APEA EXAMS AND PRACTICE EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATION, Exams of Nursing

Download APEA EXAMS AND PRACTICE EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATION and more Exams Nursing in PDF only on Docsity! 1 | P a g e APEA EXAMS AND PRACTICE EXAMS WITH ACTUAL CORRECT QUESTIONS AND VERIFIED DETAILED RATIONALES ANSWERS 2024 (NEWEST) ALREADY GRADED A+ NP examines the skin of an elderly patient which findings below is NOT benign lesion associated with the aging process dermatophytosis phenazopyridine (pyridium) is recommended very short-term use in patients with UTIs because occurrence of hemolytic anemia estrogen-progestic contraceptives should be avoided in women with: migraines with aura the addition of benzoyl peroxide to erythromycin for the topical tx of acne: improves the efficacy of erythromycin an elderly male with BPH should be advised to avoid antihistamines. What is the reason? urinary retention exam of the hair reveals a fine silky appearance. This finding may be seen in patients that have hyperthyroidism a patient develops a cough secondary to ACE. the most appropriate statement related to the ACEI cough is that the cough typically resolves within a week after stopping the medication 20 year old male living in college dorm, complains of a dry cough for the past month. assessment finding associated with an atypical, community acquired pneumonia would include: low-grade fever, malaise, clear lung fields on auscultation most appropriate med indicated for reversing anticoagulated effects of dabigatran etexilate (pradaza) idarucizumab (paxabind) common patho finding of patients with asthma hypertrophy of smooth muscle 2 | P a g e typical presentation of severe acute aortic regurgitation includes sudden severe shortness of breath rapidly developing heart failure and decreased blood pressure when palpating the prostate gland during the rectal exam, the prostate feels tender, swollen, boggy, and warm. this finding is consistent with acute bacterial prostatitis this contagious disease causes fever, headaches, stiff neck, photophobia, N/V, and AMS. what immunization prevents this meningococcal vaccine serotonin syndrome is a potentially life-threatening condition associated with increased levels of serotonin which of the following statements about treating scabies with lindane (kewell) is correct? lindane lotion and/or shampoo is not considered first line therapy treatment of scabies Nix earliest clinical manifestation of diabetic nephropathy microalbuminuria children born with down syndrome often have other anomalies. they especially require eval of what body system cardiac When deciding on initial treatment option for an acute flare of atopic dermatitis, unresponsive to emollient therapy, the next best choice of tx is: desonide 0.5% headaches with symptoms of N/V may be associated with all the following except: tension headache which of the following findings could indicate a need for further eval of the cardiac pt low density lipoprotein of 190 mg/dl an alpha-adrenergic blocker increases urine outflow in males by relaxing the prostate smooth muscle the scoliosis patient who would cause the greatest concern for the NP is 5 | P a g e which assessment findings are NOT associated with pyloric stenosis in a 2 month old infant? bloated and tense tympanic abdomen what should be included int he initial tx of bacterial epididymitis in a sexually active 22yo male doxycycline and ceftriaxone hyperkalemia is associated with diminished renal function assessment of 72yo male causes NP to have concern that pt is at risk for suicide. RF for suicide for the elderly do NOT include retirement most common tx for H.pylori is a triple therapy, interpreted as 2 abx and ppi for 7-14 days which drug class is NOT indicated for tx of depression buspirone (buspar) Snellen chart eval indicated the patient vision is 20/30. what is the proper description of this result? at 20 ft, the pt can see what a person with normal vision can see at 30 ft which is NOT a common sx of vit b12 def vomiting which is the appropriate med for a 31 yo pregnant diagnosed with UTI cefuroxime (zinafed) or nitrofurantoin (macrobid) which med is NOT indicated for muscle spasms baclofen (lioresal) which condition is caused by an insufficient production of intrinsic factor by gastric mucosa and vit b insufficiency pernicious anemia multiparous preg pt at 24 wks gestation with complaint of painless vaginal bleeding placenta previa when measuring fundal height of pregnant female at 32 wks, which measurement would the NP suspect fetal growth 32 cm 40yo has breast tissue that is soft with uneven contour bilaterally. NP informs pt that 6 | P a g e warrants a mammogram pregnant women are evaluated for syphilis with serology testing because syphilis during pregnancy predisposes the fetus to spontaneously abort or the newborn to have congenital syphilis recommended combination therapy for uncomplicated anorectal and pharyngeal gonorrhea is ceftriaxone and azithromycin When performing a visual acuity test the nurse practitioner notes 20/30 in the left eye and 20/40 in the right eye using the Snellen eye chart. This means: refer the patient to an ophthalmologist The american psychiatric association's diagnostic and statistical manual of mental disorder defines Munchausen Syndrome by Proxy a caregiver making up or causing an illness or injury in a person under his or her care Symptoms of depression are a side effect of which neurotransmitter medication? dopamine Which lesion is dark raised and asymmetric with irregular borders? melanoma A 32 year old woman presents with dull puffiness of the eyes pronounced nonpitting periorbital edema, this finding is suggestive of which condition? myxedema