- d/c itching, hearing loss, tragus, green d/c. TREATMENT: Corticosporin, Cipro EXAM
Sinusitis
TX AMOXICILLIN OR AUGMENTIN ALLERGY MACROLIDE
Meiniers disease
VERTIGO TINNITUS, HEARING LOSS. nystagmas
Mono
test heterophile antibody test. ON EXAM
MR. ASS
(Systolic Murmur) Only systolic murmurs will radiate to a location on the exam.
Mitral Regurg
(Holo/pansystolic)- radiates to axilla. Think Mitral area 5th ics MCL.
Aortic Stenosis (mid systolic ejection) radiates to neck. Think 2ics rsb.
All diastolic murmurs are pathological. Grades Murmurs
I-barely II-audible III- clearly audible. IV- first time thrill V-Steth edge VI-entire steth. EXAM
MVP
MVP- S2 click, followed by systolic murmur. Asymptomatic. MVP with palpitations is treated with BB. LATE SYSTOLIC.
S3- HF,
S4-LVH stiffening,
S3- HF, Kentucky, early diastole. Abn >35. Bell EXAM
S4-LVH stiffening, Tennesse, late diastole. “Atrial kick/gallop” EXAM
Isolated Systolic HTN
CCB
PAD/ PVD
PAD/ PVD (same)- Nocturnal pain relieved by lowering legs, poor pulses, dependent rubor, intermittent claudication, atrophy, shiny, hairless, cold feet. Initial do a pulse check, ABI 0.9 or less is PAD. Ateriography is the most DEFINITIVE test. Try to develop collateral circulation. Otherwise- Trental, Pletal. EXAM
CVI
CVI- Impaired venous return. Achy legs relieved by elevation, edema after prolonged standing, night cramps, brownish discoloration, cold, ulcers. Etc. do support stockings. EXAM
blood pressure
BP – ST 1 (140-159/ 90-99), if you know this you will get the rest!! Normal is <120/80. ELERGLY OVER 60 150/90 IS OK. ISH WILL INCREASE SYSTOLIC NOT DIASTOLIC. ON EXAM.
Thiazide diuretics
no sulfa allergies, hyperuricemia, hypokalemia, hypomagnesia, hyponatremia, hyperglycemia, hypertriglycerides. ON EXAM
Statin
Must check LFT before starting Statin. Know when to start statins and what to check for to decide mod-high dose statins. ON EXAM
Pulses paradoxus
Pulsus paradox Apical pulse can still be heard even though the radial pulse is no longer palpable. Certain issues cause impairment with diastolic filling, 10 or greater drop in the SYSTOLIC pressure. I think her patient had asthma and their pressure dropped by 10 etc. ON EXAM
Emphysema
Emphysema Lungs- Percussion-HYPERENNOSANCE tactile frem + egophony- dec. CXR- flattened diaphragms with hyperinflation. Inc. AP diameter, accessory muscles, pursed-lip breathing, weight loss. ON EXAM
Acute Bacterial Pneumonia- CXR
middle lobe. ON EXAM
OSA
does not include Microglossia which is an absent tongue congenital. EXAM
TB
fatigue, fever, cough. Never do fewer than 3-4 drugs initially if positive, then u can narrow it down. Latent TB usually treated with INH. If u suspect ACTIVE TB order, NAAT, C&S, AFB. The AFB is not diagnostic. SPUTUM FOR C & S if gold standard. Deep morning cough collected for three “consecutive days”. TB is usually upper lobes.
TPO
TPO- this lab is off MEANING ELEVATED in BOTH hyper/hypo thyroidism. TPO is GOLD stand for diagnosis in Hashimotos. But you always want to order a TSH first, THEN ur thyroid panel do not get ahead of yourself. Check ur TSH lab on both in 6-8 weeks but never sooner than 6 weeks that is how long these meds take to work. TOPIC ON EXAM
hyperthyroid
Hyperthyroid- Low TSH, high “FREE” T4/T3. ALWAYS DO FREEs. Graves disease-autoimmune. Lid lag, exophthalmos, everything is hyper (body wise). Treatment: PTU/Tapazole. PTU PREFER IN PREGNANCY
RAIU-no w/ prego. Destroys thyroid, lifelong treatment for hypo then.
A1C > 9
If you are already on TWO oral drugs for diabetes and A1c is 9 or higher, start BASAL insulin. If you cannot tolerate metformin and your A1c is 9 or higher start BASAL insulin. ON EXAM
Parathyroid
For parathyroid- dx blood test. You will have elevated calcium because your parathyroid is releasing too much from bones and this will just cause it to float around and not help ur bones. TX: BIPHOSPHANATES FOR SECONDARY HYPERPARATHY. EXAM
cushings
Central obesity, moon face, purple striae, hairy, hypertension, elevated plasma CORTISOL in AM. “INC BS, SODIUM” Dec K. You must draw cortisol levels in the morning.
Fructosamine test
checks sugar for past 2-4 weeks.
triglycerides
causes pancreatitis >500. If >500 treat with Niacin or Fibrate or Niaspan. If your patient is already on NIACIN you can add a fibrate like (LOPID/TRICOR). Apparently an insulin infusion works also. ON EXAM
Pancreatitis
diagnosed with amylase / lipase draw. Amylase beings 2-12 h. Lipase 4-8 hours. Lipase however is MORE specific and sensitive to alcoholic pancreatitis. ACUTE: Grey Turner/ Cullen sign. Abd pain that rates to midback “boring” epigastric pain. Fever, n/v. EXAM TOPICS
Metformin
Metformin – monitor BUN, Creatinine.
contraindicated renal and liver disease
ARF creatinine up and GFR down.
affects liver enzymes, weight loss, avoid in alcohol drinkers, lactic acidosis, diarrhea flatulence
CT: hold 24 hr before and 48hr after
Polycythemia vera
slow growing blood cancer. blood too thick, clots. bone marrow to many RBC. risk bleed , anemia, CBC
CCB
BLE edema- walk around
Kava Kava
anxiety and insomnia, don’t mix w sedating benzos.
Bipolar med
lithium- monitor TSH, toxicity bind to TH cause hypothyroidism.
Depression med
acute Anxiety/ panic med
GAD med
depression SSRI
panic benzo, Xanax, ativan
GAD SSRI
SNRI- Buspar, Effexor, Cymbalta- Taper OFF
SNRI/ Benzo Discontinuation
Buspar, Effexor, Cymbalta and Benzo Taper OFF
Thiazide GLUT-
Glyceridemia
Lipidemia
Uricacidemia
Triglyceridemia
HYPO-Kalemia
ACE/ARB contraindications
pregnancy
Renal failure
Renal Stenosis
METABOLIC SYNDROME
METABOLIC SYNDROME
NO THIAZIDES,CCB (HF)
NO TZD ACTOS (Pioglitazone)
GIVE Metformin, ACE or ARB- kidney protective, BB- causes hypoglycemia,
Triglyceride < 300 what do we do first?
Triglyceride in 300 plus risk for _ what do we do?
Lifestyle modification
Pancreatitis, Niacin then add, fenofibrates
Serotonin syndrome ss
hyper rigidity, fever, myoclonus, dilated pupils, AMS, hyper reflexes, from SSRI or mix w MAOI and TCA
NSAID contraindicated in
HF and ARF
increase BP impair renal prostaglandin and sodium retention
strabismus
misalignment of eyes, abnormal after 6 months
macular degeneration
loss of central vision
retinal detachment
floaters, curtain, flashes
Xanthelasmas
sharply demarcated yellowish deposit of cholesterol underneath the eye
Red reflex absent
retinoblastoma (leukorrhea) , cataracts, glaucoma.
Will have white reflex
Mono, return to play and Dx
4-6 weeks when spleenolmegaly resolves
Mono spot/ Heterophile
Viral stomatitis
ulcer on cheek
(Aphthous)- viral canker sore
cholesteatoma
chronic sinusitis or OM. cauliflower, foul-smell, hearing loss.
erodes bones in face affects facial CN 7.
Benign- risk hearing loss refer SURGERY
Acute Closed Angle Glaucoma
Vs
Open Angle
Acute: Sudden pain, halos, cupping, dilated, cloudy , IOP, HA, refer ED
Open (primary) : CN 2, gradual loss peripheral vision first
Papilledema
Swollen, optic disc, increase cup to disc ratio, HA, ICP, HTN,
Acyclovir (cheapest)
200mg 5 x day
Pt on PPI, has osteoporosis has a cough,
refer for EGD r/o Barrett’s.
allergic rhinitis
blue pale turbinate clear drainage. Tx inhaled corticosteroids
hordeolum Vs
chalazion
blepharitis
hordeolum: painful swollen red warm abscess TREAT hot compress erythromycin, dicloxacillin.
chalazion does not hurt
Blepharitis always unilateral, Tx baby shampoo warm compress
Sialolithiaisis
painful lump, calculi or salivary stones.
sub mandibular gland whartons; duct.
Roseola infantum- Sixth disease
viral, young children, high Fever 3-4 days followed by maculopapular rash
Herpetic keratitis
ocular herpes – blurr vision, inflammation of eye; gritty feeling, conjunctivitis, sharp pain, and photophobia- AVOID SUN
REFER OPTHO Tx acyclovir
Cranial nerves responsible for extraoculomotor movements?
a. 2, 3, 6?
b. 3, 4, 6?
Patient with hx of hypertension and stroke, now having memory loss and confusion – indicates what?
a. Alzheimer’s
b. Vascular Dementia?
CAGE acronym
?
Treatment for chronic alcoholism?
?
Frail elderly mammogram breast tissue?
?
Patient has Barrett’s esophagus, insurance no longer covers gastroenterologist who was treating condition, patient at the FNP office, wanting a prescription for medication… What should the FNP do?
a. Refer to oncologist?
b. Refill prescription?
GERD treatment?
a. PPI? Per American College of Gastroenterology, treatment should begin with a PPI.
b. H2? An H2 is inferior to PPI’s.
3 months on Symmetrel, TSH increased, T4 normal, what do you do?
a. Increase medication?
b. Decrease medication?
Lipid level of 1500, increased risk for?
a. pancreatitis?
Frail elder, increased creatinine, indication?
?
Fingernail hematoma treatment?
a. drill hole and drain blood?
Abnormal cells on PAP, what do you do next?
a. Refer for colposcopy?
Red beefy tongue?
a. Pernicious Anemia?
b. Iron Deficiency?
c. Folate Deficiency?
Low Hemoglobin, Low Hematocrit, High MCV – Indicates what?
?
Koplick Spots?
a. Measles?
Signs and Symptoms of Roseola?
Pregnant teacher, with exposure to Fifths’ Disease – what risk is there for the fetus?
6 Month Old with Closed Anterior Fontanel?
3 Month Old infant with Down Syndrome, due to milk intolerance, mom started infant on Goat’s Milk; now has pale conjunctiva but otherwise healthy; with low Hematocrit, what other test would you order?
a. CBC
b. Iron, TIBC
4 Month Old with Strabismus, mom worried, what do you tell her?
a. Normal?
4 Month Old “won’t keep anything down”, what is the main thing you look for?
a. Dehydration?
Man with HTN, CAD, present femoral pulses, but absent pedal pulses?
a. DVT?
b. Venous Insufficiency?
c. Arterial Insufficiency?
Diabetic patient with foot laceration, at risk for what?
a. foot ulcer?
b. acute osteomyelitis
Definition of metabolic syndrome?
Treatment for Gonorrhea?
a. Rocephin IM and Zithromax po
b. Doxycycline po
Diagnose trich?
a. Wet Prep?
b. KOH?
Patient with history of PID, increase risk for?
a. Infertility?
Increased risk for ectopic pregnancy, history of…?
a. Salpingitis
Newborn with foot turned in (“toeing in”), what do you do?
a. Refer immediately to orthopedist?
b. Routine followup?
Osgood Schlatter Disease pain location?
Growth plate fracture (Salter-Harris fx) location and pain?
Rotator Cuff injury presentation?
Causes of tachycardia?
a. Fever?
b. Anemia?
c. Hypotension?
Definitive diagnosis of acute bacterial proctatitis?
a. Urinalysis and Culture
b. Vigorous Massage of Prostate to Release Fluid for Culture?
c. Urethral Culture?
Man with high BPH, perform digital rectal exam – how does prostate feel?
a. Asymmetrical, Nodular, Firm
b. Symmetrical, Boggy
?
Patient present with “bag of worms”, what does this indicate?
a. Varicocele
Legg-Calve-Perthes disease?
Avascular necrosis of the proximal femoral head…
McMurray’s Sign
Epitaxis is most common in the area of the nose known as Kiesselbach’s Triangle, where is this located?
a. anterior septum?
b. middle turbinate?
c. sinus turbinate?
Elderly presents with atrophic vaginitis, small uterus, and palpable 4×5 ovary, what do you do?
a. Pelvic ultrasound?
Grade 3 cells on Pap, treatment?
?
Patient with bleeding after menopause?
a. Endometrial biopsy?
Young adult female, wants birth control, forgets to take pills, doesn’t want to get pregnant for at least 5 years, what do you suggest?
a. Intrauterine Device?
Shingles near eye, patient wants cream and analgesic, what do you do?
a. Order Acyclovir cream and analgesic?
b. Immediate referral to opthamologist?
Patient presents with rash on shoulder, erythematous maculopapular rash with center clearing, and scaling?
a. Tinea Pedis?
b. Tinea Corporis?
c. Psoriasis?
Peripheral vision loss = ?
Central vision loss = ?
Patient with Atopic Dermatitis, look for what other diseases?
a. Asthma?
Patient forgot to start Thanksgiving dinner, and husband states that she has trouble remembering tasks and has trouble with organization… What is this indicative of?
a. Alzheimer’s?
b. Delerium?
Quick assessment of patients fall risk?
a. Timed Get up and Go?
Mitral Regurgitation = sound and heard best at?
Mitral Stenosis = ” ” ” ” ” “?
Mitral Prolapse = ” ” ” ” ” “?
Mitral Sclerosis = ” ” ” ” ” “?
Aortic Stenois = ” ” ” ” ” “?
Aortic Regurgitation = ” ” ” ” ” “?
Aortic Sclerosis = ” ” ” ” ” “?
3 ways to assess cognitive function in patient with signs/symptoms of memory loss – all but which of the following?
a. Mini Mental
b. Depression Screen
c.
d.
Patient voices aching when ambulating? This question did not specify if it was bilateral or unilateral Mentioned something about “rubor” but I can’t remember what it said exactly…
a. DVT?
b. Venous Insufficiency?
c. Arterial Insufficiency?
Patient with HIV took high-potency anti-viral treatments and CD4 is >400, what does this indicate?
a. Patient has full-blown AIDS as defined by the CDC?
?
Patient has following labs: listed serology for Hepatitis, and then had to know if they had an active infection or immune, etc…
how long will a cough last for acute bronchitis?
up to three weeks is completely normal
how do you treat acute bronchitis?
95% cases are viral– tessalon pearls to help with cough. * prednisone is never the answer **
explain the following views of chest xrays: AP, PA, PA and lateral
which one do you want for pneumonia patient?
AP- shows the heart predominantly because its from front to back
PA- shows the lungs predominantly because its back to front
lateral shows fluid line
what is the gold standard for diagnosing community acquired pneumonia
chest xray- PA/lateral, repeat post treatment in 6 weeks (repeat not really done anymore)
treatment guidelines for CAP- healthy adult no comorbidities
MAD LUNG
amoxicillin 1 gram TID (best choice)
doxycycline 100 mg twice daily
macrolide (mycin) in areas with low macrolide resistance so not the best choice
treatment guidelines for CAP- adult with comorbidities
monotherapy: respiratory quinolone (levofloxacin 750 mg daily)
combination therapy: augmentin or cephalosporin PLUS macrolide or doxy
what are common respiratory fluroquinolones?
Think FLOXACIN– moxifloxacin, gemifloxacin, levofloxacin
what are common macrolides for CAP
think “MYCIN” — azithromycin, clarithromycin
what are common tetracyclines for CAP
doxycycline
what are common beta lactams for CAP
amoxicillin, augmentin (amox with clav), cefpodoxime, cefuroxime
how would you treat a pregnant 29 year old with pneumonia?
Amoxicillin 1 g TID– cant give levaquine (flouroquinolones no in pregnancy due to fetal ligament destruction, doxycycline no in pregnancy stains tooth bones in fetus)
how long do you give antibiotics to patient with pneumonia?
5-10 days, you always want to continue antibiotics for 3 more days after clinically stable (no fever)
When do you get a chest xray for pneumonia?
it is the gold standard for diagnosis, you do not need to do resolution chest xray unless things are lingering or you suspect something else.
When do you give pneumococcal vaccine?
adults > 65 years old you give PPSV23 or you can give both PCV 13 and PPSV23 but must be 1 year apart
adults > 65 with immunocompromising condition give both pcv 13 and ppsv23
adults 19-64 at increased risk of pneumococcal disease (asthma, copd, smokers, cv dz) – give PPSV23 only
adults 19-64 with asplenia, cochlear implants, csf leak– give pCV13 NOW then PPSV23 in 8 weeks , then PPSV23 in 5 years.
What is the diagnostic criterion for COPD
FEV1/FVC ratio of < 0.70
What are characteristics of COPD
midlife onset, symptoms slowly progressive, exposure to lung irritant, DOE is progressive, chronic cough and chronic sputum production
what are characteristics of asthma
onset early in life, symptoms vary widely from day to day, symptoms worse at nighttime/early AM, allergic rhinitis, eczema, family history, obesity
what are characteristics of heart failure (when evaluating diff dx of COPD)
chest xray with dilated heart, pulmonary edema
what are characteristics of tuberculosis when ruling out for COPD patient
onset all ages, chest xray with lung infiltrate, microbiologic confirmation
what are the characteristics of bronchiectasis
LOTS OF PURULENT SPUTUM, chest xray shows bronchial wall thickening and bronchial dilation
What intervention has the greatest influence on slowing progression of a COPD patient?
smoking cessation!!
what are first line smoking cessation drugs? (3)
varenicline (chantix), nicotine patch, buproprion extended release (zyban)
what is second line smoking cessation drug?
sertraline (zoloft)
what smoking cessation drug would you give to someone with a history of a suicide attempt?
nicotine patch– NOT CHANTIX OR ZYBAN
What are the short acting beta agonists
albuterol, levalbuterol
what are the long acting beta agonists
“terols”
Salmeterol
Formoterol
How do inhaled anticholinergic drugs work?
used in COPD, prevent bronchoconstriction
how do beta agonists work?
stimulate beta 1 (tachycardia) and beta 2 (bronchodilation)
what is the suffix for inhaled anti-cholinergic drugs?
“tropium” think ipratropium (atrovent) SHORT ACTING, tiotropium (spiriva) long acting
What is a SAMA?
short acting antimuscarinic (anticholinergic) – Ipratropium
what is a LAMA?
long acting muscarinic antagonist (anticholinergic) Tiotropium (spiriva)
what are the 4 steps of GOLD guidelines
1) SABA or SAMA prn
2) LABA or LAMA PLUS rescue med
3) ICS + LABA/LAMA plus rescue med
4) ICS+ LABA AND LAMA plus rescue med
THEN REFER
How to manage COPD exacerbation?
figure out the cause
mild: sabas with spacers / nebulizer
moderate: SABAs plus AB and or steroid
Severe: hospitalization
right supraventricular nodes signal what malignancies?
lungs, mediastinum, esophagus
left supraventricular nodes signal what malignancies?
abnormal (stomach, GB, liver, pancreas, ovaries, prostate)
us preventive services task force routine lung cancer screening recommends what annual screening for current smokers aged 55-80 with 30 pack year history or have quit within the last 15 years?
annual low dose CT (LDCT)
how do you diagnose asthma > 5 years of age:
presence of asthma features
reversible airway obstruction on spirometry
12% improvement from baseline or FEV1 > 200 ml after SABA
How do you treat asthma?
saba always as rescue inhaler
Step wise approach (GINA)
Low dose ICS
then ICS + LABA
increase dosage strength
acute bronchitis classic case symptoms
cough that keeps awake at night
dry cough but may be productive
low grade fever or chest pain with cough
wheezing and rhonchi
median duration of cough is 18 days up to 3 weeks
history of a cold before onset of symptoms
objective findings in acute bronchitis
lungs: clear to severe wheezing, rhonchi
percussion: resonant
CXR: normal
afebrile to low grade fever
treatment plan for bronchitis
symptomatic treatment- increas fluids and rest
tessalon perles, expectorant / mucolytic (guaifenesin)
ventolin (albuterol) for wheezing
for severe wheezing consider short term oral steroid
complications of acute bronchitis
exacerbation of asthma
pneumonia from secondary bacterial infection
pertussis “whooping cough”
caused by bordetella pertussis (gram negative)
coughing illness at least 14 days
paroxysmal coughing, inspiratory whooping
neonates / infants at highest risk for death
three stages of pertussis
catarrhal 1-2 weeks, if treated at this stage can shorten disease course
paroxysmal: lasts 2-4 weeks, treatment has little influence but is useful to decrease spread
convalescent: treatment goal is to eradicate carriage state / disease spread
how to diagnose pertussis
nasopharyngeal swab for culture – collect at 0-2 weeks following cough
PCR may provide accurate results up to 4 weeks
Pertussis antibodies by ELISA
CBC with elevated WBCs and marked lymphocytosis
cxr should be negative
how to treat pertussis
administer a course of antibiotics to close contacts iwthin 3 weeks of exposure
first line: macrolides – azithromycin z pack x 5 days
alternative bactrim x 14 days
antitussives, mucolytics, rest, hydration, frequent small meals
complications of pertussis
sinusitis, otitis media, pneumonia, fainting, rib fractures from coughing
signs of pulmonary embolism
new onset dyspnea, hemoptysis, pleuritic chest pain, vital signs with tachycardia, tachypnea, may have signs of DVT
Hegar’s sign
Softening of lower uterine segment
Chadwick’s sign
Bluish color of cervix and vagina at 6-8 weeks
Goodell’s sign
Softening of cervix at 4+ weeks
Lipids in chronic inactivity
Low HDL
Lipids in under- or untreated hypothyroidism
Elevated total cholesterol, TG, and LDL
Lipids in chronic renal insufficiency
Elevated total cholesterol and TG
Lipids in alcohol abuse
Elevated TG, HDL, and LDL
Vaccines with live attenuated viruses
MMR, varicella, flu-mist(intranasal), Zostavax
Drugs of choice for abdominal infection
Beta lactams + metronidazole (most common); fluoroquinolones
Drugs of choice for urinary tract infection
Fluoroquinolones (except moxi), TMP-SMX, fluconazole, b-lactams, nitrofurantoin, fosfomycin if pt has many allergies
Drugs of choice for pulmonary infections
Macrolides, resp fluoroquinolones, b-lactams, doxycycline (MRSA, atypical coverage)
Drugs of choice for skin and soft tissue infections
MRSA: TMP-SMZ, doxycycline, clindamycin; b-lactams
Drugs of choice for MRSA
Vancomycin, daptomycin , linezolid, TMP-SMZ, doxycycline, ceftaroline
Macrolide drugs
Erythromycin, clarithromycin, azithromycin
Macrolide AEs
GI, QT prolongation
Tetracycline uses
MRSA, rocky mtn spotted fever, atypicals (mycoplasma pneumonia, chlamydia), spirochetes (Lyme), h.pylori
Tetracycline AEs
GI, teeth, hepatic dysfunction, photosensitivity
Fluoroquinolone drugs
Ciprofloxacin, levofloxacin, moxifloxacin
Fluoroquinolone uses
UTI (cipro or levo), atypicals (mycoplasma, legionella)
Fluoroquinolones and dairy or vitamins
Take 2 hrs before or 4 hours after (decrease concentrations)
Metronidazole (Flagyl) uses
C. Diff, vaginitis
Metronidazole AEs
GI, peripheral neuropathy, disulfiram reaction
Nitrofurantoin uses
UTI -not pyelonephritis due to no systemic absorption
Nitrofurantoin AEs, contraindications
Pulmonary fibrosis, contraindicated in CrCl <60 (excludes many elderly)
Aminoglycoside drugs
Gentamycin, tobramycin
Aminoglycoside uses
Atypical coverage, resistant infections, tobramycin for CF only
Aminoglycoside AEs
Ototoxicity (irreversible), nephrotoxicity (reversible)
Aminoglycoside monitoring
Renal dose adjust, hearing test, drug level monitoring
Antifungals (azoles)
Fluconazole, itraconazole
Itraconazole interactions
Acid suppressive therapies
Fluconazole dose adjust
Renal
Antifungal AEs
GI, QTc prolongation (fluconazole)
Antifungal drug interactions
QT prolongation meds, warfarin
Anti-infectives not for pregnant
Tetracyclines, TMP-SMZ
TMP-SMZ coverage
G+, G-, MRSA, Protozoa (toxoplasma gondii), fungus (pneumocystis jirovecii), poor anaerobic activity
TMP-SMZ AEs
Sulfa allergy, photosensitivity, hematologic (anemia, leukopenia, thrombocytopenia)
TMP-SMZ on renal function
Dose adjust in renal impairment, false elevation in serum Cr
TMP-SMZ drug interactions
Warfarin
Gram + only coverage
Clindamycin, linezolid, vancomycin, daptomycin
Gram – only
Monobactams (aztreonam), penicillin VK
Gram +/-
PCN (aminopcn, ext. spectrum), carbapenams, aminoglycosides, TMP-SMZ, fluoroquinolones, fosfomycin
Head growth in first year of life
Total 12cm
Head growth 0-3mo
6cm
Head growth 4-6mo
3cm
Head growth 6-12mo
3cm
Head growth 2-7yo
0.5cm/yr
Head growth 8-12yo
0.3cm/yr
Tumor grading: T0
No evidence of primary tumor
Tumor grading: T1
2 cm or less in greatest dimension
Tumor grading: T2
2-5cm
Tumor grading: T3
5cm
Chvostek sign
Hypocalcemia, spasm when tap facial nerve
Trousseau sign
Hypocalcemia, spasm when compress brachial artery w/ BP cuff
Myocardial ischemia EKG changes
Inverted T wave, T wave depression
Myocardial injury EKG changes,
ST segment elevation, tall peaked t wave
Myocardial infarction EKG changes
Q wave
1st gen antihistamines
Diphenhydramine, chlorpheniramine
2nd gen antihistamines
Loratadine, desloratadine, cetirizine, fexofenadine, levocetirazine
Ishihara chart
Test for color blindness
Scarlet fever presentation
Sandpaper-like rash, exudative pharyngitis, localized anterior cervical lymphadenopathy, rash 2 days after pharyngitis then peels later
Roseola (HHV-6) presentation
Rash lasts hours to 3 days, follows 3-7 day high fever, sometimes febrile seizures, tx supportive
Rubella (German measles, rubella virus)
Mild sx, posterior and postauricular cervical lymphadenopathy, arthralgia 5-10 days before rash, teratogenic, contagious 1 week before and 2 weeks after rash
Measles (rubeola)
Acute presentation, generalized lymphadenopathy, photophobia, koplik spots, pharyngitis mild w/o exudate, rash 3-4 days after sx, contagious 1 wk before and 2-3 weeks after rash, permanent neuro impairment and/or death possible, tx supportive
Hand foot mouth dz (coxsackievirus a16)
Fever, malaise, sore mouth, anorexia, lesions, fecal-oral or droplet, highly contagious 2-6 wks, tx supportive
Fifth disease (human parvovirus b19)
Rash starts on face (slapped cheek) spreads to trunk, extremities, contagious before rash but not during or after. Droplet. Leukopenia. Hydrops fetalis in pregnant. Tx supportive.
Infectious mononucleosis (Epstein-Barr)
Diffuse lymphadenopathy, hepatic and splenic tenderness/ enlargement, incubation 20-50 days, systemic corticosteroids if resp distress from swollen airway, monospot/leukopenia w/ atypical lymphocytes diagnostic. Avoid contact sports at least one month.
Kawasaki disease
Acute phase: fever >= 104 >= 5 days, polymorphous exanthem on trunk/flexor region/perineum, erythema of oral cavity (strawberry tongue), chapped lips, bilateral conjunctivitis w/o discharge, edema/erythema of hands and feet w peeling skin. Children 1-8yr. Tx IV immunoglobulin, pop aspirin, consult
Lyme stage 1 (early localized disease)
Mild flu-like illness, singular annular lesion (erythema migrans), sx resolve 3-4 wks w/o tx
Lyme stage 2 (early disseminated)
Months after initial infx, classic rash may reappear w/ multiple lesions. Arthralgias, myalgia, HA, fatigue. Less common: heart block, neuro findings (Bell’s palsy)
Lyme stage 3 (late persistent)
1 year after initial infection, msk s/s persist w/ joint pain, frank arthritis, joint damage. Neuropsychiatric findings – memory problems, depression, neuropathy.
