ENT (9 Qs) Allergic Rhinitis and Other Conditions (PDF)

ENT (9 Qs) Allergic Rhinitis -sx: sneezing, runny nose, mouth breathing, pruritus, chronic sinusitis Tx: #1 is allergen avoidance pale + boggy nasal turbinates...

ENT (9 Qs) Allergic Rhinitis -sx: sneezing, runny nose, mouth breathing, pruritus, chronic sinusitis Tx: #1 is allergen avoidance pale + boggy nasal turbinates -If mild or episodic sx: afebrile, bilateral allergic shiners -​ oral antihistamine (ex cetirizine, loratadine) → 2-5h b4 exposure Periorbital edema -​ 2nd gen Antihistamine nasal spray (ex azelastine) Dennie's lines- extra fold of skin -​ Glucocorticoid nasal spray (flonase) → more effective than Shiner- dark rim antihistamines -causes: allergic v bacterial v viral (Triggers: pollens, animal dander, flooring, -​ Cromolyn nasal spray upholstery, mold, humidity, smoke) -Persistent or moderate/severe sx: continue above + immunotherapy injections Pharyngitis Viral Bacterial (GABHS) Allergic subacute onset sore throat, URI strep causes tender, swollen lymph nodes, patchy tonsillar exudates, acute sneezing/itchy/watery eyes, rhinorrhea symptoms, absent fever, oral ulcers onset sore throat, absence of URI, fever >101 and mild sore throat, worse lying down -can be d/t adenovirus, parainfluenza, Strep: PCN 500mg PO BID for 10 days Allergic rhinitis, post nasal drip, GERD, covid, coxsackie (hand/foot/mouth ​ If PCN rash → cephalexin 500mg mouth breathing lesions on hard palate) ​ If PCN anaphylaxis: azithromycin 500mg/day 1st day, then 250 mg PO -tx: warm water, lemon,, lozenges, once a day x4 days Tx: avoid allergens, antihistamine, NSAIDs, tylenol N. gonorrhea: ceftriaxone 500mg IM x1 hydration  Rhinosinusitis (viral, allergic, or bacterial) 1) Viral: d/t adenovirus yellow green discharge, oral Bacterial: d/t step PNA, H influenza, moraxella dx (any of 3): pain, bad breath, head P, 10 d wo improvement b.​ fever >39 (102 F) + drainage or facial pain for 3-4d c.​ onset worsening symptoms or new onset fever, HA, or increase in nasal discharge following URI of 5-6 d that were initial improving (double sickening) Only if s/s are orbital, intracranial, or soft tissue Amox-clauv 875/125mg PO BID x5-7 days or Amoxicillin 500mg TID or 875mg BID PO abscess: Imaging (films, CT, US) for Facial swelling, -​ If PCN allergy: Doxy 100mg toxic appearance, unresponsive asthma ***failure to improve in 48h suggests a resistant organism → imaging -supportive management: saline irrigation, neti pot, ibuprofen + tylenol Acute Otitis Media Otitis externa (swimmer's ear) Eustachian tube dysfunction or obstruction d/t inflammation from Strep -Diffuse inflammation of external auditory canal, can be bacterial or fungal d/t frequent PNA + H flu most common pathogen water exposure or ear phone use (airpods) → Sx: Earache, Muffled or difficulty hearing, Vertigo → S/sx: Pruritus, purulent drainage with crusting, tender tragus, diffuse canal edema, → PE: Cloudy/full red or bulging TM , Decreased TM mobility + bony erythema, radiating pain to fact or neck, vertigo landmarks, Increased vascularity of TM -​ If pt has not had abx within past mo: amox 1000mg TID x 10 days Gentile cleaning w ⅓ white vinegar, ⅔ rubbing alcohol after swimming, then abx drops -​ Otherwise: amox-clauv 875/125mg BID x 10 d -​ Cipro + hydrocortisone: 3 drops in ear BID x 7 days -​ Cipro and dexamethasone: 4 drops in affected ear BID x 7 days Dermatology (9 Qs) Cellulitis Onychomycosis erythema with poorly demarcated borders, mild edema, and warm to touch with Chronic fungal infx of toenails or fingernails tenderness to palpation, Regional lymphadenopathy, unilateral Cause is yeasts or molds, prevalent in T2DM + PVD, immunosuppression Get culture to determine if Common agent: strep A, s pyogenes Tx not mandatory but patient may desire it for cosmetic reasons ​ Amox 500mg PO TID OR PCN 500mg PO QID 7-10 days ​ Topical: Efinaconazole 10% nail lacquer daily for 48 wks or Ciclopirox nail ○​ If PCN allergy: Cephalexin 500mg PO QID 7-10 days lacquer daily for 48 wks If MRSA: Doxycycline 100 mg BID or trimethoprim sulfamethoxazole BID 