Emory Certification / Recertification Review for Physician Assistants
Board Review Pearls
Preparing for Success on the PA Board (Certification and Recertification) Exam 1. Read about the exam and follow instructions carefully before you study and before you take the exam. 2. Develop and stick to a study schedule 3. Focus your studies on the topic areas, which you know are personal weaknesses. 4. Review complex topic areas such as Acid/Base Disorders. 5. When you study, dont just memorize facts to recall, but take the time to understand the reasoning. 6. Learn the generic name for medications. 7. If study time is limited, prioritize topic areas to review based on NCCPAs test matrix and list of diseases. The Cardiovascular system accounts for the highest percent of test questions, followed by the Pulmonary system, musculoskeletal and GI/Nutrition. The tasks that account for the highest number of test questions is Pharmaceutical Therapeutics, followed by Formulating The Most Likely Diagnosis. 8. Do not exit a block of questions unless you are sure you are done with the section. You wont be able to return to that section. 9. Get plenty of sleep, eat healthy and exercise in moderation a few days before the exam. 10. Use recommended preparation methods and resources. Dont dilute your time with additional resources. 11. Make a few note cards with lists such as pathonomonic signs, gold standard diagnostic studies for common disorders, classic S/S complexes and findings, triads. 12. Practice taking computerized exams, and review the explanations for answers. 13. Use study groups for Q&A sessions with areas of focus: Infectious diseases, Classic chest and musculoskeletal X-ray findings for common disorders. 14. Think positively! Orthopedic Pearls:
1. When empirically treating osteomylitis from age 4 into adulthood, S. Aureus should be the pathogen one considers first when deciding on antimicrobial treatment. 2.Sudden joint effusions which occur in middle age to elderly men with associated pain, erythema and warmth (especially in the great toe, knee and wrist) should have gout at the top of the differential diagnosis. 3. Children with sudden onset of monoarticular joint pain, fever, anorexia, and inability to bear weight on the affected limb should be considered to have a septic joint until proven otherwise. 4. Rheumatoid arthritis spares the DIP joints of the hands yet affects to PIP and MCP joints where it most often presents in the early development of the disease. 5. Tylenol or the lowest effective dose of an NSAID should be a first line treatment in the management of osteoarthritis along with exercise, diet and weight control. 6. Septic flexor tenosynovitis is a surgical emergency and irrigation and diebriedment should take precedent over antibiotic treatment. 7. Rotator Cuff tears are very common over the age of 50 and should be considered it the differential diagnosis of shoulder pain especially in patients with Diabetes and/or RA. 8. Most clavicle fractures can be treated conservatively, operative indications are limited to open fractures, polytrauma and gross displacement. 9. Colles fractures of the wrist, in all but the most in-firmed patient, are best treated with open reduction and internal fixation in adults. 10. Septic pre-patella bursitis can be separated from a septic intraarticular joint infection in that, with the former the patient will allow knee ROM but not in the latter. 11. Multiple Myeloma is uncommon in patients under 40, chiefly in males and twice as common in African-American males. 12. Sarcomas like to present in the proximal metaphysis of long bones, chiefly the femur, tibia and humerus. 13. Axial back pain with radiculopathy, saddle anesthesia, loss of bladder and/or bowel control is a sign of Cauda Equina syndrome and is a surgical emergency. 14. Elderly men with back pain, leg weakness and increased pain with lumbar spine extension should be evaluated for spinal stenosis. 15. Lateral epicondylitis, by definition, is not a tenosynovitis but a degeneration of the common extensor tendon attachment therefore making oral NSAIDs an ineffective treatment. . Derm Pearls Eczema Pearls 1. Atopic individuals: Sensitive to everythingenvironmentally & to chemicals, cosmetic products & skin care products 2. Infants develop patches on the extensor surfaces whereas children & adults are likely to have it on flexures (mc popliteal & antecubital fossa) 3. Keratosis pilaris, salute sign & allergic shiners common Seborrheic Dermatitis 1. Children past age one dont get dandruff until puberty (their sebaceous oil glands arent active yet). If their scalp is scaly & they have cervical lymphadenopathy its most likely Tinea capitis. 2. Treat for full 6 weeks at 25mg/kg of griseofulvin Pityriasis Rosea 1. Christmas tree distribution 2. Herald Patch 3. Always draw an RPR to rule out the great imitator, Syphilis Psoriasis 1. Symmetry of lesions 2. Silvery plaques 3. Besides skin, nails & joints are frequently affected 4. Sun exposure helps resolve lesions. Shingles: 1. Grouped vesicles on an erythematous base = herpes virus (HSV I/II,VZV) 2. 50% of cases are thoracic (T3-L2) 3. Must have had a history of chicken pox in order to get shingles Impetigo 1. Honey colored crusting 2. Mico: staph aureus 3. Treat with topical mupirocin and/or Cephalexin BCC & SCC 1. Any new site that is changing on a patient, esp. over age 35-40+, should be sent for pathology 2. Sun related skin cancers: a) BCC = pearly pink papule on sun exposed area or The acne bump that wont clear b) SCC = thick scaly nodule or plaque The wound/scab that wont heal Emergency Medicine Pearls 1. Anaphylaxis is treated with .3 to .5 ml of 1:1,000 epinephrine given IM. 2. Nerve entrapment may occur with Blow-Out fracture of the orbit and requires evaluation to detect. 3. A nasogastric tube should NOT be inserted in a patient with significant mid-face trauma. 