Lyme organism
B. burgdorferri (tick-transmitted spirochete)
Lyme testing
ELISA confirmed with western blot
Lyme tx
Doxycycline (children >8yo), amoxicillin, cefuroxime – adults and children
Chancroid tx
Azithromycin or ceftriaxone, alt. ciprofloxacin or erythromycin
Genital herpes (HSV 2) tx
Acyclovir
Lymphogranuloma vereneum (c. trachomatis) tx
Doxycycline, or erythromycin
Nongonococcal urethritis/cervicitis (c. Trachomatis) tx
Azithromycin or doxycycline
Gonococcal urethritis/cervicitis tx
Cefixime or ceftriaxone, add azithromycin or doxy if chlamydia not ruled out
Bacterial vaginosis tx
Metronidazole
Pelvic inflammatory disease tx
Ceftriaxone+doxycycline +/- metronidazole
Trichomoniasis tx
Metronidazole
ADA screening for DM in Children
-symptomatic children (polyuria, polydipsia, polyphagia, blurred vision) regardless of risk factors
-asymptomatic children after puberty or 10 years of age or older if overweight or obese (>85th percentile). Plus 1 of the following:
*T2DM in 1st or 2nd degree relative
*high risk racial/ethnic group
*signs of insulin resistance (HTN, dyslipidemia, acanthosis nigricans, PCOS, SGA)
*maternal hx of DM or GDM during the child’s gestation
Statistics
- leading causes of death: Heart disease, cancer, lung disease
- leading cause of cancer death: lung
- leading cause of death in adolescents: accidents
- most common cancer: skin.
- in males: prostate. in females: breast
suicide: males more successful, women more attempts. highest rate is older white males.
Osgood-Schlatter:
knee pain in young adults, overuse. Repetitive stress pain, tenderness, swelling at the tendon’s insertion site. The tibial tuberosity. Rule out avulsion fracture if there is an acute onset and order a lateral xray. RICE. Usually stops when the growth stops.
If patient has right sided weakness, etc. the CVA occurred where
left side
initial evaluation of symptoms of acute prostatitis
Urinalysis and urine culture
A 65-year-old woman presents for a follow-up examination after a new patient visit. She has not seen a healthcare provider for several years. She is a smoker and her hypertension is now adequately controlled with medication. Her mother died at age 40 from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In addition to starting Therapeutic Lifestyle Changes, the nurse practitioner should start the patient on:
- bile acid sequestrant.
- a statin drug.
- a cholesterol absorption inhibitor.
- low-dose aspirin.
A statin drug
Ortolani’s Click
a click is heard or felt as dislocation is reduced (developmental dysplasia of hip) (good until one year)
Which of the following laboratory tests should a nurse practitioner order when the suspected diagnosis is temporal arteritis?
Erythrocyte sedimentation rate (ESR)
What are narrow therapeutic index drugs?
- Warfarin sodium (Coumadin): monitor INR
- Digoxin (lanoxin): monitor digoxin level, EKG, electrolytes(potassium, magnesium, calcium)
- Theophylline: monitor blood levels
- Carbamazepime (Tegretol) and Phenytoin (Dilantin): Monitor blood levels
- Levothyroxine: Monitor TSH
- Lithium: Monitor blood levels, TSH (risk of hypothyroidism)
Otitis Externa tx
Fluoroquinolone & Polymyxin B cortisporin drops
An elderly male patient complains of a new-onset, left-sided temporal headache accompanied by scalp tenderness and indurated temporal artery. The NP suspects temporal arteritis. What screening test would you order to assist with diagnosis?
sedimentation rate (expect to be very elevated)
Basal Cell Carcinoma
Pearly domed nodule with overlaying telangiectatic vessels. Could be plaque, papule, possible central ulceration and crusting. Dx: Biopsy Tx:
Normal, healthy woman of reproductive age
white, clear, flocculent(physiologic leukorrhea), no complaints, pH 3.8-4.2 (toward acidic), no odor, microscopic shows lactobacilli (gram+bacteria)
Multiple infections from bacteria and fungus?
Screen for HIV
Screening Tests
- sensitivity: detect those WITH the disease. higher the sensitivity is higher the false positives
- Specificty: detect those who DONT have the disease.
erythromycin for chlamydia eye infection in infants
…
to assess pts ability to think abstractly a nurse pract could ask the patient
the meaning of a common proverb
The most commonly prescribed medication for mild systemic lupus erythematosus (SLE) is:
1.
azathioprine (AZA).
2.
belimumab (Benlysta).
3.
ibuprofen (Advil).
4.
cyclophosphamide (Cytoxan).
ibuprofen (advil)
A 17-year-old female is suspected of having polycystic ovary syndrome. In addition to testosterone, the most appropriate diagnostic tests to order would be:
follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and thyroid-stimulating hormone (TSH).
Barlow’s Maneuver
Feeling of a slip as the femoral head slips away from the acetabulum (toward the butt) (good until 6 mo)
Candida vulvovaginitis
etiology: candida albican (80-90%)
white, curdy, “cottage-cheese” like, sometimes increased, itching/burning discharge, pH <4.5, odor is usually absent, microscopic shows mycelia, budding yeast, pseudohyphae w/KOH prep. Treatment: oral diflucan or vaginal miconazole or terconazole
PSEUDOHYPHAE, CLOTRIMAZOLE CREAM
Proton Inhibitors
Increased risk of fractures(postmenopausal women),
Pneumonia, Clostridium difficile infection, hypomagnesemia, B12 and iron malabsorption, atrophic gastritis, and kidney disease
Bacterial Conjunctivitis tx
Eye drops or ointment: Polytrim, trimethoprim, polymyxin, macrolide
A patient with an elevated WBC (>11k) accompanied by neutrophilia (>70%) and the presence of bands is what kind of shift and prognosis?
-Shift to the left
-Serious bacterial infection
Actinic Keratosis
Rough flat, dry crusty, erythematous papules or plaques. Scaly patch of red brown skin caused by years of SUN exposure. Precursor to squamous cell carcinoma. Dx. Biopsy. Tx: topical 5 fluroracil 5-FU, cryotherapy.
A patient with macular degeneration has deficit vision in?
Central vision
Dacyrocystitis
Typical symptoms of acute tear duct infection include:
Pain, redness and swelling of the lower eyelid at the inner corner of the eye
Excessive tearing
Pus or discharge from the eye
Fever
Tx:
lacrimal sac massage- rub down towards mouth.
oral clindamycin (topical tobramycin or moxifloxacin if mild-purulent drainage, no redness)
Pre-DM in children values
A1C: 5.7% to 6.4%
Fasting: 100-125
2 hour GTT: 140-199
Primary Prevention
- individual actions: eating nutritious diet, exercise, seatbelts, gun safety. IMMUNIZATIONS
squamous epithelial cells with stippling appearance, no lactobacilli and many WBCs is
wet mount that shows BV
trigeminal neuralgia manifests
electric shock facial pain
The most common sign of cervical cancer is:
1.
postcoital bleeding.
2.
strong odor from vaginal discharge.
3.
itching in the vaginal area.
4.
molluscum contagiosum.
postcoital bleeding
To assess a patient’s ability to think abstractly, a nurse practitioner could ask the patient:
the meaning of a common proverb.
Auspitz sign
droplets of blood when scales removed = psoriasis
Bacterial vaginosis
etiology: unclear, likely polymicrobial, associated with G. vaginalis, M. hominid, others.
thin, homogeneous, white, gray, adherent, often increased, discharge is foul odor(fishy), itching is occasionally present, pH 5-7(alkaline- no active bacilli in vagina), “fishy” smell, microscopic > 20 clue cells/HPF, few or no WBCs. Treatment: metronidazole topical, oral Flagyl, clindamycin vaginal cream, oral tinidazole (Tindamax)
CLUE CELLS, METRONIDAZOLE GEL OR ORAL, CLINDAMYCIN CREAM
Omeprazole (Prilosec)
interacts with with Warfarin (Coumadin),
diazepam (Valium),
Carbamazepine (Tegretol),
Pheytoin (Dilantin),
ketocanazole (Nizoral)
Viral Conjunctivitis tx
Antihistamine, decongestant drops (Trigluridine in herpes conjunctivitis)
What is the common presentation of a navicular fracture?
Tenderness at the “N spot,” which is defined as the proximal dorsal portion of the navicular (see the image below). This is the most important physical finding.
Melanoma
ABCDE: asymmetry, border irregularity, color variation, diameter greater than .6 mm, elevation above skin level.
Type 2 DM in children values
A1C: >6.5%
Fasting: >126
2 hour GTT: >200
Random: >200
Central clearing lesion after camping trip flu like symptoms with muscle aches for several days is? and treated by?
Lyme disease; doxycycline
Wilms tumor
(Nephroblastoma)- Not painful. Asymptomatic abd mass does NOT cross the midline. 2-3 y. o.d. do not palpate. Do ABD US. PUNT. Think Nephro doesn’t cross. Stays where kidney is.
the headache of an intracranial tumor
focal neurological signs and pain worse in supine position
socioeconomic status
not important during employment physical with 21 yo with bruising on breasts
The nurse practitioner prescribes amitriptyline (Elavil) for a patient with neuropathic pain secondary to diabetes mellitus. On follow-up, the patient complains of urine retention and dry mouth. The practitioner would:
1.
discontinue amitriptyline and begin ibuprofen (Motrin).
2.
refer to physical therapy.
3.
start methocarbamol (Robaxin).
4.
discontinue amitriptyline and begin gabapentin (Neurontin).
discontinue amitriptyline and begin gabapentin (neurontin)
To assess spinal function at the S1 level, which deep tendon reflex should be tested?
Achilles
Herald patch + christmas tree
pityriasis rosea
Secondary Prevention
- screening tests (pap, mammogram, CBC).
Strep Pharyngitis tx
PCN, amoxicillin, macrolide, cephalosporin
Vitamin K Agonist Warfarin (Coumadin)
Interactw with “G” hers:
Garlic
Ginger
Gingko
Ginseng
Other herbs/supplemts:
Feverfew
green tea
fish oil
**Discontinue 7 days before surgery
What is the gold standard test for sickle cell anemia, glucose-6-phosphage dehydrogenase (G6PD) anemia, and alpha or beta thalassemia??
Hemoglobin electrophoresis
Postherpetic neuralgia
Tx: Prophylaxsis TCA-Elavil
Atrophic vaginitis (genitourinary syndrome of menopause GSM)
etiology: estrogen deficiency (after menopause). D/C scant, white-clear dryness as well sometimes urinary incontinence, itching/burning, discharge but often w/o symptoms, pH >5 (little to no lactic bacilli), odor is absent, microscopic few or absent lactobacilli.
Treatment: topical and/or vaginal estrogen if symptomatic and/or recurrent UTI. (Oral estrogen as solo intervention likely inadequate)
Diverticulitis: Treatment s/s:
Antibiotics and clear liquids and increased fiber (some say no nuts or seeds). (7 to 10 days ABT)
Ciprofloxacin (500 mg PO twice daily) plus metronidazole (500 mg PO three times daily). Amoxicillin-clavulanate (875/125 mg twice daily) is an acceptable alternative.
The criteria for patients with acute uncomplicated diverticulitis to be treated in the outpatient setting include:
●Reliability to return for medical reevaluation if condition worsens
●Compliance with outpatient treatment plan
●Abdominal pain is not severe
●No higher than a low-grade fever
●Can tolerate oral intake
●No or minimal comorbid illnesses
●Available support system
Approximately six weeks following the resolution of symptoms of acute diverticulitis, patients who have not had a recent colonoscopy should undergo one to exclude other possible diagnoses (such as colonic neoplasia) and to evaluate the extent of the diverticulosis.
Recomendations for surgery: Patients in whom elective surgery has been recommended following a single attack of diverticulitis include younger patients (variously defined in the literature as less than 40 or 50 years of age) and those who are immunosuppressed.
Neuroblastoma-
painful abd mass fixed first irregular, crosses midline. Most common side is adrenal glands. Weight loss fever. HORNERS syndrome. RACOON eyes, bone pain, HYPERTENSION. 1-4 year olds. Dx ultrasound PUNT to nephro. NEURO think brain in middle crosses midline. **Urine catecholamines and anemia
ADHD
hyperactivity, impulsive and/or inattention.
DSM-5 Criteria:
*sx present before 12 years of age
*sx for at least 6 months
*sx in 2 different settings
Medications considered 1st line if over 6 years of age
TZD
Pioglitazone (Actos)
Black Box warning: cause or exacerbate congestive heart failure in some patients; do not. use if New York health association Class III or IV Heart failure
STOP if causes dyspnea, weight gain, cough (heart failure)
in order to improve longevity of patient with COPD, tx of choice is
oxygen
current social relationships,
history of present or past traumas
mental health status
all important on the pe of 21 yo, for employment with bruising on breasts
A 17-year-old male with rheumatoid arthritis is being treated with an NSAID and omeprazole (Prilosec). The patient complains of headache, abdominal pain, and gas. These symptoms are most likely:
1.
associated with the omeprazole.
2.
related to the underlying condition.
3.
the result of the NSAID.
4.
caused by viral gastroenteritis.
associated with the omeprazole
Koplick Spots
white with red ring inside cheek from rubeola or mumps
Tertiary Prevention
- AA, support groups, education for those with the disease, rehab, exercise programs for obese
Which of the following signs/symptoms are often associated with headaches due to an intracranial tumor?
Pain worse in supine position; focal neurological signs
Acute rhinosinusitis tx
Wait 10 days then Amoxicillin or Augmentin (If allergy, use fluouroquinolones/tetracyclines)
MRSA
Tx:
Autism
Impairment in social communication and social interaction. Restricted, repetitive patterns of behavior, interests and activities.
Red flags: delayed language/communication milestones, regression in social and language skills, sibling with autism
screen at 9, 18, 24 and 30 months or when concerns are raised by parents
Genital Herpes
causative organism: human herpes virus 2
clinical findings: painful, ulcerated lesions, marked lymphadenopathy with initial lesions. Women=thin vaginal discharge if lesion at vagina or intoitus
with recurrence symptoms vary- asymptomatic transmission common
treatment: oral acyclovir (Zovirax), famciclovir (Famvir), valacyclovir(Valtrex), dose and length of treatment depends on the medication choice and the clinical presentation.
Diverticulosis: Treatment s/s:
Diverticu-lO-sis has nO inflamation: Both diverticulitis and *osis are similar to umbilical hernia in that a vein running through the muscle of the bowel muscle weakens the area and pressure causes a hernia “out pouching”.
RETINOBLASTOMA
leukocoria: Hallmark sign white spots in eye. Cancer. Red light reflex negative
What are first and second line antibiotics for acute otitis media?
- Amoxicillin
- Amoxicillin-Clavulanate (Augmentin)
Screening Tests:
- Breast Cancer: 50yrs q2years until 75yo. (40-49 is individualized)
- Cervical Cancer: 21yrs q3yrs until 65y. no screening after hysterectomy
- Colorectal Cancer: 50yrs until 75. FOBT x3 yearly. Flex sig q5yrs OR colonoscopy q 10yrs
- Lipids: men >35y and women >45y. unless increased risk for heart disease
- Prostate: don’t screen
- Skin Cancer counseling: 10-24yo with fair skin
which of the following criteria differentiates a TIA from a CVA
absence of residual symptoms – TIA sx occur rapidly and then resolve, CVA sx are residual – TIA is temporary block and usually no residual sx
CD4 count and viral load
most widely accepted indicators of HIV infection
The medication of choice for the initial treatment of juvenile rheumatoid arthritis is:
1.
acetaminophen.
2.
prednisone.
3.
aspirin.
4.
ibuprofen.
ibuprofen
Which of the following laboratory tests are most widely accepted as indicators of the progression of HIV infection?
CD4 count and viral load
slapped cheek and lacy exanthem
Erythema Infectiosum or Fifths disease
Intertrigo tx
Nystatin
Atypical antipsychotics:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
High risk for weight gain
metabolic syndrome
Type 2 DM
** high mortality in elderly patients
Monitor: weight and blood sugar
TSH, L lipids, weight body mass index
If a patient is allergic to penicillin and has a gram+ infection what are the alternative antibiotic choices?
- macrolides (azithromycin, clarithromycin)
- clindamycin
- quinolones with gram+ activity (levofloxacin or moxifloxacin)
Xerosis
Dry skin. Use petroleum based product.
Nongonococcal urethritis and cervicitis
causative organism: chlamydia trachoma’s, ureaplasma urealyticum, mycoplasma genitalium (obligate intracellular pathogen)
clinical findings: Friable cervix=bleeds easily, may have no symptoms, irritative voiding symptoms, occasional mucopurulent discharge, microscopic shows large number of WBCs. Treatment: azithromycin 1 g PO 1 time dose
ABUNDANT WBCs
Bacterial vaginosis: s/s and treatment
Clue cells such as: stipling of squamous epithelial cells with indistinct borders, no lactobacillus rods, many white blood cells
Nonpregnant women
Drugs — Metronidazole or clindamycin administered either orally or intravaginally results in a high rate of clinical cure (70 to 80 percent at four weeks of follow-up) (table 4) [88-91]. Oral medication is more convenient, but associated with a higher rate of systemic side effects than vaginal administration.
Side effects of metronidazole (oral or vaginal) include a metallic taste, nausea (in 10 percent of patients), transient neutropenia (7.5 percent), a disulfiram-like effect with alcohol, prolongation of International Normalized Ratio in patients taking vitamin K antagonists (eg, warfarin), and peripheral neuropathy.
Erythema infectiosum
(5th disease)- “slapped cheeks” 5-14 y.o. LACY, spreads to upper arms lgs trunks dorsum of hands and feet. Rash can last up to 40 days. Fever, rash, runny nose, headache. EXAM humanparovirus19, no labs for it.
Most common bacterial pathogen causing pneumonia
strep pneumoniae, but most pathogens 6 months to 5 years are viral
Biphosphonates:
Alendronate (Fosamax)
Risedronate (Actonel)
Erosive esophagitis, abdominal pain,
Stop immediately if symptoms:
esophagitis (chest pain, difficulty swallowing, burning (mid back)
jaw pain (osteonecrosis)
Contraindicated: Active GI disease (GERD, PUD), CKD, esophageal stricture/varices
prednisone
management of polymalgia rheumatica
A 12-year-old with sickle cell anemia has recently experienced a sickle cell crisis and presents for a follow-up examination after a recent hospitalization. It is most important to continue monitoring growth, development, and:
1.
white blood cell levels.
2.
fecal occult blood test.
3.
hemoglobin levels.
4.
urine dipsticks.
hemoglobin levels
A 3-year-old patient presents at an inner-city clinic with fever, cough, malaise, and loss of appetite. The patient lives with several relatives, including a grandmother who also has a cough. Which of the following diagnostic tests would be most appropriate for the patient?
Sputum culture
Thumb sign
swelling of the epiglottis, which may be visible on a lateral radiograph in patients with Epiglottitis
Lung Cancer Screening
- 55-74yo with >30y pack smoking history and who quit <15y ago. LDCT annually
med of choice for polymyalgia rheumatica
prednisone
Urticaria tx
Benadryl or Zyrtec
Shingles
Prodrome: itching burning photophobia fever headache malaise. Acute phase: Dermatomal rash 3-4 days, unilateral, macupapular rash progresses to vesicles then pustules 3-4 days. Convalescent phase: 2-3 week rash resolves. Dx PCR. Tx: acyclovir, zostrix, gaba, amitriptyline. (one dermatone)
Gonococcal urethritis and vaginitis
1 million cases daily WW- abx resistance prevalent
causative organism: neisseria gonorrhoeae (gram – bacteria)
clinical findings: irritative voiding symptoms, occasional purulent discharge, often w/o symptoms in either gender
Microscopic exam: large number of WBCs
STI most likely to give penile DC also called the “drip”
Treatment: ceftriaxone 250 mg IM as a one time dose plus azithromycin 1 g PO x 1 dose
If you find Gonorrhea ALWAYS tx for chlamydia
CEFTRIAXONE
10 month old child with runny nose, rash, cough, with tiny white papules with red areola in mouth what does this suggest?
Measles
ADHD
hyperactive, impulsive, inattentive.
Present prior to 12 years.
Symptoms last > 6 months,
should be evident in at least 2 different settings. Treated with schedule II – Ritalin, Adderal, vyvanse, streterra etc
most sensitive sign of pneumonia in children
increased respirations. fever is inconsistent.
A patient with COPD is prescribed ipratropium bromide (Atrovent) for dyspnea. If no relief at follow up visit what is the next step?
- Albuterol inhaler (Ventolin)
- OR a combination inhaler
Statins
Atrovastatin (Lipitor)
Lovastatin (Mevacor)
Rosuvastatin (Crestor)
Simvastain (Zocor)
Do not mix with grapefruit juice
Drug induced hepatitis
Rhabdomylsis higher if mixed with azole antifungals
High dose zocor (80mg) has highest risk of rhabdomyolis (muscle pain/tenderness)
Chenese Descnet: higher risk myopathy or rhabdomyoliss when taking simvastatin 40mg/day with niacin
Creatine Kinase level goes up
polymyalgia rheumatica
Risk factors include female gender and age >50
Pain stiffness of the shoulder/pelvic girdle typically seen in >50 year olds with the “hallmark” difficulty combing/brushing hair responding well to low dose steroids
A 90-year-old female is brought to the clinic by her neighbor. She states that everything is fine, but the nurse practitioner notes that she has poor hygiene and bruises on her trunk. The neighbor is concerned that the patient often has no money to buy food, despite income from social security and a coal miner’s pension. The nurse practitioner suspects abuse. Which of the following is the nurse practitioner obligated to do next?
1.
Report the case to the proper authorities.
2.
Tell the neighbor to check on the woman daily and report back.
3.
Document the data and report the information to risk management.
4.
Call the patient’s family and inquire about the concerns.
report the case to proper authorities
Which of the following best describes psoriatic lesions in an elderly patient?
Red, sharply defined plaques with silvery scales
Steeple Sign
tapering of the upper trachea on a frontal chest radiograph reminiscent of a church steeple suggestive of Croup
Active Immunity
- via immunization or a person who was exposed to agent
helical CT pulmonary angiography
test for PE
Actinic Keratosis tx
Topical 5 fluoracil 5-FU cryotherapy
What is the classic triad of symptoms for mononucleosis?
- sore throat
- prolonged fatigue
- enlarged cervical nodes
(usually a teen)
Dog bite
Treat analgesia (tyenol, Nsaids, Demerol) Ab: Augmentin/doxycycline/Bactrim, wound cleaning with soap and water, betadine, lidocaine. Wound debridement, facial bites closed with sutures. Tetanus
Trichomoniasis
causative organism: trichomonas vaginalis (protozoan pathogen)
clinical findings: dysuria, itching, vulvovaginal irritation, yellow-green vaginal discharge, occasionally frothy (30%), cervical petechial hemorrhages (“strawberry spots”) in about 30%, often w/o symptoms in either gender, microscopic exam: motile organisms and large number of WBCs, pH is alkaline
Treatment: metronidazole 2 g (No alcohol) PO or tinidazole 2 g PO as a 1 time dose (parasitic infection) no etoh -GI upset
ORAL METRONIDAZOLE
Trunk like rash:
Roseola: measles
MASTITIS
red firm tender area fever chills, flu like symptoms. Dicloxacillin, or Keflex. If you suspect MRSA, do Bactrim or clinda.
treatment of bacterial pneumonia in children:
High dose amoxicillin, augmentin or 3rd generation cephalosporin (cefdinir).
if type 1 reaction to PCN use clindamycin or azithromycin
electric shock unilateral facial pain
trigeminal neuralgia
serum ferritin level
distinguish iron deficiency anemia from other anemias
In most cases, the first manifestation of Alzheimer’s disease is:
1.
impaired judgment.
2.
decrease in short-term memory.
3.
disorientation in time and place.
4.
decrease in long-term memory.
decrease in short-term memory
A 25-year-old presents with the chief complaint of decreased mobility and pain of the right shoulder exacerbated by movement. The patient reports that he participated in extensive house painting 24 hours prior to the onset of pain. He denies any trauma. Passive ROM is intact. No redness or ecchymosis is present. What is the next step that should be taken in order to make a diagnosis?
Palpate structures around the shoulder.
Galeazzi’s Sign (aka Allis sign)
uneven knee heights – Developmental Displasia of the Hip
Passive Immunity
- immunoglobulin or through breast feeding/from mother
Atopic Dermatitis (eczema) tx
Topical steroids, emollients
Lincosamides
Clindamycin (cleocin)
Higher risk of CDAD
Metronidazole (flagyl) PO TID x 10-14 days
Probiotics daily-BID x few weeks
Alpha thalassemia is more common with what ethnicity?
Southeast Asians (Filipinos)
Lupus
Multisystem autoimmune disease, ch by remission and exacerbations. Butterfly rash, avoid sun exposure, Tx: Refer rheumatology, topical steroids and oral steroids.
Syphilis
causative agent: treponema pallidum (spirochete bacterium)
clinical findings:
Primary stage: chancre, firm, round, painless genital and/or anal ulcers with clean bas and indurated margins, localized lymphadenopathy, aprox 3 weeks duration, resolves w/o treatment. Secondary stage: nonpruritic skin rash, *palms and soles, as well as mucous membrane lesions, fever, lymphadenopathy, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. Resolution w/o treatment is possible.
Latent stage: presentation variable w/ decrease in cognitive function, occurs when primary and secondary symptoms have resolved
Treatment: antimicrobial therapy, with dosage and length of therapy usually dictated by disease stage. Options include injectable PCN or PO doxycycline
IM Bi-cillin- used as well
INJECTABLE PENICILLIN OR IF SEVERE PENICILLIN THEN GIVE DOXYCYCLINE
Other Childlike rashes: Key characteristics:
INSERT HERE
UTI in pregnancy
10 (3) wbc is considered positive in prego with symptoms. Normal people its 10 (5). MEDS: Macrobid (not for 3 trimester) Augmentin, Amoxicillin, Cephalexin, Fosfomycin.
bronchiolitis
Lower resp. tract illness that occurs when an infecting agent causes inflammation and obstruction of the small airways (bronchioles).
Common under 2 years of age.
Management: supportive. No bronchodilators or steroids
Anaphylaxis
- Pruritus/uticaria or angioedema AND EITHER respiratory compromise OR hypotension/end organ dysfucnction
- give Epi pen then send to ED
- refer to allergy if cause is unknown
sudden vision loss in which person feels like a curtain came down over his eye
retinal detachment
tx with clear liquids and oral antibiotics
pt with diverticulosis, temp 100, localized LLQ discomfort, palpable mass, leukocytosis, and CAN TOLERATE FLUIDS
The optimal treatment for latent tuberculosis is:
1.
rifampin (Rifadin) for 5 months.
2.
isoniazid (Nydrazid) for 9 months.
3.
pyrazinamide for 6 months.
4.
ethambutol for 6 months.
osioniazid (nydrazid) for 9 months
A patient who is 28 weeks pregnant reports a single episode of vaginal bleeding. History indicates normal prenatal progress to date, and the patient denies pain, vaginal itching, or discharge. Which of the following is the most appropriate intervention to aid in the diagnosis of this case?
Ultrasound
Gower’s Maneuver
patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength = muscular dystrophy
Anthrax
Tx: doxycycline/fluoroquinolones
Seborrheic Dermatitis tx
Rotation of prescription/non-prescription antifungal shampoo (Ketoconazole/metronidazole), Capitrol shampoo, selenium sulfide, selsun blue (adults / children) ciclopirox shampoo, topical stroid gel (hydrocortizone face, ears hydrocortizone cream), eyelids – baby shampoo
cystic fibrosis
*Effects lungs, GI and sweat glands.
*Autosomal recessive
*Routine screening in all states
*Presents with recurrent lower respiratory infections and persistent productive cough
*Weight loss and greasy BM common
*Mucous blocks ducts of the pancreas
Genital warts (Condyloma acuminata)
Causative organisms: HPV (commonly HPV-6 & 11)
Clinical findings: verruca-form lesions can be subclinical or unrecognized
Treatment: prevent w/immunization, topical podofilox, liquid nitrogen, cryoprobe, trichloroacetic acid, bichloracetic acid, surgical removal, or topical imiquimod (only indicated for external warts treatment).
trichloroacetic acid use acceptable in pregnancy
DO NOT USE IF PREGNANT: podofilox, podophyllin, sinecatechins and imiquimod
IMIQUIMOD
Erythema toxicum
A rash of small yellow or white bumps surrounded by red skin. Can appear anywhere on the body. Disappears on its own in about two weeks. Common in newborns, usually showing up two to five days after birth.
Alpha fetal protein test
AT 16 WEEKS TEST FOR AFP
Low- Downs
High-Neural tube deficits
Beta thalassemia is more common with what ethnicity?
Mediterranean people
Live Vaccines
- MMR: 1 yr and 4-6y (if out of country give 1 dose)
- Varicella: 1 yr and 4-6yr
- FluMist
- Zoster
- Rotavirus
*give same day or separate doses by 1 mo.
decreased gastric production with aging
…
tests for polycystic ovarian syndrome
testosterone, follicle stimulating hormone, luteinizing hormone, prolactin, thyroid stimulating hormone
Unilateral spontaneous serous or serosanguineous discharge from a single duct of a breast is most often caused by:
1.
intraductal papilloma.
2.
mucinous breast lesions.
3.
Paget’s disease.