7-10d ​ Oral: Terbinafine/Lamisil 6 or 12 weeks (check LFTs before starting) Advil, elevate to reduce edema, rest ○​ Only given once LFTs + rental fx checked Burns ** be suspicious for physical abuse Superficial (1st deg) Partial thickness (2nd deg) Deep partial Full thickness (3rd deg) Deep full thickness (4th deg) -epidermis painful, tingling, itchy, red, -some dermis red, painful, -blisters, wet or -leathery, dry, nonblanchable SC -charred fascia, muscle and/or dry, blanchable to pressure edematous, moist blisters waxy, variable tissue d/t flames, prolonged bone d/t prolonged exposure to -ex. outermost layer of skin peeling d/t contact, scalding colors, painful to exposure to hot liquids, electric, high voltage electricity d/t sunburn, superficial scar P chemical, direct/prolonged contact -risk of shock Tx: clean with cool water/soap, cool -recovery in 2-3 weeks heals >21 days -damage to nerves (no pain) → requires surgery cloth (dont use ice), prevent infx, Usually requires requires graft apply aloe/lotion, wash daily surgical tx Do not pop blisters  Impetigo (S. aureus usually, few strep A infx) Classifications: Primary (direct invasion of normal skin) vs secondary (infx at sites of minor trauma- abrasion, insect bite) ​ highly contagious, carried in fluid that oozes from blisters, spread by direct person contact, common in 2-5 yo ​ Predisposing factors: warm temp, high humidity, poor hygiene, skin trauma ​ Tx: Topical abx→ bactroban (mucpirocin) 2% TIDx5 days ○​ Oral abx reserved for more serious cases Nonbullous Bullous Most common type (70% of cases): Red crusting rash → Gold, Large fragile, fewer bullar lesions more on trunk, seen in young children honeycomb appearance crusts on face and extremities rupture → Ooze clear yellow turbid fluid → brown crusting Lyme Disease (ticks) -all tick diseases cause fever + typically erythema migrans ​ only tx if 3 high risk criteria are met: ixodes vector (black leg tick) occurs in high endemic area (half the country) + tick attached >36 hrs ○​ if not high risk, perform serologic testing for lyme disease if symptoms, outdoors, or traveled to endemic area ​ admin 200 mg doxy for prophylaxis or 4mg/kg for children but not to exceed 200 within 72h of removal acute bulls eye rash→ progresses to things like severe headache, neck stiffness, arthritis, heart Chronic: Untreated can lead to edema, facial drooping, cardiac palpitations, inflammation of spinal cord, nerve pain, facial palsy (days/mnths after bite) issues, intermittent pain in tendons Seborrheic keratosis Actinic keratosis Black waxy leather appearance but harmless, Friable, vascular bled Rough textured keratin scale, pink, erythematous, grey or brown, "liver spots" relatively easily -​ Refer to derm Tx: lesion removal for cosmetic reasons -​ Topical 5FU applied 2x/day for 3 weeks -​ Retinoids -​ Cryotherapy  Squamous cell carcinoma Basal cell carcinoma Malignant melanoma Arises in epithelium Most common type of skin cancer atypical nevi develop, rarely on areas exposed to sun like Common in middle aged and elderly Nodular, superficial, pigmented varieties hands or face→ most deadly bc metastasis to any organ Appears as papules, plaques, nodules Pearly surface, rolled edge, friable ABCDE Rule: asymmetry, border,c olor, diameter, evolving May be smooth, keratotic, ulcerated, painful or friable Shingles (Herpes Zoster) Acute vesiculobullous eruption seen in dermatomal distribution with sharp demarcation at midline, spread only when they have vesicular rash -​ Reactivation of varicella virus in nerve root ganglion in 10-20% of persons who get it -​ Can be emergent condition Antiviral tx for patients >50yo, Moderate to severe rash or pain, Involvement of face/eye, Acute complication of infx, OR Immunocompromised -tx: Mild to mod: valacyclovir 1000 mg PO TID x 7 days, Severe: Acyclovir 10mg/kg IV Q8h 7-14 days -CDC recommends 2 doses of recomb RZV for >50 to prevent shingles + complications, 2 doses RZV in >19 who are immunosuppressed Atopic Dermatitis (most common eczema) Psoriasis Flexor surfaces "in the folds) Extensor surface Overactive