D118 FINAL REVIEW STANFORD
UNIVERSITY ,, RESERACHED AND
VERIFIED
, allergic rhinitis , allergic rhinitis-Pharmacological treatment
1. Steroid nasal spray, 2 sprays each nostril
a) Beclomethasone dipropionate (Beconase) bid
b) Ciclesonide (Omnaris) qd
c) Fluticasone propionate (Flonase) qd
d) Mometasone (Nasonex) qd
2. Antihistamine daily
a) Loratadine 10 mg
b) Cetirizine 10 mg
c) Fexofenadine 180 mg
d) Levocetirizine (Xyzal) 5 mg
e) Desloratadine (Clarinex) 5 mg
3. Antihistamine nasal sprays each nostril bid
a) Azelastine (Astelin) nasal spray 2 sprays
b) Azelastine/fluticasone propionate (Dymista) 1 spray
c) Olopatadine nasal (Patanase) 2 sprays bid
4. Montelukast (Singulair) 10 mg hs
, correlational-
, The difference between descriptive and correlational studies is that a correlational study
seeks to understand the relationship between the variables. A correlational study can also
establish whether this relationship has a positive or negative direction. A positive correlation
means that both variables move in the same direction, whereas a negative correlation means that
the variables move in opposite directions.he key is that correlational studies do not provide
definitive proof that one variable leads to the second variable.
, stasis dermatitis, occurs in the lower leg when varicose veins slow the return of blood and
the accumulation of fluid interferes with the nourishment of the skin
.
A 25-year-old patient has a tuberculosis skin test which reveals an area of induration of 12 mm.
The patient is a recent immigrant from Mexico and lives in a homeless shelter.
What is the recommended treatment for this patient?
Order INH and rifampin
Administer the BCG vaccine
Perform regular TB skin testing every few months
Begin INH preventive therapy Correct! Patients younger than 35 who have any risk
factors for TB and with an area of induration ≥10 mm should be considered for INH preventive
,therapy. This patient is an immigrant from Mexico and lives in a homeless shelter, so TB
preventive therapy is acceptable.
.
A patient comes to a clinic with reports of unilateral arm pain and weakness with mild neck pain.
The provider notes that the patient prefers holding the affected arm crossed in front of the throat.
A history reveals a recent onset of sexual dysfunction.
What does the provider suspect based on this history?
Axial neck pain
Facet joint pain
Cervical myelopathy
Diabetic neuropathy Correct! Patients with neurological symptoms have radicular neck pain,
which is usually greater in one arm and involves neurological findings. Patients with concurrent
lower extremity findings may have cervical myelopathy and should be evaluated immediately.
. Carnett's sign: . Carnett's sign: have the patient lie flat with his or her head lifted up and
with the chin close to the chest (or shoulder off the bed); this will tighten the abdominal muscles.
Pain elicited with this test is usually from the abdominal muscle wall; if pain decreases, this
indicates that pain is from intra-abdominal structures.
. Rovsing sign: peritonitis or appendicitis.
· sprains, A sprain involves injury to the supporting structures of a joint and is described
using three grades of severity. The degree of damage to these structures depends on the amount
of tissue/fiber shearing and tearing that occurs. A Grade 1 sprain usually involves minimal injury
of an overstretched ligament resulting in mild pain and edema. A Grade 2 sprain is an incomplete
tear of a ligament and includes some moderate functional impairment, ecchymosis, edema, and
discomfort with weight bearing. A Grade 3 sprain is a full or complete tear of the ligament with
loss of ligament integrity.
