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2011-12-14 19:55:31
Primary Care Families

final notes
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  1. Actinic keratosis--PRECANCEROUS--squamous cell

    * single or multiple discrete, dry, rough adherent scaly lesions on sun-exposed skin
    *may be tender if excoriated with fingernail
    *may be papular, rough like coarse sandpaper
  2. Solar lentigo--BENIGN

    *circumscribed 1-3cm brown strictly macular on sun-exposed areas
    *may happen acutely after sunburns
    *most common in Caucasion but can be seen on Asians
  3. Seborrheic keratosis--BENIGN, most common

    *lesions range from small, barely elevated papules

    *if become traumatized/irritated/bleeding/painful r/o SCC
  4. Melanoma:
    Border irregularity
    Color variegation
    Diameter >6mm
  5. Basal cell carcinoma of the skin:

    Pearly-colored nodule, fine telangiectasis, depressed center, rolled elevated edge
  6. Squamous cell CA:

    Firm irregular papule with a scaly, keratotic, bleeding and friable surface (e.g. actinic keratosis)
  7. Leukoplakia-PRECANCEROUS

    *check mouth annually
    *chronic white plaque/lesion
    7X higher risk w/smokers & alcohol
  8. Hearing--voice range is 4000-6000db, normal is 0-25,000 db
    *most common cause of conductive loss-cerumen impaction, then OM

    *Waardenburg's--white lock of hair kid--eval for hearing loss
  9. Hearing--cholesteatoma

    *cauliflower appearance, eats thru bone, r/t OE or OM, foul smell, may attach to TM, extremely difficult to cure
  10. Hearing--classic triad for acoustic tumor

    Hearing loss/tinnitis/dizziness--always get CT head!

    ASA, Lasix can cause tinnitis
  11. Glaucoma--leading cause of blindness in African-Amer.--peripheral field loss

    Classic triad--increased intraocular pressure, cupping of optic disc & visual field loss

    Risk factors: HTN, DM, aging, trauma, black--check eye pressure q 4-6 months
  12. Acute, sudden onset, closed-angle glaucoma:
    --intense pain, blurred vision, halos, red eye, fixed & dilated pupil, N/V, cornea may appear cloudy, iris may bow forward
    --medical emergency--surgical window
    --routine screening for > 35 y/o (2-3 X/yr for high risk)
  13. Open angle/wide angle glaucoma--slow, progressive
    --no eye pain or N/V
    --anti-glaucoma drugs not prescribed by family practice
    --BB, adrenergic agonist, papasympathomimetics (topicals)
    --systemic drugs: carbonic anhydrase inhibitors, hyperosmolar agents
    Surgery & laser for both types

    • --windows
    • --outflow of trabecular system or uvea
  14. Proliferative retinal changes--DM, HTN, gradual, pt notices after a lot of vision loss
    --vascular neogenesis with new weak vessels that cannot stand up against high sugar or HTN
    *nicking of blood vessels
    *small dark dots=hemorrhage
  15. Retinal detachment--seen in DM, after surgery, tumors, inflammation

    *symptom of "curtain coming down"
    *flashing lights & floaters
    *need reattachment w/in 24 hrs.
    *send to ER or ophthalmalogist
  16. Macular degeneration--progressive, loss of central vision

    *use Amsler grid for home monitoring
    "dry" painless, progression of central vision loss, drusen bodies (lipofuscin deposits)
  17. Macular degeneration--"wet"--choroidal neovascularization, loss of central vision

    *submacular hemorrhage is common
    *tx is photocoagulation
  18. Papilledema--margin goes uphill then down into disc.

