Leik NP Exam Tips

Leik NP Exam Tips

Leik’s Exam Tips

Medication

1) Aspirin irreversibly suppresses platelet function for up to 7 days (due to irreversible

acetylation).

2) Discontinue ASA if patient complains of tinnitus (possible aspirin toxicity).

3) For chronic use, the recommended dose is 81 mg/day (some exceptions exist).

4) Aspirin given post-MI or after a stroke/TIA is considered tertiary prevention.

5) Avoid using in children with viral infections who are less than 16 years of age (Reye’s

syndrome).

1) Memorize the FDA category and dose of finasteride (Proscar 5 mg PO once a day).

2) Accutane is a potent teratogen. Reproductive-aged females must use 2 reliable forms of

birth control and must have a negative pregnancy test 1 month before, during, and 1 month

after Accutane.

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3) High-dose vitamin A is teratogenic in animal studies—avoid “mega-doses” of vitamins in

pregnancy.

4) Avoid mixing warfarin with sulfa drugs—can increase INR and bleeding risk.

HEENT

■Treatment for otitis externa is Cortisporin Otic drops.

■ Otitis externa’s common bacterial pathogen is Pseudomonas.

■ Ruptured spleen is a catastrophic event. Avoid contact sports (i.e., 4 weeks) until ultrasound

documents resolution.

■ Betimol (timolol) has the same contraindications as oral beta blockers.

■ Cholesteatoma, periorbital sinusitis complication.

■ Do not use amoxicillin if used in the past 3 months. Advance to second-line antibiotics such

as Augmentin or Ceftin.

■ Penicillin-allergic patients, use macrolides, sulfas (avoid cephalosporins, especially if had

Class I reaction or anaphylaxis from penicillins).

■ Learn to recognize a description of eye findings such as pinguecula, pterygium, chalazion.

■ Rinne test result of BC greater than AC with conductive hearing loss (i.e., cerumenosis,

AOM).

■ Weber test result is lateralization to the “bad” or affected ear with conductive hearing loss.

■ Weber or Rinne are testing the acoustic or CN 8.

■ Lateralization on the Weber exam is an abnormal finding.

■ Normal finding in Rinne test is air conduction that lasts longer than bone conduction (AC

greater than BC).

■ Remember what 20/40 vision means: patient can see at 20 feet what a person with normal

vision can see at 40 feet.

■ Carbamide peroxide (similar to hydrogen peroxide) is one of the most common OTC treatments

for cerumenosis.

Dermatology

Differentiate between contact dermatitis and atopic dermatitis. The best clue is the unilateral

location and the shape of the lesions in contact dermatitis.

■ Rashes that are very pruritic at night and located on the interdigital webs and/or penis are

scabies until proven otherwise. Treat entire family. Wash linens/clothes in hot water.

■ Preferred antibiotic is Augmentin for human, dog, and cat bites.

■ Do not confuse actinic keratosis (precursor to squamous cell cancer) with seborrheic keratoses

(benign).

■ Diagnose hidradenitis suppurativa, psoriasis, RMSF, meningococcemia, erythema migrans

(Lyme disease), contact dermatitis, rosacea.

■ Instead of silvery scales, may see “covered with fi ne scales” with psoriasis.

■ Psoralens (tar-derived topicals) used to treat psoriasis, antimetabolite (methotrexate).

■ How to treat mild and moderate acne. Mild acne is treated only with topicals.

■ Accutane in females: Use two forms of reliable birth control.

■ “Herald patch” or a “Christmas tree” pattern is found in pityriasis rosea.

■ PHN (post-herpetic neuralgia) prophylaxis: Tricyclic antidepressants (TCA), amitriptyline

(Elavil).

■ A clue in a case scenario on cellulitis may involve a patient walking barefoot.

■ Recognize erysipelas versus other types of cellulitis.

■ Treatment for rosacea is topical metronidazole gel.

■ Recognize herpetic whitlow.

Cardiac

There are usually 2 or 3 questions regarding murmurs on the exam.

■ Learn to use the mnemonics “MR. ASH” and “MS. ART.”

■ Memorize the locations of the mitral area as well as the aortic area.

■ Regarding mitral murmurs, the word mitral will not be used because it is an obvious clue.