(atopic) dermatitis, Second-line therapy for frequent, hard-to-control flare-ups with moderate
to severe symptoms is topical immunomodulators
a) Tacrolimus (Protopic) ointment 0.03% for children 2 to 15 yr of age; 0.03% to 0.1% for >15
yr of age; apply to lesions bid
b) Pimecrolimus (Elidel) 1% for >2 yr of age; apply bid to lesions; can be used in sensitive areas
where steroids may cause serious or systemic reactions
c) Crisaborole (Eucrisa) ointment 2% for >2 yr of age; apply thin layer bid; not for eyes, oral, or
intravaginal use
`allergic conjunctivitis allergic conjunctivitis typically occurs simultaneously in both
eyes-Agents to consider include fexofenadine and loratadine
1. Describe the clinical presentation, physical examination, and management of patients with
cardiac arrhythmias, including tachyarrhythmias and bradyarrhythmias-ATROPINE OR
PACINING tachyarrhythmias -NARROW
I. Sinus tachycardia-Treat the cause- Requires appropriate diagnostic workup after analysis of
the history and possible causes
WIDE-V TACH -Amiodarone IV Dose: First dose: 150 mg over 10 minutes. electrical
cardioversion
,bradyarrhythmias-ATROPINE OR PACING
1. Describe the clinical presentation, physical examination, and treatment of patients with acute
bronchospasm. A patient who speaks in words instead of phrases, sits in a hunched
position, and uses accessory muscles is in severe respiratory compromise
While waiting for transport, the patient should be given inhaled short-acting β2-agonists
(SABAs), ipratropium bromide, s
ystemic corticosteroids and, if available, supplemental oxygen.5 For patients unable to
coordinate a metered-dose inhaler (MDI) or who show no improvement, epinephrine and
terbutaline, if available, are indicated.
Pulsus paradoxus (a change in blood pressure during inspiration) of greater than 20 mm Hg is a
uniform indicator of severe respiratory compromise.
The presence of a urticarial rash with decreasing blood pressure is a sign of anaphylaxis,
necessitating immediate treatment with supplemental oxygen through nasal cannula or mask and
diphenhydramine (Benadryl), 25 or 50 mg intravenously (no faster than 25 mg per minute) or
intramuscularly; or epinephrine, 0.3 to 0.5 mg of a 1 : 1000 (1 mg/mL) solution intramuscularly
in the vastus lateralis muscle (middle-outer aspect of the thigh), anterolateral aspect for the adult
patient
MDI or nebulizer. Short-acting β2 agonists include medications such as albuterol, levalbuterol
(Xopenex), metaproterenol (Alupent), and pirbuterol (Maxair). Other medications include
anticholinergics, such as ipratropium bromide (Atrovent), and systemic corticosteroids, such as
methylprednisolone, prednisolone, and prednison
Treatment to reverse bronchospasm by an MDI (90 mcg/puff) consists of 4 to 10 puffs of
albuterol every 20 minutes for the first hour. "After the first hour, the dose of SABA required
varies from 4-10 puffs every 3-4 hours up to 6-10 puffs every 1-2 hours, or more often
As an alternative, nebulizer treatments with 2.5 to 5 mg of albuterol can be administered every
20 minutes for up to three treatments, and the
1. Describe the clinical presentation, physical examination, and treatment of patients with
anaphylaxis. Uniphasic and biphasic reactions can occur anywhere from minutes to up to 10 to
12 hours after exposure.1-3 Protracted reactions can be severe, lasting from 24 to rarely 72 hours
Initial Diagnostics
Laboratory
• Pulse oximetry
• Arterial blood gases
• Electrocardiogram (ECG)a
• Serum glucose to assess for hypoglycemia
• Additional diagnostics
• 24-h urine specimen for histamine metabolites9, a
• Plasma histamine level9: to confirm anaphylaxisa
• Serum tryptase level—elevation is indicative of mast cell activation9, a
, Imaging
• Chest radiograph
Epinephrine dose for pregnant or non-pregnant adults:
• Aqueous epinephrine: 1:1000 dilution (1 mg/mL), 0.2 to 0.5 mg intramuscularly in the
anterolateral aspect of the mid-thigh as the preferred site. Repeat every 5 to 15 minutes as needed
to a maximum dose of 1 m
1. Describe the he clinical presentation, physical examination, and treatment of patients with
various types of bites and stings: tick bites, -Ticks are effectively removed with blunt,
angled, medium-tipped forceps or a specific tick-removal instrument. The tick should be
removed as soon as possible by grasping it close to the mouth, flipping the tick so the backside is
closest to the skin, and pulling the tick straight up.5 After removal of the tick, the health care
provider should inspect the bite area for retained mouth parts, remove if possible, then carefully
clean the area with an antiseptic.5 Antibiotic prophylaxis may be indicated where Lyme disease
is endemic or if the length of time the tick has been imbedded is not known. A tick needs to be
embedded and feeding for more than 36 hours to infect with Lyme disease (see Chapter 213).
