FNP Board Study Guide.pdf \u00b7 version 1.pdf - FNP REVIEW AANP Document created using Leik Hollier and Fitzgerald I do not own the copy rights to images

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Unformatted text preview: FNP REVIEW - AANP Document created using Leik, Hollier and Fitzgerald – I do not own the copy rights to images, etc. JULY 27, 2018 PREVENTION/HEALTH PROMOTION/IMMUNIZATION IMMUNIZATION PEARLS LEVEL OF PREVENTION PRIMARY o Goal: preventing the health problem, the most cost-effective form of healthcare o Example: immunizations, counseling about safety, injury and disease prevention SECONDARY o Goal: detecting disease in early, asymptomatic, or preclinical state to minimize its impact o Example: screening tests, such as BP check, mammography, colonoscopy, ASA in hx MI TERTIARY o Goal: minimizing negative disease induced outcomes o Example: in established disease, adjusting therapy to avoid further target organ damage. Potentially viewed as a failure of primary prevention, support groups IMMUNIZATION PRINCIPLES Community (herd immunity) o Immunize those who can be to protect those who cannot be immunized Active immunity o Resistance developed in response to an antigen (either infection or vaccine) Passive immunity o Immunity conferred by an antibody produced in another host (infant of mother or immune globulin Immunize unless sending to the hospital in an ambulance HX of Anaphylactic reaction Neomycin Streptomycin, polymyxin B, neomycin Baker’s yeast Gelatin, neomycin Gelatin Immunization to avoid IPV, MMR, varicella IPV, smallpox Number of packs-per-day (PPD) Multiplied by # of years smoked 5 A’S OF SMOKING CESSATION Hepatitis B Varicella zoster MMR Previously unvaccinated adults age 19-59 with diabetes should be vaccinated against Hepatitis B LIVE VACCINES o SMOKING - PACK YEAR HX 1. Ask about tobacco use 2. Advise to quit 3. Assess willingness to make a quit attempt 4. Assist in quit attempt 5. Arrange follow-up MMR Patients born before 1957 have likelihood of immunity due to natural infection Two doses 1 month apart for those never immunized o Varicella o Zostavax o Intranasal Flu Mist Avoid these with Pregnancy, immune suppression and with HIV (CD4 count < 200) – case by case situation Rotavirus o Avoid with SCID (severe combined immunodeficiency) HEPATITIS B Chronic Hep B can lead to hepatocellular carcinoma, cirrhosis and continued infectivity Childhood Hep B vaccines began in 1982 3 dose series 0, 1, 6 months If not vaccinated and exposed – HBIG and series If vaccinated and exposed – single dose vaccine PNEUMOCOCCAL IMMUNIZATION PCV13 associated with greater immunogenicity PPSV23 not licensed for children under 2 Indications: chronic lung disease, chronic cardiovascular disease, diabetes, chronic liver disease, chronic alcohol abuse, smokers, malignancy, chronic renal failure, asplenia, sickle cell, immunocompromised, HIV. PCV13 followed by PPSV23 one year later and then again at 65 o Exception: HIV (8 weeks later) If PPSV23 before age 65, repeat in 5 years PREVENTION/HEALTH PROMOTION/IMMUNIZATION TETANUS SMALLPOX Caused by variola virus Infective droplets – contagious during fever, but most contagious during rash o Contagious until last scab falls off Stopped vaccinating in 1972 Incubation period 7-17 days Prodromal stage – fever, malaise, headaches, body aches Rash starts on face > arms/legs > hands/feet o All lesions within same phase and spreads within 24 hours Vaccination within 3 days of exposure reduces severity Vaccinia – unique immunization method o 2-pronged needle dipped into vaccine and then pricks skin POLIOVIRUS Transmission is fecal-oral SENSITIVITY AND SPECIFICITY Sensitivity – ability of a test to detect a person who has disease (SEN rule in) Specificity – ability of a test to detect a person who is healthy (SPOUT – rule out) VARICELLA Live virus; 2 dose series starting > 1 year of age Although highly protective, mild cases of chicken pox have been associated with the disease Varicella antibody titers should be ordered on a healthcare