4.
ductal carcinoma in situ.
intraductal papilloma
A 29-year-old male with noncomplicated Chlamydia infection may exhibit:
no remarkable clinical symptoms.
Fat pad/Sail sign
Elbow fracture (in kids, a posterior fat pad sign suggests a condylar fracture of the humerus. In adults it suggests a radial head fracture)
Moderate acne tx
oral abx + topical retinoid +/- benzoyl peroxide (tetracycline + tazarotene +/- Benz Pero ….
Retin topical, oral tetracycline then Accutane (isotretinoin)
What do pica and spoon shaped nails indicate?
Iron deficiency anemia
Subungual hematoma
collection of blood underneath a toenail or finger nail. Tx: Trephination, drill hole and drain the blood.
Which HPV viruses most likely to cause malignancies
16, 18, 31, 33, 45, 52,& 58. Gardasil effective against all of these plus 6 & 11
Fifth disease
Starts with a slight fever, achiness, and cold symptoms, followed a few days later by bright red cheeks and a lacy, red, sometimes itchy rash on the trunk and feet. Also called slapped cheeks disease or erythema infectiosum. Most common in preschool and school-age children.
Condyloma Acuminata
genital warts types 6/11 HPV. Treatment: trichloracetic acid….Condylox, aldara, veregne. In pregnancy: TCA or ablation
Lead toxicity
*Sx: fatigue. stomach ache, irritability.
*IDA
*Cognitive and behavioral changes cannot be reversed
Hep B Vaccine
- 3 doses.
- don’t ever restart series
- test pregnant women for HBsAg
- if received series and then exposed to Hep B if no HbsAb test done give another dose to be safe
MED FOR MYCOPLASMA PNEUMO
AZITHROMYCIN
primary amennorhea presentation
17 yo Tanner Stage III- never had menses, normal weight and height
A young child with asthma presents for follow-up evaluation. After numerous changes in medications and doses, the parents report that the child continues to have difficulty with coughing, especially during the night. Which of the following conditions would be the most likely cause of the continued asthma symptoms?
1.
Vocal cord dysfunction
2.
Cystic fibrosis
3.
Gastroesophageal reflux
4.
Allergic rhinitis
gastroesophageal reflux
An 88-year-old patient presents with right-sided weakness after being unable to rise unassisted following a fall to the bathroom floor. History includes aphasia and noncompliance with a hypertension medication regimen. What is the most likely diagnosis?
Left-sided stroke
Adam’s sign
Forward bend test for scoliosis
Leukemia
*Most common in children ALL
*Pancytopenia
*Long bone pain
*Hepatosplenomegaly
*Lymphoblasts
Hidradentitis suppurativa tx
Doxycycline, topical atb
What is a common presentation for systemic lupus erythematosus (SLE)?
malar rash (butterfly rash) and should minimize sunlight exposure
Peripheral arterial disease
Impedance of arterial blood flow in lower extremity ankle brachial index <0.9, plaque develops in vessel d/t atherosclerosis, pain with exercise, relief w rest, lack of hair growth on LE, gangrene toes Tx: check pedal pulses, ABI test, exercise by walking, lifestyle Modifications – smoking cessation, antiplatelet
Pelvic inflammatory disease (PID)
causative organisms: N. gonorrhoeae C. trachomatis, bactericides, enterobacteriaceae, streptococci, gram – anarobes
clinical findings: irritative voiding symptoms, fever, abdominal pain, cervical motion tenderness, vaginal discharge. *Increased risk of ectopic pregnancy and/or infertility with each outbreak.
treatment- Ceftriaxone 250mg IM as a single dose plus doxy 100mg po bid x14days with or without metronidazole 500mg PO BID 14days
Folliculitis
Pimples or pustules form around hair follicles and may crust over. Typically occurs on the neck and in the underarm or groin area. Uncommon before age 2.
Syphillis
Syphillis- PAINLESS GENITAL CHANCRE- Condyloma lata. First test do RPR, VDRL SCREENING if reactive then confirm with FTA ABS.
Td/ TdaP
- q10yrs. or if dirty wound give booster if last dose >5yrs ago.
- Tdap is only once (older than 7yo), q10is Td. and during EVERY PREGNANCY
- C/I if Guillain- Barre syndrome
-Dtap 3 doses in children or unimmunized (adults get 2 Dtap and 1 tdap)
SSRIs can cause delayed ejaculation
…
secondary amennorhea
started but now stopped. Causes are: pregnancy, weight loss, obesity, manipulation. Treatment is hormone replacement, ovulation stimulation (CLOMID) periodic progesteronal
A pregnant woman with known HIV infection can reduce the risk of perinatal transmission through zidovudine (Retrovir) therapy. Based on current research, optimal therapy is to start daily dosing:
1.
post amniocentesis.
2.
after 14 weeks of gestation.
3.
if premature rupture of membranes occurs.
4.
if maternal viral loads are greater than 10,000.
after 14 weeks gestation
A patient with macular degeneration has difficulty seeing objects:
in the center of the visual field.
Kernig’s Sign
Flex hips 90 degrees pain with extension of leg = meningitis or subarachnoid hemorrhage
Headache red flags
*awakens child
*thunderclap
*neuro findings – n/v, AMS
*<3 years old
*absent family hx of migraines
Postherpetic Neuralgia PHN Tx
Prophylaxis: TCA (Elavil)
What is the presentation of polymyalgia rheumatica (PMR) and first-line treatment?
- Pain, severe stiffness in shoulders and hip girdle (risk for temporal arteritis)
- Long-term steroids
chronic venous insufficiency
Varicose veins results from venous incompetence secondary to valvular dysfunction. Symptoms LE edema, skin discoloration, ulceration, DVT/PE are complication. WARM TO TOUCH. Tx: light exercise, stockings, wt loss, elevate legs
Vulvovaginitis or STI?
- Clue cells with alkaline pH
- Pseudohyphae
- Abundant WBCs
- Clue cells with alkaline pH = Bacterial vaginosis
- Pseudohyphae= Candida vulvovaginitis
- Abundant WBCs= Nongonococcal cervicitis/vaginitis
Hand, foot, and mouth disease
Fever, loss of appetite, and a sore throat, followed by painful, blisterlike sores in the mouth. Rash on the palms of the hands, the soles of the feet, and sometimes the buttocks. The rash starts as small flat red dots that may turn into bumps or blisters. Most common in preschoolers but can occur at any age.
chanCROID
PAINFUL, purulent lesion (NOT chancre, which is painless and associated with syphillis) oral dose (1 gram) of azithromycin, a single IM dose of 250 mg ceftriaxone, oral 500 mg of erythromycin q.i.d for seven days, or 500 mg of Ciprofloxacin b.i.d for three days.
best laboratory test to distinguish IDA anemia from other anemias is
serum ferritin
whether the pt has reversible airway obstruction
office spirometry using an albuterol nebulizer can confirm asthma, because it can indicate
T-wave inversion with a normal ST segment on a 12-lead EKG may represent:
1.
acute coronary ischemia.
2.
right ventricular hypertrophy.
3.
atrial hypertrophy.
4.
hyperkalemia.
acute coronary ischemia
Which of the following is the leading cause of cancer-related deaths in the majority of women?
Lung Cancer
Brudzinski’s Sign
Involuntary flexion of legs when neck is passively flexed = meningitis
Flu vaccine
- 6mo or older. allergy to egg is no longer a contraindication
- flu mist not to pregnant women
- children 6mo-8yo need 2 doses for first flu season
Cellulitis tx
Pcn, Macrolide
What is the gold standard exam for temporal arteritis?
- biopsy of the temporal artery
- Refer to ophthalmology
Bacterial endocarditis
Fever, chills, anorexia, weight loss. malaise, headache, myalgia, arthralgia, night sweats, abdominal pain, dyspnea, cough, pleuritic pain. Symptoms janeway lesions, red spots on the soles of the feet or palms. Osler’s nodes red, tender spots under the skin, whites of your eyes, or inside your mouth.
Splinter hemorrhages on nails, Janeway lesion (red macules palms/soles not painful), Osler’s nodes (painful violaceous nodes found mostly on pads of the fingers and toes).
Intervention in vulvovaginitis
- Clotrimazole cream
- Metronidazole gel
- Oral metronidazole
- Clindamycin cream
A. Candida vulvoginitis
B. Trichomoniasis
C. Bacterial vaginosis - Clotrimazole cream. A. Candida vulvoginitis
- Metronidazole gel. C. Bacterial vaginosis
- Oral metronidazole.
C. Bacterial vaginosis
B. Trichomoniasis
. - Clindamycin cream. C. Bacterial vaginosis
Impetigo
Small red bumps that may be itchy. Often develops around the nose and mouth but can easily spread to other parts of the body. Bumps become pus-filled blisters that may burst and develop a soft yellowish-brown crust. Child may have a fever and swollen lymph glands in the neck. Most common in children between 2 and 6 years old.
PID
cervical motion tenderness indicates PID.
results in infertility
Treat symptomatic PID even if chlamydia and gonorrhea are negative. plus doxycycline (100 mg orally twice daily for 14 days)
ceftriaxone 250 mg IM x1 + Doxy 100 mg Q12 x 14d Follow up with bimanual exam in 2-3 days
child headaches
*c/o abdominal pain, n/v
*auras common
bump on testicle can indicate cancer of testicle
…
CBC and hemoglobin electrophoresis
12 yo, family hx of thalassemia and anemia, with Tanner Stage II, HCT 35 should order this
The 16-year-old mother of a 2-month-old presents the infant, reporting that the child is very irritable and does not feed well. During physical examination, the child’s head drops back and the child exhibits sudden flexing of the extremities. As the flexing stops, the child cries uncontrollably. Funduscopic examination reveals retinal hemorrhages. Which of the following diagnostic tests should be ordered?
1.
Skull X-rays
2.
MRI
3.
CT scan
4.
Pet scan
CT scan
Which of the following would be most appropriate to perform in the initial evaluation of a patient with symptoms of acute prostatitis?
Urinalysis and urine culture
Café au lait spots
neurofibromatosis (tumors and seizures)
Varicella
- LIVE
- 2 doses one month apart.
- give if no history of chicken pox
Erysipelas tx
PCN or macrolide
What does a positive Finkelstein test indicate?
de Quervain’s tenosynovitis
Treatment for which of the following STIs?
- Ceftriaxone
- Injectable pcn
- Imiquimod
- Trichloroacetic acid (TCA)
A. External genital warts in a 25yo man
B. Gonococcal urethritis in a 22 yo man
C. Syphilis in 45 yo man
D. External genital warts in a 28 yo pregnant woman - Ceftriaxone-B. Gonococcal urethritis in a 22 yo man
- Injectable pcn-C. Syphilis in 45 yo man
- Imiquimod-A. External genital warts in a 25yo man
- Trichloroacetic acid (TCA)-A. External genital warts in a 25yo man. *D. External genital warts in a 28 yo pregnant woman
Measles
Starts with fever; a runny nose; red, watery eyes; and a cough. Red bumps with tiny white dots appear a few days later on the inside of the cheeks. Next, a rash appears on the face and progresses down the back and trunk to the arms and hands and finally to the legs and feet. The rash starts as flat, red patches but eventually develops bumps and may be itchy. It lasts about five days, then fades to a brownish color, leaving skin dry and flaky. Rare due to vaccinations; most likely to occur in unvaccinated children.
Gonorrhea
Rocephin 250 mg IM and Azithromycin 1 gm po x1, or doxy 100 mg BID x7d. Green colored vaginal discharge, friable cervix
hyperbilirubinemia
*Infants >35 weeks w/ total bilirubin >95th percentile.
*Total bilirubin >25 to 32 = risk for neurologic dysfunction.
*Physiologic – 2 to 3 days after birth (full-term). Peaks day 5 to 7 in preterm infants.
*Pathologic – 1st 24 hours after birth.
PPD >5mm
Induration of 5 or more millimeters HIV-infected persons
-A recent contact of a person with TB disease
-Persons with fibrotic changes on chest radiograph consistent with prior TB
-Patients with organ transplants
-Persons who are immunosuppressed for other reasons
Shingles/Zoster
- 60yo
- regardless of history of shingles
for diabetic patients taking beta blockers, best indication of hypoglycemic episode will be
sweating (WILL NOT SEE TACHY AND PALPITATIONS DUE TO BETA BLOCKER USE)
absence of residual symptoms
differentiates TIA from stroke
The most important diagnostic factor in evaluating angina pectoris is the patient’s:
1.
King of Heart’s monitor.
2.
physical examination.
3.
history.
4.
echocardiogram.
history
Which of the following gastrointestinal changes is associated with normal aging?
Decreased production of gastric acid
Howell-Jolly Bodies and target cells
Sickle Cell Anemia
MRSA tx
Bactrim or tetracyclines
What does a positive Anterior drawer or Lachman maneuver indicate?
Positive indicated anterior cruciate ligament (ACL) is damaged
PPD: 10mm positive for
An induration of 10 or more millimeters
-Recent immigrants (< 5 years) from high-prevalence countries
-Injection drug users
-Residents and employees of high-risk congregate settings
-Mycobacteriology laboratory personnel
-Persons with clinical conditions that place them at high risk
-Children < 4 years of age
- Infants, children, and adolescents exposed to adults in high-risk categories
Genital Candida albicans infection in men typically presents
balanitis, groin-fold involvement, and scrotal excoriation (no penile discharge. Jock itch does not affect the scrotum.)
Milia
Tiny white or yellow pearly bumps on the nose, chin, and cheeks. Common in newborns. They go away without treatment in a few weeks.
mammogram frequency
50-74 q2years unless family history or other concerns (Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s.)
Pyloric Stenosis
*Narrowed pyloric sphincter due to hypertrophy
*Sx mostly likely to occur at 3-6 weeks
*Projectile, non-bilious vomit after eating.
*Olive like mass
*Dx with US
*Refer for surgery
Meningococcal MCV4
1-2 doses: 11-12yo and booster at 16yo
lung ca
leading cause of cancer deaths in men and women.
There are three reasons for latex allergies. Which of the following does NOT cause the problem?
1.
Immediate hypersensitivity
2.
Irritant contact of dermatitis
3.
Cytotoxic hypersensitivity
4.
Immune complex reaction
cytotoxic hypersensitivity
Which of the following is NOT an indication of preeclampsia?
Gluosuria
Burtonian Lines
Thin, blue-black discoloration of gingival border = lead poisoning
S1 spinal function is assessed with what DTR
achilles
Xerosis tx
Petroleum based product (not lotions)
PPD: 15mm
An induration of 15 or more millimeters is considered positive in any person, including persons with no known risk factors for TB.
Consideration in caring for a 68 yo m w/a BMI of 38, otherwise healthy, who is now presenting with genital candidiasis includes which of the two most helpful measures?
A. Order a medium potency topical steroid to the affected region to help with symptom control
B. prescribe topical miconazole
C. obtain an in office blood glucose
D. advice on the use of antimicrobial soap to the region
B. prescribe topical miconazole
C. obtain an in office blood glucose
Molloscum contagiosum
Flesh-colored, dome-shaped lesions that can be pearly in appearance and have a dimpled center. May be itchy. Uncommon before the first birthday.
Postmenopausal bleeding f/u testing
- ENDOMETRIAL BX
GER
*Frequent regurgitation
*GERD = pathology
*Immature LES until 9-12 months old
*Red Flags: choking with eating, coughing with eating, forceful vomiting, bilious vomit, blood in stool, poor weight gain, refusal to eat, constipation or diarrhea, abdominal tenderness, fever.
*Avoid smoke, small frequent feedings (thickened), trial of PPI.
What can a positive McMurray’s sign indicate?
Meniscus injury of the knee.
Pneumonia Pneumovax- PPSV-23
- one dose 65yo in well adults
- if vaccinated before 65y need booster in 5 yrs and then again at >65yo
Paxil, SSRI
delayed ejaculation
A patient on warfarin (Coumadin) therapy for recurrent deep vein thrombosis (DVT) is about to have lumbar spinal fusion surgery. The patient’s warfarin is put on hold starting 5 days prior to the surgery and subcutaneous Lovenox has been ordered for DVT prophylaxis until the resumption of the warfarin. The nurse practitioner knows that the patient’s postoperative warfarin dose should be restarted based on the:
1.
value of her morning Prothrombin time.
2.
loading dose of 10 mg, plus the previous warfarin dose.
3.
baseline PT and INR values.
4.
target INR of 2.
caseline PT and INR values
Assessment findings that would support a diagnosis of mitral regurgitation include:
loud, high-pitched pansystolic murmur.
Goodwell’s Sign
Softening of the cervix (pregnancy indication)
children over 8 years old can use doxy
…
Psoriasis tx
Topical Steroids
Lateral X-ray of the neck
Epiglottitis
Acute, uncomplicated UTI in non pregnant women
Pathogen: E. coli (gram-, most common), Klebsielle spp. (gram-), S. saprophyticus (gram+)
Treatment: E. coli: TMP/SMX-DS PO BID x 3 days (always order double strength). If E. coli resistant or sulfa allergy then nitrofurantoin (Macrobid) 100 mg BID x 5 days or fosfomycin (Monurol) 3 g PO x 1 dose. Add phenazopyridine (Pyridium) PO to assist with symptom control.
Roseola
Usually starts with a sudden relatively high fever, often over 103 degrees Fahrenheit, that typically lasts three to five days. A pink rash on torso and neck follows and may spread to the arms, legs, and face. Child may be irritable and may have diarrhea or vomiting. Most common in children between 6 months and 3 years old.
Atrophic vaginitis cause and tx
lack a estrogen, apply topical estrogens
Intussusception
*Intestinal obstruction
*Sudden onset. Intermittent. Crampy abdominal pain.
*Cries and pulls legs up to chest
*Currant jelly BM
*Dx: US
*Non-operative: enema under fluoroscopy or surgery
On eye exam, what does neovascularization, cotton wool spots, and micro-aneurysms indicate?
diabetic retinopathy
PCV13
- children receive
- give first
- only ever need 1 dose
in doing initial eval of patient with suspected acute prostatitis, what test to do
urinalysis and culture
Somogyi effect
Type 1 diabetes with increased early am levels with correct insulin dose
An 87-year-old patient presents with round, pruritic plaques and small vesicles on the lower legs. The most likely diagnosis is:
1.
allergic contact dermatitis.
2.
plaque psoriasis.
3.
cutaneous T-cell lymphoma.
4.
nummular eczema
nummular eczema
An 18-year-old college student presents for an athletic physical. When asked about current medications, she mentions that she takes “some herb” she bought at a health food store for migraines and menstrual cramps. Which of the following herbal remedies has been commonly used for these conditions?
Feverfew
Chadwick’s Sign
bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow observed 6-8 weeks after conception
On eye exam, what can atrioventricular nicking, silver and/or copper wire arterioles indicate?
Hypertensive retinopathy
Shingles Dx & Tx
Dx: Viral Culture, polymerase chain reaction (PCR)
Tx: Acyclovir, Zostrix cream, Gabapentin, amitriptyline
Croup (laryngotracheobronchitis) Parainfluenza (*)
cold symptoms, low fever, stridor, barking cough, and hoarseness. No drooling, nasal flaring, sore throat, resp distress, ab breathing. Steeple sign frontal radiograph of neck. Mild: Outpt supportive care Mod: Hosp resp support Racemic epi, short course corticosteroids
Which of the following is inconsistent with BPH?
A. obliterated median sulcus
B. size >= 2.5 cm x 3 cm
C. symptoms improved w/use of an alpha-1 receptor blockade such as tamsulosin (Flomax)
D. surgical intervention should be offered early in the disease process
D. surgical intervention should be offered early in the disease process
Ringworm
Rash of one or several red rings, ranging from dime- to quarter-size. Rings are usually crusty or scaly on the outside and smooth in the center and may get larger over time. May also appear as dandruff or bald spots on scalp. Most common in children 2 and older.
WET PREP for which gu infections
BV, YEAST, TRICH
Encopresis
*Involuntary soiling in child 4 years or older
*Underlying issue: constipation
*Loss of urge to defecate
*Management: PEG, Miralax. Behavior change, fiber, fluids, reward system.
Hegar’s Sign
Softening of the cervicouterine junction
Koplik spots
measles
dawn phenomenon
Characterized by hyperglycemia that is present on awakening in the morning due to the release of counterregulatory hormones in the predawn hours.
A 3-year-old presents with a 2-day history of acute diarrhea with a total of 8 watery stools without blood or mucus, and 2 episodes of vomiting in the past 48 hours. Assessment reveals no current antibiotic therapy, dehydration <5%, soft abdomen with hyperactive bowel sounds, no masses or organomegaly; other physical findings are normal. Which of the following is the most appropriate management plan?
1.
Stool culture; Immodium AD liquid.
2.
No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
3.
Start diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup over next 72 hours; Imodium AD liquid, 1 mg/sml
4.
Stool for ova and parasites; advise parents of likely sources of Giardia; prescribe furazolidone (Furoxone)
No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
An 88-year-old patient has had a gradual onset of hearing loss in the left ear. Examination shows a large accumulation of cerumen in the external auditory canal. Assuming there is no neural loss, the nurse practitioner would expect the Weber test to:
lateralize to the left
BCG
- LIVE for TB
- not in US.
Spider bite tx
Atb on wound, cold packs, NSAIDS
When checking deep tendon reflexes (DTRs) in a patient with severe sciatica or diabetic peripheral neuropathy, what can you expect the Achilles reflex to show?
The achilles reflex may be absent or hypoactive (0-1+)
Epiglottis (*)
Hemophilus influenza, Streptococci, Pneumococci. (6-10) Rapid onset, acute bacterial infection, high fever, stridor, choling sensation, resp distress, drooling, head tilted back to breath (hyperextension). Thumb sign on radiograph. ER!! Cephalosporin
Epididymoorchitis (upper reproductive e tract infection with inflammation of epididymis/testis)
Age ⬇️35
Causative organisms: N. gonorrhoeae, C. trachomatis
Presentation: irritative voiding symptoms, fever, painful swelling of epididymis and scrotum. Infertility is possible post infection due to scarring of the vas deferins
Treatment: Ceftriaxone 250 mg IM x 1 dose plus doxycycline 100 mg po BID x 10 day.
Scrotal elevation to help with symptom relief. (Prehn’s sign=relief of discomfort with scrotal elevation)
Rubella (German measles)
Pink-red rash that appears first on the face, then spreads over the body and lasts two to three days. Child may have a mild fever, swollen lymph nodes behind the ears, a runny or stuffy nose, a headache, and a sore throat. Rare due to vaccinations; most likely to occur in unvaccinated children.
Trichomonas s/s, dx, tx
Dysuria, itchy, strawberry cervix, +/- discharge: grayish bubbly, wet prep: mobile unicellular organisms with flagella tx Flagyl 2g x 1 OR 500 mg q12h x 7d
Viral Gastroenteritis
*Fecal oral route common
*Measure for dehydration: weight loss, capillary refill, loss of skin turgor, increased and deep RR.
*Oral rehydration for mild to moderate dehydration over 3-4 hours
*50 mL/kg (mild) to 100 mL/kg (moderate) over 4 hours
Dog bite tx
Analgesics: Tylenol, nsaids, Demerol
ATB: Augmentin/doxycycline/Bactrim,
macrolide antibiotic
smoker with acute bronchitis with cough with thick, yellow-green foul smelling sputum
A mother presents her 12-month-old child with concern because the child does not yet say “mama” or “dada.” The mother reports that in the first months of life, the child loved listening to music and being talked to. The past medical history is negative for ear infections. The nurse practitioner should:
1.
evaluate for hearing loss.
2.
refer to speech therapy.
3.
re-evaluate in 3 months.
4.
check for cerumen impaction.
evaluate for hearing loss
During an employment physical examination of a 21-year-old female, bruising around the areolae on the breasts is noted. An appropriate health history for these findings should include all of the following EXCEPT:
socioeconomic status
Chvostek sign
tap the facial nerve in front of the tragus and the ipsilateral muscles of face contract – indicative of hypocalcemia
pernicious anemia is B12 deficiency
…
True or false, a benign S4 heart sound may be auscultated in some elderly patients
True
Dacrocystitis
inflammation of the lacrimal sac. Symptoms includes thick eye discharge, pain, redness/swelling/warmth of lower eyelid. Tx includes lacrimal sac massage downward toward mouth 2-3 times daily and systemic antibiotics if needed.
Epididymoorchitis usually e-coli
Age ⬆️ 35 or insertive partner in anal intercourse
Causative organisms: Enterobacteriaceae (coliforms)
Presentation: irritative voiding symptoms, fever, painful swelling of epididymis and scrotum. Infertility is possible post infection.
Treatment: Levofloxacin 500 mg PO QD or ofloxacin 300 mg PO BID x 10 days
Scabies
Severely itchy rash of scattered red bumps, usually between the fingers, around the wrists, in the armpits and diaper area, and around the elbows. May also show up on the kneecaps, palms, soles, scalp, or face. May leave curvy white or thin red lines or little blisters on nearby skin. Itching is most intense after a hot bath or at night and may keep the child awake. May occur at any age.
VVC
Candidia Vaginitis- wet smear= pseudohyphae / spores w/ lrg wbc.
Cheese curd like pruritis, itching, swelling, redness. TREAT: Diflucan 100 mgx1. Or OTC= Monistat, clotrimazole
Hydrocele
Common in newborns and is a collection of fluid in the scrotum. Usually resolves before 12 months of age.
most appropriate dx tests for PCOS are
testosterone, LH, prolactin, TSH
The most common side effect of the oral ribavirin used in the treatment of hepatitis C is:
1.
hemolytic anemia.
2.
weight loss.
3.
depression.
4.
hypothyroidism.
hemolytic anemia
Which of the following findings is typically a sign of acute appendicitis?
Rebound tenderness at McBurney’s point
Dix-Hallpike or Nylen-Barany maneuver
- = Vertigo & nystagmus when quickly move pt to supine position with head 30 degrees lower than table and to turned to the side at 45 degree
What is a rare but life threatening reaction to ace-inhibitors? What is a common side effect?
Angioedema
-cough
Lyme Disease tx
Doxycycline, amoxicillin, or azithromycin
Erysipeals
Skin infection involving upper dermis and superficial lympahtics. Strep A and has clear demarcated boarder, tx includes PCN such as dicloxacillin qid x 10 days, Cephalexin, clindamycin for PCN allergic do Azithromycin.
Acute bacterial prostatitis
Age ⬇️ 35
Causative organisms: N. gonorrhoeae, C. trachomatis
“it hurts when my bottom hits the chair.”
Presentation: irritative voiding symptoms, suprapubic, perineal pain, fever, a tender, boggy prostate, leukocytosis increased white count
Treatment: ceftriaxone 250 mg IM as 1 x dose w/doxycycline 100 mg PO BID x 10 days
Scarlet fever
The rash begins as a mass of tiny red bumps in the armpits, neck, chest, and groin and rapidly spreads over the entire body. The bumps feel like fine sandpaper and may itch. Child may have a fever and a red sore throat. Early in the infection, the tongue may have a white or yellowish coating that later turns red. The bumps on the tongue may appear larger than normal, a condition called strawberry tongue. Tonsils may be swollen and red. As the rash fades, the skin may peel, especially on the hands and feet and in the groin. Uncommon before age 2.
BV : s/s, microscopy, test, tx,
fishy, smelly vaginal discharge, wet smear reveals epithelial cells with bacterial coating, KOH to cotton swab – whiff test, flagyl cream x 7 days, clindamycin cream, flagyl PO
UTI
*Causes: Bowel and bladder dysfunction (withholding, incontinence, constipation), anatomic abnormalities, vesicoureteral reflux.
*Treatment: 2nd or 3rd generation cephalosporin (cefixime, cefdinir, ceftibuten) for 3-5 days if afebrile, 10 days if febrile.
*Renal and bladder US for all infants 2 to 24 months with 1st febrile UTI.
*Voiding cystourethrogram for vesicoureteral reflux.
*Get US in any child with recurrent febrile UTIs and UTI with family hx of renal or urologic disease, poor growth or HTN
Lupus tx
Topical and oral steroids
weight loss, shoulder and pelvic pain, pain with ROM, no weakness, elevated ESR
polymyalgia rheumatica!!!!
An 86-year-old patient presents with pinguecula, a yellow triangular degenerative tissue thickening of the bulbar conjunctiva. This condition is:
1.
cured by eye drops.
2.
a genetic process.
3.
a malignant growth.
4.
a solar-induced lesion
a solar-induced lesion
The best laboratory test to distinguish iron deficiency anemia from other anemias is:
serum ferritin level
McBurney’s Point
RLQ of abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus (location of appendix)
Acute bacterial prostatitis (uncomplicated disease in men with low risk for STI)
Causative organisms: Enterobacteriaceae (coliforms)
Presentation: irritative voiding symptoms, suprapubic, perineal pain, fever, a tender, boggy prostate, leukocytosis
Treatment: ciprofloxacin 500 mg PO BID or ofloxacin 200 mg PO daily x 14 days
What class of drug is Ipratropium (Atrovent)
Anticholinergic
Normal HR at birth
120-160
Warts
A small grainy bump or cluster of bumps, usually on a hand but can occur anywhere on the body. Warts are usually skin-toned but may be lighter or darker in color and can contain black dots. Flat warts, which are smaller and smoother, can also appear anywhere on the body, but in children they most often show up on the face. Plantar warts show up on the soles of the feet. Most warts disappear on their own in a few months to a few years. Uncommon before age 2.