All insect bites and stings require local wound care, removal of the stinger, cleaning the area
with soap and water, ice packs, antihistamines (H1 and H2 blockers) for itching, topical steroids
for inflammation, topical or systemic antibiotics for secondary infection, and nonsteroidal anti-
inflammatory drugs to relieve discomfort.1,3
Flea bites may resemble varicella. Reactions to blister beetles may resemble bullous impetigo,
burns, contact dermatitis, and viral exanthems. Because of such similarities, a history of
exposure may be the only diagnostic clue.3
1. Describe the management of hypotension, syncope, and hypovolemic shock. hypotension,
S/S Lightheadedness and dizziness are common symptoms of hypotension. In addition, some
individuals may experience blurred or tunnel vision and a dull pain in the back of the neck and
shoulders
failure of the pulse to increase with a decrease in blood pressure is indicative of neurogenic
hypotension or central or peripheral nervous system diseases resulting in autonomic failure.7
Tachycardic heart rates that are exaggerated suggest underlying volume depletion such as
dehydration
Relatively simple bedside tests with a high diagnostic yield include electrocardiography (ECG),
Laboratory
• Hemoglobin
• Serum electrolytes, BUN and creatinine, glucose
• Stool testing for occult blood
• Urine or serum pregnancy test (all women of childbearing age)
• D-dimer test (when pulmonary embolus is suspected)
• Urinalysis and blood cultures (when sepsis is suspected)
Imaging
• Electrocardiogram
• Echocardiography, cardiac monitoring (when cardiac dysfunction is suspected)
• CT imaging of the chest (when pulmonary embolus is suspected)
• CT imaging of the abdomen (when intraabdominal bleeding is suspected)
UNIVERSITY ,, RESERACHED AND
VERIFIED
, allergic rhinitis , allergic rhinitis-Pharmacological treatment
1. Steroid nasal spray, 2 sprays each nostril
a) Beclomethasone dipropionate (Beconase) bid
b) Ciclesonide (Omnaris) qd
c) Fluticasone propionate (Flonase) qd
d) Mometasone (Nasonex) qd
2. Antihistamine daily
a) Loratadine 10 mg
b) Cetirizine 10 mg
c) Fexofenadine 180 mg
d) Levocetirizine (Xyzal) 5 mg
e) Desloratadine (Clarinex) 5 mg
3. Antihistamine nasal sprays each nostril bid
a) Azelastine (Astelin) nasal spray 2 sprays
b) Azelastine/fluticasone propionate (Dymista) 1 spray
c) Olopatadine nasal (Patanase) 2 sprays bid
4. Montelukast (Singulair) 10 mg hs
, correlational-
, The difference between descriptive and correlational studies is that a correlational study
seeks to understand the relationship between the variables. A correlational study can also
establish whether this relationship has a positive or negative direction. A positive correlation
means that both variables move in the same direction, whereas a negative correlation means that
the variables move in opposite directions.he key is that correlational studies do not provide
definitive proof that one variable leads to the second variable.
, stasis dermatitis, occurs in the lower leg when varicose veins slow the return of blood and
the accumulation of fluid interferes with the nourishment of the skin
.
A 25-year-old patient has a tuberculosis skin test which reveals an area of induration of 12 mm.
The patient is a recent immigrant from Mexico and lives in a homeless shelter.
What is the recommended treatment for this patient?
Order INH and rifampin
Administer the BCG vaccine
Perform regular TB skin testing every few months
Begin INH preventive therapy Correct! Patients younger than 35 who have any risk
factors for TB and with an area of induration ≥10 mm should be considered for INH preventive
,therapy. This patient is an immigrant from Mexico and lives in a homeless shelter, so TB
preventive therapy is acceptable.