immune response → triggers inflammation, red/dry skin, unbearable itch → weakened skin Chronic genetic immune mediated Dysregulation of T barrier and bacteria/viruses can enter on neck, arms, inside elbows and back of knees cells → chronic inflammation → Rapid accumulation of -​ Acute: vesicles, intense redness, blisters (contact allergy) epidermal cells → raised scaly cutaneous plaques favoring -​ Sub acute: red, scale, fissuring, parched to scalded appearance elbows, knees, scalp, gluteal cleft, fingernails, toenails  -​ Chronic: thickened skin, lichenification, excoriations, fissuring -tx: cream, systemic therapies, phytotherapies ​ Moisturizers (w ceramides) to relieve dry cracked skin, decrease inflammation, reduce the severity of, and increase the time between flair up ​ 1st line: Topical corticosteroids to reduce inflammation, itch and infx ○​ Topical phosphodiesterase 4 inhibitor (PDE-4) crisaborole (eucrisa) ointment: to reduce inflammation, itch and infx ​ short term tx: Topical janus kinase inhibitor ruxolitinib (opzelura) to reduce inflammation and itch in mild to moderate AD, >12 yo Not responsive to topical tx: biologics such as Dupilimab, Conditionally recommend phototherapy, cyclosporine, Methotrexate → do NOT recommend: systemic corticosteroids GI (5 Qs) Acute abdomen: Sudden onset of severe abd pain, emergency -​ d/dx: appendicitis, GERD, PUD, diarrhea/constipation, diverticulosis/litis, cholecystitis -​ Types of pain: achy, dully, sharp, referred(**pancreatic ca referred R shoulder pain) -​ In geriatrics, less likely to have pain/fever, more likely to have sx of lethargy, hypotension, confusion Appendicitis (epi→RLQ) GERD (LUQ/epigrastric) PUD (epigastric) blockage of appendiceal lumen, leading to Reflux of gastric contents from stomach to esophagus d.t ulceration of gastric and duodenal mucosa distention and appendix + bacterial infx sphincter being open -Early signs: acute onset pain in epigastric area -burning chest sensation (heart burn/indigestion), comfort 30-60 -sharp, burning, aching or gnawing epigastric that migrates to LLQ (rebound tenderness), min AFTER a meal, exacerbated by supine, halitosis, enamel loss pain, dyspepsia rigidity, acute onset pain -OAs atypical s/s first present with alarm s/s: dysphagia, -If pain relieved after meals = duodenal, if -Late signs: anorexia, n/v, constipation odynophagia, chest pain, cough, sore throat, asthma, vomiting pain worse with meals = gastric -Mcburney point (RUQ between umbilicus and Risk factors -causes: h pylori, use of NSAIDs anterior superior spine) Big meal size, weight loss, low HOB or 3 cfu mL of urinary pathogen cultures (+) + Tx: cipro 500 PO BID or 400 mg IV q12 x 7-14d -​ Tx: IV if seriously ill symptomatic in 1 yr, 2 Peds: 6-10 mg/kg cipro IV q8h or 10-20" PO q12h -​ PO amox-clauv 10-15mg/kg PO q8h UTIs in 6 mo Female adult/adolescent Tx: Nitrofurantoin 100mg PO BID x 5 days Adult male Tx: Cipro 500mg PO BID 5-7 days -Dipstick analysis: (suprapubic aspiration or catheterization for non toilet trained vs clean void for trained). Dipstick tests are convenient and inexpensive, however they are only 88% sensitive at best Asymptomatic Bacteriuria Prostatitis bacteria in the urine and no urinary symptoms Acute and chronic usually caused by gram negative organisms, 25% of PC visits → Indication to screen for and treat: 1) acute: caused by gram negative w e coli from urethra to prostate, abd pain, risk of sepsis -​ Pregnancy 2) chronic bacterial: fever, chills, myalgias, incomplete emptying, low back pain -​ Urologic procedure 3) nonbacterial: same as bacterial -​ Recent renal transplant 4) prostatodynia: noninflammatory pelvic pain w/o evidence of infx -​ For those who are not pregnant and have asymptomatic Risk of inducing bacteremia: vigorous massage (can disseminate bacteria in the bloodstream) bacteriuria we do NOT treat with abx +Transurethral catheterization -​ Drink cranberry juice Increase fluids, bed rest, sitz bath TID, avoid sex, FU 48-72 h -​ Use vaginal estrogen in perimenopausal women with → If prostatitis + risk factors for STIs: Dual