4. Look for tip of the nose and forehead skin involvement in a patient suspected of having ocular herpes. 5. A urethral catheter should NOT be inserted in a trauma patient with blood at the urethral meatus. 6. First degree burns (superficial partial thickness) appear red, are painful and blanch with pressure, Second degree burns (deep partial thickness) will blister and third degree burns (full thickness) are pale or charred, painless and do NOT blanch with pressure. 7. Review Rule of Nines and Parkland Formula and be able to work a problem for each. 8. Heat stroke differs from other heat related illness in that it is associated with altered mental status. 9. No one is dead until they are warm and dead. (hypothermia) 10. Red next to yellow, kill a fellow: Red next to black, venom lack (coral snake identification for venomous snakes in the US). The other group of venomous snakes in the US are the pit vipers which can be identified by triangular head, elliptical pupils, and facial pit. 11. Always consider and rule-out Clenched Fist Injury or Fight Bite in those with Boxers fracture. (treat as a human bite) 12. Review the criteria for tetanus prone wounds and the chart for management . 13. Skunks, bats, raccoons and foxes are the usual vector animals involved in rabies in the US. 14. Toxidrome for Cholinergic = BAD SLUDGE (bradycardia, anxiety, delirium, salivation, lacrimation, urination, defecation, GI distress, emesis). 15. Toxidrome for Anticholinergic= Hot as a Hades, Red as a beet, Blind as a bat, Dry as a bone, Mad as a hatter, Electrocardiograms Pearls: 1. Utilize an organized approach to rate and rhythm analysis: a. Look in the rhythm strip (lead II) i. What is the ventricular rate ii. Is the rhythm regular (cardiac cycles are equal) iii. Is the P wave upright, look the same in each cardiac cycle; there is a p wave before each QRS; each consecutive PR interval measures between .12secs and .20 secs (3 small squares to 5 small squares); are the atrial rate and rhythm (P to P duration) regular? b. Look in the anterior or posterior chest leads i. Is the QRS duration normal? (</= .10 secs [2&1/2 small squares]) ii. If the QRS duration is normal, the pacemaker is located above the ventricles (Sinus or junctional rhythm). If the QRS is wide, the rhythm is ventricular in origin. 2. An irregularly irregular rhythm is highly suggestive of atrial fibrillation. 3. A wide QRS (.12 secs or >) in the anterior chest leads with an Rr (rabbit ears) appearance is consistent with a Right Bundle Branch Block. If the QRS is wide and the Rr pattern is in the posterior chest leads, you have a Left Bundle Branch Block. 4. Ventricular Tachycardia is defined as 3 or more consecutive PVCs, with a Ventricular rate of >100. V. Tachy is usually regular in rhythm and has peaks in the R and S waves. 5. All Types of AV Blocks will show a prolonged PR interval in the rhythm strip. If the PRI is prolonged and constant, you have either a 1 st degree AV Block or a 2 nd
degree Mobitz Type II AV Block, BUT there will be a dropped QRS with Mobitz Type II. 6. Mobitz Type I (Wenkebach) AV block also shows dropped QRS complexes, BUT the PRI increases with each consecutive cycle until the QRS drops. 7. Complete AV block will show a pattern of equal cardiac cycles as measured from QRS to QRS, as well as from Pwave to Pwave. The atria and ventricles are each pacing themselves, thus the QRS duration is usually wide. 8. U waves in most leads suggests HYPOkalemia; tall peaked T waves in most leads suggests HYPERkalemia 9. A STEMI will progress over time (unless there is an intervention) to form significant Q waves. 10. ST elevation or depression of at least 1 mm in the leads that look at the anatomical location of the ischemia/infarction, means that the infarction is in the acute phase. 11. Once significant Q waves form with a STEMI, they will not disappear. The ST-T wave changes usually return to normal. 12. A prolonged QT duration can be congenital or acquired. Many medications can cause a prolonged QT, particularly when combined, as will HYPOcalcemia. A prolonged QT is a harbinger of sudden death. 13. If the PR interval is short, consider WPW, LGL syndromes, which may result in a tachyarrhythmia; WPW has a delta wave. 14. S1, Q3, T3 especially if associated with ST-T strain in the anterior chest leads, and a new Right Bundle Branch Block is characteristic of a Pulmonary Embolus. Neurology Pearls 1. Stroke. The test that immediately differentiates ischemic versus hemorrhagic stroke is a non contrast CT scan of the head. 2. Antiplatelet therapy is the treatment for ischemic stroke; a statin is often added for cholesterol management. 3. Headache. A new and different headache requires workup. Look for papilledema on funduscopic exam, and check a head CT for pathology like hemorrhage, infection, or tumor. 4. Migraine treatment can be abortive (triptans, NSAIDs), or preventive (Beta blockers, Calcium channel blockers, Antiepileptics) 5. Epilepsy is a disorder of recurrent seizures without known structural or medical cause. 6. Older, first generation antiepileptic drugs require careful management due to narrow therapeutic range, drug interactions, and birth defects of the neural tube. 7. Newer, second generation antiepileptics are also useful for migraines, bipolar disorder, and peripheral neuropathy. 8. Basilar skull fracture presents with clinical hallmarks of raccoon eyes, mastoid bruising, and CSF rhinorrhea or otorrhea. 9. Multiple sclerosis is diagnosed by history of episodes of varying neurologic symptoms, with MRI showing "multiple sclerotic plaques," or CSF electropheresis showing oligoclonal bands. 10. If meningitis is suspected, start antibiotics first, then get LP within 30 minutes. If a focal neurologic deficit exists, start antibiotics, get a non contrast head CT, and then LP. 11. Delerium is acutely life threatening; find an underlying cause to treat. Dementia is insidious and chronic; find long term care and social support.