a 42 year old woman with a PMH of migraine headaches is requesting prophylactic medication treatment. Which medication should the nurse practitioner prescribe? amitriptyline (elavil) A pediatric patient has areas of scaling on the scalp with round patches of alopecia. this clinical finding is consistent with: tinea capitis what is the appropriate prophylactic medication for an 18 year old woman with a past medical history of migraine headaches? propanolol (inderal) Why would a combined hormonal contraceptive be contraindicated in a 36 year old patient with a PMH of type 2 diabetes, obesity, chronic smoking, and sedentary lifestyle her age and tobacco use 7 | P a g e During the breast examination of a perimenopausal woman, the NP detects a bloody spontaneous discharge from the right nipple. This indicates further evaluation an intraductal papilloma when interpreting a CBC lab report which of the following results describes the size of the RBCs Mean corpuscular volume (MCV) What medication should be avoided when prescribing prophylactic therapy for headaches? Venlataxin (effexor) Which of the following conditions is NOT a typical finding of hyperprolactinemia in a 47 year old premenopausal woman? gynecomastia which immunization reduces a patients risk for infection with the virus that causes painful localized blistering rash? shingles (herpes zoster) vaccine The client with iron deficiency anemia should be advised to take the iron supplement on an empty stomach between meals Which one of the following statements is true of Munchausen syndrome by proxy under the supervision of adults other than the abuser, the patient does not exhibit symptoms Which of the following is the most common presenting sign of substance abuse in adolescents? changes in behavior A woman is 11 weeks pregnant and has a maternity history of one full term vaginal delivery, a set of premature triplets delivered vaginally, and a first trimester abortion. Using her TPAL system to document her maternal status Gravida 4 Para 1114 the nurse practitioner palpates an enlarged right epitrochlear lymph node in a 30 year old patient. The nurse practitioner should assess the patients right forearm and hand anticholinergics are indicated for the treatment of urge incontinence on exam of the neck, a dome shaped lesion in the dermis forming a benign closed firm sac attached to the epidermis is noted on the right lateral side of the neck. This type of lesion is known as a cutaneous cyst 10 | P a g e sumatriptan (imitrex) acute lymphocytic leukemia is usually diagnosed by bone marrow examination The groove of the metacarpophalangeal joint can be palpated by having the patient... Flex their hand/spread their fingers When auscultating breath sounds in a patient who has left sided heart failure, the breath sounds are... Vesicular with late inspiratory crackles in the dependent portions of the lungs and resonant on percussion The ankle-brachial index is a screening test used to assess a person's risk for... Peripheral Artery Disease (PAD) Olecranon bursitis maybe caused by all of the following except... Frozen shoulder In patients who have allergic rhinitis, the nasal mucosa appears... pale A term used to describe an increase in muscular bulk with diminished strength is... Pseudohypertrophy If abdominal pain persists when the patient raises his head and shoulders, the origin of the tenderness is probably... In the abdominal wall On auscultation of the abdomen, rushes of high-pitched sounds are audible and coincide with abdominal cramps. These findings are most consistent with... Intestinal obstruction Ophthalmoscopic examination of the fundus reveals tiny, round, red spots in and around the macular area. These findings are consistent with... microaneurysms Symptoms of subdural hematoma include... Noticeable bleeding between the dura and cerebrum on x-ray On examination of the adult patient, symptoms of fixed posture, tremor, rigidity, and shuffling gait are observed. These findings are consistent with... Parkinson's Disease 11 | P a g e When discussing the musculoskeletal system, all of the following statements related to articular structure disease are true except which one? Articular disease is usually due to stiffness or pain Focal tenderness over the trochanter confirms... Bursitis Assessing the neurological status of a child with a ventriculoperitoneal shunt should include... Use of the Glasgow coma scale The easiest recognizable clinical manifestation(s) of cystic fibrosis in an infant is... Salty taste on the skin A reddish blue, irregularly shaped, solid, and spongy mass of blood vessels that may be present at birth and enlarge during the first 10 to 15 months is characteristic of a... Cavernous hemangioma The hamstring muscles flex at the knee and are located on the... Posterior aspect of the thigh Ophthalmoscopic examination reveals dark specks noted between the fundus and the lens. These specks are most likely... vitreous floaters When performing the first Leopold maneuver on a pregnant woman, if the buttocks and head are not easily palpated at the fundus, the fetus is said to be in... Transverse lie When performing a musculoskeletal examination, the nurse practitioner instructs the patient to move his arm in front of his body. The motion of the shoulder girdle would be an example of... Flexion To locate the twelfth rib, palpate... Between the spine and lateral chest Walking on the toes and heals may reveal... Distal muscular weakness in the legs When performing a bimanual exam of the vagina, the examiner should lubricate the index and middle fingers of the gloved hand. From a standing position, the fingers should be inserted into the vagina while exerting pressure primarily... posteriorly 12 | P a g e