Sarah Michelle Crash Course Study Guide Review (2026/2027) — Latest Update (400+ Verified Questions & Answers | Nursing Comprehensive Review | Graded A+)

Sarah Michelle Crash Course Study Guide Review (2026/2027) — Latest Update (400+ Verified Questions & Answers | Nursing Comprehensive Review | Graded A+) 2026/2027 | GRADED A+ | 100% VERIFIED Question: What are first line meds in hyperlipidemia? Answer HMG-CoA reductase inhibitors (statins) Classified by HOW they reduce LDL Question: Goals of primary prevention without ASCVD Answer prevent ASCVD from developing Question: ASCVD risk calculator Answer Tool to assess cardiovascular disease risk over the next 10 years. Question: Patients aged 20-75 with LDL levels 190 need which level of statin? Answer HIGH INTENSITY Question: What are the 2 go to high intensity statins? Answer rosuvastatin (Crestor) atorvastatin (Lipitor) Question: what intensity statin is rosuvastatin (Crestor) Answer high intensity Question: what intensity statin is atorvastatin (Lipitor) Answer high intensity Question: Patients aged 40-75 with DM -- does their ASCVD risk need to be calculated? Answer No. Should be started on a moderate intensity statin bc risk score is already high due to DM Question: Patients aged 40-75 with LDL 70-189 and an ASCVD risk score of 7.5 Answer WITHOUT DM BUT ELEVATED ASCVD RISK Need moderate intensity statin MINIMUM Question: AHA/ACC ASCVD risk cutoff Answer 7.5% Question: USPSTF ASCVD risk cutoff Answer 10% Question: What is secondary prevention when prescribing statins? Answer Prescribing to those who already have a known ASCVD to prevent a future cardiovascular event Question: What level of statin therapy should those receiving secondary prevention recieve? Answer High intensity Question: HyperTRIglyceridemia patients will typically be prescribed what? Answer Fibrates Fenofibrate Question: If the patients have triglyceride levels over _______ what are they at increased risk for? Answer over 500 acute pancreatitis Question: alcohol drinker and triglyceride over 500 at risk for what? Answer necrotizing pancreatitis -- watch for Cullens and Grey Turner sign send to ED immediately Question: Cullen sign Answer bruising around umbilicus (pancreatitis or ectopic pregnancy) Question: Grey Turner sign Answer ecchymoses of the flanks associated with fulminant hemorrhagic pancreatitis; very poor prognostic sign Question: Which organization has stricter blood pressure guidelines? Answer ACC/AHA Question: What are the BP guidelines for JNC-8 Answer 140/90 is hypertension 150/90 in patients 60+ with NO UNDERLYING DM or CKD Question: ACC/AHA Guidelines for HTN Answer Elevated: systolic 120-129 AND 80 diastolic Stage I HTN: 130-139/80-89 Stage II HTN: 140/90 Question: What level of hypertension is a person at according to the ACC/AHA if their systolic is 120-129 AND 80 diastolic Answer Elevated Question: What level of hypertension is a person at according to the ACC/AHA if their BP is 140/90 Answer Stage II HTN Question: What level of hypertension is a person at according to the ACC/AHA if their BP is 130-139/80-89 Answer Stage I HTN Question: How many readings do we need to diagnose HTN? Answer 2 separate readings on 2 separate occasions **ALSO GO W HIGHER STAGING IF SYS & DIASTOLIC FALL IN 2 DIFF CATEGORIES Question: How do we treat Stage 1 HTN WITHOUT ASCVD risk? Answer Lifestyle modifications & reassess in 3-6 months Question: How do we treat Stage 1 HTN WITH established ASCVD risk of 10% or greater? Answer Lifestyle modifications + medications Remember: HyperTENsion Question: How do we treat Stage 2 hypertension? Answer Medications from the start + lifestyle modifications 1st line drug classes for HTN Answer ACE Inhibitors ARBs CCBs Thiazide Diuretics Question: For those with CKD (or diabetes because it increases the risk for CKD) which antihypertensives will be used first? Answer ACE's or ARBs Question: If a patient has osteoporosis which anti hypertensives do we prescribe them? Answer Thiazide diuretics d/t their ability to stimulate osteoblasts (which help build up bone and calcium effects) Question: ACE inhibitors SE: Answer A&C Angioedema & cough Angioedema can occur at ANY point in using ACE inhibitors regardless of how long they've been taken Question: What can we do if the patient develops a cough on an ACE inhibitor? Answer Switch to an ARB Question: What are some labs that need to be monitored on an ACEs & ARBs? Answer Kidney function Potassium Question: CCBs 2 types Answer DHPs Non-DHPs Question: Which type of CCBs are DHPs? Answer -end in pine Example: Amlodipine Question: Which CCBs are NON DHPs??? Answer Verapamil Diltiazem What SE do CCBs typically cause? Answer Ankle edema Headache Which patient population should not receive CCBs? Answer Patients with GERD because it can relax lower esophageal sphincter Which patient population SHOULD NOT receive NON-DHP CCBs? Answer Those with heart failure or those with reduced EF because they will cause bradycardia and reduced cardiac output What 3 side effects are thiazide diuretics known for? Answer May increase "TUG" Triglycerides Answer Uric Acid Glucose Which patient population are Thiazide diuretics preferred in? Answer Osteoporosis African American Who are the CCB's preferred in? Answer Patients over 65 d/t their arteries stiffening Preferred in African American patients What is the GOAL BP after starting meds? Answer 130/80 or less When should a patient follow up after starting BP meds? Answer In 1 month After BP is stable 3-6 months Which complications should we monitor for in pt w hypertension? retinopathy of the eyes CV complications like heart failure renal disease Which are the preferred medications for BP control in pregnancy? Think NEW LIL MAMA Nifedipine Labetalol Methyldopa Which medications are contraindicated in pregnancy? ACE's ARBs Statins DMARDs What is metabolic syndrome? cluster of high-risk symptoms that, if they occur together, can increase your risk of heart disease, stroke, and DM 1. abdominal obesity 2. increased triglycerides 3. low HDL 4. high blood pressure 5. impaired fasting glucose (prediabetes 110) Metabolic syndrome first line treatment for metabolic syndrome lifestyle modifications and weight reduction What is an abdominal aortic aneurysm? AAA is a weakening of the wall of the aorta in the abdominal region. Weakened area is prone to rupture. A ruptured AAA will likely cause rapid, fatal bleeding. acute tearing or ripping abdominal or back pain, low blood pressure, pulsing abdominal mass AAA - call EMS what does a drop of SBP indicate (pulsus paradoxus)? cardiac tamponade or constrictive pericarditis What is the mneumonic for metabolic syndrome? PHATS P -- pressure (high BP) H -- HDL = low A -- abd girth (40 men & 35 women) T -- triglycerides (150) S -- sugars (fasting glucose 100) Need 3 or more to confirm diagnosis What are the USPSTF guidelines for AAA? Abd US between ages 65-75 for patients who have EVER smoked What is pulses paradoxus? When there is a 10 point drop in the SBP on INSPIRATION What causes pulses paradoxus? Status asthmaticus Cardiac tamponade Pneumonic for heart valves all people take money Where do you hear the Aortic heart sound? 2nd intercostal space right side Where do you hear the Pulmonic heart sound? 2nd intercostal space left Where do you hear the tricuspid heart sound? 