Antibiotic Therapy Pearls: 1. Trimethoprim-sulfamethoxazole, doxycycline, and clindamycin are all reasonable oral choices for a community-acquired MRSA soft tissue infection (purulent cellulitis). For non-purulent cellulitis, oral cephelaxin is probably the best choice. 2. For serious MRSA infections, IV vancomycin and daptomycin are the two most widely used antimicrobials. 3. Hypersensitivity reactions are most likely to occur with beta-lactam antibiotics (penicillins, cephalosporins, carbapenems) and sulfonamides. 4. Clostridium difficile can occur with ANY antimicrobial (including metronidazole) but it is most classically associated with clindamycin. 5. Doxycycline is the treatment of choice for a lot of strange infections (Vibrio, Rocky Mountain Spotted Fever, ehrlichia, leptospirosis, etc) 6. Echinocandin antifungals should not be used to treat cryptococcal infections (use fluconazole or amphotericin). 7. Nitrofurantoin should be used for only for uncomplicated UTI (cystitis), not for upper tract urinary infections or complicated urinary infections with or without bacteremia, or in patients with abnormal renal function (i.e. renal failure).
Approach to Choosing Antibiotics.
1. First-line antibiotic for outpatient community acquired pneumonia (CAP) is a macrolide or doxycycline, UNLESS the patient is elderly, has co-morbidities, or has been previously treated with antibiotics within the past 90 days, then use a respiratory flouroquinolone (levofloxacin). Treat for all (inpatient or outpatient) CAP for 5-7 days. 2. Inpatient treatment for CAP should include either: 3 rd generation cephalosporin (ceftriaxone or cefotaxime) PLUS either a macrolide (azithromycin) OR a respiratory fluoroquniolone (levofloxacin) 3. If aspiration is being considered, use clindamycin. 4. First-line treatment for an uncomplicated UTI is trimethroprim/sulfamethoxizole x 3 days. You can use fosfomycin (1 dose) or nitrofurantoin x 5 days if its cystitis in a young woman with normal renal function. Reserve fluoroquinolone (3 days) if cant use the above agents (allergy) or local resistance patterns >20%. Urine cultures are not always needed 5. For complicated UTI, use a fluoroquniolone x 10-14 days. Always send urine culture before treatment. Repeat urine cultures are not needed if symptoms resolve. 6. Pyelonephritis requires treatment with any one of the following: fluoroquniolone, 3 rd
generation cephalosporin or ampicillin/sulbactam. 7. Most common bacterial causes of acute sinusitis are S. pneumoniae, H. influenzae and Moraxella catarrhalis, but viruses are much more common causes of sinusitis. First- line antibiotic, if one is needed at all, is amoxicillin. Nasal saline irrigation and mucolytic/decongestants should always be used initially and during treatment. 8. Treatment of meningitis in adults and children > 2 yrs should include: high dose ceftriaxone or cefotaxime PLUS vancomycin PLUS dexamethasone BEFORE or with the FIRST dose of antibiotics. Add ampicillin for Listeria if age >50 or immunocompromised. 9. Antibiotics to AVOID during pregnancy include: tetracyclines, aminoglycosides, sulfa in the 3 rd trimester and flouroquinolones. Drugs classes which are generally considered safe are penicillins, cephalosporins and macrolides.
Cardiology Pearls I 1. Risk factors for atherosclerosis: tobacco use, LDL cholesterol >100, HDL <40, DM, HTN, sedentary lifestyle, male relative with CAD @ <55 yo, female <65 yo 2. Unstable angina vs. MI: UA = new onset chest pain/ at rest/worsening, NO enzyme elevation, EKG shows ST depression/T wave inversion; MI = severe prolonged chest pain, elevated CPK (total and MB)/troponin/LDH 1 , EKG shows ST depression/T wave inversion (NSTEMI) or ST elevation and later permanent Q waves (STEMI) 3. Most common sx of ACS is chest pain but 15-20% are painless (especially in DM) or may present only with severe fatigue (especially in women) or with dyspnea (CHF) 4. Localizing MI by EKG changes: inferior (RCA) = II, III, AVF; anteroseptal (LAD) = V1, V2; anteroapical (distal LAD) = V3, V4; anterolateral (CFX) = I, AVL, V5, V6; posterior (RCA) = V1, V2 tall R, no Q 5. ACS initial management = MONA (morphine, oxygen, nitrates, aspirin) and if within 6 hours of onset, do reperfusion thrombolysis Cardiovascular Pearls II 1. Systolic dysfunction means the LV is unable to pump: post MI, long term HTN, dilated cardiomyopathy, toxins; diastolic dysfunction means the LV cant fill: infilatrative diseases e.g. hemochromatosis, amyloidosis, LVH, pericardial ds. 2. Compensatory responses in systolic dysfunction include the Frank-Starling mechanism (dilatation), catecholamines (beat faster, stronger), and activation of rennin-angiotensin-aldosterone (increase preload) 3. To diagnose infective endocarditis, you must have blood cultures (echo alone is not diagnostic!) 4. Pericarditis: MCC is viral so antibiotics are not helpful. NSAIDS are used but steroids are overkill 5. To diagnose acute rheumatic fever, you must fulfill 2 major (Polyarthritis, carditis, subcutaneous nodules, erythema marginatum, chorea) or 1 major and 2 minor (fever, arthralgia, elevated ESR or CRP, previous ARF or rheumatic heart disease) of the Jones criteria plus evidence of Group A Strep infection 6. Most common sequelae of rheumatic heart disease is mitral stenosis, 2 nd