LSIL in 21-24 y/o. 25-29 year old. >30 year old
21-24y.o.: Repeat PAP in 12 mo
25-29 yo: refer for colpososcopy/biopsy.
30 if HPV (-) repeat PAP in 12 mo. If HPV (+) then colp / biopsy
Cellulitis
Skin infection involving deep dermis. Diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling. Tx:. MRSA tx: Bactrim, Clinda, or Doxy. Non MRSA infection: Keflex
Anthrax tx
Doxycycline/Fluoroquinolones (Cipro)
pansystolic murmur
mitral regurgitation
During a well-child examination of an 18-month-old, premature tooth decay and inflamed gums, particularly of the maxillary incisors, are noted. The approach to this problem includes:
1.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water.
2.
teaching the mother to brush the child’s teeth, encouraging vitamin supplements.
3.
recommending fluoride mouthwash and toothpaste, suggesting celery sticks for snacks.
4.
providing fluoride treatment, teaching dental hygiene, and eating foods high in calcium.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water
A patient is referred with a diagnosis of diabetes mellitus, hypertension, and coronary artery disease. The patient is on both insulin and a beta blocker. Assuming that the patient will continue the beta blocker, it will be important to educate the patient on the recognition of hypoglycemia. Which symptom would be most indicative of hypoglycemia in this patient?
sweating
McMurray’s Test
audible/palpable click when knee is raised with tibia externally rotated and then straightened- one hand on knee other on foot
What drug class are erythomycin, azithromycin (Z-pack), clarithromycin (Biaxin)?
Macrolides
Cutaneous anthrax
Normal prostate
firm, smooth, nontender
about as firm as pressing in on the tip of your nose
What antibiotic is used for corneal abrasion:
Gentimicin ophthalmic solution
Young woman with breast mass. Preferred imaging
Ultrasound in young (less dense tissue, better image). Can tell if mass is fluid filled cyst or solid
HR of 3 year old
80-120
Raynaud’s Phenomenon tx
CCB
tx corneal abrasion with
gentamicin
Which of the following is typically observed in the GI system upon stimulation of the parasympathetic nervous system?
1.
No overall effect
2.
Increased sphincter tone
3.
Increased peristalsis
4.
Decreased secretions
increased peristalsis
An 88-year-old male presents with concerns about memory loss. He feels good, takes an aspirin daily, and has no chronic diseases. He lives alone, drives his own car, and manages his financial affairs. To evaluate his memory, which of the following tests should the nurse practitioner choose?
Folstein Mini-Mental State Examination
Lachman’s Test
drawer test for acl or pcl test knee at 20-30 degrees one hand on thigh other on proximal tibia, pull tibia forward to assess anterior motion of tibia to femur (intact ACL should prevent anterior movement)
HR of 6 year old
70-110
name first generation cephalosporins
Keflex
Contraindication for beta blockers?
Asthma, COPD, chronic bronchitis, Emphysema, bradycardia and AV block. Inhibits of bronchodilator response to beta agonists
Acute prostate
tender, boggy, indurated
about as firm as pressing in over your puffed out cheek
S/s of CHF:
s3, edema, dyspnea, JVD, x-ray reveals cardiomegaly, long standing hypertension, systolic murmur, tachycardia INSERT MORE HERE
Risk factors/findings for ovarian ca
Family history.
Should not ever be able to palpate an ovary, r/o US ovarian CA.
Risks: >50, early menarche, late menopause, obesity, family history, 1st prego after 35, or not ever prego.
Chronic Venous Insufficiency tx
Light exercise, stockings, Wt loss, elevate legs
feverfew is used for
migraines and menstrual cramps
Type 2 diabetes mellitus is characterized by which of the following?
1.
Decreased production of exogenous glucagon-like peptide
2.
Autoimmune beta-cell destruction
3.
Relative deficiency of dipeptidyl peptidase-4
4.
Decreased reabsorption of sodium-glucose transporters
decreased reabsorption of sodium-glucose transporters
Which of the following wet-mount results confirms a preliminary diagnosis of bacterial vaginosis?
Squamous epithelial cells with stippling appearance and indistinct borders, no lactobacillus rods, and many white blood cells
Apley’s Grind test
flex knee 90 degrees with patient prone put pressure on heel hands and rotates leg laterally and medially, repeat while pulling up on leg (+ = limited ROM or pain)
Prostate cancer
nodular, firm, nontender
usually malignant lesions not palpable until disease is advanced
Name second and third generation cephalosporins
Second- Cefaclor, Ceftin, Cefzil
Third- Rocephin, Suprax, Omnicef
When to start screening BP
3 years old – age, gender and height
Levothyroxin may worsen?
Osteoporosis
Natural estrogen-
Isoflavones
Adverse effects of beta blockers
Bronchospasm, bradycardia, depression, fatigue, ED, HF, hypoglycemia
Infective Endocarditis tx
Amoxicillin or macrolide
most common 2 pathogens for older adults residing in community
strep pneumo, H. flu
In pulmonary function testing, forced vital capacity represents the:
1.
maximum volume of air that can be forcefully exhaled after maximum inspiration.
2.
total volume of air that is exhaled after normal inspiration.
3.
total volume of air that the lungs can hold, minus the expiratory reserve volume.
4.
volume of air that can be forcefully exhaled in 1 second.
maximum volume of air that can be forcefully exhaled after maximum inspiration
Office spirometry performed with an albuterol nebulizer treatment can confirm a diagnosis of asthma because it indicates:
whether a patient has reversible airway obstruction.
Straight leg raise
lie supine, leg elevated off table produces radiating or sciatic pain – herniated disc
Name a quinolone antibiotic
Ciprofloxacin, ofloxacin
TB
Gold std Culture and stain
Which of the following is least likely to be noted in a 55 yo M who presents with bladder cancer?
A. textile worker for 25 years
B. 60 pk yr smoking history
C. Report of intermittent painless gross hematuria
D. report of recent-onset intermittent acute urinary retention
D. report of recent-onset intermittent acute urinary retention
Testicular torsion s/s?
Absent cremaster reflex, testicular pain, difficulty walking, nausea, MORE?
Ectopic pregnancy s/s, physical exam findings, increased risk for
Light to scant bleeding in 6-7 weeks/lower abd pain/pelvic pain. Intermittent cramping, if radiating to right shoulder think rupture.
Pain is worsen with SUPINE or with JARRING. Previous ectopic pregnancy, tubal ligation, PID. Anything that is causing scaring
what age should dyslipidemia risk assessment begin?
2 years old. 2, 4, 6, 8, 10 then annually
Ventricular Septal Defect tx
Lasix & Lisinopril
what class of anti-HTN meds is absolutely CONTRAINDICATED in bilateral renal artery stenosis and has been associated with acute renal failure
ACEs – With stenosed renal arteries, afferent flow cannot be increased, angiotensin II can actually become the only mechanism by which the kidney can increase filtration, and with severe stenosis, efferent arteriole constriction is crucial for maintaining some degree of filtration. ACE inhibitors would prevent conversion of Ang. I (which is inactive) to Ang. II, and therefore make everything worse by removing the kidney’s only remaining regulatory mechanism as well as cutting the perfusion pressure and eliminating what little renal function remains. With tubular cells that are already less effective due to damage from chronic ischemia, the resulting decrease in GFR would effectively accelerate kidney failure .
An adult male presents as first patient of the day after awaking about 5:00 AM with indigestion and chest pressure. On checking his pulse, he found no change from previous measurements. He states that, while waiting for the nurse practitioner to arrive, he began to feel a little clammy. A 12-lead EKG records the following patterns. On the basis of these EKG readings, the diagnosis is:
1.
anterior-septal acute myocardial infarction.
2.
lateral acute myocardial infarction.
3.
inferior acute myocardial infarction.
4.
anterior acute myocardial infarction.
inferior acute myocardial infarction
A 32-year-old patient reports a 6-month history of intermittent symmetrical swelling of the wrists and daily morning stiffness lasting 1 hour or more in and around other joints. What is the most likely diagnosis?
Rheumatoid arthritis
Pelvic Rock test
Screens for sacroiliac joint dysfunction. Place hands on bilateral anterior superior illac spines and attempt to rotate SI joint, or side lying apply pressure to ilium (+ = pain at SI joint)
CHD is the most common what in newborns?
congenital anomaly
Name a quinolone with Gram + coverage
Levaquin, moxifloxacin, gatifloxacin
ectopic pregnancy
Light scant bleeding in 6-7 weeks, lower abd pain, intermittent cramping, pain radiating to right shoulder and pain is worsen with supine position
Which of the following is a worrisome finding noted during pelvic exam on a 62 yo F?
A. flattening of the vaginal rugae
B. vaginal pH=5.6
C. ovary palpable on bimanual exam
D. scant white vaginal discharge
C. ovary palpable on bimanual exam
Alternate ABT for erythromycin for mycoplasma pneumonia?
macrolide such as azithromycin.
BPH physical findings, tx, when to take meds, evaluating PSA post tx,
BPH- Symmetrical rubbery and enlarged. All of BPH meds, take at bedtime. Hytrin is good for ppl with HTN and BP; If on Proscar must times PSA X2.
HCTZ should not be taken with digoxin
may increase risk of digoxin toxicity
During the past 24 hours, a 62-year-old has experienced abdominal pain that radiates to the back. The patient also reports several episodes of nausea and vomiting, a low-grade temperature, and a history of excessive drinking. Physical examination reveals a distended abdomen. Laboratory serum values indicate elevated alkaline phosphatase, amylase, and serum lipase. The most likely diagnosis is:
1.
alcoholic liver disease.
2.
acute mesenteric ischemia.
3.
viral hepatitis.
4.
acute pancreatitis.
acute pancreatitis
A 47-year-old patient presents with complaints of upper abdominal discomfort with nausea and burning after eating. The patient does not currently take any medications. The most likely differential diagnoses would include:
gastritis and peptic ulcer disease.
Prehn’s sign
lifting the scrotum relieves pain of epididymitis
Cholesterol <200 HDL >40
LDL <100
Triglycerides <150
Lifestyle modification first line
Niacin, fenofibrate
Name two sulfa drugs
- Trimethoprim-sulfamethoxazole (Bactrim, Septra)
- Nitrofurantoin (macrobid)
Herniated disc and sciatica
better with standing and worse with sitting
Alternate ABT for common conditions such as Pneumonia, Atypical pneumonia, MRSA, Impetigo, Bladder infection, Otitis media etc
INSERT HERE
Acute bacterial prostatitis: S/s, physical exam findings, labs, tx based on age
High fever, chills, suprapubic, perineal pain, radiates to back or rectum, s/sx of uti.
Prostate is warm and boggy.
UA/ Culture is definitive. CBC shift to left (band cells) UA, pyuria, hematuria.
Older than 35= cipro, levaquin 4-6 wk. other Bactrim.
<35-Rocephin 250mg IM and doxy 100 mg BIDx10d.
Innocent murmur clues
*Grade <2
*Softer intensity when sitting compared to supine
*Not holosystolic
*Minimal radiation
*Musical or vibratory quality
Urge incontinence
reports of strong sensation of needing to void that cannot be supressed, often has involuntary loss of urine
most common in older adults
Treatment: behavioral therapy, pharmacotherapy (antimuscarinics such as: Detrol,Ditropan, VESIcare, Enablex, Toviaz. Adverse effects = dry mouth, sedation, mental status change, particularly in higher doses.
Addison’s Disease tx
Steroid Cortisol
Erythema multiforme
a milder form of Stevens-Johnson syndrome that produces pink-to-red targetlike lesions, wheals, and blisters, with no mucosal involvement. The clinician should look for a history of antibiotic and other drug treatment such as sulfa drugs, penicillins, and other drugs. Hypersensitivity reaction from meds, allergy, or infection.
An otherwise healthy adult female presents complaining of vaginal burning and itching during urination. She has a social history of two sexual partners. She denies fever or vaginal discharge, but has noted a lesion on one labium. The nurse practitioner should order all of the following EXCEPT:
1.
wet mount and potassium hydroxide.
2.
dark-field microscopy of fluid from the lesion.
3.
nucleic acid amplification testing for gonorrhea.
4.
serology for Haemophilus ducreyi.
dark-field microscopy of fluid from lesion
A 2-month-old infant is presented for examination and immunizations. History includes an uncomplicated full-term delivery and hepatitis B virus immunization shortly after birth. Examination is unremarkable except for a diffusely erythematous (non-beet-red) macular rash in the diaper area, sparing the inguinal folds. No satellite lesions are noted. The infant’s diaper rash is most likely caused by:
contact dermatitis.
Romberg Test
Evals proprioception and cerebellar fxn; stand with feet together, arms at side, close eyes. + = loss of balance
Name two tetracycline drugs
- doxycycline
- minocycline (Minocin)
Lumbar stenosis
is aggravated by long periods of standing and walking, relieved by sitting and rest.
Stress incontinence
associated with lifting, coughing, sneezing, exercise, anything that causes intraabdominal pressure
more common in F, rare in M
Treatment: vaginal tampon, urethral stents, periurethral bulking agent injections, pessary use. Kegel exercise in younger, premenopausal patients. Pelvic floor rehab w/biofeedback, electrical stimulation and bladder training.
Side effects and uses of ortho-novum and other antibiotics:
INSERT HERE: spotting? amenorrhea etc
Generalized anxiety disorder
SSRI, SNRI, Wellbutrin. May do benzo for short time (for acute anxiety attack)
Pathologic murmur clues
*Grade >3
*Holosystolic
*Max intensity at LUSB
*Harsh or blowing quality
*Systolic clicks
*Diastolic murmurs
*Increased intensity in upright position
*Gallop
*friction rub
Meniere’s Disease tx
Meclizine (Antivert), diuretics, diazepam
how is MS dx
lumbar puncture
A 3-year-old female has been diagnosed with bacterial meningitis. She attends preschool daily at a local church day care program. The day before her diagnosis, she ate lunch with her mother at a local restaurant. For which contact(s) would chemoprophylaxis with rifampin be recommended?
1.
Preschool contacts in the past 7 days
2.
A friend of the patient’s sister who visited after school yesterday
3.
The checkout employee at the grocery store yesterday
4.
Diners at the restaurant during lunch the day the patient ate there
preschool contacts in past 7 days
A nurse practitioner is evaluating a 40-year-old patient suspected of having a pulmonary embolus. The patient complains of anxiety and cough. A stat chest X-ray is normal. Which of the following tests should the nurse practitioner perform next?
Helical CT pulmonary angiography
Finger to Nose test
Tests cerebellar function – patient alternately points from their nose to examiner’s finger
Barlow-Ortolani maneuver
- To detect hip dislocation in newborn
What category of drugs are allowed for pregnant or lactating women? (A, B, C, D)
Category B
ex: pick acetaminophen over NSAID. Avoid nitrofurantoin and sulfa drugs during third trimester (hyperbilirubinemia)
sentinel nodes (virchow’s nodes)
Left superaclavicular area. They are the first lymph nodes that a cancer lesion will drain into. Therefore, when cancer is diagnosed, these nodes are biopsied to see whether the cancer has spread into the lymph system.
Functional incontinence
often occurs I presence of mobility problems, associated w/the inability to get to the toilet or the lack of knowing that there is a need to void.
Usually found in those with limited mobility or altered cognition. Worsens when there is limited availability of an assistant for toileting.
Treatment: Ameliorated by having an assistant who is aware of voiding cue available to help with toileting activities.
Orthonovum (estrogen based contraception) causes spotting? T/F
True
PTSD, major and minor depression, first choice meds?
SSRI Paxil (sex dysfunc causes). Zoloft, Celexa (Good for older few drug interactions) Lexapro. Gradually wean paxil.
Hep B tx
Peg-IFN, Interferon, ETV, TDF
diabetes can contribute to pregnancy induced HTN
…
Congenital dysplasia of the hip:
1.
more commonly affects both hips.
2.
occurs more commonly in females.
3.
is correctable at any age.
4.
typically self-corrects by 12 weeks of age.
more commonly affects both hips
A 65-year-old male presents to a clinic complaining of increasing fatigue, dyspnea on exertion, and ankle edema during the day. He has a history of mild hypertension, for which he saw his physician years ago. The physician advised the patient to decrease his salt intake. On physical examination, the patient is tachycardic, positive for jugular venous distention, and positive for S3, with a systolic murmur. Chest X-ray reveals cardiomegaly with vascular redistribution. The nurse practitioner’s diagnosis should be:
heat failure
Heel to shin test
Tests cerebellar function – runs heel of one foot along the shin of the opposite leg fairly quickly
What HTN medication can cause acute renal failure and is contraindicated in bilateral renal stenosis?
ACE inhibitors. How to monitor? Test renal function.
What is the preferred treatment for cutaneous anthrax and how do you get it?
- Ciprofloxacin 500mg BID for 60 days (8 weeks)
- Doxycycline 100mg BID if cipro allergy
- Comes from touching fur or animal skins that are contaminated with anthrax spores (not contagious)
Transient incontinence
occurs during an acute illness such as UTI, delirium, medication use, restricted activity
Treatment: discontinuation of offending medication.
Where should the examiners 2nd-5th fingers be placed to perform Ortolani’s
the greater trochanter
Acute serotonin syndrome, s/s , causes
s/s Dilated pupils, high fever, muscular rigidity, mental status changes, hyperreflexia/clonus, shivery.
causes: SSRI, MAOIs, TCA. Could be potentially life threatening
syncope
Blood glucose. Checking the blood glucose is indicated for patients with syncopal and near-syncopal episodes. The nurse practitioner should also perform a thorough history of the incident. Possible causes of syncope are cardiac arrhythmia, vasovagal, hypoglycemia, orthostatic hypotension, seizure, accidental fall, and others.
Hep C tx
Antivirals and PEG-IFN
Anticholinergic agents such as ipratropium (Atrovent) and tiotropium (Spiriva) are used in COPD primarily to:
1.
induce bronchodilation.
2.
decrease airway inflammation.
3.
expand the lung fields.
4.
treat hypoxemia.
induce bronchodilation
Trigeminal neuralgia manifests itself primarily with:
electric-shock-like unilateral facial pain.
Cullen’s sign
bruising or bluish discoloration and/or edema around the umbilicus = pancreatitis, ruptured ectopic pregnancy, aortic rupture, abdominal trauma
hold assistive device (like cane) on opposite side
…
Optic disk
normal examination has sharp margins, a yellowish orange to a creamy pink color, and round or oval shape. The ratio of veins to arteries is 3:2
Treatable causes of urinary incontinence
(DIAPPERS)
Delirium
Infection (urinary)
Atrophic urethritis and vaginitis
Pharmaceuticals (diuretics, others)
Psychologic disorders (depression)
Excessive urine output (heart failure, hyperglycemia due to undetected or poorly controlled DM)
Restricted mobility
Stool impaction
Acute bacterial sinusitis is treated with?
amoxicillin
Lumbar stenosis
Aggravated by long periods of standing and walking. Relieved by forward flexion, sitting and rest.
Club foot AKA
talipes equinovarus
sickle cell, thalassemia and leukemia can all cause
hepatosplenomegaly – but IDA wil not
The clinical presentation of placenta previa that develops during the third trimester includes:
1.
intermittent dark-red spotting.
2.
occult bleeding with abdominal or back pain.
3.
sudden onset of painless and profuse bleeding.
4.
painless occult bleeding that becomes visible upon onset of labor.
sudden onset of painless and profuse bleeding
Which of the following criteria differentiates a TIA from a stroke?
Absence of residual symptoms
Grey Turner’s Sign
bruising or bluish discoloration of the flanks indicative of retroperitoneal hemorrhage = pancreatitis
arcus senilis
gray-white arc or circle around the limbus of the iris that is common with aging. caused by lipid deposits deep in the edge of the cornea and is quite commonly present in elderly. However, it can also appear early in life as a results of hypercholesterolemia
Idiopathic Thrombocytopenia purpura tx
Initial: Glucocorticosteroids (prednisone)
Overactive bladder medication with highest anticholinergic effect and lowest
Highest is oxybutynin (Ditropan)
Lowest is mirabegron (Myrbetriq)
Not used to treat OAB: tamulosin (Flomax) or finsasteride (Proscar)
S/s of acute bacterial sinusitis versus viral?
Insert here. How long before treat? Alternative to amox allergy?
sciatica
sciatica is a form of radiculopathy and one of the most common causes is a herniated disc. So both are aggravated by long periods of sitting.
metatarus adductus
“c” shaped foot or “kidney bean shaped” foot without ankle deviation. in-toeing
Myerson’s Sign / Glabellar tap sign
tapping between eyebrows, above bridge of nose (glabella) produces a sustained blink response = Parkinson’s Disease
VSD sx
cyanosis and poor feeding – murmur is heard in tricuspid area
A 27-year-old male patient, who works as a janitor, presents with a 6-month history of an intermittent rash on his hands. History reveals itching and occasional burning. Examination reveals irregularly-distributed scaly maculopapular erythematous patches extending from the dorsum of the hand several inches up the forearms, and dry palms with no nail involvement. The most likely diagnosis is:
1.
contact dermatitis.
2.
scabies infestation.
3.
psoriasis.
4.
eczema.
contact dermatitis
A 20-year-old male presents with a 1-month history of a “bump on my testicle.” He reports being sexually active, with frequent episodes of unprotected intercourse with multiple partners. Which condition should be suspected?
Cancer of the testicles
Ishihara chart
A chart used to test for color blindness. (7 yr old)
Contraindications for Metformin
Significant renal & hepatic disease, Sepsis, Alcoholism, Hypoxia causing conditions (cardiac/pulmonary), dehydration, & advanced age.
Healthy 32 yo F who is taking combined oral contraceptives, is here to review the results of her recent liquid-based Pap screening that revealed atypical squamous cells of unknown significance(ASCUS) and high risk HPV +. No h/o previous abnormal cervial cytology, with her last screening aprox 2 yr ago. After discussing the significance of these findings, the most appropriate next step is to:
A. Advise that she return in 6-12 months for a repeat Pap w/HPV cotesting
B. obtain screening tests for N. gonorrhoeae and C. trachomatis infection.
C. referral for colposcopy
D. counsel that the usual cervical cancer screening guidelines should be followed
C. referral for colposcopy
Delayed ejaculation is caused by a common medication:
Paxil- SSRI
Treatment to prevent fracture in patient with low vitamin D high TSH low HCT
- VITAMIN D 600-800, CALCIUM 1000-1200.
Nursemaid’s elbow
Annular ligament displacement over the radial head
Macrocytic Folate Deficiency tx
Folate, leafy green veggies, beans, liver, pasta, cereals
Anorexia nervosa occurs most commonly in which of the following?
1.
Painters
2.
Only children
3.
High-level athletes
4.
Individuals from large families
high level athletes
A 65-year-old female presents with shoulder and pelvic girdle pain for the past 6 months. She reports recent unintentional weight loss. On physical examination, there is pain on ROM, with no weakness noted. Laboratory studies show a low hemoglobin and an elevated sedimentation rate. Which of the following is the most likely diagnosis?
Polymyalgia rheumatica
Murphy’s sign
Deep pain on inspiration while fingers are placed under right rib cage = cholecystitis
Down’s syndrome patients can have
congenital heart defects, seizures, eye issues, hearing loss, obesity – NOT failure to thrive
Straight leg raise
This test is performed by laying on your back with both legs straight and the physician raises one of your legs upward, keeping the knee straight. This is done to help find the reason for low back and leg pain. (sciatic nerve/herniated disk)
Which of the following is demonstrated to provide the most symptom relief in treating vasomotor symptoms? (hot flashes)
A. clonidine
B. paroxetine
C. conjugated estrogen
D. venlafaxine
C. conjugated estrogen
Uncomplicated chlymydia: may present with?
No clinical s/s:
Difference between complicated and uncomplicated chlamydia?
Morton’s neuroma
Morton’s Neuroma- do mulder test. “pebble, burning, numbness” ¾ metatarsals. PUNT TO pod
Mulder sign or foot squeeze test – Sharp pain b/w 3rd & 4th toe when foot is squeezed in pt w/ MORTON NEUROMA
Scoliosis
10 degree curve. Use Adam’s forward bend test
hyperinflation of lungs can be seen on chest X-ray in patients with asthma
…
A frail elderly patient presents with constipation. Which of the following normal physiologic changes seen with aging is the most likely cause?
1.
Decreased bowel muscle tone
2.
Increased bile secretion
3.
Increased absorption of calcium
4.
Decreased pancreatic secretions
decreased bowel muscle tone
An 85-year-old patient relates that on the way to an annual physical examination, the patient suffered a sudden loss of vision in the right eye characterized by “a bunch of lights” and a feeling that “a curtain came down.” The most likely diagnosis is:
retinal detachment.
Psoas sign
RLQ pain with passive right leg elevation off table or with right thigh extension side lying = appendicitis
Lachman’s Test
ACL instability of the knee
What is Galaezzi sign
one femur appears shorter when infant is supine
Risk Factors and Cancer:
Obesity and history of PCOS: endometrial cancer
HPV 16 and/or 18: Cervical cancer
BRCA 1 and BRCA2 gene mutation: Ovarian cancer
Unexplained abdominal bloating and constipation: Ovarian cancer
Cancer:
Abnormal vaginal bleeding: Cervical and Endometrial cancer
Often without significant signs or symptoms: All Cervical, Endometrial and Ovarian cancer
Pap test: Cervical cancer
No specific screening tests available or recommended: Ovarian and Endometrial cancer
Treatment for chlamydia?
INSERT HERE: azithromycin. Alternative tx?
Tibial overuse stress syndrome
“inner border” painful on palpation.
DO bone scan or MRI cuz a plain X-ray won’t show a stress fracture.
FOLLOW RICE.
Osgood-Schlatter disease
*Anterior knee pain
*Osteochondritis of the tibial tubercle
*Common during growth spurt
*Pain reproduced with extending the knee against resistance
*Straight leg raise is painless
*RICE and quadricep strengthening
What is Acute Dacryostenosis? How to dx?
redness warmth tenderness and swelling of one lacrimal duct, complication of orbital cellulitis
Dx: Lacrimal sac massage & culture of discharge then treat with atb.
A patient reports to your office, having been struck on the right cheek with a baseball bat. On examination, you notice tenderness and swelling over the cheek. The patient is unable to gaze laterally with his left eye, and he complains of double vision when he attempts to do so. This is most likely associated with:
1.
retinal hemorrhage.
2.
orbital rim fracture.
3.
subarachnoid hemorrhage.
4.
periorbital cellulitis.
orbital rim fractures
A 70-year-old male presents with paresthesia of the lower extremities. On examination, the patient appears pale and shows a decreased vibratory sense. Laboratory tests reveal elevated indirect bilirubin; Hct = 30%; mean corpuscular volume (MCV) = 120 µm3 [normal = 87-103 µm3]. The most likely diagnosis is:
pernicious anemia
Obturator sign
RLQ pain with internal rotation of flexed right thigh = appendicitis
Kerley’s B lines on X-ray indicate
Pulmonary edema
MMR and pregnancy
Don’t get pregnant within the next 4 weeks
COPD patients may prolong their life by the use of?
Oxygen
Rheumatoid Arthritis s/s
Early morning stiffness, sausage joints. Symmetrical involvement. Longer stiffness than OA. Joint space narrowing. Pain, warm, tender, swollen, things.
Hip pain causes?
Legg-Calve-Perthes disease, SCFE, irritable hip
Hydrocele
Collection of serous fluid that causes painless scrotal swelling, easily recognized by transillumination.
Common in older men.
What is Caput Succedaneum
Diffuse edema of scalp due to intrauterine pressure (Cone head)
A 7-year-old child presents with group A streptococcal infection confirmed by throat culture. Past history includes treatment for positive streptococcal infection with erythromycin (EryPed oral suspension) 3 weeks ago. What is the most appropriate next intervention?
1.
Treat with amoxicillin for 10 days.
2.
Obtain culture for all household members.
3.
Treat with azithromycin (Zithromax) for 10 days.
4.
Intramuscular Penicillin.
treat with amoxicillin for 10 days
A 14-year-old patient who fell on an outstretched hand complains of proximal forearm pain. X-ray reveals a positive fat pad sign, and the patient is unable to fully extend the elbow. No definitive bony changes are seen on X-ray. The most likely working diagnosis is:
radial head fracture
Rovsing’s Sign
RLQ pain when pressure is applied to the LLQ = appendicitis
Depo provera can cause
menstrual irregularities and amenorrhea
caude equina syndrome
Varicocele
A palpable “nest of worms” scrotal mass that is only evident in a standing position.
COPD- other points of interest?
INSERT HERE
Rheumatoid Arthritis tx
: NSAIDS, steroids, DMARDS, TNF.
Legg-Calve-Perthes Disease
*Osteonecrosis of the capital femoral epiphysis due to interrupted vascular supply
*Common 3-12 years and more in boys
*Pain in hip or radiation to knee.