4th intercostal space midsternal border Where do you hear the mitral heart sound? left midclavicular line 5th ICS Where would we hear S1 best? At the APEX or BOTTOM of the heart d/t valves closing Where would we hear S2 best? This is closure of the semilunar valves which are the aortic & pulmonic valves BEST HEARD AT BASE OF HEART When would we hear the S3 heart sound? Typically in volume overload from heart failure or pregnancy Sounds like ken-tuc-ky Where would we best hear S1? Heard loudest at apex Closure of AV valves the mitral & tricuspid This is the act of the heart actively PUMPING blood (systole) What part of the cardiac cycle involves ventricular filling? Diastole (ventricles relax as blood flows from the atria) What part of the cardiac cycle involves ventricular contraction? Systole (valves between atria and ventricles close and so the ventricles contract and push blood out of the heart) Where would you best hear a split S2 sound? At the BASE of the heart Normal during inspiriation/abnormal during expiration What would we do if we hear a split s2 during inspiration and expiration? refer to cardiology When would we typically hear an S4 heart sound? Commonly in uncontrolled HTN or LV Hypertrophy Sounds like Ten-Nes-See What happens if you hear an S4 heart sound in an elderly adult? This is considered benign Distolic Murmurs Remember: MS ARD Mitral Stenosis Aortic Regurgitation Diastolic characteristics of diastolic murmurs: Early diastolic blowing murmur Aortic Regurgitation A is early characteristics of diastolic murmurs: Mid diastolic, low pitched in nature Mitral stenosis How to manage diastolic murmers? refer to cardiology diastolic = doom Systolic Murmurs MR PASS MVP Mitral Regurgitation Physiological Aortic Stenosis Systolic Mitral Valve Prolapse Systolic murmurs do what... RADIATE outside of the heart If a mumur heard at the aortic valve that radiates to the neck... what is the cause? AORTIC stenosis What happens if you have a murmur heard at the apex radiating to the axilla? This is from Mitral Regurgitation Mitral Regurgitation HIGH PITCHED & hallow systolic Which condition is Mitral Valve Prolapse typically associated with? Marfans Syndrome Mitral Valve Prolapse Often described as a CLICK What grade of murmer will note a palpable thrill? Grade 4 (or higher) Is dental clearance necessary in those with mitral valve prolapse? NO What grade of murmur will we note a palpable thrill? between 4-6 What is the most common type of heart failure? Left sided heart failure What causes diastolic HF? when left ventricle is too stiff to fill up with blood Whats is diastolic HF called? HF with preserved EF The EF is preserved because the problem is with FILLING not with pumping If the left ventricle is not PUMPING properly what is this called? HF with reduced EF Right sided HF is less common than left but what is the most common cause? from left sided HF and the pressure from fluid backing up to the right side Where would you see symptoms of right sided HF? Systemically JVD peripheral edeam ascites hepatomegaly In left sided heart failure where do you see symptoms? (think Left in lungs) SOB wheezing cough pink, frothy sputum orthopnea What labs are we ordering in HF patients? CBC CMP BNP ECG Echo What is diagnostic for systolic HF? EF 40% What is the mainstay of treatment for heart failure? Diuretics What labs need to be monitored if paitents are taking diuretics? Potassium What is a unique characteristic of potassium sparing diuretics in men? Gynocomastia WHY? Because it blocks aldosterone What other med classes are used in HF patients Potassium sparing diuretics ARNI's Beta Blockers SLGT2 Inhibitors Which drug class do we absolutely AVOID in HF patients? NSAIDs Why? these cause fluid retention Which CCBs do we ABSOLUTELY AVOID in HF patients? non-DHPs or Verapamil Diltiazem reduces cardiac output When should a patient report his/her weight when doing daily weights? 2-3lbs in 1 day or 5lbs in 1 week low sodium diet Atherosclerosis condition in which fatty deposits called plaque build up on the inner walls of the arteries Risk factors for CAD? Hyperlipidemia HTN DM Symptoms of CAD chest pain palpitations fatigue sob What causes CAD? Plaque build up in the coronary arteries that supply blood to the heart What causes angina? Develops when there is reduced blood flow to the heart What is the go to med for angina Nitroglycerin which reduces demand on the heart d/t its potent vasodilation effects acute coronary syndrome sudden symptoms of insufficient blood supply to the heart indicating unstable angina or acute myocardial infarction Which populations show the least symptoms during an MI? Elderly DM patients Women Which is the most common type of MI? Inferior Usually shows up in leads II, III, AVF What type of meds will a patient be on following an MI? Dual antiplatelet therapy x1 year Aspirin + P2Y12 inhibitor P2Y12 inhibitor plavix berlinta What are symptoms of afib? Sometimes patients will not have but can be: palpitations fatigue dizziness mild SOB What type of rhythm is this? Irregularly irregular What is missing in afib? p waves What are DOACs? Direct oral anticoagulants Apixaban (Eliquis) Rivaroxaban (Xarelto) Warfarin requires routine monitoring with what lab? PT/INR What is the INR goal in afib? 2-3 What is the antidote to Warfarin? Vitamin K What is likely occurring if a patient is experiencing variances in their HR between inspiration and expiration? Sinus dysrhytmias Valsalva maneuver A process that involves expiring against a closed windpipe, creating additional intra-abdominal pressure and spinal stability. What is likely occurring if a patient is experiencing variances in their heart rate between inspiration and expiration? sinus dysrhythmia Which population are sinus dysrhythmias typically associated with? Young healthy athletes Endocarditis Inflammation of the inner lining of the heart What are the 2 S's that typically cause endocarditis? Staph Strep What are the 5 D's risk factors for endocarditis? Dental disease IV Drug use Cardiac Devices Preexisting Diseases & Defects of the heart What symptoms do you anticipate in endocarditis? Janeway lesions Osler nodes Splinter hemorrhages Roth spots Janeway lesions (endocarditis symptom) flat red macules on hands Osler nodes (endocarditis symptom) painful red leisons on hands Splinter hemorrhages (endocarditis symptom) red-brown linear streaks from damage to nail bed capillaries Roth spots (endocarditis symptom) retinal hemorrhage with DISTINCT WHITE CENTER What is a major risk factor for peripheral artery disease (PAD)? Smoking Classic symptom in which lower extremity muscle pain develops with activity and is relieved with rest? Intermittent Claudication PAD s/s Cool, shiny skin, decreased pulses How do you diagnose PAD? Ankle Brachial Index Compares the blood pressure in the upper and lower limbs What is considered an abnormal ABI? 0.9 = abnormal 1 = normal How will PAD present cool, shiny skin decreased peripheral pulses How is ABI calculated? Calculated by dividing highest systolic ankle pressure by the higher of the two brachial systolic pressures Chronic venous insufficiency involves damage to the what? The leg veins What are classic symptoms of CVI Darkened, hard, or leathery skin varicose veins venous ulcers lower extremity edema What is treatment for CVI? compression therapy leg elevation exercise as tolerated adequate skin care What test can you do to evaluate for a DVT? Homans' sign will be positive -- pain on dorsiflexion of the foot Homan's sign pain in calf upon dorsiflexion of foot and may indicated thrombophlebitis What diagnostic tests do we order to rule out DVT d-dimer Homans sign ***DOPPLER US 1st line treatment for DVT? DOAC's or Warfarin (for those with severe kidney disease) Raynaud Phenomenon Triggers? Cold or Stress How is Raynaud Phenomenon treated? Avoid triggers i.e., cold or stress Treat with VERAPAMIL Aphthous Stomatitis inside of the mouth red base with white