worker who had chicken pox as a child Varicella Zoster Immune Globulin (VZIG) is made of pooled blood product with excellent safety rating (given if contraindications for vaccine) Pregnant women without immunity should be vaccinated with two doses after giving birth Varicella is transmitted via droplet Vaccination within 3-5 days of exposure has shown benefits to reduce disease STAGES OF CHANGE MODEL PRECONTEMPLATION o Not interested or minimalizes CONTEMPLATION o Considering change, looks at positive and negative, feels “stuck” PREPARATION o Exhibits some change behaviors, but does not have tools to proceed ACTION o Ready to go forward, takes concrete steps, but no consistency MAINTENANCE/RELAPSE o Learns to continue the change and embraced the healthy habit Infection caused by Clostridium tetani – found in soil lead to lockjaw If no previous immunity - give Tdap followed by Td in 1 and 6 months Need vaccine every 10 years with a single dose of Tdap in adulthood If dirty wound – BOOST if not TD in 5 years (Tdap and Immunoglobin if no previous vaccine) HEPATITIS A Peak infectivity occurs the 2-week period before the onset of jaundice or elevated liver enzymes Approximately 50% of cases have no specific risk factors identified When traveling to developing nations, avoid foods that are eaten raw Administer 4-6 weeks prior to traveling to an area where disease is endemic Treatment is supportive SHINGLES VACCINE Recommended for everyone except those contraindicated Infectious until lesions dry/crusted Zostavax o Live; One-time dose age 60 Shingrix o Non-live; 2 doses age 50 o Preferred vaccine PREVENTION/HEALTH PROMOTION/IMMUNIZATION US PREVENTATIVE SERVICES TASK FORCE Aspirin use to prevent cardiovascular disease and colorectal cancer o Age 50-59 with >10% ASCVD Breast Cancer o Mammography age 50-74 (every 2 years) o Risk factors (start age 40 or BRCA1/2) Previous hx of breast cancer >2 first-degree relatives Early menarche, late menopause, nulliparity obesity Cervical Cancer o Age 21 – screen every 3 years o Age 30 – screen with HPV every 5 years o Hysterectomy with removal of cervix – only need screening if hysterectomy due to cervical cancer o Stop screening at age 65 o Risk factors: Multiple sex partners Younger age at onset of sex Immunosuppression and smoker Colorectal Cancer o Start age 50-75 Colonoscopy every 10 years Flex sigmoidoscopy or CT colonography every 5 years FOBT (3 consecutive stool samples) annually New Cologuard o Risk Factors Familial polyposis First degree relative w/ colon CA Crohn’s (ulcerative colitis) Prostate Cancer o Benefits of PSA screening do not outweigh the disadvantages o Risk factors: Age > 50 African ancestry First degree relative Ovarian Cancer o Routine screening not recommended o BRCA1/BRCA2 mutations – refer to specialist Skin Cancer Counseling o Recommend for those with fair skin Abdominal Aortic Aneurysm o Men age 65-75 who have smoked o One-time ultrasound Lipid Disorders o Start low – moderate statin when all: Age 40-74 CVD risk factor ASCVD > 10% Lung Cancer o Smoke 30 pack-years or quit in last 15 years o Age 55-80 (annual screening with CT) OVARIAN CANCER No recommendation for routine screening In postmenopausal women with palpable ovary o Intravaginal ultrasound and CA-125 Strongest risk factor is BRCA1 or BRCA2 Other risk factors include age, obesity, Clomid use or endometriosis Prostate/testicular cancer screening not recommended CANCER PREVALENCE Skin cancer is most common cancer o Basal cell carcinoma o Melanoma highest mortality Men – prostate cancer Women – breast cancer Gynecological o Uterine/endometrial o Ovarian Children – acute lymphoblastic leukemia (ALL) MORTALITY Leading cause of death (all ages) o Heart disease o Cancer Men (lung, prostate, colorectal) Women (lung, breast, colorectal) o Chronic respiratory ADOLESCENTS Death rate for teen males is higher than females o Accidents (MVC most common) o Suicide o Homicide PHARMACOLOGY DRUG -DRUG INTERACTION FIRST-PASS EFFECT NARROW THERAPEUTIC INDEX DRUGS -table/ Drug is