*Limp
*Trendelenburg Test – positive pelvic tilit
when rx hormones, consider fam hx of what cancers
uterine and breast
A 16-year-old female adolescent is brought to the nurse practitioner’s office by her mother, who is concerned about her daughter’s recent weight loss. History reveals that the daughter was consistently in the 50th percentile for weight, but is now in the 10th percentile. The mother states that she is concerned that her daughter is purging herself after meals since she often goes to the restroom after eating and remains there for a long period of time. The daughter denies any self-induced vomiting, starvation or excessive activity. She does state that she jogs five miles a day and is in good condition. In addition to a complete blood count with differential, which of the following laboratory tests will be most helpful for further assessment?
1.
Electrolytes, fasting blood sugar
2.
Creatine phosphokinase, follicle-stimulating hormone (FSH)
3.
Electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
4.
Electrolytes, FSH, stool for occult blood
electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
A 72-year-old female presents with a medical history unremarkable except for the occasional headache. She enjoyed emotional health throughout marriage and childrearing, although her family history is significant for strokes and nervous breakdowns. Since her husband died a year ago, however, she has been waking every morning at 3:00 A.M., is reluctant to go out although she has family members living nearby, and feels a continual urge to sleep. She cannot discuss her late husband without crying. Differential diagnoses would include:
depression, unresolved grief, and hypothyroidism.
Kerley B lines
Horizontal lines on CXR = heart failure
Phalen’s test
The test is performed by pushing the back of the hands together for 1 minute. This compresses the median nerve within the carpal tunnel. Characteristic symptoms (burning; tingling; numbness over the thumb, index, middle, and ring fingers) convey a positive test result.
Hirschsprung’s disease
A condition of the large intestine (colon) that causes difficulty passing stool.in first 48 hours of life, meconium
Testicular torsion
Characterized by scrotal pain and loss of the cremasteric reflex (Stroke inner thigh for contraction of crenatic muscle- testicle raise).
Urologic emergency.
Serous in middle ear may remain in Acute otitis media for weeks after the infection: any treatment needed?
no.
Swan Neck Deformity
deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it (DIP flexion with PIP hyperextension). Associated with RA
SCFE
*hip/knee pain
*limp
*common in teens
*Trendelenburg test
Korsakoff Syndrome
chronic thiamine deficiency
An adult female who is homeless presents for an initial obstetric visit at 34 weeks of pregnancy. She is diagnosed with Chlamydia trachomatis infection. What complication will her newborn be most at risk?
1.
Conjunctivitis
2.
Hearing loss
3.
Pneumonitis
4.
Meningitis
conjunctivitis
A 66-year-old patient presents with bilateral otitis media with effusion and white patches in the mouth that do not rub off when wiped with a 4 × 4. The patient should be evaluated for:
HIV infection
Levine’s sign
Clenched fist over chest sign = ischemic chest pain
nuva ring does not affect menstrual cycle
…
Osteopenia is defined as T-score
-1.0 to -2.5
Phimosis
The foreskin cannot be pulled back to expose the glans. head of penis
Potential urologic emergency.
Acute otitis media tx?
alternative? INSERT HERE
Bouchard’s nodes
Swelling to PIP, in RA there will be Bouchard’s nodes (and not Heberden’s nodes)
Transient Synovitis of the Hip
*”irritable hip”
*limp
*hip pain
*small effusion on US
*h/o URI 1 week prior
*no x-rays
*resolves in 1-2 weeks
implant can help with cramps
…
A 2-year-old male presents for reevaluation. Two days ago, he had four episodes of vomiting and six diarrheal stools. On physical examination today, his vital signs reveal P = 120 and capillary refill of 3 seconds. The patient’s eyes are sunken and his extremities are mottled and cool to the touch. The treatment plan would include:
1.
start oral electrolyte mixture every hour.
2.
hospitalization for IV fluid replacement.
3.
giving the child loperamide for each diarrheal stool.
4.
catheterizing the child to obtain accurate urine output.
hospitalization for IV fluid replacement
A 17-year-old female has never had her menses. She is at Tanner stage III of sexual development. Her physical examination is completely normal, and her weight is appropriate for her age and height. What is the most likely diagnosis?
Primary amenorrhea
Palm Sign
palm of the hand to the chest = ischemic chest pain
Osteoporosis is defined as T-score
-2.5 and less
Dystonia
involuntary repetitive muscle movements muscle spasms
Paraphimosis
Retracted foreskin that cannot be brought forward to cover the glans.
Potential urologic emergency.
S/s of retinal detachment?
Feels like curtian coming over vision, flashes of light OTHERS? TX?
Osteoarthritis s/s, first line tx
Large weight bearing joints. Early morning stiffness with inactivity. Has both nodes. FIRST LINE Acetaminophen.
Roseola
Human herpesvirus 6. High fever for 2-4 days, then abrupt cessation of fever with appearance of maculopapular rash but not on face
itraconazole – oral
…
A nurse practitioner places a 76-year-old patient on nifedipine (Procardia) 10 mg t.i.d. for angina. The patient is unable to remember to take the medication at the scheduled times. The practitioner should:
1.
discontinue the issue with the patient’s daughter.
2.
change the dose to extended release 30 mg daily.
3.
reinforce the importance of taking the medication.
4.
increase the dosage to 20 mg b.i.d.
change the dose to extended release 30mg daily
According to the American Diabetes Association, the newest standard for determining the presence of diabetes mellitus based on fasting plasma sugar level is a value equal to or greater than:
126 mg/dL.
Arm Sign
touching the left arm with right arm = ischemic chest pain
Thayer-Martin culture
Used to diagnose gonorrheal pharyngitis or proctitis
Dyskinesia
abnormal involuntary muscle rigidity
Cryptorchidism
Testicle located in inguinal canal or abdomen. Undescended testicle.
S/s of epididimitis?
???? Prinse test
Osteoarthritis recommended exercise
EXERCISE: Isometric exercises for knee OA. Non-weight bearing, like biking, swimming, stationary bike.
Fifth Disease
Parvovirus B19. “Slapped cheek” rash. Lacy. Macular rash.
griseofulvin
tinea capitis
A pediatric male is present with his mother, who states that he is extremely restless at night and constantly scratches his anal area. Which diagnostic procedure would confirm a diagnosis of pinworm infestation?
1.
The patch test
2.
Examination of bed linens
3.
Examination of transparent tape sample from perianal skin
4.
Blood tests for anemia and eosinophilia
examination of transparent tape sample from perianal skin
A 38-year-old male experiences a sudden onset of acute abdominal pain radiating to his groin. He is having difficulty walking and is nauseated. He denies any trauma or previous groin injuries. Examination reveals diffuse swelling of the left testicle and negative cremasteric reflex. The most likely diagnosis is:
testicular torsion.
Pointing Sign
pointing to chest with 1 finger = non-ischemic chest pain
Positive strep allergic to PCN
clarithromycin (biaxin) 250 mg bid x 10 days
Symptoms of initial hearing loss in adults
Loss of high frequency tones & harder to hear consonants than vowel sounds
Current guidelines recommend initiating antiretroviral therapy (ART) when?
in all individuals with HIV-1 infection, including those with early HIV-1 infection and all HIV-infected women, including pregnant women. It should be started regardless of the CD4 T lymphocyte cell count.
Varococele?
Sack of worms
Lachman’s: how to do, what does it test for
flex knee to 30 degrees, slightly externally rotate tibia, stabilize femur, pull up on tibia. If feel laxity (more forward movement) then there is laxity of ACL (instability of knee joint)
Rubella
Rubella virus. Maculopapular rash. Looks like measles rash. Remarkable lymphadenopathy. Macules on soft palate (Forchheimer spots)
miconazole – topical
…
Which of the following microorganisms are most frequently associated with acute bacterial rhino-sinusitis?
1.
Staphylococcus aureus and Mycoplasma pneumonia
2.
Staphylococcus aureus and Methicillin Resistant Staph aureus
3.
Streptococcus pneumoniae and Haemophilus influenzae
4.
Streptococcus pneumoniae and Pseudomonas aeruginosa
strep pneumo and haemophilus influenzae
Akathesia
intense need to move, restlessness
Babinski’s Sign
big toe remains extended or extends itself and other toes fan out when the sole of the foot is stimulated (normal in children until age 2). If seen child over 2 years or adult = CNS disorder (ALS, brain tumor/injury, meningitis, MS, spinal cord injury/defect, stroke)
A 10-month-old presents with a rash, runny nose, and cough. Examination reveals a cluster of tiny white papules with an erythematous base on the buccal mucosa. What does this suggest?
Measles
Jarisch-Herxheimer reaction
Infections caused by a spirochete such as syphilis or lyme. They dying bacteria release antigens that causes an host reaction. (occurs treating early stage syphilis. Symptoms are headache, myaligas, rigors, sweat, hypotension, and worsening of rash. Resolves on its own.
Cancer of testes?
nodule on teste
OTHERS?
Anterior drawer sign
pulling up on tibia more than expected shows tear/laxity in ACL. Flex hip to 45 degrees, flex knee to 90 degrees – sit on foot.
Rubeola (measles)
Rubeola virus. Maculopapular “brick red” rash. Starts on head and neck, spreads centrifugally to trunk and extremities. reportable disease. 3 C’s (conjunctivitis, coryza, cough). Koplik spots (1-3mm whitish, bluish or gray elevations on the buccal mucosa and hard/soft palate)
What is the goal of antiretroviral therapy (ART)?
suppress plasma viral RNA to undetectable levels and can be important in preventing and managing opportunistic infections.
Akinesia
reduced voluntary muscle
The parent of a 13-year-old diagnosed with seizure disorder calls to report that the child is exhibiting symptoms of a cold, but has no fever. The nurse practitioner should advise the parent that the development of fever may:
lower the seizure threshold.
Battle Sign
bruising around the mastoid process (behind ears) = serious head / brain injury
A child is being treated with methylphenidate (Ritalin) for attention-deficit disorder. The following are all side effects of Ritalin EXCEPT:
1.
muscle cramps
2.
mild irritability.
3.
increased heart rate.
4.
slight increase in growth velocity.
slight increase in growth velocity
Dx: Of BV
Amsel criteria with microscopy: (need 3)
-white thick adherent discharge
-vaginal pH >4.5
-positive whiff-amine test, KOH
-clue cells on saline wet mount (greater than 20%) – epithelium, “bread crumb dip cells”
gram stain, DNA probe. (Epithelial cells dotted with with large numbers of bacteria that obscure cell borders)
S/s of gonorrhea?
Treatment?
Posterior drawer sign
flex knee 90 degrees. sits on toes of the tested extremity to help stabilize it. The examiner grasps the proximal lower leg, approximately at the tibial plateau or joint line, and attempts to translate the lower leg posteriorly. The test is considered positive if there is a lack of end feel or excessive posterior translation
Chickenpox
Herpes virus. Vesicular lesions on erythematous base appearing in crops
16-24 hours sexually active screen for chlamydia is reportable There is also EPT= expedited partner therapy
additional testing= for STI risk reduction
GC/Chlamydia
HIV
syphilis
HAV
HBV
HCV
HSV-2
Agnosia
inability to recognize familiar people or objects
A geriatric female presents for her annual examination. She has been on antihypertensive medications for over 20 years, with good control. Laboratory values are within normal ranges. The nurse practitioner is concerned about the patient’s cardiac health risks, due her to weight and her waist circumference. According to the AHA guidelines, which of the following goals is expected for this patient?
1.
Physical activity for 60 minutes daily, for a minimum of 6 days a week
2.
Physical activity for 30 minutes daily, 7 days a week
3.
Physical activity for 30 minutes daily, for a minimum of 5 days a week
4.
Physical activity for 60 minutes daily, 7 days a week
physical activity for 30 minutes daily, for a minimum of 5 days a week
After a 3-week camping trip, an 11-year-old is seen for a target lesion with central clearing, located in the inguinal area. The patient has had a severe headache, malaise, fatigue, and generalized musculoskeletal pain for several days. Pharmacologic management of this condition includes:
doxycycline (Doryx).
Blue Dot Sign
tender nodule with blue discoloration on the upper pole of the testicle = testicular torsion
vulvovaginitis or STI dx with clinical findings or microscopic examination
1-Bacterial Vaginosis
2-Candid vulvovaginitis
3-Nongonococcap cervicitis/vaginitis
A-Clue Cells with alkaline PH
B- Pseudohyphae
C- Abundant White cells
BV= Clue cells with alkaline ph
Candida Vulvovaginitis= Pseudohyphae
Nongonococcal cervicitis/vaginitis= Abundant white blood cells
Legal scope of practice
defined by the nurse practice act in the state where you practice.
Torsion of testes?
S/S
McMurray’s test – how to do, what does it test for
McMurrays test- “CLICK” medial meniscus (valgus) EXAM. LateRal meniscus (vaRus).
With the patient supine the examiner holds the knee and palpates the joint line with one hand, thumb on one side and fingers on the other, whilst the other hand holds the sole of the foot and acts to support the limb and provide the required movement through range. The examiner then applies a valgus stress to the knee whilst the other hand rotates the leg externally and extends the knee. Pain and/or an audible click while performing this maneuver can indicate a torn medial meniscus. To examine the lateral meniscus the examiner repeats this process from full flexion but applies a varus stress to the knee and medial rotation to the tibia prior to extending the knee once again.
Herpangina
Coxsackie A virus
Astereognosis
inability recognize object placed in palm
An 18-year-old patient presents with complaints of maxillary facial pain and yellow nasal discharge for 14 days. What is the appropriate initial pharmacologic intervention?
Amoxicillin-Clavulanate (Augmentin)
Cremaster Reflex
lightly stroke superior and medial thigh – normal response is elevation of the ipsilateral testicle = negative elevation seen in testicular torsion (not 100%)
The management of COPD in the elderly is best guided by:
1.
spirometry.
2.
arterial blood gases.
3.
radiologic imaging.
4.
symptomatology.
symptomatology
Osteoporosis
Kyphosis causes curvature of the spine that causes rounding of the back, slouching posture. Severe thinning of bones.
Hand, foot and mouth
Coxsackie A virus
An intervention in vulvovaginitis-
1-Candida vulvovaginitis
2-Trichomoniasis
3-BV
A-Clotrimazole Cream
B-Oral Metronidazole
C-Metronidazole gel
D-Clindamycin cream
1-Candida vulvovaginitis
2-Trichomoniasis
3-BV
A-Clotrimazole Cream= Candida
B-Oral Metronidazole= Trich and BV
C-Metronidazole gel= BV
D-Clindamycin cream= BV
Rotator cuff tendonitis
after repetitive overhead activities (throwing, raking), abduction and elevation of shoulder joint worsen symptoms.
disturbed sleep because of pain, arm weakness, dull ache
Pt with pulmonary embolus suspected. After x ray what is next test?
helical CT pulmonary angiogram
Scarlet fever
exotoxin rash secondary to group A strep. Sandpaper like rash that ultimately desquamates
Hook test
bicep tendon rupture, normally with the elbow in flexion and arm supinated, you can hook your finger under the biceps tendon at the level of the AC and it will meet with resistance as you pull your finger against the tendon. A distal bicep tendon tear means that your finger will not feel resistance or be able to hook under the tendon in a hook test. (positive).
Symogi effect v dawn phenomenon:
Symogi: hypoglycemia causes hyperglycemia
Dawn phenomen: increase in insulin due to growth hormones, cortisol etc
Treatments for STI- matching
External genital warts in a 25 yo adult
Gonococcal urethritis in a 22 year old adult
Syphilis in a 45 yo adult
External warts in a 28yo pregnant woman
Ceftriaxone
Injectable PCN
Imiquimod
Trichloroacetic acid TCA
Ceftriaxone= Gonococcal urethritis in a 22 year old adult
Injectable PCN= Syphilis in a 45 yo adult
Imiquimod= External genital warts in a 25 yo adult NEVER in A PREGNANT WOMAN
Trichloroacetic acid TCA= External warts on the 25 yo and thee 28 yo who is pregnant
Ataxia
difficulty cording voluntary movement
Finkelstein’s Test
grasp the thumb and ulnar deviate the hand sharp and quick towards pinky = + De Quervain’s tenosynovitis
A 40-year-old male presents with a 2-week history of rectal pain and itching. He reports a past history of constipation and finding spots of bright red blood on toilet paper several times a week. Rectal examination reveals a tender, swollen, bluish, ovoid mass. The stool guaiac test is negative. Which of the following actions should the nurse practitioner take?
Prescribe bulk-forming agents and hydrocortisone suppositories.
A young, athletic adult presents with shoulder pain and inability to raise the arm above the shoulder. The most likely diagnosis is:
1.
frozen shoulder syndrome.
2.
cervical radiculopathy.
3.
rotator cuff tear.
4.
polymyositis.
rotator cuff tear
Thiazide diuretics
Favorable effect in pts with osteopenia and osteoporosis. They slow down the kidney’s excretion of calcium and increase distal tubule Ca+ reabsorption. Decreases bone demineralization.
Apraxia
difficulty to remember learned motor skill
A 50-year-old male presents with bruises and abrasions on the left leg and forearm, claiming to have had a number of minor accidents at home and at work. The patient reports general feelings of depression, forgetfulness, and, despite the fact that he is regularly employed, a mounting collection of unpaid and overdue bills. In taking the patient’s history, a significant pattern of parental alcohol abuse, stroke, TIA, and MI emerges. During questioning to elicit a more thorough diagnosis, the patient becomes hostile and leaves the clinic without further treatment. The most likely explanation for this behavior is:
1.
Alzheimer’s disease.
2.
chronic alcoholism.
3.
cancer.
4.
carotid artery stenosis.
chronic alcoholism
A nurse practitioner is suturing a simple laceration on an 11-year-old patient. The use of lidocaine with epinephrine is contraindicated in all of the following areas EXCEPT the:
scalp
Homan’s Sign
pain in the calf on forceful and abrupt dorsiflexion of the patient’s foot at the ankle = possible DVT
Which signs and symptoms are associated with-epididymoorchitis
acute bacterial prostatitis
or both
Irritative voiding symptoms
perineal pain (between scrotum and anus)
Prehn’s sign
Usually presents with fever
Scrotal swelling
Irritative voiding symptoms- BOTH
perineal pain (between scrotum and anus)- Prostatiits
Prehn’s sign =Epididymoorchitis
Usually presents with fever=BOTH
Scrotal swelling-Epididymoorchitis
Lachman’s maneuver and sign
Knee joint laxity. Suggestive of ACL damage of the knee.
How to test s1 nerve function?
achillies tendon reflex
bicep tendon rupture – looks like
bicep is curled up into a giant ball
herpangina
painful vesicles on the soft palate and mouth
hand foot and mouth resolves when
2-3 days
blood tests for sickle cell
screening is CBC, diagnosis is HGB electrophoresis
- HbS and HbF elevated, Reticulocytosis, hemolytic anemia
- Normocytic/Normochromic
- shortened life-span of 10-20d (norm 120d)
How to test s2 function? S3, s4? etc?
?
Cancers of the Female Reproductive Tract
- cervical cancer caused by HPV types=abnormal vag bleeding, vag discomfort during intercourse, malodorous dc and dysuria- symptomatic w 1st abnormal pap
pap test followed by colposcopy and biopsy
pelvic ct/MRI or PET
Tx based on disease progression surgery radiation chemo - uterine or endometrial cancer- older age , estrogen tx, nulliparity, obesity, tamoxoifin use, DM family hx-abnormal vag bleeding, Diagnostics – transvag ultrasonography hydroutrsonography endometrial biopsy and D&C
- ovarian cancer- post menopausal nuliparity 1st preg after 35 fertitlity drugs Braca + has shared etiology with breast ca
minimal non specific symptoms bloating bladder pressure constipation vag bleeding indigestion, SOB, lethargy weight loss
Diagnostics- CT w/ contrast of abdomen,
MRI,US tumor markers 125
surgery followed by chemo
Drawer sign
A test for knee stability. A diagnostic sign of a torn or ruptured ligament. The positive anterior drawer sign is the test for the anterior cruciate ligament (ACL). The posterior drawer sign is the test for the posterior cruciate ligament (PCL).
Anomia
form of aphasia, unable to recall names of everyday objects
Pel Epstein fever
cyclic fever = rarely seen in Hodgkin’s lymphoma
A 16-year-old female in the first month of taking Ortho-Novum 7/7/7 complains of midcycle spotting. She has not missed any doses and uses no other medication. Which of the following is appropriate?
Providing reassurance
A 28-year-old patient presents with profuse yellow vaginal discharge, odor, and local irritation. She reports completing a 7-day course of oral metronidazole (Flagyl), 500 mg b.i.d. 4 weeks ago. She has had multiple recurrences over the last 18 months. Microscopic examination reveals presence of clue cells. What is the most appropriate treatment intervention?
1.
Oral metronidazole (Flagyl), 500 mg b.i.d., plus metronidazole vaginal gel (MetroGel), for 5 days
2.
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
3.
Metronidazole vaginal gel (MetroGel) twice weekly for 4 to 6 months
4.
Treat patient with metronidazole vaginal gel (MetroGel) b.i.d. and partner(s) with tetracycline, 250 mg q.i.d., for 7 days
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
Aphasia
difficulty verbalizing
An adult female who recently returned from a business trip to Japan presents for a recheck appointment. The only remarkable laboratory result is for thyroid-stimulating hormone (TSH), at 0.3 microunits/mL (normal = 0.4-6 microunits/mL). The patient reports that her neck hurts; examination reveals thyroid tenderness. Which of the following laboratory tests should the nurse practitioner order now?
1.
Triiodothyronine (T3) and free thyroxine (FT4)
2.
Triiodothyronine (T3) only
3.
Triiodothyronine (T3) resin uptake assay
4.
Triiodothyronine (T3) and free triiodothyronine (FT3)
Triiodothyronine (T3) and free thyroxine (FT4)
Research findings have shown that, in order to improve the longevity of a patient who has COPD, the treatment of choice is:
oxygen
vaccination for sickle cell pts
all vax given Preventive strategies that decrease the risk of infection are the routine use of daily antibiotics until five years of age, immunization of children with the 7-valent pneumococcal conjugate vaccine in addition to the 23-valent polysaccharide pneumococcal vaccine, annual influenza vaccination after six months of age, and meningococcal vaccination after two years of age
Finkelstein’s test
identifies deQuervain’s tenosynovitis which is caused by an inflammation of the tendon and its sheath, which is located at the base of the thumb. Test is positive if there is pain and tenderness on the wrist (thumb sign) upon ulnar deviation.
Lidocaine and epinephrine can be used on fingers, earlobes, nose?
False- may lack blood supply due to epinephrine.
match the following cancer types
1-cervical cancer
2-endometrial cancer
3-ovarian cancer
A-Risk factors include obesity and personal history of PCOs (do not shed lining of uterus obesity increases estrogen
B-Long term infection with HPV19 and or-18
C-BRACA1 and BRACA2 gene mutation
D-presentation includes unexplained abdominal bloating and constipation
E-Presentation includes abnormal vaginal bleeding
F-Often without significant clinical signs and symptoms until later disease
G-Screening include PAP
No specific screening tests available or recommended
Risk factors include obesity and personal history of PCOs (do not shed lining of uterus obesity increases estrogen= Endometrial Ca
Long term infection with HPV19 and or-18+Cervical Ca
BRACA1 and BRACA2 gene mutation= Ovarian Ca
presentation includes unexplained abdominal bloating and constipation=Ovarian
Presentation includes abnormal vaginal bleeding= Cervical and Endometrial Ca
Often without significant clinical signs and symptoms until later disease=Cervical, ovarian and endometrial
Screening include PAP=Cervical
No specific screening tests available or recommended =Endo and ovarian ca
otitis media
*Cloudy, bulging TM with impaired mobility
*Effusion – fluid collection w/o infection
*PCV has decreased AOM
*Viral – RSV, influenza
*Bacterial – strep pneumoniae, H. influenzae, M. Catarrhalis
McMurray Test
knee pain and click upon manipulation of the knee, injury to medial meniscus, (KNEE FEELS LIKE LOCKING UP) DX gold standard test for joint damage is the MRI (supine raise knee twisting knee inward/outward while extending in/out)
In treating a pregnant female with migraine headaches, which of the following drugs is in Category X?
1.
Ergotamine tartrate (Ergomar)
2.
Sumitriptan succinate (Imitrex)
3.
Frovatriptan (Frova)
4.
Amitriptyline (Elavil)
ergotamine tartate (ergomar)
Sacrcopenia
loss of muscle mass related to aging
A routine laboratory assessment of a 12-year-old patient with a family history of thalassemia and anemia reveals Tanner stage II presentation and Hct = 35%. In addition to a complete blood count (CBC), the nurse practitioner should order which of the following?
Hemoglobin electrophoresis
Cervical Screening Guidelines
screening should begin at age 21
21-65 it should be every 3 years.
21-29 every 3 yrs.
30-65 – every 5 + HPV.
65 after 3 normal paps – and negative HPV or terminate paps
NO NEED FOR ANNUAL SCREENING FOR AVERAGE RISK WOMEN AT ANY AGE.
WOMEN WITH HYSTERECTOMY with cervix removed – NO SCREENING.
scarlet fever: s/s and treatment and alternative ABT for those who cannot accept 1st line ABT.
???
lead poisoning anemia type, s/s
microcytic hypochromic anemia. s/s n/v, fatigue, loss of appetite, abdomen and joint pain, slowed growth, mental disability.
AOM management
- <6 months: ABX
- 6 months to 2 years – ABX ASAP if bilateral or severe illness. Otherwise observe if unilateral or mild
- >2 years – ABX if severe, observe if not severe or uncertain of diagnosis
- Amoxicillin.
- Recent ABX – Augmentin
- Mild PCN reaction – cefdinir, ceftriaxone, cefuroxime, cefpodoxime
- Severe PCN allergy – Zpack or clindamycin
Prostatitis- first test to dx?
urine and culture.
Varus stress test (knee)
LCL ligament stability — test should be done at both 0 and 30 degrees.
1) Examiner places fingers of one hand over the lateral joint line assessing for increase in joint line opening while applying a varus stress to the other.
2) Must be done bilaterally for comparison in order to asses laxity/disruption of ligament.
Positive test is that one joint line is opening is larger than the other side. Indicates possible LCL ligament laxity on the side of the larger joint line opening.
Cachexia
underlying illness involving marked weight loss and muscle loss
A common rule to follow when prescribing many medications for the elderly is to:
start at a lower dose than what is commonly prescribed for adults, and increase the dose slowly.
A nurse practitioner is evaluating an infant for possible colic. Which of the following could indicate the need for a more extensive evaluation?
1.
3-oz (85 g) weight gain over the past 2 weeks
2.
Stool negative for occult blood
3.
Moist mucus membranes and flat fontanels
4.
Onset at 4 weeks of age
3-oz (85 g) weight gain over the past 2 weeks
thalassemia alpha – which population
African, Asian
Which of the following would be an appropriate alternative to erythromycin therapy in an 18-year-old patient with Mycoplasma pneumoniae infection?
Azithromycin (Zithromax)
Which of the following is a hallmark of lumbar spinal stenosis?
1.
Incontinence of bowel and/or bladder
2.
Point tenderness of the lumbar spine
3.
Leg, buttock or back pain precipitated by walking.
4.
Bilateral leg pain with sitting.
leg, buttock or back pain precipitated by walking
thalassemia beta – which population
African, Mediterranean, Middle Eastern
Macular Degeneration
loss of center vision, loss of visual acuity, contrast sensitivity but still have peripheral vision, may find Drusen bodies
Valgus Stress Test
application of a medial force to the lateral aspect of a joint in an attempt to create a gap in the medial joint line, thereby testing the stability of the medial aspect of the joint. Medial collateral ligament
Prostitis s/s, tx?
???
thalassemia type of anemia
- Genetic d/o that bone marrow produces abnormal hemoglobin
- microcytic, hypochromic, ferritin/iron normal or high, high RDW
- Gold standard: Hgb electrophoresis: abnormal in beta
- Blood smear: microcytosis, anisocytosis, poikilocytosis
- Ferritin and iron normal
- Provide genetic counseling
- Minor trait does not require treatment
Acute Bronchitis with purulent discharge with fever tx? (NOT PCN!)
Primary Options:
azithromycin : 500 mg orally as a single dose on day one, followed by 250 mg once daily for 4 days, or 500 mg once daily for 3 days
Secondary Options
erythromycin base : 250-500 mg orally every 6 hours for 7-14 days
clarithromycin : 250 mg orally every 12 hours for 7-14 days
doxycycline : 100 mg orally every 12 hours on day one, followed by 100 mg once daily for 7-14 days
trimethoprim/sulfamethoxazole : 160/800 mg orally every 12 hours for 7-14 days
cephalexin : 250-500 mg orally every 6 hours for 7-14 days
NSAIDS
effect the renal prostaglandins and the effectiveness of the diuretic. NSAIDS inhibit the vasodilatory effect of PG, which predisposes the kidney to ischemia. Decrease blood flow to kidney.
Cataracts
opacity in lens, difficulty with glare, halos around light, blurred vision, gradual onset of decreased night vision, red reflex disappears (Red reflex is now opaque gray instead of orange red glow
A patient with a diagnosis of diverticulosis presents with localized left lower quadrant discomfort, a palpable mass, mild leukocytosis, and T = 100°F (37.8°C). The patient does not appear toxic and can tolerate fluids. An appropriate plan should include:
clear liquids and oral antibiotics.