ulcer topical relief Herpes outside of the mouth painful clustered vesicles on an erythema base antiviral- valtrex/acylovir within in 48 to 72 hours Keratosis Pilaris Chicken bumps seen in children most of the time will outgrow rough patches small acne- like bumps from too much keratin blocking hair follicles TXT: emollients & moisturizers Impetigo Honey crusted lesions Strep Anginosus & Staph Aureus Bolus= oral antibiotics NonBolus= mupirocin/Bactroban ointment Pityriasis Rosea Distributed in Christmas tree pattern starts with a herald patch self-limiting Brown recluse spider bite bite becomes under and turns deep purple in color with a white halo around it may have systemic symptoms Rocky Mountain Spotted Fever Tic Bite TXT: Doxycycline- even if pregnant rash 3-5 days after symptoms on palms of hands and soles of feet North Carolina Lyme Disease Bulls-eye lesion (Erythema Migraines) TXT: Doxycline Amoxicillin if allergic Sialolithiasis mass under the chin while eating salivary gland stone Actinic keratosis dry pink lesions on sun exposed areas if left untreated may lead to CANCER- squamous cell carcinoma TXT: 5-FU or cryotherapy Squamous Cell Carcinoma Slow-growing, scale, ulcerated & bleeds easily DX: BIOPSY REFER to dermatology Cafe au Lait Spotsq Benign & do not require interventions unless you have more that 8= neurofibromatosis Malignant Melanoma Asymmetry Border irregularity Color Diameter 6mm Evolving or Elevated above the skin could also present as a dark spot under the nail that is not related to trauma Splinter hemorrhage black lines under the nail not related to melanoma but caused by endocarditis Seborrheic Keratosis Pasted on skin lesions BENIGN- does not need to be removed Basal Cell Carcinoma Most comnmon skin cancer Telangiectasias= visible blood vessels across the lesion Shiny, waxy, or pearly in nature BIOPSY & REFER to DERM Eczema Extremely PRURITIC commonly found on flexor surfaces TXT: emollients & Topical steroids Atopic dermatitis, Asthma & Allergies Plaque Psoriasis Thick Silvery Scales Auspitz Sign- when the plaques are scratched pinpoint bleeding occurs Koebner's phenomenon- Trauma to skin leads to plaque forming TXT: topical steroids & Cole Tar & Refer to Dermatology Contact Dermatitis Linear distribution TXT: topical steroids & avoid irritant Shingles Across the dermatome Vascular & burning & tingling at the site prior to rash TXT: Acyclovir (CHEAPER)/Valcyclovir Anywhere close to the eyes- refer to ophthalmology b/c risk for permanent corneal scaring & blindness Shingrex- can be given no matter when the last outbreak was b/c inactivated also give at 50 years old Zosyvax- old vaccine & off the market Stage 1 pressure injury red does not blanch no breaks in the skin TXT: foam dressings Unstageable pressure injury can not see the depth of the wound bed because of the presents of a sloth Eschar on the heel typically seen with diabetics if it is stable with no signs of infections it should not be removed or soaked by the patient Scabies between fingers & ties intently pruritic & everyone in the house has same symptoms TXT: permethrin cream & wash everything in hot water usually have to treat twice to get rid of it effectively Chicken Pox Lesions in various stages of healing Varicella Vaccine- LIVE must be 12 months of age Can return to school when all of the lesions are crusted over Head Lice Pruitis all throughout the day and night TXT: permethrin- only kills live lice therefore the nits (eggs) must be combed out. may need 2 treatments. wash bedding & other items in hot water Molluscum Contagiosum If located in the groin area- possible sexual abuse Impregnated or dimple lesion highly contagious TXT: self-limiting takes a few months Anthrax Cattle Farmer ulcerated & black lesion that is painless TXT: CIPRO for at least 2 months. also treated with tetracycline- doxycycline Hidradenitis Suppurativia Recurrent issue- not due to hygiene more linked to genetics risk factors- smoking & obesity abscess in the axilla TXT: I&D & wound culture Mild= warm compresses and ABX- long term Folliculitis infection of the hair follicles TXT: topical mupirocin Severe- oral ABX penicillin or Keflex Rosacea Erythematous facial rash that does NOT spare the nose TXT: topical flatly gel Lupus Erythematous facial rash that DOES spare the nasolabial folds (MALOR RASH) Sjogren's Syndrome Very dry eyes & mouth commonly seen in Lupus Erysipelas Sharply defined with well-defined borders superficial cellulitis TXT: Keflex or Penicillin Purulent Cellulitis Possible MRSA Bactrim Clindamyacin Doxycline Non-Purulent Cellulitis Erythematous angry looking swollen TXT: Keflex or PCN Geographical tongue BENIGN caused by spicy & hot foods Leukoplakia can not scrape off of tongue refer to dentists commonly seen with HIV Candidiasis Can scrape off of tongue Rubeola Measles starts with a fever, cough, congestion (Coryza) & conjunctivitis (pink watery eyes)- 10 days after exposure rash on day 15 when fever breaks Koplic Spots- mouth tiny sand grains surrounded by erythematous base on the buccal mucosa (2-3 days after symptoms) contagious airborne- 1 week after exposure 304 days before rash & 3-4 days after rash causes PNA & encephalitis TXT: antpyretics, hydration & rest (days 22-24 rash resolves along w/ measles) MMR at 12 months & 4 yrs- LIVE vaccine Mumps Parotid gland swelling (bulimia can cause this too from repetitive vomiting) Rubella German measles Rash- pink & starts on face and spreads to rest of the body fever, swollen cervical lymph nodes TXT: hydration, rest, Tylenol & Motrin Contagious- do not want pregnant women to catch- fetus= birth defects or miscarriage most worrisome 1st trimester Roseola 6th disease high fever- 103, irritable, fussy, fever breaks on day 3-4 and rash appears (rose pink papules starts on the trunk and blanches, spreads to neck, arms, face, & legs) cervical adenothopy herpes virus no longer contagious when rash appears TXT: symptomatic 5th disease Erythema infectious mild cold symptoms for 1 week then red rash on cheeks (SLAPPED CHEEK) with Lacey rash on the body that may be itchy especially the feet parvovirus B19 No longer contagious when rash appears Pregnant women- 1/2 are already immune but can cause severe anemia in the fetus- draw a titer to check immunity TXT: symptomatic Hand, Foot & Mouth Disease Fever for 1-2 days with sore throat then painful sores around the front of the mouth then vesicular rash to palm or hands and soles of feet skin may peel with rash COXSACKIE virus TXT: symptomatic Tinea Annular Lesion TXT: Antifungal cream- Fluconazole Tinea Capitous head Tinea Barbae Beard Tinea Cruris Groin Tinea Pedis Foot Tinea Versicolor All over the body Enterobiasis Pinworms Intensely pruritic at night scotch tape test early in the morning TXT: Mebendazole or Albendizole TXT for Dog Bites Augmentin Lichen Planus inflammatory skin condition commonly seen with ulcerative colitis, vitiligo, & myasthenia gravis can also be caused by stress & infection seen on the flexor surface of the limbs but can be on the mouth & genitals too carries in presentations skin= reddish-purple flat top itchy bump MM= Lacey white appearance Self-liming resolves in 3 to 6 months Milld= pink w/ flat top bumps- topical steroids & antihistamines Purple= healed and does not need steroids Lichen Sclerosus Always white in appearance and primarily found on the genitalia seen in postmenopausal women's vulva b.c of overactive immune system itchy & causes painful sex & bleeding TXT: reoccurent topical steroids at risk for SQUAMOUS CELL CARCINOMA Licen Simplex Chronicus Lichenification skin becomes leathery and rubbery in appearance due to repetitive