Download J 1. Evidence based decisions based on four cardinal elements: 1-the research evidence 2-the patients clinical state 3-the patient's preference 4-the clinician's judgement and expertise 2. Which study design will provide the most powerful results, and is the gold standard for determining the effect of a therapeutic intervention?: Randomized controlled trial(RCT) 3. PICOT format: *P* - Identify the population or problem (age, gender, ethnicity, disease/disorder) *|*- Intervention, or range of interventions of interest (therapy or diagnostic test in question) *C# - What will you compare the intervention against? (no disease, absence of risk factors, placebo or no intervention) *O* - Outcome of interest (risk of disease, rates of occurrence of adverse outcomes, accuracy of diagnosis) *T* -Time it takes for intervention to achieve the outcome (selected to observe the population or problem/condition) 4. What stimulates the chemoreceptor trigger zone and causes vomiting: - Chemical stimuli from the circulation that crosses the blood brain barrier, which includes:-Certain drugs -Uremia -DKA “Toxins derived from gram-positive bacteria 5. Causes of acute nausea and vomiting: Acute infection (esp Gl) Ingestion of toxins G.I. obstruction or ischemia New medication Pregnancy Head trauma/increased ICP 6. Causes of chronic nausea and vomiting: Defined as the persistence of symp- toms for more than one monthPartial mechanical obstruction Intracranial pathology Dysmotility, such as gastroparesis 10Metabolic or endocrine etiology Psychological disturbance 7. Patients with a pyloric, peptic ulcer or psychogenic vomiting, may present with vomiting when?: During or soon after a meal 8. Patience with a gastric outlet obstruction as a diabetic or post vagotomy gastroparesis are more likely to experience...: Delayed vomiting of more than one hour after eating 9. Old food in the vomitus may suggest: Gastro paresis Gastric outlet Proximal small bowel obstruction 10. Bilious vomit indicates: Patency between the stomach and the proximal duo- denum 11. ematogenic drugs: Opiates Chemo Antibiotics General anesthesia12. Symptoms of Cardiac etiology in presence of nausea: Diaphoresis Dyspnea Changes in HR Changes in BP Hx cardiovascular risk factors 13. If the symptoms | had a fortune to the clinical scenario, or unusually prolonged, like Persistent N/V four days after general anesthesia for anon-ab- dominal surgery, what is indicated?: Diagnostic evaluation beyond just supportive care 14, Treatment goals of N/V: -correction of fluid and electrolyte imbalance -identification of treatment of the underlying cause, if one exists -Relief of symptoms, either by suppression or by elimination, if the primary cause cannot be promptly identified and removed. 15. Patients with long-standing, chronic nausea and vomiting, or risk for de- veloping what?: Malnutrition 16. Ifa patient is not able to tolerate adequate oral caloric intake after five days, what should be considered?: Enteral or parental feeding Enteral feeding is usually the first option however, dislodgment of enteral tube with acute vomiting is not uncommon and occasionally parental feeding may be required17. Two categories of anti-emetic agents: Central anti-emetic agents Peripheral prokinetic agents18. Nausea medications for vestibular disease and motion sickness: Antihist- amines and antimuscarinic agents 19. Abdominal pain without other symptoms or signs: Rarely a serious problem 20. Roth spots: Round or oval hemmorhagic retinal lesions with small white centers 21. petechiae: a small red or purple spot caused by bleeding into the skin. 22. Osler nodes: painful erythematous nodules on the pads of the fingers and toes 23. Splinter hemorrhages under nails: 24. erosive esophagitis: -epigastric pain, difficulty swallowing, reflux, intermittent burning, regurgitation, substernal pain, typically some degree of dysphagia -can lead to esophageal bleeding and commonly associated with heavy alcohol use and NSAIDs. -Pts w/ esophagitis commonly have dysphagia -can be d/t prolonged GERD 25. diagnosing erosive esophagitis: definite diagnosis by endoscopy 26. Main difference between gastritis and PUD: Gastritis can progress to PUD whenthe inflammation of the stomach wall causes an irritation in the lining of the stomach. Irritation can lead to formation of an ulcer. Often preceded by H. pylori infection. Both diseases aggravated by NSAIDs and caf- feine, and lessened by antacids. Given similarities in diseases, diagnostics needed to confirm if ulcer has formed. 