most common is aortic stenosis. 7. 5 Ps of acute arterial occlusion: Pain, Pallor, Pulseless, Paresthesia, Paralysis 8. Aortic aneurysm management: if <5 cm: watchful waiting with elective surgery when reach 5-6 cm
Renal, Fluids and Electrolytes, Acid-Base Pearls 1. Nephrotic syndrome ALWAYS has >3.5 g protein in a 24 hr urine collection and NEVER causes HTN or hematuria. Maltese cross and oval fat bodies on UA 2. Nephritic syndrome ALWAYS causes HTN, hematuria and RBC casts and MAY have some proteinuria (but <3.5 g) 3. Acute renal failure may be prerenal (poor perfusion, e.g. shock), intrarenal (intrinsic kidney disease- MCC acute tubular necrosis, e.g. aminoglycosides) or postrenal (obstruction, e.g. prostate disease) 4. MCC of CRF is DM, other causes are HTN, chronic GN, polycystic kidney disease, lupus 5. All renal failure has high BUN, creatinine potassium, phosphate, magnesium, and metabolic acidosis with increased anion gap. Chronic renal failure also has anemia and hypocalcemia. 6. ALL acidosis has pH <7.4; metabolic has low bicarbonate (compensation is low pCO2) and respiratory has high pCO2 (compensation, if present is high bicarbonate) 7. Anion gap = Na + - (Cl - + HCO3 - ); cause of increased AG metabolic acidosis are MUDPILES and normal AG metabolic acidosis are ANDRU. 8. ALL alkalosis has pH >7.4; metabolic has high bicarbonate (compensation is high pCO2) and respiratory has low pCO2 (compensation, if present is low bicarbonate). Endocrine Pearls 1. Best test to diagnose hyper or hypothyroidism is TSH 2. Goiter may be hyper, hypo, or euthyroidit just means enlarged thyroid 3. Cancer is LEAST common cause of thyroid nodules, MCC is toxic (hyperfunctioning) nodule 4. In 1 o hyperparthyroidsim, high PTH causes high calcium; but in 2 o
hyperparathyroidism, low calcium cause high PTH 5. In hypoparathyroidism, low PTH causes low calcium, in pseudo hypoparthyroidism, there is normal or high PTH but low calcium because of renal receptor problems 6. Cushing SYNDROME is adrenal or iatrogenic excess glucocorticoid; Cushing DISEASE is pituitary excess ACTH 7. In central (neurogenic) diabetes insipidus, there is inadequate ADH production; in nephrogenic, there is adequate ADH but renal receptors dont function Surgical Pearls 1. CT scanning is the radiograph of choice for an acute abdomen. 2. In the workup of a thyroid nodule, radioisotope scanning is not as valuable as once thought. 40% of all hot areas have cancerous tissue. 3. Direct inguinal hernia repairs have a high recurrence rate approaching 30%. 4. In the physical exam for hernias, direct hernias tap the side of your finger as an indirect hernia will tap the tip of your finger. 5. Hidradenitis Suppurativa is considered a severe form of acne. 6. The most common permanent complications of thyroidectomy are hypoparathyroidism and recurrent laryngeal nerve injury.
ID pearls
1. The most rapid test for the diagnosis of cryptococcal meningitis is the india ink test 2. The treatment of choice for the suppression of histoplasmosis is itraconazole 3. One cannot rule out pulmonary tuberculosis until the cultures are finalized as negative; the AFB smear from sputum is only positive just over half the time 4. HIV infection must be treated with at least two and preferably three active antiretroviral agents 5. The most important treatment modality for staphylococcus aureus furunculosis/skin abscess is incision and drainage
Pediatric Pearls 1. Vaccines are contraindicated at times of serious illness. They are not necessarily contraindicated because of fever or antibiotics. 2. Live vaccines in common use include MMR, varicella, and the mist form of influenza vaccine (LAIV.) These are contraindicated in pregnancy and immune deficiencies. 3. No vaccines are contraindicated during nursing, and no vaccines are contraindicated if there are pregnant contacts. 4. Initial antibiotic therapy for any serious neonatal infection is ampicillin + gentamicin; add acyclovir if herpes simplex is possible. 5. Refer strabismus early for treatment to prevent amblyopia. 6. The diagnosis of otitis media requires both a history of symptoms and an abnormal exam. 7. The diagnosis of streptococcal pharyngitis should be confirmed by rapid assay or culture. 8. Most diarrheal illness in children, including those caused by bacteria, should not be treated with antibiotics. 9. Normal puberty can start at 8 (girls) or 9 (boys). The first signs are breast budding and testicular enlargement. Isolated pubic hair growth is not a sign of true puberty. 10. Most angular deformities including toeing in, toeing out, knock knees, and bowlegs require no therapy. 11. The most common chronic itchy rash of childhood is eczema.