■ All murmurs with “mitral” in their names are only described as located:

– on the apex of the heart or the apical area or

– on the 5th ICS on the left side of the sternum medial to the midclavicular line.

■ On the exam, only the systolic murmurs radiate (to the axilla in mitral regurgitation and to the

neck with aortic stenosis).

■ S3 is a sign for CHF; S4 is a sign of LVH.

■ A split S2 is best heard at the pulmonic area.

■ Memorize the mnemonic “Motivated Apple” to help you remember the names of the valves

that are responsible for producing S1 and S2.

■ Grading murmurs: First time thrill is palpated is at Grade IV.

■ If you forget on which side of the sternum the aortic or pulmonic area lies (left or right?):

– The “r” in aortic is for the “right side.”

– The “l” in pulmonic is for the “left side.”

■ Rule out AAA in an older male who has a pulsatile abdominal mass that is more than 3 cm in

width. The next step is to order an abdominal ultrasound and CT.

No EKG strips are included in the exam. Instead, the symptoms of the arrhythmia or its

appearance on the EKG strip will be described.

■ Atrial fibrillation and PAT are usually in the exams.

■ PAT and AF have many causes, such as alcohol intoxication, hyperthyroidism, stimulants

such as theophylline, decongestants, cocaine, and heart disease.

■ Learn the proper procedure to check for pulsus parodoxus.

Follow JNC 7 guidelines for both ANCC and AANPCP exams until JNC 8* is released.

■ Eye findings: Learn to distinguish the findings in hypertensive retinopathy (copper and silver

wire arterioles, AV nicking) from those in diabetic retinopathy (neovascularization, microaneurysms,

hard exudates, cotton wool spots).

■ Know how to treat isolated systolic HTN in the elderly.

■ To assess orthostatic hypotension, measure both the sitting AND standing BP.

■ Know the side effects of thiazide diuretics such as hyperglycemia, hyperuricemia,

hypertriglyceremia.

■ Spironolactone side effect of gynecomastia.

■ Memorize the numbers for a normal BP and for Stage I and II HTN.

■ ACE inhibitors: The drug of choice for diabetics, causes a dry cough (10%).

■ Careful when combining ACE inhibitors with potassium-sparing diuretics (i.e., triamterene,

spironolactone) because of increased risk for hyperkalemia.

■ Bilateral renal artery stenosis: ACE inhibitors will precipitate acute renal failure.

■ Alpha-blockers are not first-line drugs for HTN except if patient has preexisting BPH.

■ Women with HTN and osteopenia/osteoporosis should receive thiazides. Thiazides help bone

loss by slowing down calcium loss (from the bone) and stimulating osteoclasts.

A case of DVT will have a positive Homan’s sign (in the exam). In real-life practice, most

cases of DVT are asymptomatic.

■ Memorize INR of 2.0 to 3.0.

■ Learn how to manage elevated INR (see Table 7.1).

■ Memorize presentation of a patient with NYHA Class II heart disease.

Raynaud’s phenomenon: Think of the colors of the American flag as a reminder of this disorder.

■ Medicines for Raynaud’s phenomenon include calcium-channel blockers (nifedipine, amlodipine).

Advise all patients with hypertension (or prehypertension) to lower dietary salt intake.

■ Borderline cholesterol, high cholesterol, HDL, LDL goal for CHD or DM.

■ Low HDL (less than 40 mg/dL) is a risk factor of CHD even though total cholesterol, triglyceride,

and LDL are normal.

■ To lower triglycerides, advise patient to reduce intake of simple carbohydrates, junk foods,

and fried foods.

■ To increase HDL, increase aerobic-type exercises and take niacin.

■ Become familiar with dietary sources of magnesium, potassium, and calcium.

■ Niacin and fibrates are best at lowering triglycerides.

■ If patient has markedly high triglycerides (500 or higher), lower triglyceride first (niacin or

Tricor) before treating the high cholesterol and LDL levels. High triglycerides increase risk of

acute pancreatitis.

Pulmonary

First-line treatment for COPD (2011 guidelines) is an inhaled anticholinergic (Atrovent) AND/

OR a long-acting B2 agonist (salmeterol, formoterol).

■ Ipratropium (Atrovent) is an anticholinergic.

■ Salmeterol and formoterol are long-acting B2 agonists.