27. Diagnosing PUD: Endoscopy 28. Achalasia: absence of peristalsis of the lower esophagus resulting in difficulty swallowing, regurgitation, and sometimes pain, Heartburn is a common symptom of this. 29. Non-ulcer dyspepsia (functional dyspepsia): symptoms of indigestion with no obvious cause 30. Esophageal cancer: malignant cells within the esophagus sx: heartburn, dysphagia 31. Hiatal hernia: prolapse of a portion of the stomach through the diaphragmatic esophageal hiatus. Most people asymptomatic - may have heartburn 32. GERD treatment: Lifestyle modification:-nonrestrictive clothing -weightless-symptom journaling -wait 3 hrs after meal to lay down -raise HOB 8 inches -avoid large fatty meals -dont eat before bed -avoid alcohol, caffeine, mint, chocolate, spicy food, acidic food, carbonated drinks. Pharmacological: -PPIs (front line and most commonly prescribed) Omeprazole, ianoprazole, esomeprazole 33. Red flags for GERD: -severe or persistent dyspepsia -dysphagia -unexplained wt loss -GI bleeding persistent or protracted vomiting -severe coughing spells -palpable abdominal mass 34, Atopic Dermatitis (Eczema): chronic inflammation of the skin; rash occurs in face,neck, elbows, knees, and upper trunk of the body along with itching dry skin scaly, patchy 35. contact dermatitis: irritated or allergic response of the skin that can lead to an acute or chronic inflammation Burning, pruritis Found in areas in contact with the irritant 36. Pityriasis Rosea: Presents with a herald patch, Christmas-tree pattern. 37. Alarming signs that accompany abdominal pain: Weight loss Gastrointestinal bleeding Anemia Fever Frequent nocturnal symptoms Onset of symptoms in patients older than 50 years old 38. Types of lesions pathognomonic of infective endocarditis: -Roth spots -Petechiae ~Janeway lesions-Osler Nodes -Splinter hemorrhages under nails39. atopic dermatitis: Dry skin Scaly, patchy Elbows, knees 40. contact dermatitis: Burning Pruritis Areas in contact with irritant 41. Pityriasis Rosea: -Raised truncal patch (Harold patch) ~Scaly plaques or papules, Christmas tree shaped -Scattered on trunk and limbs 42. herpes zoster: -Painful -Fluid filled vesicles that crust over -Segmentary rash; does not cross midline of body; follows dermatome -often appears during times of low immunity or stress. Can also cause fever, headache, fatigue, and sensitivity to light. 43. Psoriasis: chronic, recurrent dermatosis marked by itchy, scaly, red plaques covered by silvery gray scales 44. Scabies: -Pruritus worse at night-Small erythematous papules -Waist, web of fingers, buttocks -prefer warm moist areas such as skin folds 45. Rosacea: Chronic skin disorder of the face with red inflamed areas appearing mostly on the nose and cheeks 46. Pityriasis rosea treatment: Symptomatic treatment to reduce pruritus, fever, and discomfort associated with this condition: -Second generation antihistamines —Allegra, Zyrtec, Claritin, etc. -Acetaminophen -Natural sunlight exposure or phototherapy -Spontaneous resolution occurs within 6 to 12 weeks, occurrences are uncommon 47. atopic dermatitis treatment: Prevention and maintenance: -Reduce triggers if possible -Baseline therapy of dryness w/ emollientsPharmaceutical therapy: -Nonsteroidal or steroid topicals-Oral antihistamines -Avoid the use of systemic corticosteroids Patient education and counseling: “Treatment and prevention of xerosis: — avoid taking long, hot showers, and baths — use soap only in skin body folds (like axilla, buttocks, groin), otherwise avoid soap to other skin surfaces — after bathing, lightly path, a scam with a towel so that it remains damp, but not wet — apply lotion to damp skin 48. Contact dermatitis treatment: Treatment: -Identify the causative substance and eliminate exposure Pharmaceutical treatments: “Topical steroids, systemic antihistamines -Wet dressings or cloth soaked in burrows solution for relief of pruritus -systemic therapy with glucocorticoids indicated for severe cases, or for a rash on face or genitalsPatient education/counseling: -Wear gloves or protective clothing in environments where exposure is possible -Wash area with soap and water and wash clothes that may be contaminated -Rash is not contagious (you cannot spread it to another area of the body ora person by touching the rash) -avoid scratching to prevent secondary bacterial infections 49. Rhus dermatitis treatment: Treatment: -Small topical areas respond well to low to medium potency topical steroids -Larger areas may require topical and systemic steroids tapered over 10 to 14 days Patient teaching: ~The rash is not contagious. Touching the rash and touching elsewhere. Does not make it spread. The rash occurs only in areas where the oil of the Rhys plant, urushiol, comes into direct contact with the skin. 50. Scabies treatment: -Scabicide lotion or cream -bedding, clothing, and towels need to be treated -Washing hot water and dry and a hot dryer-Dry cleanSeal in a plastic bag for at least 