scratching or rubbing seen w/ excema TXT: topical steroids & antihistamines #1 thing we do when a patient complains of an eye complaint? Visual Acuity what does 20/40 vision mean they can see at 20 feet wet a normal person can see at 40 feet amblyopia a lazy eye usually caused by strabismus what is considered legally blind 20/200 What tests for color blindness Ishihara test Eye Cranial Nerves CN2- optic= vision= Snellen chart CN3- Oculomotor= focus CN4- Trochlear= downward & inward movements CN^- Abducens= outward movements Fundoscopic exam Retinal arteries are thinner & lighter in color than veins want to see RED reflex Funsoscopic HTN exam Papilledema- swelling of the optic disk we want to see sharp disk margins AV nicking- artery cross a vein & it bulges Copper wire arteries- arteries appear red or copper Flame hemorrhages Diabetes Fundoscopic Exam Cotton wool spots- white to yellow fluffy patches seen on the retina (underlying vascular insusfencies) Blot hemorrhages Microaneurysms Neovascularization Acute angle-closure glaucoma Sudden severe eye pain, blurred vision, & feels firm to the touch TONOMATRY= increased intraocular pressure REFER to ED b/c risk of permanent vision loss Retinal Detachment Feels like a curtain is being pulled over their eyes, sudden appearance of floaters, flashes of light, blurred vision REFER Arcus senilus Grey halo around eye RUN a LIPID profile if seen with young Xanthelasma Cholesterol deposits around the eyes on the skin Benign in elderly RUN a LIPID panel if YOUNG Pterygium Begine noncancerous overgrowth of the conjunctiva eye redness & asymptomatic & CAN. in crouch into the cornea Pinguecula Does NOT in crouch into the cornea Deposit of protein and fat in the conjunctiva Hordeolum stye caused by infection (Staph Aureus) purulent drainage TXT: ABX Chalazion Blockage of a duct TXT: warm compresses Allergic Conjunctivitis Serous but more stringy and soapy drainage cervical chain lymph node enlarged starts bilateral Viral Conjunctivitis Serious drainage Preauricular or submandibular lymph node enlarged spreads from one eye to the other Bacterial Conjunctivitis Purulent Drainage NO lymph nodes enlarged spreads from one eye to the other Medical term for pink eye Adenoviral Conjunctivitis Cataracts No RED reflex & difficulty driving at night Macular degeneration central vision loss associated with aging TXT: put things in larger print to help them read Presbyopia Farsightedness Seen in older than 40 needs reading glasses "my arms seem too short" Corneal Abrasion Commonly associated with bells palsy- not lubricating the eye DX w/ florasene staining Iritis Eye pain, sensitivity to light, diminished vision, entire eye is red with inflammation & swelling REFER to ophthalmology b/c risk for permanent vision loss Brain tumor dull persistent headache in the same spot with nausea, vomiting, vision issues & behavioral changes Stroke A-fib increases the risk for ischemic stroke HTN increases the risk of hemorrhagic stroke TIA symptoms usually resolve with in 1 hour Balance, Eyes, Face, Arms, Speech, & Time Aphasia inability to understand or express speech Wernicke's area Receptive can not understand what is being said to them Broca's area Expressive trouble forming speech Wernicke-korsakoff syndrome chronic alcoholics vitamin B1 (thymin) deficiency Cluster Headache one sided headache, tearing, running nose, occurs at the same time of the day and last for a couple of days TXT: 100% O2 and calcium channel blockers Temporal Arteritis Risk for permanent blindness one sided headache, temple pulsing, visual impairment, temple pain, increased inflammatory markers TXT: longe term steroids Definitive DX: temporal artery biopsy Common with poly myalgia rheumatic- inflammatory disorder causes muscle pain HTN Headache In the morning in the occipital area Migraines Throbbing pulsating headache, difficulty with lights and noise, nausea, and vomiting, may have an aura Prophylaxis- avoid triggers, B-Blockers (Propranolol) Abortive TXT: triptans- sumatriptan (Immatrex)- NO HTN or SEROTONIN medications Parkinson's Disease Bradykinesia (most debilitating), Tremor, & Rigidity TXT: Levodopa/Carbidopa- eventually stops working Brudzinski's flex back of head and causes hips & knees to flex too Kernig's can not extend knee past 90 degree angle without pain Alzheimer's disease Apraxia- motor speech Agnosia- cant identify Aphasia- cant understand or express speech MMSE assess cognitive decline Cranial Nerve Mnemonic Oh oh oh to touch and feel a great vein ah heaven. Sensory, motor or both= Some say marry money but my bother says big brains matter more Trigeminal Neuralgia CN5 S/S: severe stabbing pain in the face TXT: Tegretol At risk for suicide from severe pain Bell's Palsy CN 7- facial nerve need to prescribe eye lubricant to prevent a corneal abrasion Rinne Rinne under the pinne normal finding: air condition is 2 times longer than bone conduction AC BC Abnormal finding: bone conduction is 2 times longer than air conduction BC AC Weber Normal: the sound will be heard EQUALLY by both ears (NO lateralization) Conductive hearing loss can visualize the issue- cerumen impaction & cholesteaoma otosclerosis- bones in the middle ear get stuck and do not vibrate anymore will lateralize to the affected bad ear Sensorineural hearing loss Can NOT visualize the issue meningitis, mumps, meniere's disease & medications Will lateralize to the unaffected good ear Meniere's disease S/S: vertigo, tinnitus, ear pressure, nystagmus risk for permanent hearing loss Depression PHQ2 if positive then PHQ9 TXT: SSRIs and SSNRIs- take 4 to 6 weeks to see effects increase dose or investigate further- thyroid? do not d/c for n/v/d- will go away on their own after 2 weeks- increase fiver diet once dose is effective re-evaluate in 6 months to see if they can tapper off patients will quit taking meds on their own b/c of sexual dysfunction & weight gain NO PROZAC in the elderly b/c 1/2 life elderly= ZOLOFT or LEXAPRO b/c low side effects Paxil is the most sedating NO PROZAC w/ anxiety b/c a side effect is jitteriness Serotonin syndrome shivering, seizures, & tremors Tricyclic antidepressants Elavil NO ELDERLY b.c of anticholinergic side effects Atypical antipyschotics Zyprexa & Seroquel weight gain & hyperlipidemia monitor lipid profile, blood glucose & weight Bipolar disorder S/S: Manic- not sleeping, impulse purchases, excited Depressed- cant get out of bed. cant do daily activities TXT: lithium- narrow therapeutic range and causes thyroid side effects PTSD S/S: nightmares, flashbacks, hypervigialnce, exaggerated startle reflex TXT: SSRIs Seasonal affective disorder changing of the seasons effects the patient's circadian rhythm becomes more depressed at the same time each year TXT: exposure to more light to reset the circadian rhythm CYP2C19 asian population impacts their ability to metabolism pain medication tramadol & codeine may not work for their pain Total cholesterol HDL LDL Triglycerides ASCVD cutoff Total cholesterol 200 HDL 40 to 60 LDL 100 Triglycerides 150 ASCVD cutoff 7.5% order a lipid profile every 5 years unless they have risk factors- increased BMI, Marcus seniles, xanthelasma TXT: lifestyle modifications first HMG COA reductase inhibitors High intensity- atorvastatin U rosuvastatin at high doses Ugh cholesterol & family history of MI @ 45 yrs needs high intensity Rhabdomyolysis- new muscle pain & CK will be 5 times the normal limit- can cause acute renal failure Acute drug induced hepatitis- Jaundice- check liver function NO GRAPEFRUIT JUICE High Triglycerides 500 can cause pancreatitis- inevitable at 1000 necrotizing pancreatitis= Cullen & Turner signs