Lipid Management Pearls 1. The gold standard reference on treatment of high blood cholesterol levels in 2010 is: National Cholesterol Education Programs (NCEP) Adult Treatment Panel III (ATP III) guidelines and goals for treatment. 2. The most common cause of dyslipidemia in children is due to: Single of multiple gene mutations (Primary Dyslipidemia) 3. The major negative risk factor for dyslipidemia is: High HDL (> 60 mg/dL) 4. The LDL-C cholesterol goal for a patient at moderately high risk 2+ risk factors with 10-year risk of 10-20%) is: <130 mg/dL 5. The dyslipidemia medication with an absolute pregnancy contraindication (Category X) is: HMG CoA Reductace Inhibitors (Statins) 6. Fibrates are primarily used to treat what form of dylipidemia? Elevated Triglycerides (lower TGs 20-50%) 7. For a patient to be clinically identified as having metabolic syndrome, they must have any three of the following: Increased abdominal girth Elevated triglycerides Low HDL Elevated BP Elevated fasting glucose 8. If triglyercide levels are 200-499 mg/dL, the primary goal of therapy is to: Reach LDL goal 9. The most common side effect of Statins are: Myalgias/arthragias 10. When considering dyslipidemia treatment medications; which medication should be used with caution in patients with gout and/or hyperurecemia? Niacin (Nicotinic Acid) Psychiatry Pearls 1. The efficacy and potency of most antipsychotics correlate with their ability to act primarily as antagonists of the dopamine type 1 (D2) receptor. 2. The mortality rate among schizophrenic patients is higher than the rate for normal controls. 3. Bipolar disorders most often start with depression. 4. Major Depressive Disorder is the most common mood disorder with a lifetime prevalence of 25% in women and 12% in men. 5. The most consistent CT and MRI findings in depressive disorders is increased frequency of hyperintensities in subcortical regions especially the periventricular area, basal ganglia and thalamus. 6. Seizures associated with alcohol withdrawal are stereotyped, generalized and tonic- clonic in character and rarely progress to status epilepticus.
CXR Pearls 1. The Cardiac Silhouette will appear falsely enlarged if the pt fails to take an adequate inspiratory effort (should be able to count 10 posterior ribs), or if an AP/portable technique is used rather than a PA technique. 2. The Silhouette Sign is the inability to visualize a portion of an organs border as a result of a lesion with the same radiodensity contacting that border. It allows one to localize an abnormality to a specific lobe based upon which borders are obliterated. 3. The Cardiothoracic Ratio is helpful in determining enlargement of the cardiac silhouette and should be less than 50% for a normal sized heart. It is determined by dividing the sum of the distance from midline to end of right atrium plus midline to end of left ventricle by the intrathoracic distance. 4. The nearly symmetrical bilateral enlargement of the left and right cardiac borders is called the Waterbottle Sign and is indicative of a pericardial effusion. 5. Right Ventricular enlargement is best determined by encroachment of the retrosternal airspace on a lateral view. 6. A Batwing or Butterfly appearance refers to increased bilateral perihilar infiltrates associated with congestive heart failure. 7. Atelectasis, the collapse or loss of volume of a lung, lobe, or segment can be seen on a CXR as Displacement thru Shifts of fissures or other structures toward the collapsed area, or Compensatory Expansion of unaffected lobes. Consolidation is another sign of atelectasis. 8. A Pneumothorax is indicated by visualization of a line of pleura (edge of lung) that is separated by air from the chest wall and the absence of vessels distal to this line. An expiratory lateral decubitus film with the affected side up can enhance these findings. 9. When evaluating a pulmonary mass, signs of malignancy include: a. incd rate of growth b. size > 4cm c. absence of calcification d. chest wall involvement e. multiple lesions f. cavitation g. irregular shape 10. Emphysema is seen on the CXR as: a. Increased lung volume b. Flattened diaphragms c. Widened rib spaces d. Elongated heart (hanging heart) e. Attenuation of vessel size and number
OB-GYN Pearls
1. The classic triad of an ectopic pregnancy is delayed menses, vaginal bleeding, and lower abdominal pain. Serum levels of hCG normally double every 48-72 hours. In an ectopic pregnancy, the increases in this hormone level will be less than expected. 2. The most common cause of secondary amenorrhea is pregnancy. 3. A pelvic exam is ALWAYS contraindicated in a woman that is greater than 20wks gestation and complains of vaginal bleeding. A trans-abdominal ultrasound needs to be done to rule out placenta previa before any type of pelvic exam. Placenta previa causes PAINLESS, bright red vaginal bleeding typically during the third trimester of pregnancy. 4. Placental abruption is a cause of third trimester bleeding. It is characterized by PAINFUL vaginal bleeding and can be associated with "port wine colored" amniotic fluid. 5. The most common area for breast cancers to be found is the upper outer quadrant of the breast. 45% of breast cancers are found here. Fibroadenoma is the most common benign tumor of the female breast. It is most common in women less than 30 years of age. 6. The use of oral contraceptives has a protective effect on both the ovaries and the endometrium of the uterus. 7. The classic PCOS patient has hirsutism, truncal obesity, amenorrhea, and infertility. 8. Endometriosis is the most common cause of secondary dysmenorrhea. 9. Vaginosis: Bacterial vaginosis is associated with a grayish discharge that has a "fishy odor" and demonstrates clue cells on the wet mount. Trichomoniasis is associated with a yellow-green discharge, a "strawberry" cervix, and demonstrates motile flagellates on the wet mount. Vulvovaginal candidiasis is associated with a white, "cottage cheese" like discharge, erythema of the vulva and vagina, and demonstrates budding yeast cells and spores on the wet mount. Atrophic vaginitis is associated with a clear discharge and pale vaginal epithelium. It is caused by decrease estrogen and demonstrates increase numbers of leukocytes on the wet mount.