During pregnancy, which hormone results in increased blood viscosity? Erythropoietin Resting tremors refer to those tremors that disappear with voluntary movement A patient presents with complaints of bright red stools over the past week. This symptom could be consistent with... Cancer of the sigmoid colon Mydriasis is a term used to describe Dilation of the pupils When performing a musculoskeletal exam on a patient with mechanical low back pain, osteoporosis is expected. Positive findings include all of the following except... Calf wasting Which stage of pressure is consistent with findings on dermatologic examination of a full thickness tissue loss and subcutaneous fat visible with mild slough on the right hip? Stage III(Three) The vertebral column angles sharply posteriorly and becomes immovable at the... Lumbosacral junction Which one of the following is at the HIGHEST risk of suicide? A 52-year-old white man When auscultating heart sounds arising from the aortic valve in an adult patient, place the stethoscope... Between the 2nd and 3rd intercostal spaces at the right upper sternal border Pain and crepitus over the patella suggests... Roughening of the patellar undersurface Which one of the following findings is NOT typical in a patient who has delirium? Intact attention and concentration When examining the skin, multiple areas of circumscribed elevations of the skin filled with serous fluid measuring 0.5cm were noted. These types of lesions could be seen in... herpes simplex/ varicella The principal muscles involved when closing the mouth are innervated by which cranial nerve? 15 | P a g e When examining the knee, swelling above and adjacent to the patella was noted. This finding could be suggestive of... Synovial thickening over the knee joint While assessing the cranial nerves, the NP touches the cornea lightly with a wisp of cotton. This maneuver tests which cranial nerve? Cranial nerve V (Trigeminal) The NP instructs the patient to look over one shoulder, then the other. This maneuver would assess cervical... Rotation During a speculum exam of the cervix, the speculum is maintained in an open position by... Gently tightening the thumb screw on the speculum The NP is examining the elbow of a 16-year-old male athlete. When he tries to extend his wrist against resistance. This finding is most consistent with... Lateral epicondylitis Which examination finding is defined as a congenital ventral displacement of the meatus on the penis? Hypospadias Bowel sounds may be increased in the presence of... Early intestinal obstruction Eversion of the upper eyelid can be performed by placed the cotton application on the upper lid above the level of the internal tarsal plates and then... gently pushing down with the stick and lifting the lashes up and flipping the lid inside out Anticipatory guidance for the family of a pre-adolescent with cognitive impairment should be include information about... Sexual development Assymetry, irregular borders, variation in color, diameter greated than 6mm, and elevation represent the "ACBDE"s of... Malignant melanoma When performing a spinal exam, the NP noted the appearance of poor posure and a "hump" appearance of the upper back. This finding could be suggestive of... Thoracic Kyphosis The area where the iliac crest terminates anteriorly on the ilium is known as the... Anterior superior iliac spine 16 | P a g e Following injury to the extremities, assessment for neurovascular competency should include the... Skin color, temperature, movement, and sensation of the extremity A patient is experiencing a dull, achy pain in the epigastric are with eating. This type of pain is consistent with... A gastric ulcer Which of the following conditions is NOT related to polyuria? Hyperkalemic nephropathy When examining the elbow for range of motion, the NP instructs the patient to turn his palm upward. This motion is an example of... Supination The forward slippage of one vertebrae resulting in spinal cord compression is referred to as... Spondylythosis Skin conditions such as pruritis, hyperpigmentation, and calciphylaxis may be seen in patients who have... Chronic renal failure The extension of the spine of the scapula located at the highest point of the shoulder is referred to as the... Acromion process A 60-year-old patient with severe, deep left eye pain. Findings reveal dilated and fixed left pupil and the cornea is cloudy. There is no ocular discharge noted. These findings are most likely consistent with... Acute angle closure glaucoma A patient has a papule with an ulcerated center on the lower lid and medial canthus of the eye. This is consistent with... Basal cell carcinoma Patients with prior hypospadias surgery who develop slow and painful urination as well as prostatitis are experiencing symptoms of... urethral stricture Which substance used during pregnancy accounts for one third of all low-birth-weight infants, placental abruption, and preterm labor? Tobacco When screening for bladder cancer in a primary care setting, the test that would be LEAST appropriate is... 17 | P a g e Cystoscopy The axioscapular group of muscles include which of the following? Trapezius A mental health condition characterized by over-the-top behavior such as emotional outbursts, noisy displays of temper, compulsive attention seeking and self-centered actions is... Historionic Social phobia, panic disorder, and post-traumatic stress disorder (PTSD) are all examples of... Generalized Anxiety Disorder (GAD) In older adults, the presence of heart sound S3 suggests... Heart failure Depigmented macules appearing on the face, hands, feet, and other parts of the body due to the lack of melanin are termed... Vitiligo Restrictions of internal and external rotation