■ Do not use long-acting B2 agonists (salmeterol, formotorol) for rescue treatment.

■ The only drug class for rescue treatment is the short-acting B2 agonist (SABA), such as

albuterol and Xopenex.

■ The only treatment known to prolong life in COPD patients is supplemental oxygen therapy.

Recognize presentation of bacterial pneumonia versus atypical pneumonia.

■ The No. 1 bacterium in CAP is Streptococous pneumoniae (and No. 2 is Haemophilus

influenzae). Phlegm is rust-colored or blood-tinged.

■ The No. 1 bacterium in atypical pneumonia is Mycoplasma pneumoniae.

■ COPD: First-time treatment, start with Atrovent. Add salmeterol if poorly controlled.

■ COPD/smoker with pneumonia: More likely to have H. influenzae bacteria.

■ Know the drug classes of the meds used to treat acute bronchitis (such as antitussives, mucolytics,

and so on).

■ Presentation and treatment of pertussis (whooping cough).

■ Symptomatic treatment for acute bronchitis. Do not pick antibiotics as a treatment option for

acute bronchitis

A PPD result may be listed as 9.5 mm. If the patient falls under the 10-mm group, then it is

negative (by definition) unless the patient has the signs/symptoms and/or CXR findings suggestive

of TB.

■ Memorize the criteria for the 5-mm and 10-mm results.

■ Small children exposed to active TB have a high chance of coming down with the disease

Memorize factors needed to figure out PERF (use HAG mnemonic).

■ Do not confuse asthma “rescue” drugs with “long-term control or maintenance” drugs.

■ Remember that all asthmatics need a short-acting B2 agonist (i.e., albuterol).

■ Chronic use of high-dose inhaled steroids can cause osteoporosis, mild growth retardation in

children, glaucoma, cataracts, immune suppression, hypothalamic-pituitary-adrenal suppression,

and other effects.

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■ Recognize respiratory failure. Severe respiratory distress: tachypnea, disappearance of or

lack of wheezing, accessory muscle use, diaphoresis, and exhaustion.

■ First-line treatment for severe asthmatic exacerbation or respiratory distress is an adrenaline

injection.

Endocrine

If patient has elevated TSH (or very low TSH), next step is to order free T3 and T4 (free T4 is

low in hypothyroidism).

■ Starting dose of levothyroxine (Synthroid) is 25 mcg/day.

■ Check TSH every 6 to 8 weeks (do not order earlier than 6 weeks) to monitor treatment response.

■ Radioactive iodine treatment results in hypothyroidism for life. Supplemented with thyroid

hormone (i.e., Synthroid) for life.

■ PTU preferred for pregnant women.

■ Thyroid cancer risk factors (history of neck irradiation in childhood or a painless nodule larger

than 2.5 cm).

■ Chronic amenorrhea and hypermetabolism results in osteoporosis. Supplement: calcium with

vitamin D, weight-bearing exercises.

Do not use any oral antidiabetic drugs on type 1 diabetics.

■ Memorize the specific key findings of diabetes versus hypertension.

■ Moderate to severe heart disease or heart failure is a contraindication to glitizone drugs such

as Avandia or Actos because they cause water retention, which may precipitate CHF.

■ Mild type 2 diabetics do not need drug therapy if able to control blood glucose by diet and

exercise alone

Gastrointestinal 

Barrett’s esophagus is a precancer (esophageal cancer). Diagnosed by upper endoscopy

with biopsy.

■ Lifestyle factors to teach patient (no mints, avoid caffeine, etc.).

■ Cullen’s and Grey–Turner’s sign.

■ Acute pancreatitis classic pain (severe midepigastric radiates to midback).

■ Rovsing’s sign.

■ Acute appendicitis presentation.

■ Psoas and obturator signs positive for acute appendicitis.

■ How to perform psoas maneuver.

■ Distinguish whether question is about H. pylori negative ulcers or H. pylori positive ulcers.

■ Both treatment regimens have appeared on the exams before.

■ Barrett’s esophagus is a precursor for esophageal cancer.

■ Worrisome symptoms of esophageal cancer and PUD.

■ H. pylori serology IgG positive plus symptoms of PUD: Treat with antibiotics plus PPI.

■ Treatment as for acute diverticulitis.