therapy of 100 mg doxy BID x10d + UTI -​ 330lbs: Ceftriaxone 1g IM progress to pyelonephritis) → acute no risk factors for STIs: 4-6 wks of many abx, alpha blocker? -​ Use methenamine hippurate to prevent UTIs → Chronic tx: Bactrim DS 8-12 wks or Ciprofloxacin 500mg BID or Levaquin 500mg q24h 28 d  Msk (8 Qs) MSK Terminology Back Pain Avascular necrosis: loss of blood flow to bone/tissue 1) Straight leg raise (SLR)/Tripod Sign: The Patient supine, examiner raises the patient’s extended leg 70°-90° of Strain: injury to bands of tissue that connect two hip flexion with foot dorsiflexed. Pt notes pain at 30°-60° degrees→ Irritation of spinal nerve L5-S1 bones 2) Femoral stretch: assess L2-4 Sprain: injury to tissue that connect muscle to bone 3) tripping= foot drop → assess dorsi plantar (assess opp side for comparison Ligament: fibrous connective tissue that connects -Red flag symptoms: fever, unintentional weight loss, incontinence, bilateral leg weakness, perineal anesthesia two bones -history of cancer, age >50 yrs, duration >1 mo, nighttime pain, unresponsive to previous therapies, Tendon: fibrous connective tissue that attaches unexplained weight loss muscle to bone -Ensure we do a neuro exam -Back pain w bowel/bladder symptoms→ emergency Mechanical Systemic (Back Pain) Referred Strain/sprain Spinal cord/cauda equina compression Pancreatitis Herniated disk or sciatica Metastatic cancer PUD Spondylolysis or spondylolisthesis Spinal epidural abscess Nephrolithiasis Spinal stenosis Vertebral osteomyelitis AA Compression fractures Connective tissue disorder Uterine fibroid/PID All → can cause sciatica (dermatomes) Prostate Carpal Tunnel Syndrome De Quervain's Tenosynovitis -Compression of median nerve caused by repetitive movements that flex or extend the wrist or -Inflammation of tendons that innervate the thumb → pain raise the arms, paresthesia in fingers, motor weakness + sensory loss if severe, worse at night making a fist, turning wrist, and lifting -Tinel's test: (+) if percussion over wrist median nerve produces pain → Dx: nerve conduction tests -Risk factors: RA, pregnancy, repetitive motions, being female, -Sensation of paresthesia after 1 min of wrist flexion → phalen's maneuver ages 40-50, eliquis (no reversal agent bc it's new) reduce movement, splinting, PT, short term glucocorticoid injections, surgery immobilization, nsaids, Modify activity, corticosteroid injection  Lateral epicondylitis Medial epicondylitis Olecranon bursitis Ulnar nerve entrapment “tennis elbow” “golfers elbow” (cubital tunnel syndrome) LT : Lateral epicondyle MG: medial epicondyle -Injury, prolonged leaning on elbow, overuse, -Prolonged bending or leaning on elbow, or “hitting tenderness + wrist extensor pain tenderness + pain with wrist inflammatory arthritis, can be infx → funny bone” → compression of ulnar nerve w resistance + flexion w elbow flexion + extension w elbow inflammation filling bursa w fluid -Pain, numbness, tingling on ulnar side of 4th + 5th extension (passive ROM) extension (passive ROM) -Tenderness over bursa with flexion fingers, motor weakness If no improvement, 3 view xray series + glucocorticoid injections Joint protection, nsaids, ice/heat -dx: X-ray + nerve conduction studies **fluid aspiration and analysis if suspect infx -Surgery if evidence of ongoing nerve damage Rotator Cuff Tendinitis Rotator Cuff Tear Common, graduate onset lateral deltoid pain seen in acute trauma or degenerative tear from repetitive stress to shoulder, pain over lateral deltoid that is worse athletes and people who repetitively reach overhead with overhead activities or at night, weakness -​ Drop arm test -​ Active painful arc test -​ Apley scratch test -​ Drop arm test -​ External rotation: infraspinatus -Tx: rest, ice, nsaids, PT, glucocorticoid injection, -​ Imaging (xray then MRI) refer to ortho if no relief x6mos -tx: conservative or surgical, ortho referral, rest, nsaids, PT, steroid injection Osteoarthritis (OA) + degenerative joining disease Trochanteric bursitis Avascular necrosis Hip fracture Cause: age, FH, previous injury, obesity→ joint