Sensitivity - ANSWER-(SNOUT) Negative results rules out the disease. Sensitivity test are good at identifying the positive markers of disease. So good
... [Show More] that it is more prone to report false positives. So a negative result is more definitive
Specificity - ANSWER-(SPIN) Positive results rules in the disease. Specificity tests are good at identifying the negative marker of a disease. So good that is more prone to report false negatives. So a positive result is more definitive.
Primary Prevention - ANSWER-Prevent the disease in its entirety. Examples include healthy diet, exercise, safety (helmets/seatbelts), immunizations, and job safety
Secondary Prevention - ANSWER-Early detection of a disease. Examples include screening tests
Tertiary Prevention - ANSWER-Rehabilitation of a disease. Examples include support groups, education for pts with pre-existing disease, drug side effect safety, medical equipment safety, any type of rehab like PT or OT
Breast Cancer Screening Guidelines (USPSTF) - ANSWER-Onset = 50yo. Biannual. Stop at age 74yo. No SBE.
Breast Cancer Screening Guidelines (ACA) - ANSWER-Onset = 40yo. Annual. No stop age.
Cervical cancer screening guidelines - ANSWER-Onset=21yo (immunocompromised individuals start at onset of sexual activity). Every 3 years Pap w/ no HPV test until 30yo. Pap and HPV test after 30 yo and can begin screening every 5 years. Stop at age 65yo. Complete hysterectomy means no Pap unless pt has history of cervical cancer or high grade lesion.
Colorectal cancer - ANSWER-Onset 50yo. 1) colonoscopy q 10 years if wnl, 2) sigmoidoscopy q 5 years if wnl, 3) annual FOBT with 3 stool samples. Stop age 75 yo.
Prostate cancer - ANSWER-USPSTF does not recommend screening with PSA but it based on individual pt.
Lipid screening - ANSWER-Onset 18-35/45yo screen if at increased risk of heart disease. Males >35yo and Females >45yo
Flu vaccine - ANSWER-LAIV - Live virus can only be given to healthy non-pregnant 2 -49 yo w/o recent hx of asthma (Peds). Cautioned or C/I in pts with egg, gentamicin or gelatin allergy and kids receiving aspirin therapy (Reye's syndrome). TIV (trivalent inactivated vaccine) is approved for >6months.
Tetanus vaccine - ANSWER-Q 10 years. Booster for dirty wounds if last TDAP/Td is > 5 years old. >7yo receive Td/TDAP. Avoid in egg allergy and Gullian Barre. 5 doses of DTAP aka Pediarix (2,4,6,15 months and 5 yo) First TDAP is at age 11-12yo. Td is the booster every 10 years or if someone has never had TDAP (came out in 2005) then they should have a one time dose of TDAP and then continue with Td boosters.
Pneumococcal vaccine - ANSWER-PCV 23 given one time at age 65 yo in healthy adults and for persons who are 2 years and older and at high risk for pneumococcal disease (e.g., those with sickle cell disease, HIV infection, or other immunocompromising conditions). PPSV23 is also recommended for use in adults 19 through 64 years of age who smoke cigarettes or who have asthma. One time booster given 5 years after first dose (So non-healthy pts will receive 2 doses of PSV23 over their lifetime). PCV 13 is for <5 yo. When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit. When indicated, PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.
Varicella Vaccine - ANSWER-60 yo. May be given to pts who have previously had shingles. May be given earlier at age 50yo. Live virus so c/I include pregnancy and immunocompromised.
Chapter 5 (EENT) - ANSWER-
Herpes Keratitis - ANSWER-Inflammation of the cornea. C/O abrupt severe eye pain, photophobia and blurred vision. Diagnose with fluorescein dye and black lamp. Look for fernlike lines (corneal abrasions appear more linear). Infection permanently damages corneal epithelium which may result in blindness.
Acute angle closure - ANSWER-Glaucoma (Increased ICP r/t blocked drainage duct). Elderly pt c/o abrupt onset of severe eye pain, HA, N/V, halos around eyes, and decreased vision. Exam reveals mid-dilated pupil that is oval shaped, cloudy cornea, and fundoscopic exam shows cupping of the optic nerve. Tx = keep pt supine, trx to ED for acetazolamide, B blockers, and topical steroids. Sx may be required
Cholesteatoma - ANSWER-Cauliflower like growth in the middle ear. Pt c/o foul smelling discharge and hearing loss. On exam, no TM or ossicles visible. PMhx of chronic OM. The mass is not cancerous but it can erode in to the bones of the face and damage CN7. Tx = ENT referral for sx, abx. Mass is usually made of epithelium and cholesterol. AKA pearl tumor.