TXT: Fenofribrate When to treat HTN older than 60 150/90 60 or w/ CKD or DM 140/90 lifestyle modifications & home BP logs Coenzyme 10 (CoQ10) assess COMPLIANCE to meds first when BP does not decrease JNC8 goal: 140/90 AHA goal 130/80 ASCVD risk 10% ACE inhibitors PRILS Monitor renal functions- BUN & Creatinine & K risl for hyperkalemia deceases cardiovascular events & mortality S/E: angioedema & dry hacky cough Thiazide Diuretucs Bad for those with increased uric acid, increased triglycerides, & increased glucose Great for osteoporosis (osteoblast to make more bone & retain CA) Calcium Channel Blockers S/E: ankle edema & headache NO GERD- vasodilator & relaxes the LES NO HF B-Blcokers not first line used after MI HTN drugs for African Americans Thiazide diuretics CA channel blockers BP meds for pregnant women NEW LITTLE MAMA Nifedapine Labetalol Methladopa NO: ACEI, ARBS, STATINS, or Methotrexate HTN & Diabetic Meds ACEI or ARBs b/c they are renal protective do NOT give THIAZIDE- b/c increased glucose Isolated systolic hypertension older arteries stiffen w/ less elasticity TXT: CA Channel blockers Respiratory sinus arrthymia inspiration increases HR and expiration decreases HR Pulses Paradoxes 10 point drop in SBP w/ inspiration cardiac tamponade & status asthmatics Heart Failure DX: BNP, EKG, Echo cardiogram= EF 40% F/U ASAP if they gain 2kg in 1 day- TXT: increase diuretic & K supplement Right- backs up into the body Left- Backs up into the lungs TXT: Lasix- causes hypokalemia, ACEI & B-Blocker If patient is on Lasix and K supplements and has another exacerbation within 2 weeks- assess med compliance S3 heard with fluid over load= HF & Pregnancy NO TZD (Diabetic med) b/c causes edema NO NSAIDS b/c increase NA & Fluid retention Atrial Fibrillation TXT: anticoagulant & metoprolol for rate control irregularly irregular & no p-wave the atria quivering and do not pump effectively which increases clotting risk Warfarin Goal INR= 2-3 Normal INR= 1 Antidote= Vitamin K S1 SYSTOLIC closure of the AV valves- Mitral & Tricuspid S2 DIASTOLIC Closure of the semilunar valves- aorta & pulmonary ONLY HEARD AT THE BASE of the heart splitting of S2 is only NORMAL during INSPIRATION S3 Extra fluid HF & Pregnancy S4 Uncontrolled hypertension & left ventricular hypertrophy Systolic Murmurs MR PASS MVP Mitral regurgitation Physiological Aortic Stenosis- radiates to the neck Systolic Mitral Valve Prolapse- usually hear a click (Marfan syndrome) & radiates to the armpit Diastolic murmurs DOOM- REFER MS ARD Mitral Stenosis Aortic Regurgitation Diastolic What grade murmur do we feel a palpable thrill GRADE 4 or higher Peripheral Arterial Disease purple or shinny decrease blood flow, pain w/ activity that is relieved with rest and dangling (intermittent claudication) Ulcer on the toe TXT: continue walking w/ PRN breaks DX: ABI (ankle brachial index) 0.9= PAD arterial ankle BP/arterial arm BP BIGGEST risk factor= smoking Chronic venous insufficiency Reddish-brown discoloration, edematous, varicose veins- refer to vascular At risk for clots- DVT- s/s: localized swelling & erythema & calf pain Homan's sign is not considered accurate anymore Raynaud's Phenomenon Decreased blood flow to the fingers caused by exposure to cold or stress TXT: CA Channel Blockers & avoid triggers Asthma Stage 1: intermittent Stage 2: Mild Stage 3: Moderate Stage 4: Severe cough is the most predominate symptom TXT is success is baed on peak flow readings NEVER give a Long acting beta agonist alone- Formoterol or Salmeterol) Cornerstone of TXT is inhaled corticosteroids Peak flow is impacted by Height, Age, Gender Asthma TXT Intermitten= inhaled corticosteroid & LABA mix PRN (budesonide/formoterol) Mild: Low dose inhaled corticosteroid daily ModerateL inhaled corticosteroid LABA mix daily or low dose corticosteroid w/ leyukotrine receptor antagonist (Singulair) Severe: refer to pulmonology Steroids end in IDE or SONE Bronchodilators end in TEROL COPD DX: FEV1/FVC ratio 0.70 S/S: barrel chest, cladding of the fingers, chronic cough, hyper resonant percussion TXT: Group A: bronchodilator (SABA or LABA) Group B: long acting bronchodilator (LABA or LAMA) Group C: LAMA Group D: LAMA or combo LAMA/ICS usually- SABA, LABA, LAMA, Combo Unintentional weight loss= cancer= lung cancer (most common cancer) or burning too many calories trying to breathe and not eating enough- needs high calorie high protein small meals 5-6 times a day Pneumonia S/S: infiltrates and consolidation in lower lobes, cough, fever, chills, rhonchi, wheezing, increased tactile fremitus TXT: Macrolide, Amoxicillin or Doxycycline if Comorbidities or ABX w/I 90 days then respiratory fluoroquinolone (Levaquin) or combo augmenting w/ macrolide cipro is not a respiratory fluoroquinolone CURB-65 criteria Confusion BUN 19 Respiratory rate 20 BP 90/60 Age 65 1 point for each. 2 points= may need admission 3 points= hospital admission Tuberculosis Commonly seen in the upper lobes Long term ABX txt up to 1 year w/ 3 ABXs 5mm: HIV, immunocompromised (HIV turns into AIDS when CD4 200- start prvofalactic Bactrim for PJP) 10mm: immigrants 15mm: general public confirm diagnosis w/ sputum culture Strep Throat Sore swollen throat w/ exudates & PALATINE PETCHIAE TXT: Amoxicillin Sandpaper rash= scarlatina risk for rheumatic fever & glomerulonephritis Mono Sore swollen throat w/ exudates & SPLEENAMEGALLY return to sports when spleen is not enlarged on US even if mono spot is still positive IF have strep throat too NO AMOXICILLIN= morbilaform rash TXT w/ PCN VK, cephalosporin or a macrolide Bronchitis Nagging cough that cant get rid of & possible productive w/ sputum most are viral Pertussis ABX does not decrease length of symptoms but decreases how contagious they are TXT:azithromycin TdAP- prevents pertussis- if they have fever from TdAP it is usually from the pertussis component Sinusitis Acute URI recently 7-10 days later symptoms reoccur, pain with bending over and unilateral toothache TXT: Augmentin- to prevent periorobial cellulitis Chronic sinus infections are at risk for nasal polyps- usually harmless but can impact their ability to breath through their nose- refer out Allergic Rhinitis AVOID TRIGGERS intranasal corticosteroids- Flonase IgE immunoglobulins detect allergies 2nd line TXT: antihistamines- Benadryl AVOID w/ ELDERLY b/c anticholinergic side effects Anticholinergic side effects cant see cant pee cant poop cant spit Hypothyroidism Normal TSH 0.5 to 5 TSH is high & T3/T4 are low TXT: Synthroid- common to see cardiac effects= ELDERLY= LOW DOSE check TSH every 4-6 weeks- before adjusting medication check compliance & taking it correctly Subclinical Thyroid hypothyroidism= TSH is elevated w/ normal T3 & T4 Hyperthyroidism= TSH is low w/ normal T3 & T4 RECHECK levels in 6 Months Hyperthyroidism TSH is low & T3/T4 are High B-Blocklers= propranolol to block symptoms Antithyroid drugs= tapizole or PTU (during 1st trimester only) PTU is obnoxious- have to take it multiple times a day and monitor labs Parathyroid located behind the thyroid releases parathyroid hormone controls calcium & phosphorus (inverse relationship) Hyperparathyroidism= increased CA & Decreased Phosphorus- investigate for cancer DM type 1 typically before age 30 Long acting insulin= Lantus & Levirmire start at night covers 24 hours Basal insulin is titrated 2 units every 2-3 days till goal Bolus short acting= Humalog, Novolog 1-2 unites every 2-3 days consistently BS checks if prandial is high- increase bolus insulin if fasting BS is high increase long or intermediate insulin Somogyi effect there is a dip in the middle of the night in their BS before it rises in the morning