space narrowing d/t spurs Vague, lateral hip pain ETOH + steroid use degeneration leading to weakened Progressively worsening pain and restricted movement that worsens getting up -groin pain, increases joining that brakes with less force, Pain in deep anterior groin that can radiate to buttocks thigh or knee or lying on affected hip with weight bearing fall or trauma Pain worse with standing, or first thing in the AM -major morbidity /mortality in elders Xray to confirm Rest, NSAIDs, PT, Refer to ED if suspected PT, Quad and hamstring strengthening, Core strengthening, Ice/heat, steroid inj Topical or oral NSAIDS Surgical hip replacement if arthritis severe + other failed tx Knee Ankle Foot ​ Tests to assess for dysfunction: -Most are inversion injuries, ~40% of sports injuries -neuroma; compression of nerves btwn toes -​ Mcmurray (meniscal injury) -Inversion- sprained lateral ligament, eversion- medial ligament (morton's: 3-4th toes) -​ Drawer test (often for ACL, PCL) ​ Ottowa rules d/t if films needed -Stress fx -​ Maneuvers for LCL and MCL tears ​ Rehab, Rest, ice, heat, NSAIDS. Ace bandage to reduce -Plantar fasciitis (fascia connecting toes to heel) -Assessment and management determined by dependent edema -spurs: calcium deposits on heel degree of mobility , --> If cannot bear weight, ****emergency if neurovascular compromise -bunions: bone protrudes at base, shifting great ortho and referral **refer to ortho if fracture, dislocation, tendon rupture, wound toe joint out of place Bracing a knee will cause stiffness! penetrating into joint, unresponsive to PT -achilles tendonitis: tendon grows thick d/t Nsaids, rest, ice/heat, PT tight calf muscles Diabetes (8 Qs) Late-onset Autoimmune Diabetes of Adults (LADA) Maturity onset diabetes Neonatal Pancreatic DM (3c) of the young (MODY) DM -onset 30-70 yo Hyperglycemia before -dx within structural + functional loss of insulin in pancreatic dysfunction -autoimmune positive GAD Ab → early insulin 25yo first 6 mo r/t trauma, CF, pancreatitis requirements (25) or have 1+ risk factors: -​ A1C is primary target of glycemic control, want with DM are attributed to CVD to lower it to ~7%  → Individualized approach to mx -​ Relative with DM, High risk, Hx CVD, HTN, Primary care goals of hyperglycemia (establish A1C PCOS, Physical inactivity 1.​ Monitor Microvascular complications: lower goal based on patient) -​ Pts with prediabetes (A1C>5.7) ASCVD risk -acanthosis nigricans, yeast infx -​ Women with GDM should be tested q3yrs → BP, lipid mx, antiPLT therapy, obesity mx, (thrush), HTN -​ Testing begins at 35: if results normal, test peripheral vascular disease mx -Preprandial: 80-130, peak regularly q3yrs 2.​ Monitor inflammation/infx postprandial: =6.5% lifestyle intervention w metformin v placebo → b)​ Fasting glucose > 126 diabetes incidence reduced 58% w intensive, 31% w c)​ 2 h OGTT >200 metformin Peds T2DM Nocturia BMI>85th% for gender and age + any 2 of the following + Primary tx is education and lifestyle + Obesity Any of 2: A1C goal less than 7.5 Acanthosis nigricans Family hx of T2DM Exercise 30-60 min daily Yeast infxs Nonwhite Metformin is the only oral agent approved by FDA for PCOS Signs of insulin resistance use in children with T2 HTN Maternal hx of gestational Insulin if DKA, glucose >250 Screen Q3 yrs Juvenile -Partial remission: 25), FH, ethnicity weeks 24 and 28 -​ Increased perinatal morbidity and mortality Fasting >92, 1 hr OGTT >180, 2 hr >153 OAs -Higher risk of cognitive decline -​ Mini mental state exam (MMSE) DKA Management: IVF to increase circulatory V + -critical to decrease risk of -​ Mini-cog correct hyperglycemia, clear serum ketones hypoglycemia, simplify -​ Montreal cog medication list ***annual screening indicated for those 65+ for early detection BMI high → Metabolic surgery 1.​ Sleeve gastrectomy (resects most of stomach) Post surgery: Avoid nsaids + pregnancy 12-24 mos, 2.