swallowed and absorbed into small intestine where it enters portal circulation o Once in liver the CYP450 is responsible for biotransformation Drugs with extensive first-pass metabolism cannot be taken orally. o Insulin CYP450 can be induced (increase drug metabolism) or inhibited (slow down drug metabolism) o Biotransformation also includes kidneys, GI tract and lungs Warfarin – monitor INR o Sulfa drugs elevate INR o Interacts with “G” herbs o Mayonnaise and green leafy Digoxin – dig level, EKG, electrolytes (K+, Mg+, Ca+, Creatinine) Theophylline – monitor blood levels Tegretol and Dilantin – monitor blood levels Levothyroxine – monitor TSH Lithium – monitor blood levels, TSH Substrates: drugs that are metabolized as substrates by the enzyme o CYP450 3A4 substrates: Sildenafil, Atorvastatin, simvastatin, venlafaxine, alprazolam o CYP450 ↓ by 30% after age 70 Inhibitors: drugs that prevent the enzyme from metabolizing the substrates (↑ drug concentration) o Macrolides (Clarithromycin, Erythromycin) – can lead to substrate induced toxicity (Ex: atorvastatin 20mg may be like 300mg) o Antifungals (ketoconazole, fluconazole) o Cisapride (propulsid – no longer in US) o Cimetidine (Tagamet) o Citalopram (Celexa) o Grapefruit (statins, erythromycin, calcium channel blocker, antivirals, amiodarone, benzodiazepines, Cisapride, carbamazepine, buspirone) Activators: drugs that increase the enzyme's ability to metabolize the substrates (↓ drug) o St John’s wort - antiretrovirals, contraceptives and cyclosporine; Also lead to Serotonin syndrome when combined with SSRI, SSNI SAFETY ISSUES NSAIDs Avoid in heart failure, GI bleeding, kidney disease o Inhibit prostaglandin synthesis – we need prostaglandins to keep things running smoothly o Long term use – document informed consent such as ↑ risk of MI, stroke, emboli, GI bleed, acute renal failure o Consider PPI, H2RA, Misoprostol PHARM FACTS Pharmacokinetics – absorption, distribution, metabolism, elimination of a drug Pharmacodynamics – biochemical and physiological effects of drugs on the body or disease (this does not change as a person ages) RANDOM FACTS Capsaicin cream can be used to treat pain in trigeminal neuralgia and post herpetic neuralgia ASA irreversibly suppresses platelet function for up to 7 days PPI - ↑ risk of fractures o Prilosec interacts with warfarin TZD – cause or exacerbate CHF Bisphosphonates – erosive esophagitis Statins – do not mix with grapefruit juice Clindamycin – high risk C. Diff Thiazide diuretics contraindication sulfa allergy o Chlorthalidone is longer acting and preferred over HCTZ Spironolactone can lead to gynecomastia DC ACEI/ARB if pregnant and are excreted in breast milk Alpha blockers are only first-line in makes with HTN and BPH ANTIBIOTIC THERAPY ANTIBIOTICS GRAM POSITIVE PRINCIPLES OF EMPIRIC ANTIMICROBIAL THERAPY Decision making process in which clinician chooses agent based on characteristics and site of infection What is/are the most common likely pathogen(s) causing this infection? What bug will this antibiotic kill? Likelihood of resistant pathogen? Danger if treatment failure? What is optimal safe dose? What duration is shortest but effective? TETRACYCLINE Gram -; Atypicals; MRSA Do not use in pregnancy or children < age 9 May cause permanent discoloration of teeth and skeletal defects if used in last half of pregnancy Treat for acne age 13-14 as all teeth have erupted o Do not use for mild comedones – start with OTC topicals such as salicylic acid and benzoyl peroxide o Try RX topicals benzamycin, Retin A and azelaic acid cream first for 2-3 months Photosensitivity Esophageal ulcerations (swallow with full glass of water) Take on empty stomach May decrease effectiveness of birth control pills Throw away expired pills – they degenerate and may cause nephropathy LINCOSAMIDE - CLINDAMYCIN Gram +, Aerobes, Anaerobes Associated with C. Diff Strep Staph Enterococcus RISK FOR ANTIBIOTIC RESISTANCE Age <2 or >65 Antibiotic use within the last month o 3 months for pneumonia Hospitalization within 5 days