.
A patient comes to a clinic with reports of unilateral arm pain and weakness with mild neck pain.
The provider notes that the patient prefers holding the affected arm crossed in front of the throat.
A history reveals a recent onset of sexual dysfunction.
What does the provider suspect based on this history?
Axial neck pain
Facet joint pain
Cervical myelopathy
Diabetic neuropathy Correct! Patients with neurological symptoms have radicular neck pain,
which is usually greater in one arm and involves neurological findings. Patients with concurrent
lower extremity findings may have cervical myelopathy and should be evaluated immediately.
. Carnett's sign: . Carnett's sign: have the patient lie flat with his or her head lifted up and
with the chin close to the chest (or shoulder off the bed); this will tighten the abdominal muscles.
Pain elicited with this test is usually from the abdominal muscle wall; if pain decreases, this
indicates that pain is from intra-abdominal structures.
. Rovsing sign: peritonitis or appendicitis.
· sprains, A sprain involves injury to the supporting structures of a joint and is described
using three grades of severity. The degree of damage to these structures depends on the amount
of tissue/fiber shearing and tearing that occurs. A Grade 1 sprain usually involves minimal injury
of an overstretched ligament resulting in mild pain and edema. A Grade 2 sprain is an incomplete
tear of a ligament and includes some moderate functional impairment, ecchymosis, edema, and
discomfort with weight bearing. A Grade 3 sprain is a full or complete tear of the ligament with
loss of ligament integrity.
(atopic) dermatitis, Second-line therapy for frequent, hard-to-control flare-ups with moderate
to severe symptoms is topical immunomodulators
a) Tacrolimus (Protopic) ointment 0.03% for children 2 to 15 yr of age; 0.03% to 0.1% for >15
yr of age; apply to lesions bid
b) Pimecrolimus (Elidel) 1% for >2 yr of age; apply bid to lesions; can be used in sensitive areas
where steroids may cause serious or systemic reactions
c) Crisaborole (Eucrisa) ointment 2% for >2 yr of age; apply thin layer bid; not for eyes, oral, or
intravaginal use
`allergic conjunctivitis allergic conjunctivitis typically occurs simultaneously in both
eyes-Agents to consider include fexofenadine and loratadine
1. Describe the clinical presentation, physical examination, and management of patients with
cardiac arrhythmias, including tachyarrhythmias and bradyarrhythmias-ATROPINE OR
PACINING tachyarrhythmias -NARROW
I. Sinus tachycardia-Treat the cause- Requires appropriate diagnostic workup after analysis of
the history and possible causes
WIDE-V TACH -Amiodarone IV Dose: First dose: 150 mg over 10 minutes. electrical
cardioversion
,bradyarrhythmias-ATROPINE OR PACING
1. Describe the clinical presentation, physical examination, and treatment of patients with acute
bronchospasm. A patient who speaks in words instead of phrases, sits in a hunched
position, and uses accessory muscles is in severe respiratory compromise
While waiting for transport, the patient should be given inhaled short-acting β2-agonists
(SABAs), ipratropium bromide, s
ystemic corticosteroids and, if available, supplemental oxygen.5 For patients unable to
coordinate a metered-dose inhaler (MDI) or who show no improvement, epinephrine and
terbutaline, if available, are indicated.
Pulsus paradoxus (a change in blood pressure during inspiration) of greater than 20 mm Hg is a
uniform indicator of severe respiratory compromise.