Hematology Pearls 1. A reticulocyte count is the best test to differentiate acute red cell loss from bone marrow production failure. 2. For Microcytic anemias remember the causes as TICS Thalassemias, Iron deficiency, Chronic inflammation and Sideroblastic which is commonly lead toxicity. 3. Vitamin B12 and Folate deficiency are the most common cause of macrocytic anemias 4. Ferritin is the best peripheral indicator of stored body iron levels. 5. Anemia with high reticulocytes, indirect bilirubin, and Lactic dehydrogenase (LDH) is most likely hemolysis. 6. Sickle cell disease is a family of hemoglobin mutations including types SS, SC, SD, SE, SOarab, S beta Thalassemia each with a different prognosis 7. Daily Hydroxyurea therapy reduces Sickle cell pain events, blood transfusions, and hospitalizations by half. It prolongs life and it is under used clinically. 8. Conditions that precipitate sickle crisis include dehydration, stress, hypoxia, temperature and pressure changes, infections and menses. 9. Bone marrow transplant is curative for Sickle cell disease. 10. The most common genetic bleeding disorder is von Wilibrand Disease. 11. The most common genetic cause of hypercoagulability is Leiden Factor V.
Urology Pearls 1. Difficulty voiding is most often a sign of BPH, not prostate cancer. 2. Erectile dysfunction can be an early sign of vascular disease. 3. PSA is specific for the prostate, not prostate cancer. 4. When hematuria is present, rule out: stones, infection, or tumors. 5. If fever is present think of upper tract sources, not simple bladder infections. ENT Pearls 1. Age related hearing loss (presbycusis) should present as bilateral, sensorineural hearing loss with gradual onset; not sudden. 2. Traumatic tympanic membrane perforations must be kept dry. 3. Classic presenting symptoms of Menieres disease include vertigo, sensorineural hearing loss, and tinnitus. 4. Treatment of posterior nosebleed with nasal packing requires prophylactic antibiotic therapy to prevent toxic shock syndrome. 5. Examination of patients with peritonsillar abscess reveals fullness in the peritonsillar space and uvular deviation to the unaffected side. Peritonsillar abscess requires incision and drainage. 6. Retropharygeal abscess require urgent treatment due to the possible complication of airway compromise. 7. The most common pathogen in Parotitis is Staphylococcus species. 8. Patients with Benign Paroxysmal Positional Vertigo will reveal clockwise rotary nystagmus, which is fatigable, when undergoing Dix-Hallpike positional testing. GI Pearls 1. Peptic ulcer disease - epigastric pain with variable relationship to meals a. Characterized by rhythmicity and periodicity b. May have no antecedent complaint c. Complications - coffee grounds emesis, melena, hematochezia
2. Malabsorption diseases - diarrhea, steatorrhea, weight loss, vitamin deficiency 3. Inflammatory bowel disease - a. Crohns colitis, full thickness, may occur mouth to anus, insidious onset, often in RLQ, can have fistulas b. Ulcerative colitis, limited to colon, bloody diarrhea, 4. Diverticulitis - acute abdominal pain and fever, LLQ tenderness and mass, leukocytosis 5. Colorectal Cancer - signs dependent on tumor location, often late findings, screening saves lives, fecal globin, change in bowel habit, iron deficient anemia check ferritin. 6. Diarrhea - check for c. difficile if associated with prior antibiotic use Acute - less than 2-3 weeks, generally self limiting Non-inflammatory - watery, non-bloody, peri-umbilical symptoms Inflammatory - fever, bloody diarrhea, less volume, lower abdominal symptoms Alarm symptoms - severe illness, abdominal pain, > 6 bloody stools daily, immuno-compromised, age > 70 Chronic - greater than 3 weeks Osmotic - stool volume decreases with fasting, increased osmotic gap Secretory - little change with fasting, normal osmotic gap Inflammatory - fevers, bleeding, abdominal pain Malabsorption - weight loss, high fecal fat Motility disorders - systemic diseases, intestinal surgery Chronic infections - parasites, AIDS, medication side effects Factitious diarrhea - laxative abuse, osmotic or secretory 7. Hepatitis - elevated transaminase, chronic is present for 6 months Viral A - self limiting, no chronic disease Viral B - exposure to blood or body fluids, acute and chronic, high incidence in asian population, pregnancy = high risk, newborn with vaccination and HBIG in first 12 hours. Risk of hepatocellular carcinoma in non cirrhotic patient, flares will occur with immune suppression, monitor transaminase and viral count Viral C - exposure to blood, up to 85% chronic disease, monitor transaminases, treatment ~50% effective Autoimmune - usual young to middle age women, positive Anti Nuclear Antibodies, Smooth muscle antibodies (actin) 8. Alcoholic liver disease - chronic alcohol use 80g/d for men (2 drinks daily), 30-40g/d for women (1 drink daily), transaminase increased, AST / ALT ratio usually >1, fat usually found in liver 9. Primary Biliary Cirrhosis - often in middle age women, alkaline phosphatase increase, positive Anti Mitochondrial Antibody, characteristic liver biopsy. 10. Hemochromatosis - elevated iron saturation, serum ferritin, family history, associated with arthralgia, cirrhosis, enlarged heart, hypogonadism