TXT: cut back on night time insulin or stop exercising before bed Dawn Phenomenon the BS steadily rises all night b/c of an increase in growth hormones TXT: needs more insulin DM type 2 Prediabetes= HgA1C 5.7 to 6.4 Diabetes 6.5 Fasting BS preDM= 100-125 & DM= 125 2 HR oral glucose tolerance preDM= 140-199 & DM= 200 Random plasma glucose DM= 200 w/ symptoms eyes- cotton wool spots, neovascularization micro aneurysms, cataracts & glaucoma- see ophthalmologist yearly see podiatrist yearly BP goal 130/80 to prevent microvascular complications immunizations= Tdap, flu, Hep B, Zoster, & PNA Kidney FX labs- BUN, Cr, GFR, & micro albumin yearly Risk Factors: obesity, sedentary lifestyle, unhealthy eating habits, family history, increased age, HTN, smoking, hyperlipidemia DM type 2 S/S polydipsia, polyphagia, polyuria, acanthuses nigricans (dark spots on the back of the neck), fatigue, neuropathy, frequent infections, blurred vision, dizziness, irritability start insulin right away if A1C 9% Microvascular complications= neuropathy, retinopathy, nephropathy Microvascular complications: CAD, PAD, CVA Metformin 1st line DM med does NOT cause hypoglycemia b/c it inhibits glucose production by the liver does NOT cause weight gain- weight neutral- some may loose weight Max dose= 2,550 mg per day Starting dose= 500mg BID increase as tolerated GI S/E= Diarrhea CONTRAINDICATED w/ GFR 30 (can use w/ GFR of 30-40 but cut dose in 1/2) Stop before procedure w/ contrast dye b/c of lactic acidosis Long-term use can cause vitamin B12 deficiency used to treat PCOS and preDM Sulfonylureas IDE glipizide & Glyburide increase hypoglycemia AVOID in ELDERLY causes weight gain SGLT2 inhibitors FLOZIN Cardioprotective cause you to urinate out glucose NO ELDERLY w/ incontinance issues or Frequent UTIs GLP-1 Agonists TIDE Cardioprotective Injections Contraindicated w/ thyroid cancer & pancreatitis TZDs ZONE can cause cardio toxicity & hepatoxticity NO HF- will gain weight Gestational DM TXT: Insulin does not cross the placenta Addison's Too little Cortisol S/S: hyperpigmentation all labs are low except for high potassium Addisonian crisis- always carry emergency kit w/ steroids Cushing's Too much cortisol S/S: Moon face, purple striae, trunks obesity All labs are high except for low potassium Lupus Antinuclear antibody test alone does not DX need positive test w/ stereotypical symptoms S/S: mailer rash= facial rash that spares the nasal labial folds Monitor Kidney FX Sjogren's Syndrome dry mouth and eyes TXT: OTC eye drops seen w/ lupus Low MCV Normal 80-100 Microcytic Lead intoxication Iron Deficiency Thalassemia S/S: nail pitting, spoon-shaped nails, pica general S/S: pale & fatigue Low iron levels, high total binding iron capacity (not enough iron to bind) limit whole milk until 12 months to prevent iron deficiency anemia Thalassemia- at risk for iron overload b.c increased intestinal absorption & blood transfusions High MCV Macrocytic Folate deficiency B12 deficiency- has neuro symptoms & beefy red tongue (glossititis) Alcoholics are at risk Sickle Cell Anemia DX: hemoglobin electrophoresis Illness & Dehydration cause crisis- TXT: IV fluid & pain meds Hepatitis B HBsAG= always growing aka either acute or chronic infection IgM= misery IgG= Gone except w/ a positive HBsAG= chronic infection Exposed w/o being vaccinated= give vaccine and immunoglobulin Hep B vaccine- okay for pregnancy & given 24 hours after birth Vaccines 7 yrs old= Dtap 7 yrs old= Tdap It's time for many happy vaccines IPV, Tdap, MMR, Hep B, & Vericella HiB- prevents epiglottits Epiglottis drooling, resp distress x-ray= thumb print Thalassemia leads to iron overload hemochromatosis also causes too much iron TXT: regular phlebotomy Polycythemia vera too many blood cells- really thick and viscous blood at risk for clotting secondary= high altitudes & chronic resp condition (COPD) TXT: regular phlebotomy Rovsing Think reverse/right palpate LLQ and the RLQ hurts Markle Pain in RLQ when hopping on one foot Blumberg REBOUND TENDERNESS Poses sign patient raises leg against resistance and causes pain Mcburney's point 2/3rds of the distance from the belly button to the anterior iliac crest tender when palpated Obturator sign internal rotation of the right hip 90 degrees causes abdominal pain Murphy's Sign palpate into subcostal area in the right upper quadrant & pain w/ inspirations Cholecystitis Hida Scan order when the US is negative for choleycyctitis but the patient has too many symptoms indicative of choleycystitis can only do a HIDA scan safely if there is no gallstones present b/c one may become dislodged into the pancreatic duct Cullen & Turner sign Intraabdominal bleeding= necrotizing pancreatitis & ruptured ectopic pregnancy Cullen's (CENTER)- periumbilical blush discoloration Turner's (TURN OVER)- flank bluish discoloration Pancreas labs= Amylase & Lipase Chvostek's & Trousseau's Hypocalcemia usually after a thyroidectomy w/ accidental parathyroid damage at risk for SEZIURES Chvostek's= tap on face and it scrunches up on one side Trousseau's= inflate BP cuff & it draws up the arm like an involuntary contractions GERD Mild- H2 blocker b/c cheaper Severe-PPI PPI long term use= osteoporosis, B12 deficiency anemia & C-diff TXT to prevent Barretts esophagus b/c at risk for cancer NO CA CHANNEL BLOCKERS If GERD is not improving investigate further= H.Pylori testing & EGD get a closer look at the stomach H Pylori Tripple therapy= Clarithromycin Amoxicillin PPI Quadruple Therapy= Tetracycline Flagyl PPI Bismius salt Colonoscopy CDC @ 50 yrs ACS @ 45 yrs every 10 yrs with an annual fecal occult blood test start sooner w/ personal history of colorectal cancer or 1st degree relative w/ colorectal cancer & inflammatory bowel disease (Chrones & UC) or prior abdominal radiation S/S colorectal cancer= ribbon shaped or the pencil stools most polyps occur in the defending colon IBS irritable bowel disease- things are irritable but not inflammation therefore NO elevated inflammatory markers (CRP & ESR) RUQ pain cholecystitis- pain radiates in-between shoulder blades & aggravated by fatty foods Hepatitis or liver disease LUQ pain stomach pain pancreatitis RLQ appendicitis LLQ diverticulitis- needs ABX C-diff- NEW ABX= vancomycin use to be flagyl Celiac disease gluten intolerance- wheat, rye, or barley TXT: remove gluten from diet Trichomoniasis Strawberry cervix- pinpoint hemorrhages TXT: Flagyl Normal Vaginal PH= 3.8 to 4.5 Bacterial vaginosis Clue cells on the wet mount & positive whiff test TXT: Flagyl- NO ETOH b/c disulfiram reaction Gonorrhea Friable cervix TXT w. chlamydia= doxycycline & rocephin if gonorrhea alone= Rocephin Chlamydia Friable cervix TXT: azthromyacin if no gonorrhea doxycline if allergic to macrolide Herpes painful burning vesicles Symphilis 1st stage- painless chancer for 3-6 weeks & disappears 2nd stage: rash on palms & soles 3rd stage neuosyphils- effects brain & spinal cord Screening test= RPR confirm with FTA-ABS TXT: IM Bicillin Contraception Non-hormonal- Copper T IUD Progestin only for breastfeeding (mini pill) Depo-prevera- increased risk for osteoporosis- give CA & Vit D and do not use for linger than 5 yrs No combo estrogen/progestin for migraines w/ aura, a current clot, liver disease, older than 35 & smoker Ortho Evra patch= highest risk for blood clot miss 2 active pills take most recent missed pill asap and get rid of the other pill & use back up contraception 18 yrs does not need consent for STD TXT, contraception & pregnancy care but needs parental consent for dysmenorrhea TXT What should you always order when I woman of childbearing age has abdominal complaints HCG urine