The presence of a urticarial rash with decreasing blood pressure is a sign of anaphylaxis,
necessitating immediate treatment with supplemental oxygen through nasal cannula or mask and
diphenhydramine (Benadryl), 25 or 50 mg intravenously (no faster than 25 mg per minute) or
intramuscularly; or epinephrine, 0.3 to 0.5 mg of a 1 : 1000 (1 mg/mL) solution intramuscularly
in the vastus lateralis muscle (middle-outer aspect of the thigh), anterolateral aspect for the adult
patient
MDI or nebulizer. Short-acting β2 agonists include medications such as albuterol, levalbuterol
(Xopenex), metaproterenol (Alupent), and pirbuterol (Maxair). Other medications include
anticholinergics, such as ipratropium bromide (Atrovent), and systemic corticosteroids, such as
methylprednisolone, prednisolone, and prednison
Treatment to reverse bronchospasm by an MDI (90 mcg/puff) consists of 4 to 10 puffs of
albuterol every 20 minutes for the first hour. "After the first hour, the dose of SABA required
varies from 4-10 puffs every 3-4 hours up to 6-10 puffs every 1-2 hours, or more often
As an alternative, nebulizer treatments with 2.5 to 5 mg of albuterol can be administered every
20 minutes for up to three treatments, and the
1. Describe the clinical presentation, physical examination, and treatment of patients with
anaphylaxis. Uniphasic and biphasic reactions can occur anywhere from minutes to up to 10 to
12 hours after exposure.1-3 Protracted reactions can be severe, lasting from 24 to rarely 72 hours
Initial Diagnostics
Laboratory
• Pulse oximetry
• Arterial blood gases
• Electrocardiogram (ECG)a
• Serum glucose to assess for hypoglycemia
• Additional diagnostics
• 24-h urine specimen for histamine metabolites9, a
• Plasma histamine level9: to confirm anaphylaxisa
• Serum tryptase level—elevation is indicative of mast cell activation9, a
, Imaging
• Chest radiograph
Epinephrine dose for pregnant or non-pregnant adults:
• Aqueous epinephrine: 1:1000 dilution (1 mg/mL), 0.2 to 0.5 mg intramuscularly in the
anterolateral aspect of the mid-thigh as the preferred site. Repeat every 5 to 15 minutes as needed
to a maximum dose of 1 m
1. Describe the he clinical presentation, physical examination, and treatment of patients with
various types of bites and stings: tick bites, -Ticks are effectively removed with blunt,
angled, medium-tipped forceps or a specific tick-removal instrument. The tick should be
removed as soon as possible by grasping it close to the mouth, flipping the tick so the backside is
closest to the skin, and pulling the tick straight up.5 After removal of the tick, the health care
provider should inspect the bite area for retained mouth parts, remove if possible, then carefully
clean the area with an antiseptic.5 Antibiotic prophylaxis may be indicated where Lyme disease
is endemic or if the length of time the tick has been imbedded is not known. A tick needs to be
embedded and feeding for more than 36 hours to infect with Lyme disease (see Chapter 213).
All insect bites and stings require local wound care, removal of the stinger, cleaning the area
with soap and water, ice packs, antihistamines (H1 and H2 blockers) for itching, topical steroids
for inflammation, topical or systemic antibiotics for secondary infection, and nonsteroidal anti-
inflammatory drugs to relieve discomfort.1,3
Flea bites may resemble varicella. Reactions to blister beetles may resemble bullous impetigo,
burns, contact dermatitis, and viral exanthems. Because of such similarities, a history of
exposure may be the only diagnostic clue.3
1. Describe the management of hypotension, syncope, and hypovolemic shock. hypotension,
S/S Lightheadedness and dizziness are common symptoms of hypotension. In addition, some
individuals may experience blurred or tunnel vision and a dull pain in the back of the neck and
shoulders
failure of the pulse to increase with a decrease in blood pressure is indicative of neurogenic
hypotension or central or peripheral nervous system diseases resulting in autonomic failure.7
Tachycardic heart rates that are exaggerated suggest underlying volume depletion such as
dehydration
Relatively simple bedside tests with a high diagnostic yield include electrocardiography (ECG),
Laboratory
• Hemoglobin
• Serum electrolytes, BUN and creatinine, glucose
• Stool testing for occult blood
• Urine or serum pregnancy test (all women of childbearing age)
• D-dimer test (when pulmonary embolus is suspected)
• Urinalysis and blood cultures (when sepsis is suspected)
Imaging
• Electrocardiogram
• Echocardiography, cardiac monitoring (when cardiac dysfunction is suspected)
• CT imaging of the chest (when pulmonary embolus is suspected)
• CT imaging of the abdomen (when intraabdominal bleeding is suspected)