Comorbidities Immunocompromised GRAM NEGATIVE H. influenzae o Cephalosporin, Augmentin, macrolides, resp. fluoroquinolones, doxycycline Everything else MACROLIDES Atypical pathogens Associated with potential QT prolongation and ↑ risk of CV death Contraindicated in myasthenia gravis Drug-drug interactions (anticoagulants, digoxin, theophylline, select statins) Erythromycin GI side effects are common Macrolide allergic: doxycycline, quinolones CEPHALOSPORIN st 1 generation: Gram +; Beta-lactam; Cephalexin, Cefadroxil Group A Strep, S. aureus – not MRSA – Keflex (pregnancy UTI, cellulitis, impetigo) 2nd generation: Gram +/- Broad spectrum – Ceftin, Cefzil – otitis media, rhinosinusitis, CAP, chronic bronchitis 3rd generation: Gram – with weak Gram +; Betalactam; Cefixime Extended 3rd generation: Gram +/-; Beta-lactam; Rocephin, Cefdinir – gonorrhea, PID, pyelonephritis, otitis media Cross reactivity between PCN and cephalosporin usually occurs with 1st generation PENICILLIN Diarrhea, C. Diff, Vaginitis, StevensJohnson syndrome Avoid amoxicillin for patients with mono (generalized rash) Dicloxacillin – mastitis & impetigo Anaphylaxis and angioedema are type 1 IgE PCN allergic: macrolides AUGMENTIN Gram +/-, beta-lactamase. NO MRSA High-dose 3-4g/day amoxicillin needed for drug-resistant Strep pneumoniae (DRSP) Clavulanate as beta-lactamase inhibitor so amoxicillin can work on H. influenzae, M. catarrhalis FLUOROQUINOLONES Cipro: Gram -; atypical pathogens Levaquin: Gram +/-; Atypical, DRSP Achilles Tendon rupture (esp. with steroid use Contraindicated – less than 18, pregnancy, breast feeding, myasthenia gravis QT prolongation, hypoglycemia ANTIBIOTIC THERAPY/PHARMACOLOGY SULFONAMIDE Gram -; MRSA; NO STREP, NO E COLI Contraindications o G6PD anemia causes hemolysis o Newborns and infants < 2 months HIV patients are high risk for Stevens-Johnson MEDICATIONS THAT REQUIRE EYE EXAM Digoxin (yellow to green, blurred vision, halos if blood level too high) Ethambutol and linezolid (optic neuropathy) Corticosteroids (cataracts, glaucoma, optic neuritis) Fluoroquinolones (retinal detachment) Viagra, Cialis, Levitra (cataracts, blurred vision, ischemic optic neuropathy, others) Accutane (cataracts, decreased night vision) Topamax (acute angle-closure glaucoma, increased intracranial pressure, mydriasis) Plaquenil (neuropathy and permanent loss of vision) SOUTHEAST ASIAN CULTURE Vietnamese, Hmong, Filipinos Pt may have difficulty verbalizing questions about treatment May consult family about major health decisions Will not tell provider if not compliant Would never verbalize disagreement in loud voice – have high regard for physicians Imbalance of hot and cold (yin/yang) Male is head of house Alpha thalassemia is common in Asians, Filipino View surgery as last resort Infants and small children may wear amulet RANDOM HERB FACTS BETA-LACTAMS Penicillin – Penicillin, Amoxicillin, dicloxacillin, ampicillin and others Cephalosporin – ceph- or cef- prefix Carbapenem – imipenem usually given with cilastatin Monobactam – aztreonam High rate of allergic reactions NITROFURANTOIN Urinary pathogens Echinacea – immunological effects Black cohosh, roasted soy beans – acts similar to estrogen for some people Kava Kava - anxiety St John’s wort – depression o interacts with oral contraceptives, cyclosporine and select antiretrovirals Saw Palmetto – BPH Fish oil and ginseng can cause bleeding Milk thistle – lower cholesterol, liver problems and diabetes VITAMIN D DEFICIENCY METRONIDAZOLE (FLAGYL) Anaerobes FOOD FACTS Tetracycline and dairy interact Avoid MAOI and high tyramine containing foods (fermented foods) Eat salmon and omega-3 for heart disease; plant sterols and stanols reduce cholesterol Collard greens are high in vitamin K Magnesium - decreases BP and dilates blood vessels (nuts, beans, wheat, laxatives) Potassium – decreases BP – most fruits, leafy greens and nuts Non-dairy calcium includes: tofu, spinach and sardines Celiac Disease - Avoid gluten, wheat, rye, barley, oats. Gluten free foods: corn, rice, potato, quinoa, tapioca, soybeans Vitamin D inhibits abnormal cellular growth; encourages reabsorption and metabolism of calcium and phosphorus; reduces inflammation Skin exposure to sun produces greatest values Someone taking phenytoin needs 2-5x vitamin D Symptoms of vitamin d deficiency o Rickets, osteomalacia, antigravity muscle weakness 25-hydroxyvitamin D is lab measurement A child must drink 32 oz of milk daily to receive recommended 400 IU (infants) of daily vitamin D 600 IU for those age 1-70 including pregnant; 800 IU > 70 Darker skin tones synthesize less vitamin D Sunscreen increase risk of vitamin d deficiency Vitamin d deficiency is common in hepatic, renal and after gastric bypass. Vitamin D3 is preferred form o 50,000 IU per week x 8 weeks o 1000-2000 daily HEENT - EYES CATARACTS EYE EYE EXAM 1. Macula – responsible for central vision Optic Disc – shaped like saucer with indentation where cup goes (balance between intraocular and intracranial pressure) – should be sharp with cup to disc ratio < 0.5 Veins pulsate and are prominent Papilledema – optic disc swollen with blurred edges due to ↑ ICP; absent vein pulsations 2. 3. 4. Angle closure glaucoma -deeply cupped disc –b/c too much intraocular pressure (cup ratio > 0.5) Hypertensive Retinopathy o Copper and silver wire arterioles (hard) o AV nicking – artery crosses over vein (atherosclerosis in eye) o Flame hemorrhages Visual Acuity - with any eye complaint o OU (both) OD (right) OS (left) o Two-line difference between each eye o Can miss up to 2 letters on each line o 20/200 is considered legally blind o By age 6 child can see 20/20 Slit-lamp or binocular loupe - evaluation of anterior eye, including cornea, conjunctiva, sclera and iris o Penlight and do 180 Fluorescein staining Lid Eversion Near vision – ask patient to read small print Triad of ophthalmologic emergency o Red eye, painful eye, new-onset vision change Presbyopia – gradual, age-related loss of eyes’ ability to accommodate stiffening of the lens; unable focus actively on nearby objects; starts around age 40 Amsler grid test – early detection of macular degeneration Tonometry – measures IOP, glaucoma screening test If a protruding object is found – it should not be removed Diabetic Retinopathy o Microaneurysms o Cotton wool spools (nerve reels dying) o Flame hemorrhages Chronic steroids, trauma, aging, sunlight, tobacco Opacity of lens of eye which can be central or on the sides Difficulty with glare (with headlights when driving at night or sunlight), halos around lights, and blurred vision Absent red reflex Retinoblastoma – leukocoria – white reflex TERMINOLOGY Palpebral conjunctiva – mucosal lining inside eyelids Bulbar conjunctiva – mucosal lining covering eyes Hyperopia – farsighted – distance vision intact, but near vision is blurry Myopia – nearsighted – near vision is intact, but distance vision is blurry Xanthelasmas – yellow plaque on the inner canthus – 50% of people have elevated lipids Uveitis – occasionally dull painful red eye with vision changes, pupil is constricted, nonreactive and irregularly shaped. Tx with pupil dilation, corticosteroids, evaluate underlying cause (autoimmune) HEENT CHEILOSIS LYMPH NODES Cancerous nodes are non-tender Tender nodes indicate infection MOUTH Gums may be red and swollen due to gingivitis or taking Dilantin Salivary glands – parotid, submandibular and sublingual Painful skin fissures and maceration at corner of mouth o Over salivation, poorly fitting dentures, nutritional deficiencies, lupus, autoimmune disease, irritant dermatitis, squamous cell carcinoma o Remove underlying cause o If yeast – treat with azole ointment BID o If staph – treat with mupirocin ointment BID o When infection clear, use barrier cream at night Zinc Petroleum jelly ORAL CANCER Sialadenitis – swelling to side of face (mumps) Sialolithiasis – calculi or stone – painful lump under tongue - ↑ fluids, moist heat, NSAIDs, antibiotics if infected, surgery to remove stone Torus pala...
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