pregnancy test- even if female states she has not started menses Pregnancy signs Presumptive (SUBJECTIVE)= breast tenderness, amenorrhea, & nausea Probable= HCG, Hager, Chadwick, & Good Postive= Palpation of the fetus, US of the fetus, & Fetal heart tones on a US Fundal Height: 12 weeks= symphysis pubis 20 weeks= umblicus +/- 2= normal NO LIVE VACCINES Pregnancy screenings 24-28 weeks screen for gestational diabetes week 28= administer RHgam & w/I 72 hours of delivery 35-37 weeks screen for group B strep- TXT w/ PCN Pregnancy and UTI TXT TXT all asymptomatic UTIs b/c risk for fetus Cephlasporins (trimester dependent) Amoxicillin Macrobid (Trimester dependent) Penicillin NO CIPRO or Florquinolones AFP testing performed 16 to 20 weeks high= neural tube defects- spinal bifida- give folic acid to prevent low= Down syndrome Down syndrome at high risk for cervical spine instability- needs x-ray of spine for sports participation althzeimers hypothyroidism Placenta Previa placenta is covering cervical opening light painless bleeding Placental abruption Placenta separates from inner wall of uterus painful & uterus is hard to the touch & bleeding typically only occurs in the 3rd trimester Mastitis TXT: dicloxacillin- safe for breastfeeding allergic to PCN- clindamycin & macrolides if finished ABX and still symptomatic= refer to GYN & mammogram maybe cancer KEEP BREASTFEEDING PAP Smears start at age 21 regardless of prior sexual activity and every 3 years for a normal female and then every 5 years after age 30 w/ HPV contesting Low-grade lesion (LSIL) & High-grade lesion (HSIL)= refer for colposcopy- CIN 2&3= more serious Atpical squamous cells of undermined significance= receive HPV testing regardless of age & if positive= colposcopy Gardasil Vaccine at 11 yrs old- can give as young as 9 yrs old HPV cancer= 16 & 18 TXT for genital warts= TCA acid Post-menopausal bleeding REFER for endometrial biopsy- possible cancer Hormone replacement therapy increases risk for cardiovascular disease, blood clots, diabetes, & ovarian cancer alternative TXT: SSRI- PAXIL for hot flashes & night sweats, oral contraceptives, IUDs, vaginal cream Herbal- Black cohosh, ginkgo (causes anticoagulation) Polycystic ovarian syndrome at higher risk for: insulin resistance DM- txt metformin Hyperlipidemia Cancer Galactorrhea Check a prolactin to rule out prolactinoma milky discharge that is expressed from the breast is not usually a big deal typically associated with breast stimulation & can be caused by atypical antiphyscotics Benign Prostatic Hyperplasia DRE findings: symmetrically enlarged rubbery prostate & the patient complains of urinary frequency & hesitancy A-Blockers= (ZOSIN) terazosin or Doxazosin- TAKE AT BEDTIME first dose effect of hypotension Finasteride (Proscar)- shrinks prostate Herbal- Saw palmetto Refer if PSA 4 May not treat prostate cancer b/c slow growing Epididymitis Unilateral testicular pain with Phren sign (pain relief when testicle is lifted) and the scrotum is swollen and angry TXT 35 yrs old: Doxycycline & rocephin TXT 35 yrs old Levofloxin Testicular Torsion Severe unilateral testicular pain with absent cremasteric reflex REFER Kidney Function Labs Glomerular Filtration Rate (GFR)- base kidney disease staging Creatine BUN (blood urea nitrogen)- less specific b/c can increase w/ GI bleed always REFER if you see cast on a urinalysis RBC cast= glomerulonephritis WBC cast= pyelonephritis Urinary Tract Infections Nitrates & leukocytes on urinalysis & c/o burning with urination & frequency Bactrim- AVOID w/ WARFARIN Cipro- AVOID w/ heal pain Macrobid Pregnancy= Augmentin recurrent UTIs need Kidney US Erectile Dysfunction PDE-5 Inhibitor- avoid w/ underlying cardiovascular risk- order EKG before prescribing NO Nitroglycerin= hypotensive Osteoporosis DX: Dexa Scan osteoporosis= -2.5 or lower osteopenia= -1 to -2.4 Risk Factors: depo-provera & steroid use & smoking Prevention: Ca & Vit D, weight-bearing exercises TXT: Bisphosphonates (Fosamax) Elderly female smoker falls at home- do not wait to x-ray b/c high risk HTN & Osteoporosis= thiazide diuretics b/c they stimulate osteoblasts to build bone & decrease the excretion of Ca Rheumatoid Arthritis can begin at any age faster onset usually bilateral stiffness 1 hour systemic symptoms TXT: DMARTS= methotrexate- causes folic acid deficiency Buchrards nodes- PIP joint Boutonniere & Swan Neck deformatites Osteoarthritis Occurs as patient ages slower onset usually unilateral Stiffness 1 hour No systemic symptoms X-ray= joint space narrowing Herberdans- ONLY w/ OSTEO & located in DIP Buchards- BOTH- located in PIP TXT: NSAIDS (1st line not w/ HF) & regular exercise Anklosing Spondylitis Bamboo spine on X-ray S/S: pain starts in the lower back and works it way up the lower back to the neck autoimmune arthritis as well as chronic inflammatory disease X-ray first then MRI Scaphoid Fracture Navicular fracture Snuff box tenderness fell with hands braced to catch them does not always show on the x-ray right away- usually takes 2 weeks TXT: thumb spice cast to prevent oestonecrosis of the wrist Carpel Tunnel Syndrome Phalen's- backward prayer hands Tinel's- Tap the inner wrist TXT: splint or brace & maybe steroids Morton's Neuroma Feels like there is a pebble in their shoe between their 3rd and 4th toe with numbness & tingling McMurry test Menisus Continued popping in knees Lachman Test ACL best test Anterior Drawer ACL 2nd best test Valgus Ligaments Sciatica Straight leg test- reproduction at 30 to 70 degrees L4= squat & rise exam and knee jerk is diminished L5= Heal walking causes numbness at the great tow S1= walk on ties & diminished or absent ankle jerk Rotator cuff tear abduct (pull away from body) shoulder then patient lowers arm to waste slowly= arm suddenly drops to the side Empty can test= supraspinatious treat Gout Prevention medication: Allopurinal= decreased uric acid levels- S/E: bone marrow suppression- monitor CBC & do not start during an acute attack TXT: Potent NSAID= Indocin or Steroids Severe multiple joints= colchicine (Colcrys) Lifestyle modifications- low purine diet, No ETOH, NO DIURETICS (HCTZ) DX: uric acid level- may not always be elevated in an acute attack Fibromyalgia Widespread pain and sensitivity- a lot of tender points DX: pain, fatigue, waking up feeling unrefreshed and cognitive problems for at least 3 or more months. symptoms can not be explained by other conditions TXT: Cymbalta, Elavil, Lyrica, Flexeril, regular exercise- is the best thing to go Hallux Valgus Bunion 1st metatarsal phalange joing DX: X-RAY- looks at degree of severity TXT: braces or severe- refer for surgery Plantar Fasciitis Pain in the heal 1st think in the morning alleviated as the day progresses occurs in runners Cauda Equina Syndrome S/S: severe low back pain with saddle anesthesia (numbness & tingling in the area that would touch a saddle) new incontinance REFER to ER!!! Needs surgery caused by severe ruptured lumbar disc De Quervain's Tenosynovitis Pain in lower thumb & wrist DX: Finkelstein Test- examiner grabs thumb & performs ulcer deviation- positive if pain occurs Quasi-experimental design no randomization Randomized control trial randomization of placebo & treatment Hierarchy of evidence 1. Meta-Analysis/Systematic reviews- pulls together research to analysts it 2. All of the C': randomized control trials, Cohort studies, case control studies, cross sectional studies (actual research is performed) 3. Editorials/opinions: No real research Health Belief Model people will not change their health behaviors unless they personally believe they are at risk and they want to avoid negative health consequences used to