Battle's sign - ANSWER-Bruise behind the ear over the mastoid process. Hx of trauma, and indicates a fracture of the basilar skull. Golden serous discharge from ear or nose. Refer to ED for abx and imaging (CSF will be + for glucose. Mucous will be - for glucose).
Cavernous sinus thrombosis - ANSWER-Blood clot in w/I cavernous sinus. This cavity houses internal carotid artery and CN III, IV, V and VI). PmHx of sinus or facial infection. Pt c/o severe HA, high fever, decreased LOC, unilateral periorbital edema, photophobia, proptosis and inability to move eye appropriately.
Peritonsillar abcess - ANSWER-Pt c/o severe sore throat, difficult and painful swallowing (odonophagia) and LOCKJAW (trimus), and a hot potato voice. Unilateral swelling peritonsillar area and soft palate with displaced uvula. Tx = I&D in ED or needle aspiration
Diptheria - ANSWER-Bull neck, dysphagia, and gray/yellow psuedomembrane that is not to displace (stuff is like concrete) and may obstruct airway
Geographic tongue - ANSWER-Benign finding
Torus Palatinus - ANSWER-Painless bony protuberance on hard palate that is benign
Fishtail uvula - ANSWER-Split uvula is usually benign (rarely a sign of cleft palate)
Nystagmus - ANSWER-Vertical nystagmus is always abnormal. Horizontal nystagmus that occurs on prolonged lateral gaze and resolves when eye moves toward midline is benign
Papilledema - ANSWER-Optic disc swollen w blurred edges r/t increased ICP (most commonly from bleeding, brain tumor, abscess or pseudo tumor cerebri).
HTN Retinopathy includes - ANSWER-result from damage and adaptive changes in the arterial and arteriolar circulation in response to the high blood pressure such as Copper/silver arterioles, av nicking, blot/flame hemorrhages, cotton wool spots, hard exudates and papilledema
Copper/silver arterioles - ANSWER-Indicates sclerosis and hyalinization of the arterioles. Silver is worse than copper.
Diabetic Retinopathy - ANSWER-Microaneurysms caused by new fragile arteries in the retina. Examples see cotton wool spots, flame hemorrhages and dot-blot hemorrhages.
Cataracts - ANSWER-Opacity of cornea
Koplik's spots - ANSWER-Small sized red papules w/ blue white centers inside the cheeks by the lower molars. They are the prodromic viral enathem of measles (Rubeola)
Hairy Leukoplakia - ANSWER-Pathognomic for Epstein barr virus in immunocompromised pts
Sjogren's syndrome - ANSWER-Chronic autoimmune disorder characterized by decreased function of lacrimal and salivary glands. Pt c/o dry eyes/mouth for > 3 months and/or gritty eyes. OTC eye drops and refer to ophthalmology and rheumatologist
Blepharitis - ANSWER-Chronic condition. Base of eyelids are inflamed. Ithcy/irritation with some crusting. Tx is johnson's baby shampoo and may need erythromycin optho ointment
Epitaxis - ANSWER-Posterior nasal bleeds can result in severe hemorrhage. Tx for anterior bleeds is tilt head forward and apply pressure over nasal bridge. Afrin nasal spray can be helpful.
Strep throat - - ANSWER-Beta hemolytic streptococcus group A. Classic triad is no cough, sore throat, and enlarged cervical anterior lymph nodes. Possible fever, petechiae on hard palate. Tx = C&S or rapid strep test. PCN x 10 days. PCN alternative are Zpak or Levaquin (for pts >18yo). Sequalae includes scarlet fever, rheumatic fever and peritonsillar abscess.
AOM - ANSWER-Common organisms are streptococcus pneumoniae (gram +), haemophilus influenza (gram - ), Moraxella catarrhalis (gram - ). Weber has lateralization to affected ear. Decreased mobility (flat trace line on typanogram). Tx = amoxicillin (80mcg/kg/day for peds and 500-875mg/day BID for adults). 2nd line agents are Augmentin, Ceflin and Cefzil. PCN alternatives include Macrolides, Bactrim or Levaquin.
Bullous myringitis - ANSWER-AOM with blisters (bulla) on TM.
Hordeolum (aka stye) - ANSWER-Acute bacterial infection of a hair follicle on the eyelid. Pt c/o itching w painful pustule. Tx abx and warm compress (Remember Horders live in a pig stye)
Chalazion - ANSWER-Chronic inflammation of the meibomian gland (aka sweat gland of the eyelid). Gradual onset of superficial nodule which is non tender. Tx if nodule does not self resolves than refer for sx.