Pulmonary Pearls 1. Most cases of acute bronchitis in healthy adults are caused by viruses. Antibiotics not only are a waste of time and money, the inappropriate prescribing of antibiotics promotes bacterial resistance. 2. The most common bacterial causes of pneumonia are: Streptococcus pneumoniae, Moraxella catarrhalis, Hemophilus influenza, Mycoplasma pneumoniae, Chlamydophila pneumonia, and Legionella pneumophila. 3. Asthma is an inflammatory disorder. For all but mild. Intermittent asthma, chronic anti-inflammmatory therapy such as inhaled corticosteroids are recommended. 4. Each time a patient brings in his inhaler, you have an educational opportunity to teach the patient how to properly use his medication. 5. In asthma, the use of a long-acting beta-agonist bronchodilator alone without use of a long-term asthma control medication, such as an inhaled corticosteroid, is contraindicated. 6. In someone is not responding to intensive asthma care, consider alternate diagnoses such as CHF, laryngeal dysfunction, or gastroesophageal reflux. 7. Consider COPD in any patient with a smoking history of at 10 pack-years and/or a history of exposure to other risk factors, dyspnea, chronic cough with or without sputum production, onset of respiratory symptoms in the 40s, respiratory infection that persists or recurs 8. A successful tobacco cessation program will address the physical aspects of nicotine withdrawal, the psychological aspects of stress management, and the behavioral aspects of environmental triggers of the urge to smoke 9. Coccidiomycosis is in the Southwest USA, histoplasmosis centers around St. Louis, and blastomycosis centers in the upper Midwest. 10. The most common cause of lung cancer is adenocarcinoma.
Pearls for Eye:
1. The common stye or chalazion is NOT infectious. The process is granulomatous, and does not respond to antibiotics. 75% of chalazia will slowly disappear over 4-6 weeks with hands off! 2. Persistent or multiple styes might benefit from tetracycline therapy (primarily for its anti-inflammatory/anti-lipase activity). 3. The most important aspect to consider in an orbital inflammatory process (e.g., orbital cellulits) is _reduced eye movement_/pain on movement. Lid swelling and red eye do occur with orbital cellulitis, but are also seen in most surface disease (viral infections, allergic/toxic reactions, etc.) -- but the eye movements will be normal! Preseptal cellulitis rarely requires hospital admission (imaging is helpful). 4. Remember that the conjunctiva has an epibulbar and palpebral portion. When both are hyperemic/swollen, you are dealing with a surface disease. When the epibulbar conjunctiva is hyperemic, but the palpebral portion is normal (compare with other eye), you are dealing with a problem IN the eye (e.g., uveitis/scleritis). 5. When patients complain of an injury with subsequent foreign body sensation, the history is absolutely critical. Innocent or low velocity problems (e.g., something in eye when riding a bicycle) will invariably be on the ocular surface or under the eyelids. High velocity injuries (hammering, grinding, weed whackers, etc.) could penetrate the globe! 6. Recognizing a traumatic hyphema is critical. Sickle status may determine the need to surgically intervene. Urgent consultation along with a Sickle Dex ordered immediately (appropriate populations) is necessary. 7. A red eye and a history of contact lens wear signals DANGER, DANGER, DANGER. Look carefully for signs of corneal infiltration and hypopyon. The most common organism to infect the cornea in these patients is Pseudomonas. 8. Remember that use of corticosteroids topically in or near the eye may initiate a rise in intraocular pressure over 10-14 days of use. Along with the possibility of aggravating ocular infectious disease, these reasons are significant for primary care physicians to avoid routine prescription of these agents to their patients. 9. Flashing lights are a common visual complaint. They can come from the eye itself, or from visual pathways in the brain. Retinal flashes (photopsias) are most often due to retinal traction/tears/detachment and are peripheral "falling stars" most accentuated in the dark and with increased eye movement. CNS photopsias are usually homonymous (seen on one side of the midline) and are often zig-zag or jagged bolts of lights (may be associated with migraine/vascular phenomena).
Diabetes Pearls 1.) Type 2 diabetes is primarily associated with insulin resistance. 2.) Type 2 diabetes is not just hyperglycemia but often includes a host of concomitant conditions such as obesity, hypertension, and hyperlipidemia. 3.) ADA guidelines define lifestyle and metformin as step 1 therapy for patients with type 2 diabetes in the absence of contraindications. 4.) ADA guidelines define sulfonylureas and insulin as step 2 and 3 therapy with insulin preferred if substantial glucose lowering is required. Pioglitazone and GLP-1 agonists are considered step 2 therapies. 5.) Selection of agents for type 2 diabetes is based on efficacy, cost, and contraindications/precautions.
Hypertension Pearls
1.) Blood pressure goals should be < 140/90 or less than 130/80 in select populations (i.e., diabetes, CKD). 2.) Lifestyle modification is important for reducing blood pressure and improving the efficacy of blood pressure lowering agents. 3.) National guidelines suggest that thiazide diuretics are appropriate as an initial choice when no compelling indications exist for use of other agents. 4.) When compelling indications (i.e., heart failure, diabetes) exist, selection of agents other than a thiazide diuretic as an initial choice may be appropriate. 5.) Selection of antihypertensives are also based on potential for side effects, contraindications, and precautions.
