NP610

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

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

Seborrheic keratosis--BENIGN, most common

*lesions range from small, barely elevated papules

*if become traumatized/irritated/bleeding/painful r/o SCC

Melanoma:
Asymmetry
Border irregularity
Color variegation
Diameter >6mm

Basal cell carcinoma of the skin:

Pearly-colored nodule, fine telangiectasis, depressed center, rolled elevated edge

Squamous cell CA:

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

Leukoplakia-PRECANCEROUS

*check mouth annually
*chronic white plaque/lesion
7X higher risk w/smokers & alcohol

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

Hearing--cholesteatoma

*cauliflower appearance, eats thru bone, r/t OE or OM, foul smell, may attach to TM, extremely difficult to cure

Hearing--classic triad for acoustic tumor

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

ASA, Lasix can cause tinnitis

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

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)

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

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

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

Macular degeneration--progressive, loss of central vision

*use Amsler grid for home monitoring
"dry" painless, progression of central vision loss, drusen bodies (lipofuscin deposits)

Macular degeneration--"wet"--choroidal neovascularization, loss of central vision

*submacular hemorrhage is common
*tx is photocoagulation

Papilledema--margin goes uphill then down into disc.

*usually bilateral, can affect all ages

*refer

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

Eye changes:
--choroid/retinal changes can be caused by laser surgery

--Histoplasmosis, CMV, toxoplasmosis & congenital measles can cause inflammation along nerves & damage to retina

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

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)

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

Meglitinides--Repaglinide (Prandin/Starlix)

--short-acting
--stimulates release of insulin from pancreas
--for T2DM only
--just before meals
--increases uric acid

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

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

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

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)

Amylin memetic--Symlin, injection only @ meal time

--for both T1DM & T2DM
-- increased hypoglycemia
--avoid using with orals
--can decrease insulin use by 50%

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

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)

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

Diabetes--renal complications

--annual UA & microalbumin screen
--Refer for GFR <70
--if stage II CKD check annual PTH (parathyroid hormone

HTN--black widow spider bites may cause severe HTN within 30-60" of bite

HTN--gout increases blood pressure

Systolic HTN-increased cardiac output, rigidity of aorta must be treated differently

--no BB, use a diuretic

Hypertensive effects on eyes:

--AV nicking
--hemorrhages
--optic disk edema
--arterial narrowing
--exudates
--papilledema (late, chronic)

HTN--lowering DBP below 60 increases risk of stroke & MI r/t reduce coronary & brain perfusion

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

S3 gallop, laterally displaced PMI, murmur
--has a cadence/roll, should be suspicious of heart failure
--increased flow problem
--use bell of stethoscope

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

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

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

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

Ulcerative colitis S&S:
--rectal bleeding
--up to 15 stools/day
--mucous, tenesmus
--nocturnal diarrhea
--fatigue, anorexia, weight loss

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

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

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