Pinguecula - ANSWER-Yellow triangular thickening of the bulbar conjunctiva caused by UV light damage (Penguins no volar far from the bulbar)
Pterygium - ANSWER-Same as pinguecula but it extends on the nasal and temporal cornea. Tx for both include weak steroids, sunglasses and sx (pterodactyl extend their wings)
Subconjunctival hemorrhage - ANSWER-Blood is trapped underneath the conjunctiva and sclera second to broken arterioles from coughing, sneezing, heavy lifting and vomiting. Self limiting. Resolves in 1 to 3 weeks
Primary open angle glaucoma - ANSWER-Most common type. R/t blockage of the aqueous humor inside of the eye. Gradual onset. CN2 undergoes ischemic changes and permanent damage occurs. Pt c/o peripheral vision loss and then central vision loss.
Anterior uveitis - ANSWER-(iritis) Pt c/o red sore eyes w/o purulent discharge. Higher prevelance in autoimmune disorders (RA, lupus, ankylosing spondylitis), sarcoidosis, and syphilis. Ciliary flushing.
Age-related macular degeneration (AMD) - ANSWER-Caused from gradual damage to the pigment of the macula Typical pt = elderly smoker. Pt c/o gradual or sudden onset of central vision loss. Straight lines may appear distorted. Peripheral vision in intact.
Otitis externa - ANSWER-Common organisms = pseudomonas aeruginosa, staphylococcus aureus. Otolagia with tragus manipulation. Tx = corticosporin otic suspension QID X7 days. Prophylaxis is ETOH and vinegar
Infectious mononuoleosis - ANSWER-Epstien Barr Virus. Peak age is 15-24 yo. Classic triad is fatigue, acute pharyngitis, and lymphadenopathy (esp posterior cervical nodes). Abdominal pain may be r/t hepatomegaly/spenomegaly. CBC may reveal lymphocytosis (>50%). Monospot (aka heterophile antibody test) will be + (if initially negative but symptoms walk and talk like mono then repeat in 2 weeks b/c first test may have been too soon for antibodies to peak). Tx US abdomen, no contact sports or heavy lifting until oregonmegaly resolves (about 4 weeks after symptoms start. Repeat US needed to prove resolution of organomegaly.
Chapter 6 - ANSWER-
Rocky mountain spotted fever - ANSWER-Abrupt onset of high fever (103-105F), HA, myalgias, conjunctival injection, n/v, arthralgia and petechiae on day 3 on symptoms (so will look a lot like a high fever flu until the spots come on day 3). Petechiae erupt on hands and feet and move toward trunk. Tick born illness from Rickettsia rickettsia. Tx = Doxy, draw anitbodies, and biopsy skin lesion. RMSF is most common NOT in the Rockies (60% of cases are in TN,NC,AR,MO and OK) and occur in the spring and early summer
Actinic keratosis - ANSWER-Precancerous lesion of squamous cell carcinoma
Meningococcemia - ANSWER-Bacterium Nesseria meningitides results in sepsis (very deadly). Abrupt onset of petechiae or hemorrhagic rash in axilla, flanks, wrist and ankles. Tx = IV abx, lumbar puncture, C&S, CT/MRI of brain, Rifamin prophylaxis for close contacts
Erythema migrans - ANSWER-Tick born illness from Borrelia burgdorferi. Creates classic "bulls eye rash" ( Rember "BB" (Borrelia burgdoferi) for target practice) which appears 3 - 30 days after deer tick bite. Rash is hot t touch, has a rough texture, and is commonly found in the belt-line, axillary area, behind knees and in groin. Flu-like symptoms. Tx = Doxy. Alts = amox and cefuroxime. Draw serum antibodies. Most common in the northeast and great lakes
Shingles infection of the trigeminal nerve - ANSWER-Threatens vision. Ractivation of the herpes zoster virus on the ophthalmic branch of CN5.
Melanoma - ANSWER-Can occur anywhere including retina or nailbeds (very aggressive usually). Risk factors are blistering sun burns as a kid, family history in 10% of cases, increasing # of nevi, and fairskin/light eyed.
Basal cell carcinoma - ANSWER-Pearly/waxy skin lesion w/ atrophic or ulcerated center with will not heal
Acral lentiginous melanoma - ANSWER-Most common type of melanoma in AA and Asians. Dark brown/black lesions are found on nailbeds, palms, and plantar surfaces.