​ Roux-en Y gastric bypass (bypasses stomach) Measure bone density with DEXA at 2yrs post surg, Labs (A1C, CBC, CMP, lipid profile, etc..) Diabetic Meds Statins GLP SGLT Sulfonylure metformin DPP4 If ASCVD as start at lowest dose 1x/wk for 4 wks d/t GI -w proven HF benefit SE of -contraindicate Intermediate High intensity:: symptoms of decreased gut motility → -reduces CKD progreszsion hypoglycemi d if eGFR 1mo dx -1st line: blood work, CXR (skeletal abn, lung masses, PNA, enlarged heart), ekg CXR if dyspnea, bloody sputum, or rusty sputum color; HR >100 bpm, (ischemia, arrhythmias, VH, low voltage), spirometry RR>24; temp >100; focal consolidation, egophony, or fremitus -2nd line: echo, PFT, stress test, chest CT → done if cause not ID mx -fever in children, severe dyspnea, new at rest, or sudden onset of chest pain → ED -symptomatic care (mucinex), albuterol inhaler if wheezing -​ Want to stabalize and improve sx, O2 supplementation -Avoid OTC cold meds in children 2-3wks consider testing pertussis -​ 6 min walk test  Obstructive Lung Diseases → expiratory airflow limitation + bronchial hyper responsiveness PFTs: decreased FEV1 or FEV/FVC ratio (decrease in exhaled air flow d/t narrowing) COPD (irreversible) Asthma (reversible) -Encompasses chronic bronchitis and emphysema → -cough variant asthma: Consider in adults with prominent nocturnal cough Cough with phlegm, abnormal match test (unable to blow -9 people die daily from asthma in US (especially women, children, minorities, + the poor) out a match from 10in away), dyspnea, wheezing/crackles -risk factors: fam hx, secondhand smoke/dust/ pollution, allergens, atopy -FEV/FVC ratio 65, obesity, DM, lung disease, immunocompromised -looks like PNA but normal CXR → mixed cardiac CHF, immobility, aspiration, smoking, -prevention: BCG vx: infants/children in high burden TB pulmonary condition immunocompromised countries → Can result in false positives so screen w Risks: E2 use, immobility, malignancy, recent surgery, -Prevention: Vaccines (RSV, covid, flu, PCV) blood test prior family hx, smoking, pregnancy, obesity, hx of RA/lupus cough/SOB, fever, rales, rhonchi, tactile 1) 2 step Mantoux TB test (TST)- antigen test 1) Use a clinical prediction tool (wells score: 0-4 points is fremitus, increase HR/RR/BP + HR, low O2 2) Interferon gamma release assay (IGRA)- blood test unlikely PE, >4 is likely) to determine which patients saturation rales, decreased breath sounds, (preferred) should get a d-dimer test (only use when likely pE d/t tactile fremitus, egophony, sputum → dx (+) test → CXR to rule out active disease poor specificity) using CXR 2) Definitive dx: Chest CT  Mx: use clinical tool (CURB-65) → >3 1) Latent tx: Managed by infectious disease, Primary 3) If confirmed, identify the source through indicates inpatient admission care role: LFTs monitoring, adherence, interactions hypercoagulability studies or malignancy workup if source -Tx: always assume bacterial → ABX (amox 2) Active disease tx: Contact local health dept, Airborne is not readily apparent or doxy) precautions: N95, (-) Pressure room 4) Closely assess vital signs Cardiac (8 Qs) EKG Basic: 12 views (“leads”): 6 limb, 6 chest (V1-V6) ECG Interpretation -Vertical measurement: amplitude (millivolts) 1.​ Rate: Counting QRSc complexes (squeeze of heart) x10 -Horizontal measurement: length of depolarization (milliseconds) -​ 6 second strip= 32 big boxes (0.2 s total each) Direction of conduction 2.​ Rhythm (deflection): upward is (+), a.​ Regular or irregular? downward is (-) because b.​ Is there a P wave before each QRS or after? energy is going AWAY from c.​ Is PR interval prolonged? V1- SA node d.​ Is QRS width wide or narrow? → BBB e.​ ST segment- are there inverted T waves? Elevated or Lack of P- identify cardiac depressed arrhythmias (afib or block) i.​ flat= isoelectric ii.​ changes are relative to PR segment PR interval:.12-.20 s (baseline) QRS interval:.06-.12 s f.