of the hip are sensitive indicators of... Arthritis Which of the following neurological findings indicate the need for further evaluation? Weak and ineffective sucking movements The infant with the lowest risk of developing elevated levels of bilirubin is the one who... breastfeeds within the first hour of life The patient experiences a sudden loss of consciousness with falling without movements and injury may occur. The type of a seizures is consistent with... Myoclonic atonic seizure When assessing the skin, it has a velvety appearance and is warm to touch. This could be associated with... Hyperthyroidism Breath sounds auscultated over the periphery of the lung fields are quiet and wispy during the inspiratory phase followed by a short, almost silent expiratory phase. These breath sounds are considered... Vesicular To palpate the medial meniscus, slightly internally rotate the tibia and palpate the medial soft tissue along the... 20 | P a g e Stools that appear black, tarry, and sticky are referred to as... Melena A patient with cirrhosis develops portal hypertension as indicated by the presence of... Splenomegaly Which of the following is considered an extrinsic risk factor for falls in the older adult? Psychoactive medications The thoracic lymph duct drains lymphatic fluid from all of the following areas except... Right upper thorax Which ethnicity is associated with glucose-6-phosphate dehydrogenase (G^PD) deficiency? Black/African American During pregnancy, which hormone is responsible for increasing insulin resistance and hyperglycemia associated with diabetes? Human placental lactogen On examination of a six-week-old infant, developmental hip dysplasia (DDH) is suspected. If DDH is present, it might be evidenced by... Limited abduction of the affected leg When should a vaginal swab for Group B streptococcus (GBS) be obtained in a pregnant woman? 35-37 weeks Percussion of the abdomen should be avoided when? An abdominal aneurysm is suspected Basic self-care activities are referred to as... Activities of daily living (ADLs) Which sexually transmitted disease (STD) is known as the 'silent' infection and often lacks abnormal physical findings? Chlamydia With transillumination of the frontal sinuses, a dim red glow is observed on the forehead. This dim red glow would be indicative of... Clear frontal sinuses During the mental status exam, a 45-year-old woman is easily distractible and seems to have difficulty responding to each question. This is an assessment of... 21 | P a g e attention The normal fetal heart rate is... 110-160 (notes say 120-160) A patient presents with a productive cough. Which of the following descriptions of the mucous is correct? Tenacious sputum is consistent The posterior cruciate ligament of the knee crosses from the posterior tibia and lateral meniscus to the medial... Femoral condyle On physical exam, the soft palate does not risk, there is an absent gag reflex, and the patient complains of taste abnormalities. This requires further evaluation of cranial nerve... CN IX; Glossopharyngeal nerve When performing a spinal exam, the nurse practitioner notices unequal heights of the iliac crests. This finding could be suggestive of... Unequal leg lengths When examining the ankle and the foot of a patient, the NP instructs the patient to point the foot toward the veiling. This motion assesses... Ankle extension Ophthalmoscopic examination of the retina reveals AV tapering. This appears as if the... vein 'winds' down on either side of the artery The concavities noted on each side and above the patella are known as the... Negative infrapatellar space The lymphatic ducts drain into the ... venous system A swollen deviated uvula may be associated with a... Peritonsillar abscess A patient complains of some pain in the distal portions of the fingers on both hands. She states that it tends to occur more frequently with exposure to cold. These symptoms may be consistent with.. Raynaud's disease When examining the elbow for range of motion, the NP instructs the patient to straighten his elbow. This motion is an example of... 22 | P a g e Extension The patellar tendon continues below the knee joint and inserts distally on the... Tibial tuberosity The hilar region of the lungs describes the area... Around the heart Physical signs associated with cervical myelopathy from cervical cord compression include... Neck flexion with resulting sensation of electrical shock radiating down the spine Peritoneal inflammation produces abdominal pain and tenderness. What technique can be used to assess a tender abdomen suspected to be secondary to peritoneal inflammation? Ask the patient to cough prior to palpation To evaluate a patient's response to a vibration sensation, the NP would ask for the patient to identify... The sensation when the tuning fork is placed on the big toe Most common type of skin cancer in USA Skin cancer Most common type of skin cancer basal cell carcinoma basal cell carcinoma symptoms Appearance varies; smooth, shiny bump, pink to pearly white Basal cell carcinoma common locations cheeks, nose, face, neck, arms, back basal cell carcinoma diagnosis gold standard biopsy. if not an option, refer to derm Actinic keratosis Precursor to squamous cell carcinoma numerous dry, round and pink to red lesions w/ rough and scaly texture --> does not heal, slow growing in sun exposed areas Actinic keratosis diagnosis gold standard Biopsy. if not an option, refer to derm Actinic keratosis treatment gold standard 25 | P a g e Rocky mountain spotted fever (RMSF) symptoms Fever chills N/V myalgia arthralgia 2-5 days later develop petechial rash on forearms, ankles, and wrists that spreads towards trunk and becomes generalised. sometimes rash develops on palms