Steven Johnson Syndrome - ANSWER-Lesions start as a bulls eye. HIV pts have a 40 fold increased risk of SJS to Bactrim
Psoriasis - ANSWER-Squamous epithelial cells undergo rapid mitiotic division and abnormal maturation which creates a classic silvery plaque on extensor surfaces (such as scalp, back of elbows/knees, sacrum and intergluteal folds. Koebner phenomenon = new plaque in areas of skin trauma. Ausptiz's sign = pinpoint areas of bleeding when plaque is removed.
Acute cellulitis - ANSWER-Infection of the deep dermis. Usually caused by gram +. Purulent cellulitis is usually S. aureus. Nonpurulent is usually streptococci. Dog/cat bites = Pasteurella multicoda (gram negative) Erysipelas is group B strep. Tx = Non MRSA non purulent dicloxacillin, Keflex or Clindamycin. Give Td booster if last vaccine was > 5 years ago. Recurrent cellulitis consider mupirocin to nares or declonization.
Clenched fist injuries - ANSWER-High risk of infection to joints/bones/fascia etc. Refer to ED
Bite injuries - ANSWER-AugmentinX10days (PCN alt = clindamycin + fluoroquinolone). C&S all wounds. Do not suture. Refer any cartilage injuries (cartilage does not grow back). Td booster is last one was > 5 years ago. Rabies vaccine may be needed. F/U w/I 24-48 hrs.
What wounds should be referred? - ANSWER-Closed fist injuries, cartilage damage, cosmetic damage, compromised hosts
Hidradenitis suppurativa - ANSWER-Bacterial infection of the sebaceous glands in the axila or groin. Most commonly s. aureus. Can be chronic which results in heavy scarring and sinus tracts. Tx = C&S, augmentin, dicloxacillin. Mupirocin ointment to nares and fingernails BIDx2 weeks. Abx soap and no deodorant
Impetigo - ANSWER-Gram + strep pyogenes or s. aureus. Bullous and non bullous Classic sign = honey colored crusts. Tx = C&S wound. Keflex or dicloxacillin. PCN alt = Macrolides
Varicella Zoster - ANSWER-Gold standard = viral culture (PCR to ZDV). Aclyclovir = tx
Post herpetic neuralgia - ANSWER-Most common in elderly and immunocompromised. Tx with TCA (low dose), anticonvulsants (Depakote, gapapentin) and lidocaine.
Paronychia - ANSWER-Infection of the culticle caused by S. aureus strep or pseudomonas. Chronic cases are associated w co- existing onychomycosis
Pityriasis Rosea - ANSWER-Herald patch appears 2 weeks before full break out. Oval salmon color pruritic lesion with fine scale follow skin folds (or Christmas tree pattern). Self limiting in about 4 weeks. If high risk of STDs then r/o syphilis (use RPR).
Tinea infections - ANSWER-(Dermatophytoses) Gold standard is KOH slide for psuedohyphae and spores. Tx is -azoles and allymines. For tinea capitis and tinea pedis oral tx (griseofulvin)is required for 6 - 12 weeks. Monitor Lfts during tx and teach pts to stay away from other hepatotoxic substances like tylenol, ETOH, statins.
Acne vulgaris - ANSWER-Step up tx. Mild (some open/cold comedones and small pustules) requires TOPICAL tx (Retinol, macrolide cream or benzoyl peroxide). Moderate acne (larger pustules and more frequent) require oral abx (Doxy - tetracyclines can be given to >13yo) or OCP. Severe acne (cystic acne) refer to derm for Accutane
Rosacea - ANSWER-No cure. Tx symptoms. Chronic small acne around nose, mouth and chin. Many have ocular symptoms like dry eyes and blepharitis. Tx = Metronidazole gel, azelaic acid and low dose doxy. Sequalae can be hyperplasia of tissue on nose and cheeks
Chapter 7 Cardiac - ANSWER-
CHF symptoms - ANSWER-Acute or gradual onset or dyspnea, fatigue, dry cough, edema in extremities, weight gain, bibasilar crackles and S3
Bacterial endocarditis - ANSWER-Flu-like symptoms. New onset murmur and abrupt onset of CHF symptoms. Subungual hemorrhages (under the nail splinter hemorrhage), petechiae on palate, painful violet colored nodules on fingers and feet (Osler's nodes), and tender red spots on palms/feet (Janeway lesions).Elevated CBC and sed rate (>20mm/hr). Tx IV abx, pan cultures
Bacterial endocarditis prophylaxis - ANSWER-No longer recommended for MVP or GI/GU incisions (unless existing infection such as an UTI before cystoscopy). Give endocarditis prophylaxsis to pts w/ hx of bacterial endocarditis, prosthetic valves, some congenital heart disease and heart transplant. Basically bacterial endocarditis is a gram + (vividans strep and S. aureus most commonly) and you basically gotta protect against their "home turf." Amoxicillin 2 g PO and 50mg/kg/day for Peds
S1 (Systole) - ANSWER-Lub of "Lub-dub." Closure or AV valves (mitral and tricuspid).