​ Is QT interval prolonged? QT interval: 35 ST elevation ST depression T wave changes Infarction= tissue/organ necrosis/death Ischemia= inadequate LVH/hypertroph r/t sudden restriction of flow (r/t coronary blood supply to meet ic CM artery obstruction or blockage) seen on O2 and metabolic Normal variants Prominent ekg needs inversion in Early repolarization LVH young athletes Pericarditis Infarct evolution 1st degree block: Prolonged PR interval Second degree AV block (Wenckebach/Mobitz 1) Fatigue- skipped beats -Progressively prolonging R to R ("longer longer drop") -missing QRS complex, then back to normal -s/s: chest pain, dyspnea syncope, fatigue  Second degree heart block (Mobitz 2) Third degree AV (complete) block -Normal PR intervals, but extra P waves. Not a QRS for every P wave AV activity are not communicating → P waves not correlating to QRS -ST depression= ischemia if pathologic or iatrogenic Likely need pacemaker → Hemodynamically unstable, symptomatic Supraventricular tachycardia Ventricular tachycardia Prolonged QT interval (above ventricles= atria) → may get adenosine if go to ED Wide misshapen QRS- tombstone can be congenital, can be r/t medications. See (to break rhythm) or can try vagal maneuvers Unstable, can be life threatening deep inverted T waves. Risk for sudden cardiac -torsades de pointes: mg IV stat death (v fib)  Ectopic beats: PAC Ectopic beats: PVC early P wave (abnormal waveform marker) coming from atria, narrow QRS complex extra beat coming from ventricle, wide + early QRS complex R Bundle Branch Block L Bundle Branch Block looks like 2 QRS complexes fused together → two Rs Wide QRS + mostly negative, absent Q waves brugada pattern of bigeminy (syndrome is history of syncope, fear of sudden death) I see ST depression= left deviation V Fib → CPR A Fib A Flutter -no P waves or QRS -Narrow QRS, no clear P waves, Irregularly regular R-R Saw tooth, jagged pattern -very little cardiac output and is life threatening interval -Uncoordinated and disorganized atrial activation → Trying not to overload ventricles to avoid vfib Anticoagulants → AF classification ​ Non-warfarin anticoagulants have a much shorter ½ life, lower bleeding risk -​ Paroxysmal: recurrent (>1 episode >=30 seconds ​ If CHADVsc score is 2+ in men or 3+ in women give anticoagulant, there is a 2% increase risk for in duration) and terminates spontaneously within AFib and Aflutter per year of Thromboembolism: Virchow's triad (hypercoagulability, stasis of 7 days blood flow, endothelial injury) → 48 h thrombus formation in L atrial appendage (LAA) → -​ Persistent: sustained >7 days or =6.5% b)​ Fasting glucose=110mg/dl c)​ Following a random blood glucose reading of 120 mg/dl d)​ If the 2-hour blood glucose during an OGTT is 136 mg/dl Question 7 Which of the side effects below is more of a concern for patients taking sulfonylureas? a)​ Urinary tract infection b)​ Rash c)​ Nausea and Vomiting d)​ Hypoglycemia Question 8 What is the most common cause of mortality for people with Type 2 Diabetes Mellitus? a)​ Unintentional injuries or accidents b)​ Pancreatic cancer c)​ Cardiovascular disease d)​ Hypoglycemia Question 9 Theodore is a 40 year old male diagnosed with type 2 diabetes 1 month ago with an A1c=8.4%. His past medical history includes obesity (BMI=42) and back strain. All other routine lab results are normal (including CBC, Chemistry panel, Lipid panel, TSH, urine alb/cre). His dilated eye exam returned normal (no retinopathy detected). His review of systems is negative. What is a reasonable A1c target for Theodore based on ADA guidelines? a)​ 7-8% b)​ 6-7% c)​ 5-6% d)​ 4-5% Question 10 A pt who should be screening for diabetes is: a)​ 25 year old healthy male BMI 24 b)​ 35 year old healthy female c)​ 25 year old healthy male BMI >25 but no other risk factors d)​ 25 year old healthy female BMI >25 but no other risk factors QUIZ 5 Question 1 A 45-year-old male presents to the clinic with a 3-day history of redness, warmth, swelling, and tenderness in his lower left leg. He denies any trauma to the area but reports having a history of type 2 diabetes mellitus. On examination, you observe an area of erythema with poorly demarcated borders, mild edema, and warm to touch with tenderness to palpation. His vital signs are: Temperature: 100.8°F (38.2°C) Pulse: 90 bpm Respiratory rate: 16/min Blood pressure: 130/85 mmHg Which of the following is the most likely diagnosis? a)​ Cellulitis b)​ Deep vein thrombosis (DVT) c)​ Erysipelas d)​ Necrotizing fasciitis Question 2 A 62-year-old woman presents with thickened, discolored toenails that have been progressively worsening over the past year. She denies pain but reports occasional difficulty trimming her nails. Her past medical history includes type 2 diabetes mellitus and peripheral vascular disease. On physical exam, her toenails appear yellow-brown, thickened, and brittle, with evidence of subungual debris. Pt would like to start treatment for this as she does not like how it looks. Which of the following is the most appropriate treatment in managing this condition? a)​ Efinaconazole 10% nail lacquer daily for 4 weeks b)​ Efinaconazole 10% nail lacquer daily for 48 weeks c)​ Ciclopirox 8% nail lacquer daily for 4 weeks d)​ Ciclopirox 8% nail lacquer daily for 8 weeks Question 3 1 / 1 pts A 34-year-old male presents to the emergency department after a house fire. He has sustained partial-thickness burns to the following areas: -​ Entire right arm -​ Entire right leg -​ Anterior chest Using the Rule of 9s, what is the total body surface area (TBSA) percentage affected by burns? a)​ 27% b)​ 36% c)​ 45% d)​ 18% Question 4 A 6-year-old child is brought to the clinic by their parent with multiple small, red sores around the mouth and nose. The sores have ruptured and formed honey-colored crusts. The parent reports that the child recently started attending daycare and has been scratching the lesions. The child is otherwise healthy and afebrile. What is the most appropriate initial treatment for this condition? a)​ Oral acyclovir b)​ Topical mupirocin c)​ Oral cephalexin d)​ Topical hydrocortisone Question 5 A 35-year-old female presents to the clinic after discovering a tick embedded in her upper thigh. She removed it about 24 hours ago. She reports no symptoms other than mild redness at the site. She went hiking in an area known for Lyme disease 2 days ago. What is the most appropriate management at this time? a)​ Prescribe a 10-day course of doxycycline b)​ Monitor for symptoms and advise to return if a rash develops c)​ Administer a single prophylactic dose of doxycycline d)​ Perform serologic testing for Lyme disease immediately Question 6 What should you expect when reviewing PFTs in an individual with Asthma (i.e. obstructive disease) before and after treatment with a bronchodilator? a)​ Reversibility is evident, but before treatment FEV1/FVC ratio are low (below normal) b)​ Reversibility is not seen and FEV1 is normal c)​ Reversibility is evident, but before treatment FVC is high (above normal) d)​ Reversibility is not seen and FEV1 is low (below normal) Question 7 Pneumonia can be diagnosed clinically. However, if the NP decides to order a test to confirm, which test is considered the definitive test for diagnosing pneumonia? a)​ Sputum sample  b)​ Blood cultures c)​ Chest CT d)​ Chest x-ray Question 8 All of the following steps should be taken in the primary care setting when the NP works up a pulmonary embolism EXCEPT: a)​ Use a clinical prediction tool to determine which patients should get a d-dimer test b)​ Order a chest xray to confirm diagnosis of pulmonary embolism c)​ If pulmonary embolism is confirmed, identify the source through hypercoagulability studies or malignancy workup if source is not readily apparent d)​ Closely assess vital signs Question 9 Primary care management of latent tuberculosis includes: a)​ Contacting the local health department b)​ Monitoring renal function c)​ Promoting adherence to medications d)​ Following contact precautions Question 10 The following are true regarding lung cancer and its screening (select all that apply): a)​ Screening recommendations are made based on the patient’s gender and amount/duration of smoking (measured as pack year history) b)​ If a patient quits smoking, their risk of lung cancer decreases as time progresses from their quit date c)​ Lower education levels are a risk factor for lung cancer d)​ Smoking cessation counseling is no longer recommended once the patient starts lung cancer screening