    *usually bilateral, can affect all ages

    Loss of red reflex can be r/t tumor, cataract, novice NP, hemorrhage into ant/post chamber

    Leukocoria--white reflex due to cataract, blindness, retinoblastoma
  19. Spots in eye:
    --cotton wool, soft, light, feather r/t infarction in nerves e.g. DM, HTN
    --hemorrhage is dark re/black, well-defined, crisp edges
    --drusen bodies are yellow, small and increase w/age--due to macular degeneration
    • --artery color changes are pink/white with feathery arterial borders due to high triglycerides
    • --choroiditis--serious change with yellowish-white feathery nerves continuous w/optic disc, wider at optic disc then narrows as it goes away
  20. Eye changes:
    --choroid/retinal changes can be caused by laser surgery

    --Histoplasmosis, CMV, toxoplasmosis & congenital measles can cause inflammation along nerves & damage to retina
  21. Diabetes: ADA says start on meds @A1C of 6, pre-diabetic 5.7-6.1

    A1C of 6.5 is diagnostic of diabetes
    Any casual BG equal to or over 200=diabetes
    Fasting blood glucose >/=126 (X2)=diabetes
    2hr pp OGTT >/=200=diabetes

    --with no risk factors do baseline A1C at age 45 then q 3 yrs
    --with risk factors do annually
    --if diabetic do A1C q 6 mo, q 3 mo if in poor control
    • Impaired glucose tolerance (IGT)
    • --higher levels of plasma glucose but<126 OR
    • --2hr pp IGTT>/= 140-200

    GTT--is test of choice if BS <200 & not sure if person is insulin resistant, specific "50 gms"
  22. Diabetes: BG 120= A1c 6; change of 60 in BG= 2% change in A1C

    Labs for DM: fasting lipids, serum Cr, UA, microalbuminuria, TSH (T4 if indicated), CBC, EKG, LFT (q 3 mo) A1C (q 6 mo, q 3 mo if poor control)
    Annual dilated eye exam
  23. Sulfonylureas--Glipizide, Glucotrol, Amaryl

    --may cause hypoglycemia
    --stimulate beta-cells to produce insulin
    --long-acting, 24 hrs
    --start monotherapy
    --when get to 1/2 of max dose--start meformin
    Amaryl is approved to use w/insulin; lower incidence of hypoglycemia
  24. Meglitinides--Repaglinide (Prandin/Starlix)

    --stimulates release of insulin from pancreas
    --for T2DM only
    --just before meals
    --increases uric acid
  25. Biguanides--Metformin, Glucophage

    --decrease glucose production in liver
    --increases glucose use in cell (for insulin resistance!)
    --metabolized by kidney
    --no hypoglycemic effects (doesn't stimulate insulin)
    --decrease weight, stimulates ovulation (PCOS)
    --start low r/t GI effects of gas, bloating, diarrhea
  26. Alpha glucosidase inhibitor--Acarbose (Precose), Miglitol (Glyset)

    --delays absorption of CHO in intestines, explosive diarrhea when eating carbs
    --doesn't stimulate insulin production
    --must take with first bite
    --may cause rise in LFTs but is reversible
  27. Thiazolidinediones--Avandia (Rosiglitazone--off market), Actos (Pioglitazone)

    --decreases insulin resistence in cells
    --increases LFTs, contraindication with CHF
    --increases cholesterol
    --4-12 weeks to take effect
    --increases ovulation
  28. Incretin mimetic (second line drugs)--Byetta (Exenatide), Januvia, Janumet, Traj (w/simvastatin)

    --requires presence of insulin to work
    --increases insulin secretion, stimulates Bcell growth
    --slows gastric emptying (don't give w/gastroparesis)
    --weight loss (acts on satiety center in brain)
    --renally excreted, reduce dose for RI
    --increase in pancreatitis
    --don't give to pt w/high triglycerides (>1500)
  29. Amylin memetic--Symlin, injection only @ meal time

    --for both T1DM & T2DM
    -- increased hypoglycemia
    --avoid using with orals
    --can decrease insulin use by 50%
  30. Insulin--exogenous produces increased insulin resistance

    Humalog made from Ecoli--better for T2DM vs beef or pork

    If on NPH & switch to Lantus, cut dose by 1/3 to 1/2

    1 unit of regular insulin decrease BG by 50 points
  31. Diabetes--dyslipidemia control--treat LDL first

    1) first glycemic control
    2) LDL--statins first choice, bile acid binding resin second
    3) HDL--increase w/weight loss, exercise, smoking cess
    4) TG--Fibric acids (gemfibrozil--Lopid, statins--but not both at same time)
  32. Lipid drugs: VLDL & TG cause microvascular dx