72 hours -Family members may need to re-treatment 51. Herpes labialis treatment: Diagnosis can be made clinically through the history and physical, however, a viral culture can be done if needed for confirmation -Antivirals if initiated within 72 hours of the onset of symptoms can be beneficial — acyclovir, valacyclovir, famciclovir — viscous lidocaine may be used to reduce the pain associated with the lesion Can treat recurrent infections with varying strategies: -Chronic suppressive therapy “Topical anti-viral -Oral antiviral 52. Janeway lesions: nontender hemorrhagic lesions - fingers, toes, nose, ear- lobes - associated with endocarditis 53. Pityriasis Rosea: 54. herpes zoster: 55. atopic dermatitis:56. contact dermatitis: 57. Rhus dermatitis: 58. Scabies: 59. herpes labialis: 60. onychomycosis photo: 61. Paronychia (photo): 62. onychomycosis: -fungal infection of the nail -May involve any component of the nail unit -Nail is usually yellow - white, with yellow streaks -Nail is thick and crumbling, and they separate from the nail bed -Rarely painful, but may interfere with standing and walking with disease progression -Long history, possibly in other nails -Assess occupational and environmental risk factors -Common in the elderly and immuno suppressed patients 63. paronychia: -Bacterial infection of the finger involving the lateral nail fold -If untreated can form an abscess between the nail plate and the nail folds, lifting the nail plate; infection and extends into the pulp space -acutely tender to touch-No systemic illness -Pain, erythema, and swelling -Inquire about occupational exposures-Inquire about a prior history of paronychia or MRSA risk factors -assess whether the patient bites the finger nails (oral Flora, anaerobes may be the source of infection) -commonly caused by an ingrown nail 64. Treatment for paronychi: farm soaks (multiple throughout the day) -May resolve the condition initially, if no cellulitis or abscess antibiotics (keflex) -needed if cellulitis, but no abscess - need to cover Staph aureus, possibly MRSA 1&D -if cellulitis and abscess Partial or full wedge resection -if ingrown nail, also, add antibiotics to cover staph aureus and maybe MRSA 65. Treatment for onychomycosis: Fungal culture Systemic treatment -typically required Topical treatment Direct microscopy -20% KOH prep false negatives do existRecurrence rate remains high, typically a long treatment process 66. Intertriginous: pertaining to a type of dermatitis occurring between folds or juxtaposed surfaces of skin and caused by sweat retention, moisture, warmth and concomitant growth of resident microbes 67. Patient presents in the hospital with fever and rash must be divided into what two categories?: Those who are critically ill and those who are not. Critically ill patients with rash often have a fulminant onset of both fever and rash. 68, Causes of critically ill patients with fever and rash: Hemorrhagic fever Meningococcemia Rocky mountain spotted fever Toxic shock syndrome Steven Johnson syndrome Toxic epidermal necrolysis Acute vasculitis 69. Obt: ig history for someone with a rash: -Age of patient -season of the year -Location of onset of rash, and time sequence of progression -Secondary changes to the rash, possibly due to self treatments, such as lotions and over-the-counter ointments, or from excoriation or picking -If there are multiple lesions present, ask the patient to show you an area that lookslike how the rash started or where there are any new lesions -systemic symptoms like fever, weight loss, lymphadenopathy, sore throat -Medication changes Allergies -Personal and family history of rheumatological diseases -Social, travel, and exposure histories -Sexual history 70, Leukopenia and rash: Usually indicates viral illnesses including arboviral infec- tions, Chikungunya virus, CMV, measles, dengue 71. Eosinophilia and rash: Suggests an allergic reaction or cholesterol emboli syndrome 72. Herpes Zoster Treatment: Prevention: -Vaccination for adults over 50 Antiviral therapy: -Oral famciclovir (Famvir) -Oral valacyclovir (Valtrex) -Oral acyclovir (Zovirax)Pain management: -Oral gabapentin -Oral pregabalin Tricyclic antidepressant (doxepin, amitriptyline) “Topical capsaicin cream 73. Characteristics of chronic vomiting: Results in weight loss Sustained vomiting results in water, loss and electrolytes, leading to dehydration and hypokalemic metabolic alkalosis 74. Metabolic and endocrine causes of nausea and vomiting: Addison's Diabetes Hypercalcemia Hyperparathyroidism Hyperthyroidism Hyponatremia Hypoparathyroidism Pregnancy Uremia 75. E/M Base on what things: Physical exam MDMPatient history Time 76. Leukocytosis with a typical lymphocytes is the hallmark of...: Mononucleo- sis from EBV