A 70-year-old patient presents to the clinic complaining of dyspnea, palpitations, and fatigue. The patient reports a 2-week history of blackened stools, which the patient attributes to drinking berry juice. Assessment reveals vital signs of BP = 110/60, P = 100, R = 24; Hgb = 4.5 g/dL; Hct = 16%. What is the most appropriate immediate intervention?
1.
Order serum iron, total iron-binding capacity (TIBC), and ferritin.
2.
Refer to a gastroenterologist.
3.
Send to the emergency room.
4.
Order a complete blood count (CBC) with differential.
Send to emergency room
6 months hx of 39 year old pt who has daily swelling of wrists?
rheumatoid arthritis
treatment of iron deficiency anemia
- 325 mg ferrous sulfate daily treat 3-6 months, take w Vit C for better absorption
- Increase fiber and fluid to prevent constipation. May notice black-colored stools.
- Red meat, beans, green leafy vegetables
- Do not take w antacids, dairy, FQ, tetracyclines
- recheck reticulocytes/CBC after 2 weeks after tx started to make sure the problem isn’t in the bone marrow (the reticulocytes should be higher).
The symptoms of benign prostatic hypertrophy are often overlooked because the older male:
1.
understands that surgery is the only cure for this condition.
2.
considers urinary problems to be a normal part of aging.
3.
is fearful of the side effects of additional medication.
4.
is concerned that he will no longer be able to obtain an erection.
considers urinary problems to be normal part of aging
The most common bacteria responsible for pneumonia in older adults residing in the community is:
Streptococcus pneumoniae.
Pancreatic Cancer Dx and Tx?
Dx: AST ALT bilirubin lipase amylase
Refer to GI surgeon for Whipple procedure
Preeclampsia recommendations
Bed rest with bathroon privi, weight and BP monitoring, follow urine protein and serum protein, Cr and plt counts.
Lichen sclerosis
Characterized by thinning of the epidermis and fibrosis (sclerosis) of the dermis; presents as a white patch (leukoplakia) with parchment-like vulvar skin. Small white spots that grow in patches. Itchy, discomfort, bleeding + blisters. In older women.
how to differential b/t B12 and folate deficiency – both are macrocytic
B12 comes with neuro symptoms tingling numbness of hands/feet, starts peripherally migrates centrally, difficulty walking, difficulty fine motor
Multiple myeloma- cancer of the bone marrow, bone pain, weakness… how to dx & tx?
Dx: CBC, FOBT,
Refer to hematologist affects African race
Which class of antihypertensive agents has been associated with acute renal failure and is contraindicated in patients with bilateral renal artery stenosis?
Angiotensin-converting enzyme (ACE) inhibitors
Upon admission to a nursing home, an 85-year-old patient receives a negative result on the purified protein derivative (PPD) test. To determine TB status in the frail elderly, a second PPD should be performed in:
1.
72 hours.
2.
1 week.
3.
3 months.
4.
6 months.
1 week
Rheumatoid arthritis dx?
Polymyalgia Rheumatica
inflammatory disorder causing muscle and joint pain and stiffness (shoulders/hips), aching stiffness about the upper arms, neck, lower back and thighs, symptoms develop quickly, and worse in the morning
An 18-month-old child presents with a bulging, immobile tympanic membrane; T = 103°F (39.4°C). Assessment also reveals a grade II/VI systolic murmur at the left sternal border. After initiation of treatment for otitis media, the most appropriate intervention is to:
reevaluate the patient in 10 days.
Which of the following is NOT used for therapy of an acute attack of gout?
1.
Colchicine (Colcrys)
2.
Indomethacin (Indocin)
3.
Methylprednisolone (Solumedrol)
4.
Allopurinol (Zyloprim)
allopurinol (zyloprim)
Tanner stage 1 girls
-Preadolescent, no pubic hair, other than fine hair similar to abdomen
-No breast dev.
Reiters syndrome?
pernicious anemia cause/tx
destruction of parietal cells in stomach leads to decreased intrinsic factor leads to B12 not being absorbed.
causes of b12 deficiency
- Macrocytic Normochromic
no intake of foods of animal origin, bariatric surgery, antacids, h2 blockers, proton pump inhibitors, metformin
Gouty arthritis?
Tanner stage 2 girls
-sparse growth of long slightly pigmented, downy, straight
-small area of glandular tissue w/ surrounding areola that begins to widen around age 10-11. Breast Bud
Polymyalgia Rheumatica dx & tx?
DX elevated sed rate, Creactive protein, (Low hemoglobin)
line TX oral prednisone
The management of choice for polymyalgia rheumatica includes:
prednisone.
A 26-year-old female presents with abdominal distention, bloating, and intermittent crampy abdominal pain relieved by defecation. She has four to six loose stools a day when stressed. Between bouts of diarrhea, she often has constipation. Physical examination results are normal. The CBC was normal. The most likely diagnosis is:
1.
diverticulitis.
2.
viral gastroenteritis.
3.
inflammatory bowel disease.
4.
irritable bowel syndrome
irritable bowel syndrome
how does fever affect seizure threshold
fever lowers seizure threshold
A mother has just noticed that her 15-month-old, 15-kg child has recently ingested an unknown quantity of iron tablets. The mother has ipecac syrup and activated charcoal on hand. The mother should be advised to:
1.
take the child to the primary care provider.
2.
give ipecac per recommendation on the bottle label.
3.
take the child to the emergency room.
4.
give the child 30 g of activated charcoal diluted with water
take child to emergency room
Club foot (Other name for?)
talipes equinovarus,
Which of the following pharmacotherapeutics would be most important to administer to a patient who has a corneal abrasion?
Gentamicin ophthalmic (Genoptic)
s/s of brain tumor:
gets worse when lying down and neurological focal deficits
Tanner stage 3 girls
Breast enlargement without separate nipple contour. One mound.
Pubic hair fills out but is straight, starts to curl
A 13-year-old is concerned because she has not yet begun to menstruate. Physical examination indicates that the patient is at Tanner stage IV and is of average height and weight. Which of the following would be the most appropriate response to this patient?
1.
“We’ll need to refer you to an endocrinologist for a complete workup.”
2.
“We’ll need to do some tests to find out why you are not having periods.”
3.
“I’ll give you some pills that will make your periods start.”
4.
“Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
“Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
ABSENCE SEIZURE other name, define
PETIT MAL SEIZURE: SUDDEN BRIEF LAPSES OF IN ATTENTION. SEEN ON
Migraine s/s? Tx? differ from tension, cluster, stroke?
?
Tanner stage 4 girls
Areola and breast projects as secondary mound
Pubic hair is more thicker, darker, coarse – starts to curl
Bouchards nodes can be found in?
RA & OA
A patient with type 1 diabetes mellitus who is on NPH and regular insulin split-dosing presents with complaints of early morning rise in fingerstick blood glucose. A review of an at-home glucose test reveals increased morning levels. After an increase in the evening insulin dose, the problem worsens. This is most likely an example of:
the Somogyi effect.
A 14-year-old male with bronchitis is being treated with fluids and expectorants. He returns to the clinic with a fever of 103°F (39.4°C), right pleuritic chest pain, and green sputum. Which of the following examination results would be expected?
Right lower lobe crackles
mini mental status exam MMSE – what is the cut off for dementia
MMSE- <24 dementia. The lower your score the worse off you are
Most common cause of death cancer Women? Men?
Lungs!
Tanner 1 Boys
Prepuberty/none
Heberden’s nodes can be found in?
OA
The most common bacterial cause of cellulitis in patients with diabetes mellitus is:
1.
Pseudomonas aeruginosa.
2.
group B beta-hemolytic Streptococcus.
3.
Staphylococcus aureus.
4.
Staphylococcus saprophyticus.
Staphylococcus aureus
subdural hematoma
skateboarding concussion. Diagnosed with CT.
List of cancers incidence?
skin: melatonin cancer most deadly?
Basal cell cancer: most incidence?
Tanner 2 Boys
testes enlarge/few straight fine hairs
Tubercle
small round projection on bone or surface
The follow-up examination of a 12-month-old treated 2 weeks ago for bilateral otitis media reveals a normal left tympanic membrane and a right tympanic membrane with visible serous fluid levels and decreased mobility. An appropriate plan should include a:
follow-up evaluation of the ears in 2 months.
A 46-year-old female found a lump in her breast this morning. History includes: no prior breast disease; G2P2 (first birth, age 22); maternal aunt diagnosed with breast cancer at age 72; last menstrual period was 2.5 weeks ago. On examination, a nurse practitioner palpates a 2-cm round, soft, mobile, tender lesion in the upper outer quadrant of the right breast. Mammogram is negative. Which of the following actions is most appropriate?
1.
Reassure the patient that no further action is necessary.
2.
Repeat unilateral right mammogram in 3 months.
3.
Schedule a right-breast ultrasound.
4.
Refer for genetic testing if the lump increases in size.
schedule a right breast ultrasound
fibromyalgia
11/18 points. Widespread pain for at least three months
Cancer death lists?
Tanner 3 (boys)
Penis lengthens, darker coarse hair starts to curl
Colles fx
fracture of distal radius of the forearm, DINNER FORK fracture, most common type wrist fracture
A 50-year-old male presents with a chief complaint of malaise. Further questioning reveals that his primary concern is delayed ejaculation. He is currently taking the following medications: atenolol (Tenormin), 50 mg daily; paroxetine (Paxil), 20 mg daily; loratadine (Claritin-D), 1 tablet daily; and hydrochlorothiazide (HCTZ), 25 mg daily. The most likely cause of the patient’s concern would be:
paroxetine (Paxil).
Risk factors for genital herpes include:
1.
multiple sexual partners and years of sexual activity.
2.
genetic transmission.
3.
infection with other sexually transmitted diseases before the age of 12.
4.
multiple sexual partners and frequent use of public spas.
multiple sexual partners and years of sexual activity
A 68-year-old female presents with a new onset of left-sided throbbing headache. She has noticed some spots in her visual fields that come and go. She is being treated with an NSAID for arthritis. Sedimentation rate is elevated, but all other laboratory values are within normal limits. The headache is most likely due to:
temporal arteritis.
On physically assessing a newborn’s head, you note an enlarged, fluid-filled area that is subperiosteal and does not cross suture lines. This finding indicates the presence of:
1.
macrocephaly.
2.
subgaleal hemorrhage.
3.
congenital hypothyroidism.
4.
cephalohematoma.
cephalohematoma
BPPV
Dix Hallpike maneuver-
Diverticulitis
small pouch like herniations, acute onset of fever, LLQ pain, anorexia, N/V,
Dx CBC, leukocytosis, shift bands to left,
TX fluoroquinolone, flagyl, , if severe refer to ER
Tanner 4 boys
penis widens, thicker, darker, coarse, curly hair
Sexual organs cancer deaths?
Ovaries in women
What about men? Prostate?
cluster headaches: tx, abortive and prophylaxis
tx High dose O2 via Mask 12L 100%, imitrex (abort) and a CCB for prophylaxis. VERAPAMIL
s/s of skin cancer:
tanner 5 boys/girls
Adult pattern
Pancreatitis symptom
midepigastric pain radiates to midback
Which of the following is the most serious outcome of Barrett’s esophagus?
Esophageal adenocarcinoma
A 65-year-old patient being treated with digoxin (Lanoxin) for chronic heart failure (HF) presents with complaints of palpitations. Three days ago, the patient was placed on clarithromycin (Biaxin) by another provider for community-acquired pneumonia. The appropriate course of action at this point would be to:
1.
increase the digoxin dosage by 25%.
2.
obtain a digoxin level and change the antibiotic to azithromycin (Zithromax).
3.
obtain a chest X-ray.
4.
obtain a serum potassium level and perform a 12-lead EKG.
obtain a digoxin level and change the antibiotic to azithromycin (zithromax)
A 39-year-old patient was diagnosed with acute bronchitis in the emergency department and treated with acetaminophen, dextromethorphan, and metaproterenol (Alupent). The patient’s history reveals a smoking habit of 1 pack per day. The patient now presents to a nurse practitioner’s office with a fever of 101.2°F (39.4°C) and a cough productive of thick, yellow-green, foul-smelling sputum. The nurse practitioner should encourage smoking cessation and prescribe:
a macrolide antibiotic.
A 54-year-old male who is 30 pounds overweight states that he awakens at night with heartburn and the taste of hot acid in his mouth. Stress makes his condition worse, yet baking soda seems to provide some relief. Findings on examination are normal and the stool for occult blood is negative. The preliminary diagnosis(es) should be:
1.
esophagitis.
2.
esophageal spasm.
3.
helicobacter pylori.
4.
gastroesophageal reflux disease.
GERD
migraine tx: abortive and prophylaxis
Triptains for abortive.
Prophylaxis:
- (propranolol)
-TCA (Amitriptyline) - Anticonvulsants (gabapentin, topiramate).
Lichen Sclerosis
whitish patches on genitals, lesions chronic affect vulva/anal in elderly patients, risk for cancer
eGFR
test used to monitor kidney function and evaluate chronic kidney disease
Anemia: pernicious anemia:
neurological deficits
Bells Palsy, which nerve
CN VII- Facial BELLS
Other anemia: s/s, tx, differentiation
Signs of depression
anhedonia, weight loss or gain, fatigue, change in appetite, insomnia or hypersomnia, feeling of guilt or suicide.
Thrichomonas
yellow-greenish discharge with dyspareunia, pelvic exam reveals strawberry patches on cervix
A 15-year-old patient returns for contraceptive services 2 weeks after a diagnosis of trichomonas vaginitis and treatment with 2 g of metronidazole (Flagyl). She reports that discharge and itching are gone, but she is urinating frequently, accompanied with a lot of burning. The patient has not resumed sexual activity and has menstruated since her last visit. Examination reveals mild suprapubic tenderness, no leukorrhea, and a normal wet mount. Gonococcal culture and chlamydia tests are negative. Which diagnostic test should be performed immediately?
Microscopic examination of urine
A late adolescent patient presents with complaints of acute-onset unilateral right eye pain, visual changes, seeing halos around lights, abdominal pain, and intermittent nausea. Physical findings include an erythematous right eye without discharge, a cloudy cornea, and a moderately dilated right pupil that is nonreactive to light. The nurse practitioner should immediately:
1.
apply steroid drops to the right eye.
2.
apply mydriatic drops to the eye.
3.
refer to the emergency department.
4.
make an appointment for him to see an ophthalmologist.
refer to emergency department
A nurse practitioner orders pulmonary rehabilitation for a 75-year-old with COPD. Expected outcomes of this program include all of the following EXCEPT:
increased lung capacity.
In a 6-year-old child, which of the following is the preferred drug for stage 1 Lyme disease?
1.
Trimethoprim-sulfamethoxazole (Bactrim)
2.
Azithromycin (Zithromax)
3.
Doxycycline (Doryx)
4.
Cefuroxime (Ceftin)
cefuroxime (ceftin)
Anemia of chronic disease
Trichimonas
dx is wet mount/prep, flagella, partner needs treated too TX flagyl PO for 7 days
ectopic pregnancy
Hx of amenorrhea and new onset of bloody vaginal spotting, left adnexal tenderness and cervical motion tenderness
Which CN control eye MOVEMENT
EOM- CN III, IV, VI. (LR6SO4) 3-pupil/accommodation `
A 4-year-old girl with a history of recurrent urinary tract infections returns for follow-up after diagnosis of the most recent infection. During the physical examination, the 4-year-old tells the nurse practitioner that her brother (age 9) lies on top of her and rubs his penis near her pubic area. After completing the physical examination, the nurse practitioner must:
report suspicions to the appropriate child protective services agency.
An 86-year-old patient is experiencing radiculopathy-associated lower back pain that has not improved over the past 4 weeks. The medical history includes a lumbar discectomy. The best type of imaging study for evaluating this patient would be a/an:
1.
MRI.
2.
spinal X-ray.
3.
myelography.
4.
nuclear bone scan.
MRI
Fitz-Hugh-Curtis syndrome
Perihepatic infection which results in liver capsule inflammation from pelvic infections such as gonorrhea & chlamydia. PID infections. Sharp pain on the right upper quadrant, with PID symptoms.
PID
DX NAAT TX ceftriaxone, doxy, flagyl
Folic deficiency anemia
UTI urine culture positive when….
KNOW THAT UTI IS 100,000 (10 x 5) CFU’S TO BE DIAGNOSED in non preg patient and 10 x 3 in preg patient
3+ protein in urine, how do you follow up ?
do 24 hour urine for protein and creat clear
Beta anemia
Chlamydia Symptoms, Dx, & Tx
Fitz-Hugh syndrome, asymptomatic, mucopurulent, vaginal discharge, bleeding
Dx: gold standard, nucleic acid amplification test NAAT, gen probe, antigen detection (swab), urinalysis, wet prep >20 WBC
Azithro 1 dose or doxycycline for 7 days annual screenings
A 2-year-old child is diagnosed with radial head subluxation (“nursemaid’s elbow”). After closed manipulation, the best indication of successful treatment is that:
the child quickly begins to use the affected arm.
A 30-month-old with a history of frequent ear infections was seen in September after a symptom-free summer. Examination revealed bilateral bulging eardrums. After two separate courses of antibiotics, fluid is noted in both ears. The parent reports speech difficulties. The most likely diagnosis is:
1.
otitis media with effusion.
2.
myringitis.
3.
recurrent acute otitis.
4.
Esutachian tube dysfunction.
otiti media with effusion
12 weeks
uterine fundus first rises above the symphysis pubis.
Any baby 2-24 months with UTI and fever. how do you follow up?
- do renal and bladder ultrasound for first febrile UTI
cycle cell anemia
Wernicke’s aphasia
difficulty with comprehension but none with speech
A 67-year-old patient with type 2 diabetes mellitus, congestive heart failure (CHF), and mild coronary artery disease is currently taking digoxin, 0.25 mg daily; hydrochlorothiazide, 25 mg daily; metformin, 500 mg daily; glipizide, 10 mg daily; and atorvastatin (Lipitor), 20 mg h.s. Which of the following is an accurate statement regarding this regimen?
The hydrochlorothiazide will predispose the patient to digoxin toxicity.
A 19-year-old patient who has used oral contraceptives for 3 years plans to discontinue the pill at the end of her current cycle to become pregnant. Which of the following daily supplements would receive the highest priority?
1.
Calcium carbonate
2.
Folic acid
3.
Ferrous sulfate
4.
Multivitamin
folic acid
16 weeks
UF is between symphysis pubis and the umbilicus
RBC casts in urine, what is possible diagosis
glomerulonephritis
iron deficient anemia
20 weeks
UF at level of umbilicus
Broca’s aphasia
comprehends speech but unable to verbalize speech
During development of a treatment plan for an 84-year-old patient with hypothyroidism, the nurse practitioner must keep in mind the possibility of the worsening of:
osteoporosis.
A frail elderly widow presents to the senior clinic with a 3- to 4-day history of confusion that became worse the evening before but currently seems a little better, although her speech is rambling and difficult to follow. During the examination, the patient is anxious and agitated. She is on cardiac medications, an antidepressant, and insulin. The most likely diagnosis is:
1.
mild stroke.
2.
polypharmacy.
3.
electrolyte imbalance.
4.
agitated depression.
polypharmacy
First choice Atb for UTI
Nitrofurantoin (Macrobid)
Hpylori negative ulcer , tx
s: h2 first bedtime, may combine them with PPI. Do 6-8 weeks. PUNT after.
pregnancy anemia
20 to 35 weeks
Measure the distance between upper edge of pubic symphysis and the top of the uterine fundus using a tape measure. + or – 2 cm. 32 30-34 weeks
Initial therapy for a 3-week-old infant with uncomplicated symptoms of gastroesophageal reflux disease includes which of the following positions and change in diet?
Smaller, more frequent feedings while holding infant
A 46-year-old female presents with a complaint of amenorrhea for 3 months. The first-line diagnostic workup is:
1.
urine pregnancy test.
2.
progesterone challenge.
3.
serum prolactin level.
4.
thyroid-stimulating hormone (TSH).
urine pregnancy test
HBsAg means what
patient current HAS HbSAg (the test has the word “HAS” in it)
Define fremitis:
When is it increased?
- Fremitus is enhanced by consolidation.
- Fremitus is decreased by pleural fluid.
- Fremitus is decreased by pneumothorax.
- TRUE. Fremitus is enhanced by consolidation.
- TRUE. Fremitus is markedly decreased by pleural fluid.
- TRUE. Fremitus is decreased by pneumothorax.
CHF
S1, S2 and S3
Temporal arteritis
The cause of the blood vessel inflammation is unknown. In some cases, the swelling affects just part of an artery with sections of normal vessel in between. Symptoms include acute onset of headaches located on one temple, skin over artery is indurated, jaw pain, vision loss, fever, and weight loss, anorexia, fatigue.
Anti-HBs positive
immunity either from previous disease or vaccine
Bronchitis:
s/s, Tx,
RF for suicide
elderly white man after death of spouse, past Hx of suicide, family Hx of suicide, gender males have a higher success rate, hx of depression or bipolar
Temporal arteritis dx & tx
Dx usually requires biopsy of the temporal artery. Elevated sed rate and c reactive protein, high risk with polymyalgia rheumatica, the condition needs Prompt treatment with steroid medications to prevent permanent vision loss
Zollinger Ellison syndrome
tumors causes stomach to produce too much acid resulting in PUD
HBeAg positive
E- EEEEEEEnfectious! It is an indicator of active viral replication; this means the person infected with Hepatitis B can likely transmit the virus on to another person
Alpha fetoprotein
produced by fetal liver, high for twins, neural tube defect. Low AFP RF down syndrome. For either order the triple screen
Barrets esophagus:
Increases risk of cancer of esophagus
Somogyi
too much insulin in the blood at night causes a rebound increasing blood sugar in the AM
Anti-HBc
c is for caught it. either has or HAD hep B. The presence of
anti-HBc indicates previous
or ongoing infection with
hepatitis B virus in an
undefi ned time frame.
HIV
Varicella contrainindicated
Sedimentation rate is elevated and patient has visual spots and left sided-headache:
temporal arteritis
Anti-HCV positive. What is next step?
order HCV RNA. Biopsy of liver to check stage.
Psoriasis diagnosis s/s and tx:
sharply defined plaques with silvery scales: use auspitz sign when scales are pealed away and capillary bleeding. Sun helps pt. OTHER INFO?
Chronic inflammatory skin disease characterized by extensive erythematous, circumscribed scaly papules, and plaques.
Runs a variable course and seldom completely subsides. Severity is aggravated by genetic, infectious, emotional, and environmental factors.
Lesions are red, inflamed, silvery-white scaly, and circumscribed papules and plaques on elbows, knees, extensor limbs, and scalp. Psoriatic nails have a pitted surface and/or hypertrophic (subungual) changes.
Diagnosis is usually clinical.
Mild or limited psoriasis is treated with topical corticosteroids and/or vitamin D analogs.
Moderate to severe and/or extensive psoriasis may require phototherapy, oral retinoids, methotrexate, biological agents, or cyclosporine.
Inevitable abortion
vaginal bleeding with pain and cervical dilation and/or effacement.
Dawn Phenomenon
early morning increase in blood sugar between 2-8am
threatened abortion
vaginal bleeding without dilation of the cervix or passage of tissue. minimal pain
Pulses paradoxes
is an abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration
s/s of preeclapsia:
headache, visual disturbances, edema.
Tests:
Treatments: metoprolol
Pencil like stool
think colon cancer: Tenesmus or the feeling of having to defecate without having stools, pain upon defecation, or sciatica can be symptoms of rectal cancer
S/s Intussusception and age it ususally occurs
Intussecption- sausage shaped mass in upper right quad. Currant jelly stool. Ur bowels prolapse into another part of ur intestine. Barium or air enema can help to reduce this. Previously healthy then they get sick. Usually before 2 years
incomplete abortion
moderate to diffuse bleeding with the passage of tissue and painful uterine cramping
Contraindications for Thiazides
Serious sulfa allergies, hypotension, gout, renal failure due to loss of sodium, hypokalemia, may worsen DM, lead to metabolic alkalosis, by action of the renin angiotensin system, decreased volume and arterial pressure. May cause hyperglycemia due to insulin resistance and decreased insulin release
How to palpate for rotator cuff injury:
??
Age of pyloric stenosis
Pyloric stenosis- 3-12 weeks
How to assess for knee injury:
Lachman
Drawer test:
Miniscus versus cruciable ligament tear
Presumptive signs of pregnancy
signs felt by women, amenorrhea, nausea, breast tenderness, N/V, urinary frequency,
Thiazides are beneficial for:
osteoporosis, reduces calcium excretion by kidneys, and stimulates osteoblasts which help with bone growth
Glimeperide
Don’t use this DM med with insulin
medications that can increase GERD
BB, CCB, HTN meds increase GERD.
when to refer ankle injury?
Grade of strain?
Probable signs of pregnancy
examiner suspects a women is pregnant. such as enlarged uterus, hegar’s sign(softening and compressibility of the lower uterus), chadwick’s sign (deepened violet-bluish color of the cervix and vaginal mucosa), goodell’s sign(softening of the cervical tip), ballottement, braxton hicks, positive pregnancy test, fetal outline felt by examiner.
what time of day should H2 blockers be taken
before bed
primary amenorrhea:
Primary amenorrhea: lack of menses by age 15 years in a patient with appropriate development of secondary sexual characteristics, or absent menses by age 13 years and no other pubertal maturation.
Secondary amenorrhea: lack of menses in a non-pregnant female for at least 3 cycles of her previous interval, or lack of menses for 6 months in a patient who was previously menstruating.
A1C result for Dx of DM
6.5 or greater and confirmed on a different day
Positive signs of pregnancy
audible fetal heartbeat, fetal movement felt by examiner, ultrasound visualization of fetus, cardiac activity on U/S.
intermittent claudication
Initial evaulation check the ankle and brachial blood pressure before and after exercise.
A1C results for Dx of Pre-DM
5.7-6.4
radial head fracture:
caused by fall onto wrist: x rays may show positive flat pad sign also known as sail sign.
epigastric pain that radiates to the back
pancreatitis
Random glucose that confirms DM
200 or higher
different between amylase and lipase
lipase more specific to alcoholic pancreatitis, starts to rise 4-8 hours after symptoms begin
amylase starts to rise 2-12 hours after onset of symptoms
Theophylline
contraindicated drugs are erythromycin, phenytoin and cimetidine.
Nursemaid elbow:
after reduction the child quickly resumes activity
treatment for high triglycerides.
High Triglycerides- causes pancreatitis >500.
If >500 treat with Niacin or Fibrate or Niaspan.
If your patient is already on NIACIN you can add a fibrate like (LOPID/TRICOR).
Apparently an insulin infusion works also
Webber test:
used to test for both conductive and neural hearing loss.
Eye tests
The cover/uncover test screens for strabismus. Visual acuity is the snellen. Cataracts screened by using the red reflex. (positive by white relaxation.
Which medications increase the risk of developing Type 2 DM?
Glucocorticosteroids
HCTZ
Atypical antipsychotics
HMG Co-A reductase inhibitors
Mitral Regurge murmur:
How to diagnose: Mitral regurgitation (MR) may present with dyspnea, usually on exertion, palpitations, and/or decreased exercise tolerance.
Typically, presents as a holosystolic blowing murmur at the apex, radiating to axilla.
1st Tests To Order
transthoracic echo
ECG
Koilonychia
spoon shaped nails associated with IDA.
CCBs (Verapamil)
Med that can make GERD worse?
Fructosamine test
checks sugar for past 2-4 weeks, high results = high blood sugar
hyperparathyroidism – labs and causes
Elevated PTH with primary- hypercalcemia or secondary-hypocalcemia
Primary hyperparathyroidism- benign adenoma (most common) or familial;
Secondary- is a response to hypocalcemia (renal failure, drugs)
s/s of hemorrhoids and tx:
Bulk forming agents with hydrocortisone tx
s3
opening snap, CHF, normal variant in healthy young adults and athelets
Negligence
When a practitioner fails to exercise the care that a reasonable person would exercise (Injury does not have to happen)
Duodenal ulcer
Type of ulcer where symptoms occur 2-5 hours after eating. (Symptoms can be relieved by antacids).
Herberden’s nodes
Hard nodules or enlargements
of the distal interphalangeal
joints of the fingers. Found in degenerative joint disease
s/s hyperparathyroidism
Fragile bones that easily fracture (osteoporosis)
Kidney stones
Excessive urination
Abdominal pain
Tiring easily or weakness
Depression or forgetfulness
Bone and joint pain
s/s of colon cancer:
herbal remedies commonly used:
Fever few: migraines, migraines during menstration.
DTAP, Tdap, Td
Dtap is the pediatric version you receive from 2 mo to 6 yrs. Adults begin with Tdap. Td as booster every 10 yes.