explain & predict health behaviors 6 components: received risk, susceptibility, the belief of consequences, risk severity, benefits to action, self efficacy, & ques to action License ability to practice in the STATE no compact APRN licenses= apply for state license in every state that you want to work in Certification Board Exam- ANCC or AANP Credentials process that allows you to bill medicaid or medicare Occurrence based Liability Insurance is not affected by job changes or retirement instead as long as you had an active policy when you saw the patient in the clinic you car covered Claims based Liability Insurance you have coverage ONLY when you are employed... loose coverage when you change jobs Needs tail coverage if you leave your job Stages of change 1. Pre-contemplation- not even thinking about change- use motivational interviewing to try to persuade the patient 2. Contemplation 3. Preparation- takes small steps to prepare for the action 4. Action 5. Maintenance/Relapse Family systems theory the family functions as a system- a cohesive unit- one big emotional unit and each family member play a specific role- if one part slacks- another member picks up the slack Lewin's change model 1. Unfreeze- figure out how to become motivated to change 2. Change- where the change occurs 3. Refreeze- is what you do to ensure that the change is permanent & becomes a habit Transitional care model Prevent readmissions and exacerbations revives around case management & discharge planners ICD 10 Codes identifies the diagnosis CPT Codes identifies the procedures performed 3 components of a chart history physical exam plan Swiss cheese model all about risk analysis and management an error occurred and we go back & see where the issue fell through the cracks NOT based on BLAME based on root cause analysis to prevent events from happening in the future Incident to billing the physical sees the patient 1st for the issue and the NP sees the same patient for the same diagnosis later on allows NP to reimburse at 100% instead of 85% if any new issues come up during the visit you can not use incident to billing What governs NPs State Nurse Practice ACt- sets scope of practice & determines our legal rights State Board of Nursing- enforces our scope of practice Collaborative agreements with physicians, dentists & DOs. NO CHIROPRACTORS HIPPA protects patient privacy can only use first name in waiting rooms can not leave documentation software open in patient rooms never leave patient results on a voicemail Telehealth patients who are following up for routine things HF patient giving you their daily weight log Social History Relationship status living arrangements highest level or education employed smoking, drugs, alcohol stress social support exercise access to running water determines over all health Medicare part A inpatient stuff including hospice Medicare Part B all of the out patient needs- diagnostic test, 2nd opinions, & medical equipment Medicare Part C advantage plans supplemental insurance dental & vision Medicare Part D Prescription drugs Medicare Care for the old, disables & ESRD Funded by the federal government Budget Reconciliation ACT- allowed NPs to bill up to 80% reimbursement Balanced Budged Act- NPI numbers for NPs HITECH Act Electronic medical records in order to get pain incorporated clinical decision supports- abnormal labs or vital signs in red and not black PHI- protection of health information= no identifying information on things that are shared Medicaid Funded by Federal & State Those who can not afford insurance b/c they live below the poverty level AID the POOR less than 2,000 per month is considered being under the poverty level Children- WIC & CHIP- technically over poverty line but cant afford insurance Levels of Prevention Primary- before the incident occurs Secondary- Screenings Tertiary- Already happened= regard or treatment Veracity truth telling Fidelity Loyalty Autonomy The patient has the ability to make own decisions Parternalism The provider tries to "parent" the patient and decide what is best for the patient Benficence too do good for the benefit of others Non Maleficence to do no harm Justice everybody gets the same treatment Native Americans Culture use shamans as healers believe that illness is a punishment uses herbal remedies avoids eye contact & loud volumes health is from living in harmony Vietnamese Culture Blood loss is worse than the illness fear lab draws stop RX when they feel better Hispanics Culture Imbalance between the person and the environment Chinese Culture Disruption between yin & yang cupping & coining women must avoid cold stuff for 1 month after birth Cobra allows for patients to continue having access to health care when they quit or get fired from a job continue on same insurance plan that they had but they are responsible for paying the covered premium- also paying for their part and the employers part can continue for up to 18 months Genetic information non-discrimination act prohibits the use of genetic information for employment & health care decisions consensus model for APRNs allows for NPs to practice at the fullest extent of their training & certification infant mortality infant deaths per 1,000 live births leading cause of death is congenital malformations Validity the actual accuracy of the results Reliability the results are repeatable Collaborative working together with a physician to care for patients Consultative asking another NP in the office for advise about a treatment option Erikson's Stages TRUST the AUTO IN INDUSTRY IDENTIFY with INTIMATE GENIUSES with INTEGRITY Sit up unassisted 6 months old holds a spoon 15 to 18 months stands 9 months old say mama/dada 12 months old walk 12 to 17 months copy a circle 3 yrs old throw a ball 3 yrs old ride a tricycle 3 yrs old draw a cross 4 yrs old ride a bicycle 5 to 6 yrs old separation anxiety 9 months old palmar grasp goes away 5 to 6 months old anterior fontanelle closure 12 to 18 months posterior fontanelle closure 2 to 3 months old strabismus clears up 4 to 6 months old genuverium bow legged goes away 2 to 3 yrs old premature babies usually catch up by age 2 birth weight doubles & triples at 6 months & tripples at 12 months nasal foreign body nasal pain & drainage from only one nare Breastfeeding effective if they have 6 to 8 wet diapers per day and if the baby is gaining weight need vitamin D supplements Vaccines live vaccines MMR & Varicella @ 12 months old no love vaccine for immunocompromised (Cancer) What bilirubin level would you initiate phototherapy 15 L:eukocria retinoblastoma or congenital cataract Regression normal to see with a big life change- anticipatory guidance is needed not normal for a 7 to 8 year old soiling pants and c/o abdominal pain Tanner stages Stage 1: nonthing Stage 2: Breast buds & straight pubic hair Stage 3: girls- 1 mound & boys- growth spurt & penis grows the most in length Stage 4: 2 mounds & star period & Curley pubic hair Stage 5: everything Puberty too early before age 8 for girls and age 9 for boys puberty starts with stage 2 2-3 yrs after puberty starts a girl should start her period normal for breast to be asymmetrical if no period by 15- investigate farther start of period= adult height vaginal bleeding can be normal within the 1st few days of life from withdrawal of hormones Anorexia at risk for bone loss & heart disease know they are getting better when they gain weight & menses show back up Bulimia at risk for enamel erosion & esophagus repeated exposure to stomach acid Salter Harris Fracture fractures that occur along the growth plate common in pediatric long bone fractures at risk to s