HIV PEARLS 1. CDC recommends routine screening of all persons age 13 -64 years old for HIV infection, regardless of identified risk. 2. All pregnant women should be screened for HIV infection as a routine part of prenatal care. 3. Acute HIV should always be in the differential diagnosis whenever one is considering secondary syphilis, mononucleosis, or streptococcal pharyngitis. 4. Patients with acute HIV may have a negative antibody test for HIV but will have a high HIV viral load. 5. All HIV patients with CD4 counts less than 200 should receive prophylaxis against PCP pneumonia. 6. All HIV patients with CD4 counts less than 100 should receive prophylaxis against toxoplasmosis and mycobacterium. 7. Annual STD and TB screening is recommended for patients with HIV 8. HIV+ women should have a gynecological exam including cervical cancer screening at least once every year. 9. Antiretroviral therapy is recommended for patients with CD4 cell counts of 500 or below, as long as the patient is ready and willing to adhere to lifelong therapy. 10. Antiretroviral medications have multiple drug interactions. Always check interactions when adding or taking away any medication for a patient on HIV treatment.
Interpretation of Heart Sounds: 1. Correlate the cardiac anatomy and physiology with your cardiac history and cardiovascular exam findings to deduce a most likely diagnosis 2. Perform a thorough exam using correct techniques to avoid missing subtle findings. Listen directly on the chest wall, not through a gown or clothing. Dont press with the bell. 3. Focus on one instrument (S1, S2, systole, diastole) at a time instead of listening to the Symphony (all sounds in general). 4. S1 and S2 are valve closure sounds 5. The diaphragm picks up high pitched sounds best; the bell picks up low-pitched sounds best. 6. To identify S1 and S2, remember: a. Systole is the normally quiet period between S1 and S2, and is shorter in duration than diastole. b. S1 is quickly followed by the carotid pulse wave. c. S1 quickly follows the jugular venous pulse a wave (the highest wave as you look at the JVP in profile). d. S1 is loudest at the apex (PMI), while S2 is loudest at the base. 7. Most regurgitant murmurs are blowing in character 8. The murmur of Aortic Stenosis is heard best at the 2 nd Right ICS at the sternal border, and usually radiates to the right clavicle or right neck. 9. Most diastolic murmurs are serious! 10. S3 and S4 are low-pitched diastolic sounds. 11. A fixed-split S2 suggests an atrial septal defect. 12. A cooing systolic murmur heard best at the apex is consistent with mitral valve prolapsed 13. A systolic murmur heard best at the apex that radiates to the left axilla or scapula is consistent with Mitral Regurgitation.Right heart flow murmurs (due to flow in the right direction through an abnormal valve) become louder during inspiration, but quieter with right heart regurgitant murmurs. 14. A split S2 heard during expiration is always pathological. 15. An innocent murmur is usually found in children, has no associated abnormal symptoms or signs, is usually a grade II/VI or less, and usually disappears when the child sits or stands 16. The murmur of mitral valve prolapsed lengthens (begins earlier)in systole during the valsalva maneuver or while standing, and shortens ( begins later) in systole when the patient squats 17. A holosystolic murmur is caused by Mitral Regurgitation, Tricuspid Regurgitation, or a Ventricular Septal Defect.
Rheumatology Pearls 1. Fibromyalgia dx requires >3 months of widespread pain, and pain and tenderness in at least 11 tender points with normal labs and no joint inflammation 2. Meds approved for fibromyalgia are Duloxetine (Cymbalta), Pregabalin (Lyrica), Milnacipran (Savella) 3. Rheumatoid arthritis most commonly affects MCP and PIP joints (Boutonniere, Swan-neck deformities) and wrists (radial deviation + ulnar deviation of fingers = zigzag deformity) 4. In gout, ~90% of pts have hyperuricemia but UA level does not precipitate attack; acute changes gout and 10% of patients with symptoms have normal serum UA levels at time of attack and though ~5-8% of population has serum UA (>7 mg/dL), only 5-20% with UA develop gout 5. In SLE, >95% will have +FANA, but its NOT diagnostic; you need to meet 4 of 11 criteria (hematologic, neurologic, renal, or immunologic disorder; malar, discoid, or photosensitive rash; serositis, arthritis, oral ulcers, +ANA) 6. Sjogren syndrome dx requires dry eyes or mouth, + salivary gland biopsy and + anti-SSA or anti-SSB antibodies 7. Scleroderma (PSS) dx requires 1 major (thick, tight, indurated skin of fingers and skin proximal to MCP or MTP joints) OR 2 minor (sclerodactyly; digital pitting scars or loss of substance from the finger pad due to ischemia; bibasilar pulmonary fibrosis not attributable to1 o lung ds) 8. Polymyositis causes insidious onset of mostly painless PROXIMAL muscle weakness; dermatomyositis has that plus the purplish heliotrope rash on the face 9. Polymyalgia rheumatic causes proximal muscle pain with AM stiffness with a very high ESR in elderly ppl; may be related to giant cell (temporal) arteritis which can cause blindness so is treated with high-dose steroids which will lead to rapid resolution. 10. Mixed connective tissue ds. Looks like SLE + PSS + myositis but Ab assoc with those ds are normal. AntiU1-RNP Ab REQUIRED for diagnosis 11. Reactive arthritis classic triad = arthritis, urethritis, conjunctivitis 2-4 weeks after a GI (Salmonella, Shigella, Yersinia, and Campylobacter) or GU (Chlamydia) infection