S2 (Diastole) - ANSWER-Dub of "Lub-dub." Closure of aortic and pulmonic valves (aka semilunar valves).
S3 - ANSWER-Pathognomic for CHF occurs in early diastole (S1,S2,S3). AKA as ventricular gallop or S3 gallop. Sounds like "SLOSH-ing-in" or "KEN-tuck-y." Maybe a normal variant in kids/younger adults if there are no s/s of heart/valve disease. Always abnormal in >35yo. Fluid overload forces ventricle to dilate abnormally. Best heard w/ Bell in L lateral recumbent position over apex.
S4 - ANSWER-Stiff left ventricle and usually indicates LVH. Maybe a normal variant in some elderly pts if there are no other s/s of heart/valve disease. S4 occurs during late diastole (S4,S1,S2). AKA atrial gallop or extra atrial kick. Sounds like "a-STIFF-wall" or "ten-NES-see." Best heard in L lateral recumbent position over apex.
Summation gallop - ANSWER-All heart sounds (S1,S2,S3,S4) are present. Very loud diastolic gallop. Always pathologic.
Benign split - ANSWER-S2 normal finding if it appears during inspiration and disappears during expiration. Splitting of the aortic and pulmonic valves. Best heard over the pulmonic area.
Ausculatory areas (Precordial points) - ANSWER-Aortic = 2ICS RSB, Pulmonic=@2ICS LSB, Erb's point = 3ICS LSB, Tricupsid=4ICS LSB, Mitral=5ICS MCL, Epigastic = Midline under xiphoid process.
Systolic murmurs - ANSWER-MR. Peyton Manning AS MVP. S1 is louder than S2. Mitral regurgitation radiates to axilla and aortic stenosis radiates to neck.
Diastolic murmurs - ANSWER-ARMS. Always pathologic.
Grade 1 Murmur - ANSWER-Soft murmur that can only be heard in optimal conditions (may be intermittent)
Grade 2 Murmur - ANSWER-Mild to moderate
Grade 3 Murmur - ANSWER-Loud murmur (easily heard when stethoscope is placed on chest)
Grade 4 Murmur - ANSWER-Feel a thrill (Four is Feel) with loud murmur
Grade 5 Murmur - ANSWER-Thrill & loud murmur that can be heard w edge of stethoscope off chest
Grade 6 Murmur - ANSWER-Thrill is easily palpated. Heard w/ no stethoscope.
When does afib require anticoagulation? - ANSWER-CHADS2 score > 2 requires anticoagulation.
What does CHADS2 stand for? - ANSWER-C=CHF, H=HTN, A=age>75yo, D=diabetes, S2 (stroke or TIA)
INR range for afib - ANSWER-INR 2.0- 3.0
Afib diagnostic test - ANSWER-EKG
Afib tx - ANSWER-Correct baseline irritants (electrolytes, thyroid, caffeine or drugs). Warfarin or others for anticoagulation, CCB, B blockers, or digoxin for rate control. Amiodarone as antiarrhythmic. Consistent one serving/day of high vitamin K foods.
Paroxysmal atrial tachycardia(PAT or PVST) - ANSWER-Usually has underlying cause like digoxin toxicity, ETOH, increased TSH, caffeine or illicit drugs. 150-250 bpm. P wave with peaked QRS. Tx= Valsalva (hold breath, ice water, carotid massage), then rate control (amio or BB) and then cardioversion
Pulsus Paradoxus - ANSWER-Apical pulse can be heard but radial pulse can not be felt. Pulmonary or cardiac condition compress the chambers of the heart (creates impaired diastolic filling). Decreased systolic pressures of >10mmHg during inspiration.
How to diagnose pulsus paradoxus - ANSWER-Listen for S1 Korotkoff sound and note when it disappears only during inspiration but is present during expiration. Then listen for S1 korotkoff sound is present in both inspiration and expiration. If the difference is >10mmHg then suspect cardiac tamponade, severe COPD, or constrictive pericarditis. [Show Less]