Gastric ulcer
Type of ulcer where symptoms occur within minutes after eating (less relief from antacids)
treatment for hyperparathyroidism
Primary: surgical parathyroidectomy if symptomatic or biphosphonates and monitoring (BP, renal, bones) if asymptomatic
Secondary: Vitamin D and calcium & treat cause
Addison’s :electrolytes, symptoms, treatment
Addison’s- adrenal deficiency – usually autoimmune cause. Deficient in cortisol (low blood sugar cuz cortisol stimulates gluconeogenesis in the liver so low cortisol = hypoglycemia in times of stress)… hyperpigmentation (Kennedy’s perpetual tan) and low aldosterone (leads to low Na in blood — SALT CRAVINGS! — high K) , You must give cortisol. (Diagnosis Plasma Cortisol <5 mcg/dl @ 0800.) *You have ADD cortisol because cortisol is low in ADDisons
Mini-mental status exam:
Also called folstein mini-mental status exam- used for memory or- attention and calculation, recall, language, ability to follow simple commands and orientation.
Menses
The onset of menses occurs between Tanner stages III and IV.
Hypertrophied left ventricle
A common early finding in pt with chronic aortic regurgitation.
Tzank, PCR, or DFA
Tests that can be used to dx shingles
Delerium
reversible acute confusion, hours to days, short attention span, memory loss and disorientated.
Causes:prescription meds, substance abuse, dru-drug interactions, withdrawl, infections, sepsis, electrolyte inbalances
Alzheihmer does not cause it
Cushing syndrome
Central obesity, moon face, purple striae, hairy, hypertension, elevated plasma CORTISOL in AM. “INC BS, SODIUM” Dec K. You must draw cortisol levels in the morning.
Fever:
decreases the threshold of seizures.
when to start basal insulin
If you are already on TWO oral drugs for diabetes and A1c is 9 or higher, start BASAL insulin. If you cannot tolerate metformin and your A1c is 9 or higher start BASAL insulin.
Beta thal anemia:
electrophoresis
Implanon
progestin-only method and provides three yrs of pregnancy protection.
Diarrhea, abdominal pain, N/V
Classic symptoms of Cdiff
parathyroid gland and PTH – role in the body
- PTH is responsible for calcium loss or gain from bones, kidneys, and GI tract.
Neutral Protamine Hagedorn (NPH)
intermediate acting insulin
E Coli
The Most common pathogen with Pyleonephritis
HIV monitor progress of disease?
CD4 and viral load tests
3-4 weeks ago
A patient with a primary case of scabies was probably infected how long ago?
Legg-calve-perthens
Referral for aggressive treatment if they are 7 yrs of age
best test to differentiate iron deficiency from other anemias?
ferritin
Hypothyroidism- lab findings, diseases associated with, tx
High TSH LOW Free T4/T3, However, Free T4 is much more specific to this disease. Hashimotos (autoimmune) think of everything in ur body is slowing down. Synthroid.
Hypokalemia
A pt taking HCTZ and complaining of muscle cramps probably has?
Primary amenorrhea
-no menarche by age 16
-usually due to anatomic or genetic causes
trigeminal neuralgia:
Facial pain syndrome in the distribution of ≥1 divisions of the trigeminal nerve.
Diagnosis is clinical, with a history of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes.
First-line therapy is medical, to which the majority of patients are partially responsive.
Primary Options
carbamazepine : 200 mg/day orally initially given in 1-2 divided doses, usual maintenance dose is 400-1200 mg/day given in 2 divided doses
oxcarbazepine : 300 mg/day orally initially, usual maintenance dose is 600-1200 mg/day, maximum 1200 mg/day given in 2 divided doses
Which tx for hyperthyroidism is preferred in pregnancy
PTU PREFERED IN PREGNANCY
HTN
AV Nicking is seen in what disease?
Dubowitz and Ballard method
tests the elasticity of cartilage in the ears only.
Acute bacterial conjunctivitis in infants:
Primary Options
azithromycin ophthalmic : (1%) 1 drop into the affected eye(s) twice for one day, then once daily for 4 days
erythromycin ophthalmic : (0.5%) apply to the affected eye(s) four times daily
polymyxin B/trimethoprim ophthalmic : (10,000 units/mg) 1 drop into the affected eye(s) four times daily
hyperthyroidism
Graves disease-autoimmune. Lid lag, exophthalmos, everything is hyper (body wise). Treatment: PTU/Tapazole.
chorionic villus sampling (CVS)
CVS 10- 12 weeks
Amniocentesis 15-18 weeks
Complications of Cellulitis with a diabetic patient
OSTEOMYELITIS
Beta Blockers, CCB, & TCAs
Medications used for migraine prophylaxis
HCTZ interacts with digoxin:
Digoxin toxicity
Hashimotos, TSH and Free T3/t4 , plus test to connfirm
first order TSH and get high TSH. Then order thyroid panel and get low t3. The diagnosis is confirmed by the presence of thyroid autoantibodies in the blood, usually at high levels. Thyroid peroxidase antibodies (TPO) are more common that thyroglobulin antibodies
most common pathogens for community acquired pneumonia in older adults:
H.Influenza and S. Pneumoniae
Pneumocystis jiroveci can cause pneumonia in people whose immune system is not working well.
Streptococcus pneumoniae, or Pneumococcus, continues to be responsible for 20 to 50 percent of CAP, and is the single most common pathogen causing CAP.
Mycoplasma, Chlamydophila, and Legionella, collectively known as the “atypical” CAP pathogens, cause 20 – 30% of CAP. Legionella is commonly implicated in severe CAP, while Mycoplasma and Chlamydophila more often result in mild clinical disease.
Influenza is the most common respiratory virus resulting in CAP. Influenza infection also predisposes to subsequent development of bacterial CAP, referred to as “post-influenza pneumonia”.
Hemophilus and Moraxella are common pathogens, particularly in patients with COPD or intrinsic lung disease.
Mammograms
UPSTK end at 75
ACOG up to 74
Hyyphae
A skin lesion fluoresces under a Wood’s lamp. What microscopic finding is consistent with this?
Latent TB treated with
Latent TB usually treated with INH
Most common cause of acute bacterial sinusitis:
H.Influenza and S. Pneumoniae
Elderly PPD
Neg PPD, a second test PPD should be performed in 1 week.
Calcium
A supplement known to cause constipation?
s/s and testing for PCOS:
Key historic findings
female of reproductive age
irregular menstruation
infertility
hirsutism
Other Factors
scalp hair loss
oily skin or excessive sweating
acne
overweight or obesity
hypertension
acanthosis nigricans
1st Tests To Order
serum total and free testosterone
serum dehydroepiandrosterone sulfate (DHEAS)
serum 17-hydroxyprogesterone
serum prolactin
serum TSH
oral glucose tolerance test
fasting lipid panel
Other Tests to Consider
serum androstenedione
pelvic ultrasound
basal body temperature monitoring
luteal phase progesterone measurement
serum LH and FSH
Tx:
Acute
with infertility and desiring fertility
weight loss
metformin
clomiphene
metformin
dexamethasone
gonadotropins
metformin
in vitro fertilization
metformin
laparoscopic ovarian drilling
Ongoing
not desiring current fertility
with hyperandrogenic features alone
oral contraceptive pill
metformin
mechanical hair removal or topical therapy
antiandrogen
antiandrogen plus oral contraceptive pill
long-acting GnRH analog plus oral contraceptive pill
with oligoamenorrhea alone
weight loss
oral contraceptive pill
metformin
cyclic progestin
with hyperandrogenic features plus oligoamenorrhea
weight loss
oral contraceptive pill
metformin
mechanical hair removal or topical therapy
antiandrogen plus oral contraceptive pill
long-acting GnRH analog plus oral contraceptive pill
Diagnosing TB, which is gold standard for dx of TB
ACTIVE TB order, NAAT, C&S, AFB. The AFB is not diagnostic. SPUTUM FOR C & S is gold standard.
Ribavirin se
hemolytic amemia
Improve Urine flow
An elderly patient will take Saw Palmetto because he thinks it will help with what?
symptomatolgy
management of COPD for the elderly
60 yo
CDC recommends Zoster vaccine in what age of immunocompetent pt?
Mantoux test results, what size induration is considered positive.
5mm-think immunocompromised or person in close contacts.
10 think Immigrants, working status (nurses), drug users, home life.
15 Think no risks
28 week old pregnant patient has single episode of vaginal bleeding without other s/s: What to do?
Ultrasound
What will you hear with percussion of emphysema lungs, what will you see on CXR, what will you notice about their breathing
Emphysema Lungs- Percussion-HYPERENNOSANCE tactile frem + egophony- dec. CXR- flattened diaphragms with hyperinflation. Inc. AP diameter, accessory muscles, pursed-lip breathing, weight loss.
TIA V. Stroke:
Tia has absence of residual s/s.
Biaxin and digoxin
Biaxin raises digoxin level
Alcohol
If a pt is taking metronidazole, they should avoid what?
Terbinafine, atorvastatin, simvastatin
Which 3 medications should have liver function test prior to starting?
McBurneys point: rebound tenderness-
sign for acute appendicitis
MANTRELS score [41]
Score is based on clinical characteristics of the patients. The higher the score out of a possible total of 10, the greater the chance of having acute appendicitis.
M: Migration of pain to right lower quadrant = 1 point
A: Anorexia = 1 point
N: Nausea and vomiting = 1 point
T: Tenderness in right lower quadrant = 2 points
R: Rebound tenderness = 1 point
E: Elevated temperature = 1 point
L: Leukocytosis = 2 points
S: Shift of WBC count to left = 1 point
Or use apache 2 calculator.
Omezaprole
se headache, abdominal pain and gas
asthma patient on low-dose ICS still has symptoms, what is next step
IF LOW DOSE ICS, NEXT IS MEDIUM DOSE
intermittent asthma, day time symptom frequency, night time awakenings, tx
<2 / week day, <2 month – night, SABA
Polymyalgia rheumatica s/s, tests and tx:
Basics:
Typically a history of neck, shoulder girdle, and/or hip girdle stiffness and pain, occurring in patients age 50 years or older.
Patients complain of difficulty rising from seated or prone positions, varying degrees of muscle tenderness, shoulder/hip bursitis, and/or oligoarthritis.
More common in women.
About 15% to 20% of patients with polymyalgia rheumatica (PMR) have giant cell arteritis (GCA); 40% to 60% of GCA patients have PMR.
Diagnosis is made via history and with supportive laboratory tests indicating an elevated ESR or CRP.
Rapid improvement often occurs within 24 to 72 hours with low-dose prednisone.
s/s:
Key Factors
shoulder/hip girdle stiffness
shoulder/hip girdle pain
rapid response to corticosteroids
Other Factors
acute onset
low-grade fever
anorexia
weight loss
malaise
depression
asthenia
oligoarticular arthritis
dx:
Criteria: must have any 3 factors, or just 1 and a temporal artery biopsy positive for giant cell arteritis
Age over 65 years
Bilateral shoulder girdle pain
More than 1 hour morning stiffness
Symptom onset <2 weeks
ESR >40 mm/hour
Depression/weight loss
Upper arm tenderness, bilateral.
Tests: 1st Tests To Order
ESR
C-reactive protein (CRP)
CBC
ultrasound
Other Tests to Consider
TSH
MRI
serum protein electrophoresis
serum creatine phosphokinase
TX:
Acute
initial presentation
corticosteroid: prednisone : 10-20 mg orally once or twice daily
calcium + vitamin D + bisphosphonate
nonsteroidal anti-inflammatory drug (NSAID)
methotrexate
folic acid
tocilizumab
Ongoing
treatment-resistant or relapse or disease exacerbation
corticosteroid (increased dose)
calcium + vitamin D + bisphosphonate
methotrexate plus folic acid
tocilizumab or leflunomide
Nummular Eczema
pruritic inflammatory dz – young, old
fall/winter, coin-shaped plaques – common on lower leg extremities
tx: moisturizers or topical steroids
Mitral Valve porlapse
Which mitral disorder results fro redundancy of the mitral valve’s leaflets?
Mild persistent, daytime symptoms, night awakenings, tx
2 but not daily symptoms, >2 per month, but not weekly, SABA + low dose ICS
interductal papilloma
is a small, benign tumor that forms in a milk duct in the breast. These tumors are made of gland and fibrous tissue as well as blood vessels. They most commonly occur in women between ages 35 and 55. Unilateral spontaneous serous or serosanguineous discharge
s/s of polymyalgia rheumatica:
pelvic girdle pain for 6 months, unintentional weight loss, pain with ROM, unintentional weight loss, low hemoglobin and elevated ESR
LDL
The lipid particle with the greatest atherogenic effect is
Mod Persistent, daytime symptom frequency, night awakenings, tx
daily daytime symptoms, night awakenings >1 per week, SABA+ICS+LABA or SABA+medium dose ICS
Fasting blood glucose of 126:
Diagnose Diabetes
Alzheimer’s disease
starts with short term memory loss
Check TSH
If a pt’s lipids are elevated, what would the NP do next?
s/s of hypoglycemia if patient is on a betablocker and insulin:
sweating. Not tachycardia
ACE inhibitors
Which class of medication is frequently used to improve long-term outcomes in pts with systolic dysfunction?
Cellulitis
Staph aureus most common bacteria with people DM
Severe persistent, daytime, night awakenings, tx
symptoms throughout the day, nightly asthma symptoms- SABA, Med ICS plus LABA.
pulsus paradoxus
Pulsus paradox Apical pulse can still be heard even though the radial pulse is no longer palpable. Certain issues cause impairment with diastolic filling, 10 or greater drop in the SYSTOLIC pressure. I think her patient had asthma and their pressure dropped by 10 etc.
Tx for trichomonas vaginitis:
metronidazole 2 grams (flagyl)
s/s: Key Factors
vaginal discharge
dysuria
discharge adherent to vaginal mucosa
Other Factors
prior episodes
fever
pruritus
vulvodynia
vaginal dryness
vaginal bleeding
abdominal pain
dyspareunia
erythema
pale epithelium
shiny epithelium
decreased elasticity
friable epithelium
strawberry cervix
testing:
1st Tests To Order
vaginal pH
amine “whiff” test of vaginal secretions
wet mount microscopy of vaginal secretions
Gram stain of vaginal secretions
HIV test
nucleic acid amplification test (NAAT)
VDRL
serum rapid plasma regain (RPR) test
Criteria:
Bacterial vaginosis:
Vaginal pH >4.5
Whiff test
Clue cells (vaginal epithelial cells with distinctive stippled appearance in saline wet mount by being covered with bacteria)
Adherent white vaginal discharge.
cepalohematoma
enlarged fluid filled area that is subperiosteal and does not cross the suture line
Iron Def. Anemia
Which hypochromic, microcytic anemia has elevated RDW?
What to check before starting statins
Must check LFT before starting Statin
normal changes with aging?
less gastric acid production.
Forced Vital Capacity (FVC)
The volume of air expired during a forced maximal expiration after a forced maximal inspiration.
Clinical Inertia
Providers who do not increase therapy even if test results indicate the need.
T wave inversion suggests:
acute coronary ischemia
Potassium supplements
A patient taking an ARB should avoid?
Gastic ulcer v peptic ulcer disease:
Peptic ulcer:
Usually presents as chronic, upper abdominal pain related to eating a meal (dyspepsia).
Use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori infection are the most common causes.
There may be some epigastric tenderness, but often there are no other signs on physical examination.
Endoscopy is diagnostic and may show an ulcer in the stomach or proximal duodenum. H pylori infection should be sought.
In the absence of “alarm” (red flag) symptoms or signs, testing for and treating H pylori and/or empiric acid inhibition therapy is appropriate.
Most common complications are gastroduodenal bleeding and perforation, either of which may be the presenting symptom, particularly in patients taking NSAIDs.
Gastritis:
A histologic term for inflammation of the gastric mucosa.
Helicobacter pylori infection and use of nonsteroidal anti-inflammatory drugs (NSAIDs) or alcohol are the most common causes. Other causes include stress (secondary to mucosal ischemia) and autoimmune gastritis. Rare forms include phlegmonous gastritis (a rare bacterial infection).
Diagnosis is based on clinical history and characteristic histological findings. A variety of methods may be used to diagnose H pylori infection.
Presence of suspicious features suggestive of upper GI malignancy requires urgent endoscopy. These include GI bleeding, anemia, early satiety, unexplained weight loss (>10% body weight), progressive dysphagia, odynophagia, or persistent vomiting.
Treatment depends on the etiology. Options include H pylori-eradication therapy, reduction of NSAIDs or alcohol exposure, and symptomatic therapy with histamine-2 antagonists and/or proton-pump inhibitors.
If untreated, progression to peptic ulcer disease may occur. Other complications include gastric carcinoma and gastric lymphoma.
Who gets statins
- Patients with any form of clinical ASCVD
- Patients with primary LDL-C levels of 190 mg per dL or greater
- Patients with diabetes mellitus, 40 to 75 years of age, with LDL-C levels of 70 to 189 mg per dL
- Patients without diabetes, 40 to 75 years of age, with an estimated 10-year ASCVD risk ≥ 7.5%
Age
The primary risk factor for development of breast cancer in women of average risk is?
Who gets moderate intensity statin
- Age > 75 years + ASCVD
- DM + 70-189 LDL but low <7.5 ASCVD risk
- healthy, 70-189 LDL, very low 5-<7.5 ASCVD risk (4 healthy, 70-189 LDL, low >7.5 ASCVD risk, may choose moderate or high intensity)
To assess abstract thought:
ask meaning of common proverb.
Lyme disease
child 6 yrs old amoxicillin or cefuroxime
14 days or longer
How long should a pt be treated with atb if he has prostatits secondary to an STD?
Latent TB
INH for 9 months isoniazid
Thiazide diuretic c/i and side effects
no sulfa allergies,
MoNKey low: hypo Mg, Na, K
GLUT – hyperGlycermia, hyperLipidemia, hyperUricemia, hyperTriglyseridemia,
No satelite lesions with diaper rash:
contact dermatitis
Satelite lesions- candida infection
Chronic Venous Insufficiency
Impaired venous return. Achy legs relieved by elevation, edema after prolonged standing, night cramps, brownish discoloration, cold, ulcers. Etc. do support stockings.
pulmonary rehab goals include:
increase exercise capacity, decreased hospitalization, enhanced quality of life.
NOT increased lung capacity.
H and H testing infant
6, 9 and 12
Cetirizine
Which long-acting antihistamine is sedating?
peripheral artery disease (same as PVascularD)
Nocturnal pain relieved by lowering legs, poor pulses, dependent rubor, intermittent claudication, atrophy, shiny, hairless, cold feet. Initial do a pulse check, ABI 0.9 or less is PAD. Ateriography is the most DEFINITIVE test. Try to develop collateral circulation. Otherwise- Trental, Pletal ( a xanthine derivative used as a drug to treat muscle pain in people with peripheral artery disease)
devlopment warning signs
-visual delay
-does not pick up toy by 6 mo
-no reaction to noise
-no laugh
does not sit up
-does not raise head by 3 mo while on tummy
Gynecological & GI bleeding
What are the 2 most common causes of IDA in adults?
Tx for isolated systolic HTN
ccb
ADHD (Attention-Deficit Hyperactivity Disorder)
a psychological disorder marked by extreme inattention and/or hyperactivity and impulsivity
-s/s present before the age of 7 as late as 12
-s/s for at least 6 mo
-must occur in home, school and play
-Tx ritalin, concerta,metadate,focalin, adderall, vyanse
Costovertebral angle tenderness (CVA)
A pt with pyelonephritis will likely have what symptom?
S4 when
S4-LVH stiffening, Tennesse, late diastole. “Atrial kick/gallop”
menarche
breast dev stage 3 to 4, predominatly 4
No significant systemic effects. They are predictable.
Class effect of nasal steroids?
s3 when heard
S3- HF, Kentucky, early diastole. Abn >35. Bell
Spermarch
genital stage 3
Hyperopic
Farsighted (objects nearby are blurry)
VSD
thrill, felt at LLSB
Presbyopic
Age-related farsightedness
MVP how it sounds, when to treat and how to treat
MVP- S2 click, followed by systolic murmur. Asymptomatic. MVP with palpitations is treated with BB.
HTN meds that can cause heartburn
BB, CCB, alpha agonists. (HTN meds). EXAM
Myopic
Nearsighted
Tx sinusitis
AUGMENTIN. if pen allergic – doxy or levofloxacin (adults). kids get clinda+3rd gen cephalosporin (IDSA) adults get treated 5-7 days, kids get 10-14 days
In what condition are the turbinates dark red and swollen?
Acute rhinitis
test for mononucleosis
monospot is a heterophile antibody test
Gyrate lesions
Scabies
Otitis Externa (swimmers ear)- bacterial cause and tx
Pseudomonas aeruginosa. (other- S. aureus). External ear pain- d/c itching, hearing loss, tragus, green d/c. TREATMENT: Corticosporin, Cipro
Topical antimicrobials or antibiotics such as acetic acid, aminoglycosides, polymyxin B, and quinolones are the treatment of choice in uncomplicated cases
Most likely diagnosis for rash that starts on belly and spreads to the rest of the body including the face. Causes severe itching.
Varicella
Weber lateralization to which ear
Weber’s test is performed by softly striking a 512-Hz tuning fork and placing it midline on the patient’s scalp, or on the forehead, nasal bones, or teeth.
If the hearing loss is conductive, the sound will be heard best in the affected ear.
If the loss is sensorineural, the sound will be heard best in the normal ear.
The sound remains midline in patients with normal hearing
Pt: NP, I can’t hear in my left ear.
NP (wonders to herself): I wonder if it is conductive hearing loss.
There are three options:
Does Weber test and pt can hear best in left ear (affected ear) == “Sir, you have conductive hearing loss.”
Does Weber test and patient can hear best in RIGHT ear (normal ear) == “Sir, you have sensorineural hearing loss”
Hears both equally == “Sir, you do not have hearing loss.”
What skin condition is a raised reddened area with a dimpled look?
Basal cell carcinoma
Rinne test results and interpretation
AC>BC is normal. BC>AC is conductive hearing loss
Skin condition that can manifest when stressed. Itchy and dries up like cream colored sand paper before healing
Eczema
Incretins do what?
Signal the pancreas to increase insulin secretion & signals the liver to stop producing glucagon
AOM tx
Amox, If your patient is only PCN allergic do azithromycin or clarithromycin.
AOM bacterial cause
. Usually S. pneumo. (others: h influ, mor catarrhalis).
Lactic acidosis is a potential adverse side effect most commonly seen with which medication?
Metformin (Glucophage)
Koplik spots are a diagnostic indicator of
lusters sm. Size red papules w/ white centers in the buccal mucosa by lower molars -rubeola measles
What is a bubo?
a swollen, inflamed lymph node in the armpit or groin.
diabetic retinopathy
Diabetic Retinopathy-Cotton wool spots (moderate retinopathy), micro-aneurysms. ALSO RETINAL HEMORRHAGES ON CENTER OF EYE APPEAR ORANGE RED
Where is the site for most breast tumors in women?
Upper outer quadrant
hypertensive retinopathy
Hypertensive Retinopathy- Copper/silver wire arterioles. AV nicking(mild retinopathy). Retinal “flame” Hemorrhages
What is a positive prehn’s sign?
Lifting of the testes
papilledema appearance and indicates what
Papilledema- optic disc swollen w/ blurred edges due to increased ICP
Which cranial nerve is most responsible for papillary constriction?
Oculomotor
S/S of retinal detachment
Retinal Detachment- Floaters, curtain, flashes of light. Painless.
Which type of ulcer feels better right after a patient eats?
Duodenal ulcer
age-related macular degeneration: how affects sight, how test
Age-Related Macular Degeneration – Painless loss of “central vision” reports straight lines appear curved. Periphery is preserved. Give amsler grid.
The most critical assessment finding with acute abdomen with peritonitis with a bowel perforation is?
Rigidity
Which ECG changes would the provider see in a pt with classic angina?
ST depression
Cataracts, how affect elderly eye sight
in elderly night vision issues. Opaque
acute angle closure glaucoma: what patient will see, findings on physical exam, disposition
Acute Angle-closure glaucoma- acute/severe halos, cupping optic nerve, cloudy cornea, mid-dilated oval pupil. ER STAT
Dependent rubor is found in what disease?
Ateriosclerotic occlusvie disease
Primary open angle glaucoma, how affects sight
Primary Open Angle Glaucoma- CN2 gradual changes in peripheral vision LOST FIRST, then second central vision
What to test for with rash on hands and feet?
rash hands soles/feet think to test for secondary syphilis RPR then VDRL are screening, then dx FTA-ABS.
pityriasis rosea
pityriasis rosea itchy, herald patch, xmas tree pattern,
Wickham’s striae
fine, lace-like network of white lines in lichen planus
lichen planus tx
topical steroids
Describe scarlet fever rash
Scarlet fever (Scarlantina)- “sandpaper textured-pink rash with sore throat” strawberry tongue, rash starts on head and neck, spreads to trunk. The skin THEN desquamates.
Impetigo appearance
Impetigo-Gram positive. Itchy pink-red lesions, evolve into vesiculopustules that rupture
Treatment for impetigo, plus for allergies
. If bullous-large blisters. Severe- Keflex, dicloxacillin. PCN Allergic-Azithro, clinda.
acne rosacea: appearance and treatment
Acne Rosacea- chronic small acne like papules/pustules around nose mouth chin. TREATMENT- Metrogel, Azelex. Low dose tetracycline.
treatment mild acne
Acne Vulgaris (common acne)- ON EXAM
mild (topicals only) *open/closed comedone w/ or w/o sm. papules. Retin-A, acne worsens 4-6 weeks if no improvement in 8-12 weeks increase dose or add erythromycin, benzoyl peroxide.
treatment moderate acne
Moderate (topicals plus antibiotics)- papules, pustules w/ comedones. Continue with topicals combined with topical antibiotics. Then add ORAL antibiotics tetra, mino, doxy
treatment of severe acne
Severe- with painful indurated nodule, cysts, abscesses, pustules. Accutane- check LFTs, 2 forms of contraceptives, monthly prego testing, only prescribe 1 month supply.
varicella zoster
“contagious 48 h. before, until all lesions crusted over” low grade fever, generalized lymphadenopathy, intense itching, erythematous macules, papules develop over macules, then vesicles erupt. “initially on trunk, then scalp and face” TREATMENT supportive, antihistamines, acyclovir 20mg/kg 5xd. If given first 24 hours works best.
MRSA tx
MRSA TREATMENT: Bactrim, doxy, mino, clinda. If sulfa allergy do not use Bactrim.
actinic keratosis: s/s, gold standard dx, tx
Actinic Keratosis- Precursor to squamous cell carcinoma. “numerous dry round and pink to red lesions” with a rough and scaly texture. Does not heal. Slow growing in sun exposed areas. Diagnosis: BIOPSY Golden Standard. Treatment: Sm. (cryotherapy), Lrg. (5-FU cream)- which causes ur skin to ooze, crust, scab, redness.
Tinea Corporis
Tinea Corporis- “ring like itchy rash, slowly enlarge central clearing”-Treatment: most respond to topical antifungals, if severe do oral Lamisil.
Eczema, s/s, mediated by which immunoglobulin, tx
Atopic Dermatitis (eczema)- Inherited. Extremely itchy. On flexural folds, neck, hands. Inc. IgE. “small vesicles that rupture leaving painful, bright-red, weepy lesions” they become lichenified from itching. First line: Topical steroids. Avoid hot water/soaps. PO antihistamines.
Koebner phenomenon
(Koebner phenomenon- new psoriatic plaques form over skin trauma)
Psoriasis tx
TREATMENT: Topical steroids, Tar preps (mild). For (severe) do anti-TNF, or immunologic.
Melanoma: how it looks
Melanoma- Dark Moles, uneven texture, different colors, irregular, >6mm, could be itchy. EXAM
Lyme: name of rash, what is the rash like
Erythema Migraines- (stage 1 Lyme) Target bulls-eye, usually appears in 7-14 days POST being bitten by a deer tick. Rash is hot to touch with rough texture, flu like symptoms.
Lyme: how dx
DX: B. Burgdorferi via ELISA, then confirm with western blot. Increased ESR.
Lyme: tx
TREATMENT: Less than 7 Amoxicillin or cefuroxime axetil. Older than 7 Doxycycline.
Rocky mountain spotted fever: s/s
RMSF- Inc. fever, chills, N/v, photophobia, myalgia, arthralgias THEN 2-5 days later you develop a petechial rash on forearms, ankles, wrists, that spreads towards trunk and becomes generalized. Think rocky NC/OK/AK/TN/MO.
Rocky mountain spotted fever – dx
DX: PCR essay with Rickessetti Antigen
Rocky mountain spotted fever – tx
TREATMENT- doxycycline.
acute sinusitis
CP?
Diagnostic?
(DDx)
Pharm, NonPharm?
f/u
Recognize normal course? Refer?
- S Pneu. H. Flu. M. Cat. Viral
- Facial or upper molar pain. Nasal congestion >10d. Purulent nasal d/c or PND- awaken at night w cough. Fever (mostly w children not adults). Can be due to allergy flare-up, then boggy swollen nasal turbinate. Tender sinuses.
- H&P, Positive transillumination.