■ IBS: Increase fiber intake.

■ There will be a serology question (as just shown). You will have to figure out what type of viral

hepatitis the patient has (A, B, or C). It is usually a patient with hepatitis B.

■ PCR tests are not antibody tests. They test for presence of viral RNA. A positive result means

that the virus is present.

■ Hepatitis C has highest risk of cirrhosis and liver cancer.

■ A lone elevation in the GGT is a sensitive indicator of possible alcoholism.

■ The alkaline phosphatase is normally elevated during the teen years.

■ A person must have hepatitis B to become infected with hepatitis D.

■ ALT more sensitive to liver damage than AST.

■ GERD and treatment.

Renal

■ Memorize definition of UTI (greater than 10,000 CFU/mL of one organism).

■ Recognize classic case of UTI and acute pyelonephritis.

■ Can use 3-day treatment for healthy women with uncomplicated UTIs.

■ WBC casts with proteinuria associated with pyelonephritis.

■ Become familiar with urinalysis results of UTIs.

■ Serum creatinine better measure of renal function compared with the BUN or BUN: creatinine

ratio. The eGFR is considered a good measure of renal function in primary care.

■ Right kidney sits lower than the left kidney because of displacement by the liver.

■ Large numbers of epithelial cells in the urine mean contamination.

■ Memorize the normal WBC count (10.5) and the neutrophil or segs (greater than 80%).

■ Neutrophils make up from 50% to 75% of all the WBCs in a sample.

■ If band forms (immature WBCs) are seen, it is indicative of a serious bacterial infection.

■ The serum creatinine and the GFR are preferred to BUN when checking renal function.

Neuro

Memorization tips on cranial nerves:

CN 1: You have one nose

CN 2: You have two eyes

CN 8: The number 8 stands for two ears sitting on top of each other

CN 11: The number reminds you of the shoulders shrugging together

■ Because cranial nerves are listed only by number on the test (not by name), the correct

chronological order is important. Memorize the mnemonic to guide you.

■ Herpes zoster infection (shingles) of CN 5 ophthalmic branch can result in corneal blindness.

■ Rash at tip of nose and the temple area: Rule out shingles infection of the trigeminal nerve.

■ Cranial nerves are listed by number only.

■ Write down on scratch paper with corresponding cranial nerve “numbers.”

■ Distinguish the drugs used for abortive treatment versus chronic prophylaxis.

■ Answer options may list the drug class instead of the generic name.

Recognize both Tinel’s and Phalen’s signs.

■ Learn classic presentation of CTS.

■ Headache treated with high-dosed oxygen is cluster headache.

■ Headache treated with high-dosed anticonvulsants is trigeminal neuralgia.

■ With the exception of muscle tension headaches, which are bilateral, all of the headaches

seen on the exam (and notes) are unilateral.

■ Muscle tension: Bandlike head pain; may last for days.

■ Migraine: Throbbing, nausea, photophobia, phonophobia.

■ Trigeminal neuralgia (tic douloureux): Pain on one side of face/cheek is precipitated by talking,

chewing, cold food, or cold air on affected area.

■ Temporal arteritis: Indurated temporal artery, pain behind eye/scalp.

■ Cluster: Only HA accompanied by tearing and nasal congestion; severe pain is behind one

eye/one side of head. Occurs several times a day. Spontaneously resolves. Seen more in

middle-aged males.

Hematological

■ The screening test for all anemias is the CBC (hemoglobin/hematocrit).

■ The diagnostic test for thalassemia and sickle cell anemia is the hemoglobin electrophoresis.

■ Learn to differentiate the lab results of thalassemia from iron-deficiency anemia.

■ If the ferritin level is low, the patient has iron-deficiency anemia.

■ If the ferritin level is normal to high, the patient has thalassemia minor/trait.

■ The ethnic background may not be “revealed” in a question about thalassemia.

■ Pernicious anemia (PA) results in:

– B12-deficiency anemia.

– Macrocytic/megaloblastic anemia.

– Neurologic symptoms.

■ A cheap screening test for sickle cell is the SickledexTM, but gold standard is hemoglobin

electrophoresis.

■ If the parietal antibody test (antiparietal antibody) and/or the intrinsic factor antibody test

(anti-intrinsic factor) are elevated, the patient has pernicious anemia.