and soles *RASH DEVELOPS INWARDS* RMSF pneumonic (RMSF) R-Rash M-Muscle aches (myalgia) S-Stomach aches (nausea and vomiting) F-Fever (>102 F) Rocky Mountain Spotted Fever (RMSF): Located: •Think "Rocky"- North Carolina, Oklahoma, Arkansas, Tennessee, Missouri Spring to Fall (April to September) Rocky Mountain Spotted Fever (RMSF): DX PCR assay by indirect immunofluorescence antibody (IFA) assay for immunoglobulin G (IgG) for Rickettsia Rickettsii Rocky Mountain Spotted Fever (RMSF): tx Doxycycline is always first line for all ages 100 mg every 12 hours x 7-10 days Can be fatal if not treated within the first 5 days Erythema Migrans (early Lyme disease): Symptoms Usually appears in 7-14 days after being bitten by a deer tick; range 3-30 days Target bull's-eye Rash is hot to touch with rough texture. Expanding red rash with central clearing • Common locations are belt line, axillary area, behind the knees, and groin area • Positive for flu like symptoms. Lesions and rash resolve within a few weeks with or without treatment Erythema Migrans (early Lyme disease): DX Dx: • First step is enzyme immunoassay (EIA) also knows as ELISA if negative no further testing needed. If positive confirm with Western Blot test (aka indirect immunofluorescence assay (IFA) for Borrelia Burgdorferi 1. Enzyme immunoassay 2. western blot test (immunoflurorescence assay/ IFA) Exam Tip: E before I 26 | P a g e Will have increased ESR Erythema Migrans (early Lyme disease): TX Doxycycline is always first line for all ages 100 mg BID x 10-21 days Remove ticks by grasping with tweezers or forceps close to the skin and pulling gently with steady pressure. After removing the tick, clean area with rubbing alcohol, iodine scrub, or soap and water. Dispose of the tick by flushing it into the toilet Tick repellant skin use DEET Tick repellant clothing use Permethrin Brown Recluse Spider Bite: SX • Fever, chills • Nausea and Vomiting • Located in the arms, upper legs, or the trunk • Bitten area becomes swollen, red, and tender, or can be painless • Blisters appear within 24-48 hours • Necrotic in center, which kills the tissue **can be painless Brown Recluse Spider Bite treatment Treatment: • Ice packs to wound as the cold inactivates the toxin • Treat like cellulitis of the skin • Antibiotic ointment at first and watch Skin lesions primary skin lesions Macule Vesicle Papule MVP Size: <1 CM Macule Flat, nonpalpable, but visually distinct areas on the skin surface with color different from the person's normal skin; less than 1 cm FRECKLE Vesicle elevated, raised lesion filled with serous fluid (herpetic lesions) Papule palpable solid lesion (acne, moles) primary skin lesions >1cm in size 27 | P a g e Nodule Plaque Bullae (Blister) Pustule Wheal Nodule raised solid lesion (BCC) Plaque solid raised lesion with flat top (psoriasis) Bulla/Bullae elevated superficial blister filled with serous fluid (2nd degree burn, impetigo) Pustule circumscribed elevated lesion containing pus (acne pustules) Secondary Skin Lesions-Lichenification thickening of the epidermis with exaggeration of normal skin due to chronic skin itching (eczema) Secondary skin lesions- Scale flaking skin (psoriasis) Secondary skin condition-crust dried exudate (impetigo) Secondary skin condition-ulceration eroding of epidermis and dermis (if deep can involve subcutaneous tissue) Secondary skin condition-scar permanent fibrotic change following damage to dermis (surgical scars) Secondary skin condition-keloids/hypertrophic scars overgrowth of scar tissue (more common in Black and Asian descent) Rule of 9's Head and neck = 9% Upper Ex = 9% each Lower Ex = 9% each Front trunk = 18% Back trunk = 18% Rule of 9's =-child leg 30 | P a g e Impetigo Bacteria (Gram Positive): Beta Streptococcus or Streptococcus aureus Most common bacterial skin infection in young children ages 2-5 Impetigo symptoms Itchy pink-red lesions, evolve into vesiculopustules that rupture easily, honeycolored crusts (from dried serous exudate) Very pruritic and contagious Impetigo Treatment Order C&S of fluid Severe Case= Keflex or Dicloxacillin QID x 10 days Penicillin Allergy o Give Azithromycin 250 mg x 5 days or o Clindamycin x 10 days **If no blisters- topical mupirocin ointment (bactroban) 2% x 10 days Acne Vulgaris (common acne): treatment First line is always topical retinoid such as tretinoin cream (Retin-A) Acne: Mild treatmetn open comedones blackheads/closed comedones (whiteheads) w/ or w/o papules topical retinoid (Retin-A) *Acne will worsen during first 4-6 weeks* IF no improvement in 8-12 weeks, increase dose or ADD benzoyl peroxide and/or erythromycin Acne: Moderate (topicals plus antibiotics) papules and pustules with comedones (3 part treatment) Topical retinoid (Retin-A) AND topical benzoyl peroxide AND oral antibiotic (Tetracycline or Minocycline) x 3-4 weeks --> Exam usually asks about moderate Acne: Severe painful indurated nodule, cysts, abscesses, pustules Accutane- check Liver function tests (LFTS) 31 | P a g e must use 2 forms of contraceptives, monthly pregnancy testing only prescribe 1 month supply of medication Usually, will refer to Dermatology Topical retinoid side effects Irritation, dry skin, flaking, redness during first 4 weeks due to increase in skin turnover After washing face wait 30 minutes before applying medication to help minimize irritation Acne medications to avoid in pregnancy (category X &C) Category X: Topical tazarotene (Tazorac), Accutane Category C: Topical retinoids (tretinoin, adapalene) Acne Rosacea Symptoms: • Chronic small acne like papules/pustules, and telangiectasias around nose, mouth, and chin symmetrically Treatment: First line: o (Avoid triggers of flushing (EtOH, excessive sun, spicy foods) Metro gel or Azelex