- If mild uncomplicated- topical decongestants (Afrin), Steroid and saline nasal spray, Mucolytic
- If severe, 1st: Augmentin
Alt: Levaquin, Doxy, Cefdinir, Cefin
Arcus Senilis
normal finding in elderly
white, grey, or blue opaque ring in the corneal margin (peripheral corneal opacity), or white ring in front of the periphery of the iris. It is present at birth but then fades; however, it is quite commonly present in the elderly.
Epistaxis
anterior -Kiesselbach plexus
risk- nose picking
posterior – Woodruff –HTN, atherosclerosis- can lead to hemorrhage- refer to ED
tx: Anterior — pressure sitting position leading forward -lessen swallowing of blood
Epiglottis
severe, life-threatening infection of the epiglottis and supraglottic structures that occurs most commonly in children between 2 and 12 years of age
Periorbital cellulitis
Strep pneumo, Strep pyogenes, H flu, Staph aureus, Staph epi, oral anaerobes
acute onset of erythematous swollen eyelid w proptosis (bulging of the eyeball) and eye pain. Bad EOM exam w pain. h/o recent rhinosinusitis or URI.
Caused by bacterial infection of the orbital contents (fat and ocular muscles).
More common in children than adults.
Serious complications. Refer to ED.
Strep throat pharyngitis
Grp A Strep
Fever, Sore throat, Tonsillar exudate, absence of cough
PCN V, Amoxicillin
Alt: Azithromycin
Ibuprofen/Tylenol
Complications:
Scarlet fever- Sandpaper texture maculopapular rash that desquamates. Strawberry tongue. Sore throat that can lead to Acute Rheumatic Fever (affects the heart and valves, joints, brain)
Poststrep glomerulonephritis- abrupt onset of proteinuria, hematuria, dark-colored urine, RBC casts a/b HTN and edema
Mono
AOM
OME
OE
macular degeneration (MD)
Retinopathy
HTN
DM
Herpetic whitlow
A VIRAL skin infection of the finger(s) that is caused by HERPES SIMPLEX (type 1 (ORAL) or type 2 (GENTIAL) virus infection, from DIRECT CONTACT with either a cold sore or genital herpes lesion.
Self-limited infection: ANALGESICS or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain PRN.
SEVERE infections: Treat with ACYCLOVIR (Zovirax).
A 65-year-old woman presents for a follow-up examination after a new patient visit. She has not seen a healthcare provider for several years. She is a smoker and her hypertension is now adequately controlled with medication. Her mother died at age 40 from a heart attack. The fasting lipid profile shows cholesterol = 240 mg/dL, HDL = 30, and LDL = 200. In addition to starting Therapeutic Lifestyle Changes, the nurse practitioner should start the patient on:
1.bile acid sequestrant.
- a statin drug.
- a cholesterol absorption inhibitor.
- low-dose aspirin.
A statin drug
The most commonly prescribed medication for mild systemic lupus erythematosus (SLE) is:
- azathioprine (AZA).
- belimumab (Benlysta).
- ibuprofen (Advil).
- cyclophosphamide (Cytoxan).
ibuprofen (advil)
The most common sign of cervical cancer is:
- postcoital bleeding.
- strong odor from vaginal discharge.
- itching in the vaginal area.
- molluscum contagiosum.
postcoital bleeding
The nurse practitioner prescribes amitriptyline (Elavil) for a patient with neuropathic pain secondary to diabetes mellitus. On follow-up, the patient complains of urine retention and dry mouth. The practitioner would:
- discontinue amitriptyline and begin ibuprofen (Motrin).
- refer to physical therapy.
- start methocarbamol (Robaxin).
- discontinue amitriptyline and begin gabapentin (Neurontin).
discontinue amitriptyline and begin gabapentin (neurontin)
A 17-year-old male with rheumatoid arthritis is being treated with an NSAID and omeprazole (Prilosec). The patient complains of headache, abdominal pain, and gas. These symptoms are most likely:
- associated with the omeprazole.
- related to the underlying condition.
- the result of the NSAID.
- caused by viral gastroenteritis.
associated with the omeprazole
The medication of choice for the initial treatment of juvenile rheumatoid arthritis is:
- acetaminophen.
- prednisone.
- aspirin.
- ibuprofen.
ibuprofen
A 12-year-old with sickle cell anemia has recently experienced a sickle cell crisis and presents for a follow-up examination after a recent hospitalization. It is most important to continue monitoring growth, development, and:
- white blood cell levels.
- fecal occult blood test.
- hemoglobin levels.
- urine dipsticks.
hemoglobin levels
A 90-year-old female is brought to the clinic by her neighbor. She states that everything is fine, but the nurse practitioner notes that she has poor hygiene and bruises on her trunk. The neighbor is concerned that the patient often has no money to buy food, despite income from social security and a coal miner’s pension. The nurse practitioner suspects abuse. Which of the following is the nurse practitioner obligated to do next?
- Report the case to the proper authorities.
- Tell the neighbor to check on the woman daily and report back.
- Document the data and report the information to risk management.
- Call the patient’s family and inquire about the concerns.
report the case to proper authorities
In most cases, the first manifestation of Alzheimer’s disease is:
- impaired judgment.
- decrease in short-term memory.
- disorientation in time and place.
- decrease in long-term memory.
decrease in short-term memory
The optimal treatment for latent tuberculosis is:
- rifampin (Rifadin) for 5 months.
- isoniazid (Nydrazid) for 9 months.
- pyrazinamide for 6 months.
- ethambutol for 6 months.
osioniazid (nydrazid) for 9 months
Unilateral spontaneous serous or serosanguineous discharge from a single duct of a breast is most often caused by:
- intraductal papilloma.
- mucinous breast lesions.
- Paget’s disease.
- ductal carcinoma in situ.
intraductal papilloma
A young child with asthma presents for follow-up evaluation. After numerous changes in medications and doses, the parents report that the child continues to have difficulty with coughing, especially during the night. Which of the following conditions would be the most likely cause of the continued asthma symptoms?
- Vocal cord dysfunction
- Cystic fibrosis
- Gastroesophageal reflux
- Allergic rhinitis
gastroesophageal reflux
A pregnant woman with known HIV infection can reduce the risk of perinatal transmission through zidovudine (Retrovir) therapy. Based on current research, optimal therapy is to start daily dosing:
- post amniocentesis.
- after 14 weeks of gestation.
- if premature rupture of membranes occurs.
- if maternal viral loads are greater than 10,000.
after 14 weeks gestation
T-wave inversion with a normal ST segment on a 12-lead EKG may represent:
- acute coronary ischemia.
- right ventricular hypertrophy.
- atrial hypertrophy.
- hyperkalemia.
acute coronary ischemia
The 16-year-old mother of a 2-month-old presents the infant, reporting that the child is very irritable and does not feed well. During physical examination, the child’s head drops back and the child exhibits sudden flexing of the extremities. As the flexing stops, the child cries uncontrollably. Funduscopic examination reveals retinal hemorrhages. Which of the following diagnostic tests should be ordered?
- Skull X-rays
- MRI
- CT scan
- Pet scan
CT scan
The most important diagnostic factor in evaluating angina pectoris is the patient’s:
- King of Heart’s monitor.
- physical examination.
- history.
- echocardiogram.
history
There are three reasons for latex allergies. Which of the following does NOT cause the problem?
- Immediate hypersensitivity
- Irritant contact of dermatitis
- Cytotoxic hypersensitivity
- Immune complex reaction
cytotoxic hypersensitivity
A patient on warfarin (Coumadin) therapy for recurrent deep vein thrombosis (DVT) is about to have lumbar spinal fusion surgery. The patient’s warfarin is put on hold starting 5 days prior to the surgery and subcutaneous Lovenox has been ordered for DVT prophylaxis until the resumption of the warfarin. The nurse practitioner knows that the patient’s postoperative warfarin dose should be restarted based on the:
- value of her morning Prothrombin time.
- loading dose of 10 mg, plus the previous warfarin dose.
- baseline PT and INR values.
- target INR of 2.
caseline PT and INR values
An 87-year-old patient presents with round, pruritic plaques and small vesicles on the lower legs. The most likely diagnosis is:
- allergic contact dermatitis.
- plaque psoriasis.
- cutaneous T-cell lymphoma.
- nummular eczema
nummular eczema
A 3-year-old presents with a 2-day history of acute diarrhea with a total of 8 watery stools without blood or mucus, and 2 episodes of vomiting in the past 48 hours. Assessment reveals no current antibiotic therapy, dehydration <5%, soft abdomen with hyperactive bowel sounds, no masses or organomegaly; other physical findings are normal. Which of the following is the most appropriate management plan?
- Stool culture; Immodium AD liquid.
- No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
- Start diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup over next 72 hours; Imodium AD liquid, 1 mg/sml
- Stool for ova and parasites; advise parents of likely sources of Giardia; prescribe furazolidone (Furoxone)
No laboratory workup; instruct parents on signs and symptoms of dehydration; diet of clear liquids, advancing to bananas, rice cereal, Jell-O, and soup.
A mother presents her 12-month-old child with concern because the child does not yet say “mama” or “dada.” The mother reports that in the first months of life, the child loved listening to music and being talked to. The past medical history is negative for ear infections. The nurse practitioner should:
- evaluate for hearing loss.
- refer to speech therapy.
- re-evaluate in 3 months.
- check for cerumen impaction.
evaluate for hearing loss
The most common side effect of the oral ribavirin used in the treatment of hepatitis C is:
- hemolytic anemia.
- weight loss.
- depression.
- hypothyroidism.
hemolytic anemia
An 86-year-old patient presents with pinguecula, a yellow triangular degenerative tissue thickening of the bulbar conjunctiva. This condition is:
- cured by eye drops.
- a genetic process.
- a malignant growth.
- a solar-induced lesion
a solar-induced lesion
During a well-child examination of an 18-month-old, premature tooth decay and inflamed gums, particularly of the maxillary incisors, are noted. The approach to this problem includes:
- referring the child to a dentist, assessing for bottle feeding and fluoride in local water.
- teaching the mother to brush the child’s teeth, encouraging vitamin supplements.
- recommending fluoride mouthwash and toothpaste, suggesting celery sticks for snacks.
- providing fluoride treatment, teaching dental hygiene, and eating foods high in calcium.
referring the child to a dentist, assessing for bottle feeding and fluoride in local water
Which of the following is typically observed in the GI system upon stimulation of the parasympathetic nervous system?
- No overall effect
- Increased sphincter tone
- Increased peristalsis
- Decreased secretions
increased peristalsis
Type 2 diabetes mellitus is characterized by which of the following?
- Decreased production of exogenous glucagon-like peptide
- Autoimmune beta-cell destruction
- Relative deficiency of dipeptidyl peptidase-4
- Decreased reabsorption of sodium-glucose transporters
decreased reabsorption of sodium-glucose transporters
In pulmonary function testing, forced vital capacity represents the:
- maximum volume of air that can be forcefully exhaled after maximum inspiration.
- total volume of air that is exhaled after normal inspiration.
- total volume of air that the lungs can hold, minus the expiratory reserve volume.
- volume of air that can be forcefully exhaled in 1 second.
maximum volume of air that can be forcefully exhaled after maximum inspiration
An adult male presents as first patient of the day after awaking about 5:00 AM with indigestion and chest pressure. On checking his pulse, he found no change from previous measurements. He states that, while waiting for the nurse practitioner to arrive, he began to feel a little clammy. A 12-lead EKG records the following patterns. On the basis of these EKG readings, the diagnosis is:
- anterior-septal acute myocardial infarction.
- lateral acute myocardial infarction.
- inferior acute myocardial infarction.
- anterior acute myocardial infarction.
inferior acute myocardial infarction
During the past 24 hours, a 62-year-old has experienced abdominal pain that radiates to the back. The patient also reports several episodes of nausea and vomiting, a low-grade temperature, and a history of excessive drinking. Physical examination reveals a distended abdomen. Laboratory serum values indicate elevated alkaline phosphatase, amylase, and serum lipase. The most likely diagnosis is:
- alcoholic liver disease.
- acute mesenteric ischemia.
- viral hepatitis.
- acute pancreatitis.
acute pancreatitis
An otherwise healthy adult female presents complaining of vaginal burning and itching during urination. She has a social history of two sexual partners. She denies fever or vaginal discharge, but has noted a lesion on one labium. The nurse practitioner should order all of the following EXCEPT:
- wet mount and potassium hydroxide.
- dark-field microscopy of fluid from the lesion.
- nucleic acid amplification testing for gonorrhea.
- serology for Haemophilus ducreyi.
dark-field microscopy of fluid from lesion
A 3-year-old female has been diagnosed with bacterial meningitis. She attends preschool daily at a local church day care program. The day before her diagnosis, she ate lunch with her mother at a local restaurant. For which contact(s) would chemoprophylaxis with rifampin be recommended?
- Preschool contacts in the past 7 days
- A friend of the patient’s sister who visited after school yesterday
- The checkout employee at the grocery store yesterday
- Diners at the restaurant during lunch the day the patient ate there
preschool contacts in past 7 days
Congenital dysplasia of the hip:
- more commonly affects both hips.
- occurs more commonly in females.
- is correctable at any age.
- typically self-corrects by 12 weeks of age.
more commonly affects both hips
Anticholinergic agents such as ipratropium (Atrovent) and tiotropium (Spiriva) are used in COPD primarily to:
- induce bronchodilation.
- decrease airway inflammation.
- expand the lung fields.
- treat hypoxemia.
induce bronchodilation
The clinical presentation of placenta previa that develops during the third trimester includes:
- intermittent dark-red spotting.
- occult bleeding with abdominal or back pain.
- sudden onset of painless and profuse bleeding.
- painless occult bleeding that becomes visible upon onset of labor.
sudden onset of painless and profuse bleeding
A 27-year-old male patient, who works as a janitor, presents with a 6-month history of an intermittent rash on his hands. History reveals itching and occasional burning. Examination reveals irregularly-distributed scaly maculopapular erythematous patches extending from the dorsum of the hand several inches up the forearms, and dry palms with no nail involvement. The most likely diagnosis is:
- contact dermatitis.
- scabies infestation.
- psoriasis.
- eczema.
contact dermatitis
Anorexia nervosa occurs most commonly in which of the following?
- Painters
- Only children
- High-level athletes
- Individuals from large families
high level athletes
A frail elderly patient presents with constipation. Which of the following normal physiologic changes seen with aging is the most likely cause?
- Decreased bowel muscle tone
- Increased bile secretion
- Increased absorption of calcium
- Decreased pancreatic secretions
decreased bowel muscle tone
A patient reports to your office, having been struck on the right cheek with a baseball bat. On examination, you notice tenderness and swelling over the cheek. The patient is unable to gaze laterally with his left eye, and he complains of double vision when he attempts to do so. This is most likely associated with:
- retinal hemorrhage.
- orbital rim fracture.
- subarachnoid hemorrhage.
- periorbital cellulitis.
orbital rim fractures
A 7-year-old child presents with group A streptococcal infection confirmed by throat culture. Past history includes treatment for positive streptococcal infection with erythromycin (EryPed oral suspension) 3 weeks ago. What is the most appropriate next intervention?
- Treat with amoxicillin for 10 days.
- Obtain culture for all household members.
- Treat with azithromycin (Zithromax) for 10 days.
- Intramuscular Penicillin.
treat with amoxicillin for 10 days
A 16-year-old female adolescent is brought to the nurse practitioner’s office by her mother, who is concerned about her daughter’s recent weight loss. History reveals that the daughter was consistently in the 50th percentile for weight, but is now in the 10th percentile. The mother states that she is concerned that her daughter is purging herself after meals since she often goes to the restroom after eating and remains there for a long period of time. The daughter denies any self-induced vomiting, starvation or excessive activity. She does state that she jogs five miles a day and is in good condition. In addition to a complete blood count with differential, which of the following laboratory tests will be most helpful for further assessment?
- Electrolytes, fasting blood sugar
- Creatine phosphokinase, follicle-stimulating hormone (FSH)
- Electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
- Electrolytes, FSH, stool for occult blood
electrolytes, blood urea nitrogen (BUN)/creatinine, urinalysis
An adult female who is homeless presents for an initial obstetric visit at 34 weeks of pregnancy. She is diagnosed with Chlamydia trachomatis infection. What complication will her newborn be most at risk?
- Conjunctivitis
- Hearing loss
- Pneumonitis
- Meningitis
conjunctivitis
A 2-year-old male presents for reevaluation. Two days ago, he had four episodes of vomiting and six diarrheal stools. On physical examination today, his vital signs reveal P = 120 and capillary refill of 3 seconds. The patient’s eyes are sunken and his extremities are mottled and cool to the touch. The treatment plan would include:
- start oral electrolyte mixture every hour.
- hospitalization for IV fluid replacement.
- giving the child loperamide for each diarrheal stool.
- catheterizing the child to obtain accurate urine output.
hospitalization for IV fluid replacement
A nurse practitioner places a 76-year-old patient on nifedipine (Procardia) 10 mg t.i.d. for angina. The patient is unable to remember to take the medication at the scheduled times. The practitioner should:
- discontinue the issue with the patient’s daughter.
- change the dose to extended release 30 mg daily.
- reinforce the importance of taking the medication.
- increase the dosage to 20 mg b.i.d.
change the dose to extended release 30mg daily
A pediatric male is present with his mother, who states that he is extremely restless at night and constantly scratches his anal area. Which diagnostic procedure would confirm a diagnosis of pinworm infestation?
- The patch test
- Examination of bed linens
- Examination of transparent tape sample from perianal skin
- Blood tests for anemia and eosinophilia
examination of transparent tape sample from perianal skin
Which of the following microorganisms are most frequently associated with acute bacterial rhino-sinusitis?
- Staphylococcus aureus and Mycoplasma pneumonia
- Staphylococcus aureus and Methicillin Resistant Staph aureus
- Streptococcus pneumoniae and Haemophilus influenzae
- Streptococcus pneumoniae and Pseudomonas aeruginosa
strep pneumo and haemophilus influenzae
A child is being treated with methylphenidate (Ritalin) for attention-deficit disorder. The following are all side effects of Ritalin EXCEPT:
- muscle cramps
- mild irritability.
- increased heart rate.
- slight increase in growth velocity.
slight increase in growth velocity
A geriatric female presents for her annual examination. She has been on antihypertensive medications for over 20 years, with good control. Laboratory values are within normal ranges. The nurse practitioner is concerned about the patient’s cardiac health risks, due her to weight and her waist circumference. According to the AHA guidelines, which of the following goals is expected for this patient?
- Physical activity for 60 minutes daily, for a minimum of 6 days a week
- Physical activity for 30 minutes daily, 7 days a week
- Physical activity for 30 minutes daily, for a minimum of 5 days a week
- Physical activity for 60 minutes daily, 7 days a week
physical activity for 30 minutes daily, for a minimum of 5 days a week
The management of COPD in the elderly is best guided by:
- spirometry.
- arterial blood gases.
- radiologic imaging.
- symptomatology.
symptomatology
A young, athletic adult presents with shoulder pain and inability to raise the arm above the shoulder. The most likely diagnosis is:
- frozen shoulder syndrome.
- cervical radiculopathy.
- rotator cuff tear.
- polymyositis.
rotator cuff tear
A 50-year-old male presents with bruises and abrasions on the left leg and forearm, claiming to have had a number of minor accidents at home and at work. The patient reports general feelings of depression, forgetfulness, and, despite the fact that he is regularly employed, a mounting collection of unpaid and overdue bills. In taking the patient’s history, a significant pattern of parental alcohol abuse, stroke, TIA, and MI emerges. During questioning to elicit a more thorough diagnosis, the patient becomes hostile and leaves the clinic without further treatment. The most likely explanation for this behavior is:
- Alzheimer’s disease.
- chronic alcoholism.
- cancer.
- carotid artery stenosis.
chronic alcoholism
A 28-year-old patient presents with profuse yellow vaginal discharge, odor, and local irritation. She reports completing a 7-day course of oral metronidazole (Flagyl), 500 mg b.i.d. 4 weeks ago. She has had multiple recurrences over the last 18 months. Microscopic examination reveals presence of clue cells. What is the most appropriate treatment intervention?
- Oral metronidazole (Flagyl), 500 mg b.i.d., plus metronidazole vaginal gel (MetroGel), for 5 days
- Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
- Metronidazole vaginal gel (MetroGel) twice weekly for 4 to 6 months
- Treat patient with metronidazole vaginal gel (MetroGel) b.i.d. and partner(s) with tetracycline, 250 mg q.i.d., for 7 days
Treat both patient and partner(s) with oral metronidazole (Flagyl), 500 mg b.i.d., for 7 days
An adult female who recently returned from a business trip to Japan presents for a recheck appointment. The only remarkable laboratory result is for thyroid-stimulating hormone (TSH), at 0.3 microunits/mL (normal = 0.4-6 microunits/mL). The patient reports that her neck hurts; examination reveals thyroid tenderness. Which of the following laboratory tests should the nurse practitioner order now?
- Triiodothyronine (T3) and free thyroxine (FT4)
- Triiodothyronine (T3) only
- Triiodothyronine (T3) resin uptake assay
- Triiodothyronine (T3) and free triiodothyronine (FT3)
Triiodothyronine (T3) and free thyroxine (FT4)
In treating a pregnant female with migraine headaches, which of the following drugs is in Category X?
- Ergotamine tartrate (Ergomar)
- Sumitriptan succinate (Imitrex)
- Frovatriptan (Frova)
- Amitriptyline (Elavil)
ergotamine tartate (ergomar)
A nurse practitioner is evaluating an infant for possible colic. Which of the following could indicate the need for a more extensive evaluation?
- 3-oz (85 g) weight gain over the past 2 weeks
- Stool negative for occult blood
- Moist mucus membranes and flat fontanels
- Onset at 4 weeks of age
3-oz (85 g) weight gain over the past 2 weeks
Which of the following is a hallmark of lumbar spinal stenosis?
- Incontinence of bowel and/or bladder
- Point tenderness of the lumbar spine
- Leg, buttock or back pain precipitated by walking.
- Bilateral leg pain with sitting.
leg, buttock or back pain precipitated by walking
A 70-year-old patient presents to the clinic complaining of dyspnea, palpitations, and fatigue. The patient reports a 2-week history of blackened stools, which the patient attributes to drinking berry juice. Assessment reveals vital signs of BP = 110/60, P = 100, R = 24; Hgb = 4.5 g/dL; Hct = 16%. What is the most appropriate immediate intervention?
- Order serum iron, total iron-binding capacity (TIBC), and ferritin.
- Refer to a gastroenterologist.
- Send to the emergency room.
- Order a complete blood count (CBC) with differential.
Send to emergency room
The symptoms of benign prostatic hypertrophy are often overlooked because the older male:
- understands that surgery is the only cure for this condition.
- considers urinary problems to be a normal part of aging.
- is fearful of the side effects of additional medication.
- is concerned that he will no longer be able to obtain an erection.
considers urinary problems to be normal part of aging
Upon admission to a nursing home, an 85-year-old patient receives a negative result on the purified protein derivative (PPD) test. To determine TB status in the frail elderly, a second PPD should be performed in:
- 72 hours.
- 1 week.
- 3 months.
- 6 months.
1 week
Which of the following is NOT used for therapy of an acute attack of gout?
- Colchicine (Colcrys)
- Indomethacin (Indocin)
- Methylprednisolone (Solumedrol)
- Allopurinol (Zyloprim)
allopurinol (zyloprim)
A 26-year-old female presents with abdominal distention, bloating, and intermittent crampy abdominal pain relieved by defecation. She has four to six loose stools a day when stressed. Between bouts of diarrhea, she often has constipation. Physical examination results are normal. The CBC was normal. The most likely diagnosis is:
- diverticulitis.
- viral gastroenteritis.
- inflammatory bowel disease.
- irritable bowel syndrome
irritable bowel syndrome
A mother has just noticed that her 15-month-old, 15-kg child has recently ingested an unknown quantity of iron tablets. The mother has ipecac syrup and activated charcoal on hand. The mother should be advised to:
- take the child to the primary care provider.
- give ipecac per recommendation on the bottle label.
- take the child to the emergency room.
- give the child 30 g of activated charcoal diluted with water
take child to emergency room
A 13-year-old is concerned because she has not yet begun to menstruate. Physical examination indicates that the patient is at Tanner stage IV and is of average height and weight. Which of the following would be the most appropriate response to this patient?
- “We’ll need to refer you to an endocrinologist for a complete workup.”
- “We’ll need to do some tests to find out why you are not having periods.”
- “I’ll give you some pills that will make your periods start.”
- “Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
“Your development is exactly as expected for your age; you’ll probably begin to have periods within a year.”
The most common bacterial cause of cellulitis in patients with diabetes mellitus is:
- Pseudomonas aeruginosa.
- group B beta-hemolytic Streptococcus.
- Staphylococcus aureus.
- Staphylococcus saprophyticus.
Staphylococcus aureus
A 46-year-old female found a lump in her breast this morning. History includes: no prior breast disease; G2P2 (first birth, age 22); maternal aunt diagnosed with breast cancer at age 72; last menstrual period was 2.5 weeks ago. On examination, a nurse practitioner palpates a 2-cm round, soft, mobile, tender lesion in the upper outer quadrant of the right breast. Mammogram is negative. Which of the following actions is most appropriate?
- Reassure the patient that no further action is necessary.
- Repeat unilateral right mammogram in 3 months.
- Schedule a right-breast ultrasound.
- Refer for genetic testing if the lump increases in size.
schedule a right breast ultrasound
Risk factors for genital herpes include:
- multiple sexual partners and years of sexual activity.
- genetic transmission.
- infection with other sexually transmitted diseases before the age of 12.
- multiple sexual partners and frequent use of public spas.
multiple sexual partners and years of sexual activity
On physically assessing a newborn’s head, you note an enlarged, fluid-filled area that is subperiosteal and does not cross suture lines. This finding indicates the presence of:
- macrocephaly.
- subgaleal hemorrhage.
- congenital hypothyroidism.
- cephalohematoma.
cephalohematoma
A 65-year-old patient being treated with digoxin (Lanoxin) for chronic heart failure (HF) presents with complaints of palpitations. Three days ago, the patient was placed on clarithromycin (Biaxin) by another provider for community-acquired pneumonia. The appropriate course of action at this point would be to:
- increase the digoxin dosage by 25%.
- obtain a digoxin level and change the antibiotic to azithromycin (Zithromax).
- obtain a chest X-ray.
- obtain a serum potassium level and perform a 12-lead EKG.
obtain a digoxin level and change the antibiotic to azithromycin (zithromax)
A 54-year-old male who is 30 pounds overweight states that he awakens at night with heartburn and the taste of hot acid in his mouth. Stress makes his condition worse, yet baking soda seems to provide some relief. Findings on examination are normal and the stool for occult blood is negative. The preliminary diagnosis(es) should be:
- esophagitis.
- esophageal spasm.
- helicobacter pylori.
- gastroesophageal reflux disease.
GERD
A late adolescent patient presents with complaints of acute-onset unilateral right eye pain, visual changes, seeing halos around lights, abdominal pain, and intermittent nausea. Physical findings include an erythematous right eye without discharge, a cloudy cornea, and a moderately dilated right pupil that is nonreactive to light. The nurse practitioner should immediately:
- apply steroid drops to the right eye.
- apply mydriatic drops to the eye.
- refer to the emergency department.
- make an appointment for him to see an ophthalmologist.
refer to emergency department
In a 6-year-old child, which of the following is the preferred drug for stage 1 Lyme disease?
- Trimethoprim-sulfamethoxazole (Bactrim)
- Azithromycin (Zithromax)
- Doxycycline (Doryx)
- Cefuroxime (Ceftin)
cefuroxime (ceftin)
An 86-year-old patient is experiencing radiculopathy-associated lower back pain that has not improved over the past 4 weeks. The medical history includes a lumbar discectomy. The best type of imaging study for evaluating this patient would be a/an:
- MRI.
- spinal X-ray.
- myelography.
- nuclear bone scan.
MRI
A 30-month-old with a history of frequent ear infections was seen in September after a symptom-free summer. Examination revealed bilateral bulging eardrums. After two separate courses of antibiotics, fluid is noted in both ears. The parent reports speech difficulties. The most likely diagnosis is:
- otitis media with effusion.
- myringitis.
- recurrent acute otitis.
- Esutachian tube dysfunction.
otiti media with effusion
A 19-year-old patient who has used oral contraceptives for 3 years plans to discontinue the pill at the end of her current cycle to become pregnant. Which of the following daily supplements would receive the highest priority?
- Calcium carbonate
- Folic acid
- Ferrous sulfate
- Multivitamin
folic acid
A frail elderly widow presents to the senior clinic with a 3- to 4-day history of confusion that became worse the evening before but currently seems a little better, although her speech is rambling and difficult to follow. During the examination, the patient is anxious and agitated. She is on cardiac medications, an antidepressant, and insulin. The most likely diagnosis is:
- mild stroke.
- polypharmacy.
- electrolyte imbalance.
- agitated depression.
polypharmacy
A 46-year-old female presents with a complaint of amenorrhea for 3 months. The first-line diagnostic workup is:
- urine pregnancy test.
- progesterone challenge.
- serum prolactin level.
- thyroid-stimulating hormone (TSH).
urine pregnancy test