    --Never use Lopid (fibrate) & a statin together
    --Statin is category X for pg
    --Crestor (rosuvastatin) has less side effects than Lipitor (atorvastatin)
    --Clindamycin & EES increase myopathy if used w/statin
    High cholesterol can cause fatty liver--do U/S
  33. Diabetes--renal complications

    --annual UA & microalbumin screen
    --Refer for GFR <70
    --if stage II CKD check annual PTH (parathyroid hormone
  34. HTN--black widow spider bites may cause severe HTN within 30-60" of bite

    HTN--gout increases blood pressure
  35. Systolic HTN-increased cardiac output, rigidity of aorta must be treated differently

    --no BB, use a diuretic
  36. Hypertensive effects on eyes:

    --AV nicking
    --optic disk edema
    --arterial narrowing
    --papilledema (late, chronic)
  37. HTN--lowering DBP below 60 increases risk of stroke & MI r/t reduce coronary & brain perfusion
  38. CCB--DOC for volume overload HTN in African-American & elderly, also diuretics

    Elderly--thiazides or BB plus thiazides or long-acting dihydrophyridine calcium antagonists (amylodipine, procardia)

    **caution in those with heart failure, conduction defects especially if already taking BB
    **never use Procardia (Nifedipine) in the office--Clonidine OK
  39. S3 gallop, laterally displaced PMI, murmur
    --has a cadence/roll, should be suspicious of heart failure
    --increased flow problem
    --use bell of stethoscope
  40. Anemia: Normochromic/normocytic--most common cause is chronic disease e.g. CRF, endocrine, heart valve, plastic, hereditary spherocytosis, pure red cell aplasia

    *MCV WNL (82-101)
    * consider erythropoietin
  41. Anemia: Microcytic/hypochromic caused by--iron deficiency, thalassemias, chronic disease, dieroblastic anemia

    *MCV below normal for age (<82)
    *happens with GI bleeding, massive bleeding or poor diet
    • TX:
    • --treat cause
    • --supportive
    • --dietary is always better than supplements
    • --take iron w/vitamin C
    • --tea, antacid & milk decrease absorption of iron
    • --iron, B complex, liver extract
  42. Anemia: Macrocytic--megloblastic due to folate deficiency (malnourishment, alcohol, celiac, vegetarian diet), decreased B12 in elderly, pts w/gastrectomy

    *MCV (>101)
    *folic acid/B12--start with 1000mg IM X 1 yr then try oral
    F/U--response to therapy, labs

    Iron toxicity--espeially children, can be lethal in 1-10 gms depending on weight
  43. Gout tx:

    Zyloprim--DOC, inhibits uric acid formation
    --no ASA or diurectics
    --probenecid--blocks tubular reabsorption of urates
    **tx not required for uric acid < 10mg/dl
    Gout subsides in 1 week untreated

    • *can cause kidney damage
    • *fluid intake of =2000ml/day if at risk for kidney stones
  44. Ulcerative colitis S&S:
    --rectal bleeding
    --up to 15 stools/day
    --mucous, tenesmus
    --nocturnal diarrhea
    --fatigue, anorexia, weight loss
    long periods of complete remission

    less common symptoms are fever & abdominal pain
  45. Crohn's S&S: get flat plate of abd & CBC

    --tends to perforate more & is transmural
    --RLQ pain, fever, weight loss
    --non-bloody diarrhea (rectal bleeding rare)
    --right sided mass
    --more indolent, causes little pain, slow growing
  46. Crohn's & Ulcerative colitis dx & tx:
    --diagnosis based on clinical hx
    --exclude bac/amebic infections w/stool cultures
    --U/C do sigmoid, colonscopy or barium enema
    --Crohn's do barium studies of sm & lrg bowel
    --Consultation recommended
    • Avoid nuts & fruits. Liquid diet during flare-ups.
    • Decrease stress, trigger, etc.
  47. Drug therapy for UC & Crohn's:
    --sulfasalazine--most UC will respond, some Crohn's
    --4or 5 aminosalicylate
    --hydrocortisone retention enema--more helpful with UC
    --oral prednisone after check for infection/peritonitis
    Azathioprin, 6 mercaptopurine, DMARDS showing promis