Order both B12 and folate levels when evaluating MCV greater than 100 (even if no neurological

symptoms).

■ Pernicious anemia results in B12 deficiency.

■ Pernicious anemia is a macrocytic anemia.

■ Learn food groups for both folate and B12.

■ RBC size is described in many ways, such as:

– MCV less than 80: Microcytic and hypochromic RBCs, small and pale RBCs.

– MCV greater than 100: Macrocytes or macroovalocytes, larger than normal RBCs, or RBCs

with enlarged cytoplasms.

■ Ethnic background may not be mentioned in a thalassemia problem, or it may be a distractor.

■ Only B12-deficiency anemia has neurologic symptoms (tingling, numbness).

Ortho

■ To remember valgum, think of “gum stuck between the knees” (knock knees). Opposite is

varus or bowlegs.

■ Distinguish classic presentation differences between RA and OA. With RA, the joint stiffness

lasts longer. It involves multiple joints and has a symmetrical distribution. RA is accompanied

by systemic symptoms like fatigue, fever, normocytic anemia, etc.

■ Heberden’s and/or Bouchard’s nodes have appeared many times on the exam. Memorize the

location of each. The following may help:

– Heberden’s: The “-den” ending on the word is the letter “D” for DIP joint.

– By the process of elimination, Bouchard’s is on the PIP joint.

– Another way to distinguish them is by using the alphabet. The letter “B” comes before the

letter “H.” Therefore, Bouchard’s node comes before Heberden’s nodes.

■ Types of treatment methods used for DJD: Analgesics, NSAIDs (PO and topical), steroid

injection on inflamed joints (NO systemic/oral steroids), surgery (i.e., joint replacement).

■ Do not confuse OA treatment with treatment for RA.

■ Treatment for RA includes all DJD treatment methods plus systemic steroids, antimalarials

(Plaquenil), antimetabolites (methotrexate), biologics (Humira, Enbrel).

Uveitis: swelling of the uvea, the middle layer of the eye that supplies blood to the retina (refer

to ophthalmologist). Patient treated with high-dose steroids for several weeks.

■ Plaquenil is an antimalarial.

■ Methotrexate is a DMARD.

■ Presentation of RA, lab findings.

■ Baker’s cyst presentation.

■ Ankylosing spondilytis presentation.

■ Anterior uveitis is complication of RA, ankylosing spondylitis.

■ Presentation of cauda equina, refer to ED.

■ X-ray of knee does not show meniscal injury or any joint cartilage.

■ The gold standard test for assessing joint damage is the MRI.

Psych

■ Antipsychotics lead to an increased risk of obesity, type 2 diabetes, and hyperlipidemia,

metabolic syndrome, and hypothyroidism.

■ Learn how medication use should be monitored (see Table 15.2).

■ FDA Black Box Warnings of SSRIs and antipsychotics.

■ Diagnose bipolar disorder, depression, and anorexia.

■ MAOI and high-tyramine foods to avoid.

■ St. John’s wort is used for depression, menopausal symptoms, and others. Herb-drug interactions

of St. John’s wort are indinavir (protease inhibitor), cyclosporine, oral contraceptives,

SSRIs, TCAs, and others.

■ Kava-kava and/or valerian root are both used for anxiety and insomnia. Do not mix with benzodiazepines,

hypnotics, or any CNS depressants.

■ In general, there are now more questions on alternative treatments.

■ A question on the MMSE (or the MME) will describe an action (such as asking a patient to

spell “world” backwards). The exam will ask you to indicate the name of the tool that is being

used.

■ Know how to diagnose minor depression and major depression.

■ Psychotic symptoms include delusions and paranoia (disorganized speech and behavior).

Hallucinations are common (usually auditory) with loss of ego boundaries. Flat and restricted

affect with poor social skills. Executive function is very poor (ability to plan and organize day to-day

activities). Onset is usually around the second decade. Peak incidence is between 16

and 30 years of age.

Labs

■ Rule out organic causes. CBC, chemistry profile, TSH, folate and B12 levels, urinalysis.

Toxicology screen to rule out illicit drug use.

Treatment Plan

■ Refer to psychiatrist for evaluation and treatment. If psychotic, refer to the ED.

■ Psychotherapeutic drugs: Safety considerations.