gel QD-BID Low dose Tetracycline 250 mg QID or doxycycline 100 mg QD if gel not effective or the patient has pustular/ocular rosacea Psoriasis Symptoms: • Inherited condition (atopy) Pruritic erythematous plaques Fine silvery-white scales with pitted fingernails Occurs on scalp, elbows, knees, sacrum, and intergluteal folds (extensor surfaces) Migratory arthritis Psoriasis treatment Treatment: • Topical steroids o Seven classes of steroids 10 o Avoid class I-III on children, and sensitive skin (face, groin, etc.) o Class I- super potent o Class VII least potent • Tar preps (mild cases) • Anti-TNF (severe cases) or immunologics o Methotrexate, cyclosporine, etanercept, adalimumab Koebner phenomenon: New psoriatic plaques form over skin trauma Auspitz sign: Pinpoint bleeding when plaques are removed Atopic Dermatitis (Eczema): 32 | P a g e Inherited condition (atopy) Extremely itchy On neck, and hands as well as other flexural folds An IgE condition Small vesicles (MVP- macule, vesicle, papule all are <1 CM all others ≥1 CM) that rupture leaving painful, bright-red, weepy lesions Will become lichenified from itching Atopic dermatitis (eczema) treatment First Line: o Topical steroids and emollients Avoid hot water/soaps Can take oral antihistamines to help with itching Avoid wool clothes Contact Dermatitis An inflammation of the skin caused by having contact with certain chemicals or substances; many of these substances are used in cosmetology. It is very pruritic, and usually there is no lichenification. Lesions evolve into vesicular bullae that easily rupture leaving bright-red moist areas that are painful Contact dermatitis Treatment: • First Line: o Stop exposure to substance • Topical steroids QD to BID x 1-2 weeks • Consider referral to allergist for patch testing Scabies Pruritic rash located in the interdigital webs of the hands, axillae, breasts, buttock folds, waist, scrotum, and penis • Severe generalized itching that is worse at bedtime • Family member will have same symptoms o Apply cream to skin from neck to soles of feet. Leave on for at least 8-14 hours then rinse off. Repeat in 1 week o Scabies never go to scalp! o Treat everyone. Wash sheets and all other items in house in hot water --Scabies never go to scalp TREAT EVERYONE Pityriasis Rosea: Symptoms May be itchy Herald patch appears 2 weeks before full breakout Christmas tree pattern Rash on the hands or soles of the feet Pityriasis Rosea: Treatment Resolves on its own in about 4-6 weeks 35 | P a g e Treatment: • Typically resolves on its own if immunocompetent (watchful waiting) o Other options: cryotherapy, curettage, cantharidin • If sexually active CDC considers this an STI if in genital region Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN): symptoms Symptoms: • Classic is target or bull's-eye rash that occurs abruptly • Hives and blisters • Petechiae and purpura • Necrosis with sloughing of tissue • Extensive mucosal involvement • Prodrome of fever with flu like symptoms Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN): Triggers Mnemonic: SANA(p) • Sulfonamides • Anticonvulsants • NSAIDs • Allopurinol • PCN *HIV patients are at a higher risk for SJS & TEN* Acanthosis Nigricans: symptoms Velvety hyperpigmented patches most common on back of neck or skin folds • Usually associated with diabetes, metabolic syndrome, obesity, and cancer of the GI tract Scarlet Fever (Scarlatina): Symptoms "Sandpaper textured-pink rash with sore throat" Strawberry tongue, rash starts on head and neck, spreads to trunk. The skin THEN desquamates (peels/sheds) Associated with strep throat Lichen Planus: symptoms & Treatment Symptoms: • Small flat topped, red to purple bumps that may have white scales/flakes • Wispy grey white streaks called Wickham's striae • Found on the inner wrists, forearms, and ankles. If on scalp causes hair loss • Can be found in vulva and vagina with soreness, burning, and rawness Treatment: Topical Steroids (even in vaginal area for Lichen Sclerosus) Anthrax: Symptoms & treatment Symptoms: Animals/hides/hair/wool Lesions begin as papules that enlarges quickly within 24-48 hrs. Develop necrosis and ulceration (sort of like a recluse spider bite) Not contagious Treatment: Doxycycline, Cipro, or Levaquin BID x 7-10 days 36 | P a g e If you suspect BIOTERRORISM treat for 60 days Prophylaxis antibiotics are Cipro and Doxy Hidradenitis Suppurativa: Symptoms & Treatment Symptoms: Recurrent episodes of painful large and tender red nodules, abscesses, and pustules in the axilla (most common), groin, perianal, and inframammary Due to occlusion of the hair follicles and pilosebaceous glands (apocrine glands) Treatment: •Avoid skin trauma, wear loose light clothing, avoid excessive heat, and friction Smoking cessation, lose weight if obese Avoid deodorant Doxycycline QD to BID x several months Blepharitis (inflammation of the eyelids): Symptoms/treatment Symptoms: Bilateral red and swollen edges of eyelids May have fine scales More common with seborrheic dermatitis Treatment: Scrub eyelids in warm water and baby shampoo Pterygium (Surfer's eye): Symptoms/Treatment Symptoms: Triangular-shaped white to yellow superficial growth On nasal side Caused by long term UV damage Treatment: Surgical remove if it grows into the pupil Prevention: wear sunglasses Pinguecula (think of Ping-Pong): Symptoms/Treatment Symptoms: White to yellowish small round superficial lesion on each side of the cornea Caused by long- term UV damage Treatment: • Prevention: wear sunglasses Chalazion: Symptoms & Treatment Symptoms: Small painless nodule Chronic inflammation of the meibomian gland (specialized sweat gland) Grows gradually 37 | P a g e Treatment: • Hot compress QID if large otherwise no treatment Hordeolum (Stye): Symptoms and Treatment Symptoms: Painful • Swollen • Red, warm, abscess, and it's acute Think Hordeolum "Hurts" Treatment: • Hot compress until it drains QID • Avoid wearing eye make-up • Erythromycin or dicloxacillin QID if preseptal cellulitis develops 17 o Refer to ophthalmology for I&D Senile arcus: Symptoms and Treatment Symptoms: White-gray ring on edge of cornea in elderly and is bilateral Normal finding in elderly Result of lipid deposit Treatment: None Age less than 50 check lipid profile Xanthelasma: Symptoms and treatment/ DX Symptoms: • Soft yellow flat plaques on the upper and lower lids by the inner canthus or palpebrum • Cholesterol plaques Dx: • Order fasting lipid profile to rule out hypercholesteremia Treatment: • Trichloroacetic acid, surgery, laser Allergic Conjunctivitis (Keratoconjunctivitis): Symptoms & Treatment Symptoms: Typically, bilateral itchy eyes with "stringy discharge and increased tearing" Type I sensitivity (IgE) Rhinitis and allergic shiner Treatment: PO (oral) antihistamines Eye drops olopatadine (Patanol), Visine (short term or episodic use only) Cool compresses and avoid allergens *May be called keratoconjunctivitis on ANCC Bacterial Conjunctivitis: Symptoms and treatment Symptoms: • Acute onset of red eye • Dried yellow-green crusting on eyelids on awakening Treatment: Topical ophthalmic fluroquinolones (Ofloxacin) Q 2-4 hours x 2 days, then QID x 5 days Viral Conjunctivitis (Pink Eye): Symptoms and treatment Symptoms: • Acute onset of red eye • Complaint of itchy eyes; one or both eyes • Periauricular lymphadenopathy 18 • Very contagious 40 | P a g e Treatment: Lacrimal sac massage (downward toward mouth) 2-3 times daily; systemic antibiotics 7-10 days Allergic Rhinitis: Background & symptoms & treatment Background: Inflammatory changes of nasal mucosa due to allergies Atopic family history (asthma, eczema) May have seasonal or daily symptoms Symptoms: Chronic nasal congestion with clear mucus discharge or post nasal drip Itchy nose, Frequent sneezing, Coughing worsens when supine due to post nasal drip, Blue-tinged or pale boggy (spongy) nasal turbinate's Treatment: • First Line: Nasal steroid sprays (Fluticasone - Flonase) BID, triamcinolone (Nasacort Allergy) 1-2 sprays QD • Antihistamine Azelastine (Astelin) QD-BID • Decongestants Pseudoephedrine PRN. Avoid in infants and children • Avoid triggers Epistaxis (Nosebleed): Background & Treatment Background: Anterior nosebleed more common. Caused by bleeding at Kisselbach's plexus Treatment: Have the pt. blow their nose first Apply two sprays of topical nasal decongestant (Afrin). Pinch alae tightly against nasal septum and hold for 10 minutes Meniere's Disease: Symptoms Vertigo Hearing loss Tinnitus Meniere's Disease Mnemonic: VAST Vertigo (Episodic) Aural (auditory) fullness Sensorineural Hearing Loss (Fluctuating) Tinnitus (Subjective) Meniere's Disease Treatment Usually, self-limiting. Treat acute attacks Antihistamines for vertigo Meclizine, dimenhydrinate Antiemetics for nausea/vomiting o Promethazine, prochlorperazine 41 | P a g e Acoustic Neuroma (Vestibular Schwannoma): Symptoms/DX/TX Symptoms: Ages 30-60 Gradual onset, one-sided Sensorineural hearing loss, tinnitus that is insidious; CN 8 Facial numbness and pain if it compresses CN 5 Dx: Order an MRI o Benign tumor of CN 8 causing sensorineural hearing loss and tinnitus. If it compresses on CN 5 will have facial numbness and pain Treatment: Surgery Cholesteatoma symptoms and treatment Symptoms: Cauliflower Foul-smell Hearing loss (typically conductive unless it's way inner than can have sensorineural) If erodes bones in face affects CN VII Treatment: SURGERY Battle Sign (Basilar Skull Fracture): Bruising behind the ear (mastoid area) appear within 1-3 days after trauma Parietal bone is most fractured. Linear fracture most common leaking of clear fluid from nose and eyes, raccoon eyes Look for clear, golden serous discharge from the ear or nose treat immediately-Refer to ER Benign Paroxysmal Positional Vertigo (BPPV): Symptoms & DX & Treatment Symptoms: Vertigo lasting <1 minute caused by sudden head movements and position changes May lose balance and fall Due to calcium carbonate crystals (otoconia) being trapped in the semicircular canals Dx: Gold Standard: Dix-Hallpike Epley Maneuver in clinic or at home by pt Test won't ask how to conduct treatment just be able to associated Epley with BPPV Vestibular Neuritis and Labyrinthitis: Cause/ Symptoms/ TX 42 | P a g e Viral infection/Inflammation Symptoms: Sudden/rapid onset of severe vertigo with nausea/vomiting for 1-2 days and then symptoms lessen • Sensorineural hearing loss and tinnitus Treatment: Ondansetron (Zofran) Methylprednisolone taper Acute Otitis Media (AOM)(Think of Media for Middle Ear): Strain & symptoms & treatment Bacteria: Streptococcus pneumonia (others: Haemophilus influenza, Moraxella catarrhalis) High rate of beta-lactamase resistance Symptoms: Unilateral ear pain (otalgia) Popping noises, and muffled hearing, Either afebrile or low-grade fever, The tympanic membrane can rupture. Blood and pus can be seen on the pillow upon awakening with relief of ear pain ,TM will be red. Bulging and the cone of light will be abnormal or displaced ,Most objective finding: Decreased mobility per the tympanogram which will be a flat line Treatment: NO antibiotic use in the prior month: o Amoxicillin high dose (first line): 1000 mg TID x 5-7 days Next antibiotic choices are: 23 Augmentin x 5-7 days o Omnicef or cefpodoxime BID x 5-7 days Penicillin Allergy: Type 1 Allergy (anaphylaxis, angioedema): Levofloxacin 750 mg QD x 5-7 days OR Doxycycline BID x 5-7 days • Type 2 Allergy (skin rash): Omnicef, cefpodoxime, Ceftin BID x 5-7 days Hearing Tests: Conductive Hearing Loss Weber- Lateralization to bad ear Rinne- BC>AC Otitis Media with Effusion: Symptoms/TX/Hearing tests Symptoms: Usually, painless May follow AOM but can also be caused with chronic allergic rhinitis Sterile CLEAR serious fluid is trapped in the middle ear. May see air bubbles, Ear pressure along with mild hearing loss and ear popping sounds, TM should NOT BE RED. TM may bulge or retract Treatment: Treat like allergies Can do supportive care and wait 3 months • Oral decongestants o Pseudoephedrine or phenylalanine • Steroid nasal spray (Fluticasone - Flonase) BID-TID x few weeks or saline nasal spray (Ocean spray) PRN Hearing Tests: • Conductive Hearing Loss • Weber- Lateralization to affected ear • Rinne- BC > AC Otitis Externa (swimmers' ear): Bacteria & Symptoms & treatment 45 | P a g e Age >44 (-1 point) Score of 0-1 unlikely need to test for strep; score of 3-4 confirm with rapid strep test Hypertension Retinopathy Cotton wool, Retinal arterioles constriction • Copper/silver wire arterioles • AV nicking (mild retinopathy) • Retinal Hemorrhages Diabetic Retinopathy: damage to the retina as a complication of uncontrolled diabetes Symptoms: • Cotton wool spots (moderate retinopathy) • Micro-aneurysms • Neovascularization Koplik's Spots Symptoms: • "Clusters of small size red papules with white centers in the buccal mucosa by lower molars" • Caused by Rubeola (Measles) o Rubeola and Koplik's have an "O" • Fever, conjunctivitis, coryza, cough • Morbilliform rash Hear Murmurs: Gold standard DX Echocardiography (TEE) Systolic murmurs occur when? During S1 mitral regurgitation 46 | P a g e Radiates to axilla 5th intercostal space (ICS) by mid clavicular line (MCL), apex, apical area Aortic Stenosis (mid systolic ejection): Radiates to neck! Higher risk of sudden death • Location: oAortic area, 2nd ICS by right upper sternum; at the base of the heart by the right upper sternum; base of heart on the right side of sternum Diastolic murmurs occur when S2 Heart sound diastolic murmurs are always PATHOLOGICAL-indicative of heart disease Mitral stenosis (Mid/late diastolic) Afib most common risk-emboli risk narrowing of the mitral valve Only murmur you listen to with your Bell *Dyspnea most common symptom* Heart Murmur Grading System: Grades I-VI : • Grade I: Barely audible • Grade II: Audible • Grade III: Clearly audible • Grave IV: First time thrill is present (more than likely will ask for this on exam) • Grade V:Hear the murmur even with edge of stethoscope off • Grade VI: Murmur is so loud that it can be heard with entire stethoscope off chest S3 sound associated with? Heart failure Sounds like "Kentucky" Abnormal in ages under 35 S3 is a normal heart sound in: Pregnancy, young children, athletes How to listen to S4 Bell of stethoscope Sounds like "Tennessee" Late diastole is when __Valves close; occurs in S1 47 | P a g e Late diastole, S1, is when the AV valves close Late diastole is when __valves close; occurs in S2 Late diastole, S2, is when the SL valves close Motivated-S1 heart sound-Lub includes what valves Motivated (S1 heart sound-lub) M (mitral valve) T (tricuspid valve) AV (atrioventricular valves) Apples- s2 heart sound-dub-includes what valves A (aortic valve) P (pulmonic valve) S (semilunar valves) Isolated systolic hypertension (ISH) Systolic is 140+ and diastolic is 90 or less--occurs mainly in older adults HTN meds that cause heartburn CCB, BB, alpha agonists Atrial Fibrillation (AF) (Most common arrhythmia in the US) • Can be paroxysmal or persistent • Pt. will complain of the sudden onset of heart palpitations accompanied by weakness, dizziness, fatigue, and dyspnea • May have chest pain and feel like passing out Rapid and irregular pulse which may be greater than 110 per minute with hypotension --> Consider antithrombic therapy Afib diagnosis A diagnostic test is 12 lead ECG which won't show discrete P waves and will be irregularly irregular CHA2DS2-VASc score C- congestive heart failure -1 H- hypertension - 1 A2- Age > 75 -2 D- Diabetes mellitus - 1 S2- Stroke - Tia - throboembo-2 V- vascular disease -1 A-Age -65-74-1 Sc- Sex women - 1 50 | P a g e Right sided heart failure effects? Edema JVD (jugular vein distention) Dyspnea on exertion BMI (body mass index) Underweight - Less than 18.5 Normal - 18.5 - 24.9 Overweight - 25 - 29.9 Obese - 30 - 39.9 Hypercholesterolemia excessive cholesterol in the blood statin first line *When triglycerides are extremely high , goal ist o lower them to prevent pancreatitis* Prior to starting statins you should check Liver function tests (LFT's) Rhabdomylosis, what drug do you hold? Hold statin and hydrate Pulmonary embolism most common cause is a DVT cough may be productive and pink tinged tachycardia, pallor and the feeling of impending doom Anaphylaxis is a ___ mediated reaction IgE Give 1:1000 IM or Subq then call 911; have one give epi and then one call 911 Percussion: Resonance low pitched, hollow sounds heard over normal lung tissue Percussion: Dull Heard over fluid filled organs such as the heart or liver. Pleaural effusion or lobar pneumonia Percussion: hyper-resonant sound emphysema Spirometry helps diagnose 51 | P a g e COPD FEVI less than 80% predicted FEV1/FVC ratio of <0.7 is diagnostic for COPD #1 risk factor for COPD smoking COPD gold guidelines Anticholinergics are first line for COPD (ipratropium/Atrovent) chronic bronchitis Productive cough that occurs >3 months/year for 2 consecutive years --> dirty-chest appearance on CXR Typically are "blue bloaters" (overweight and cyanotic) **Clinical Diagnosis** common side effect of ACE inhibitors Dry cough. Increased potassium levels in the blood (hyperkalemia) Fatigue. Dizziness from blood pressure going too low. Headaches. Loss of taste.