interview

Student Name: Kassandra Rie Mitsuru

APEA Exam:

Remediation – Knowledge Areas

Cardiovascular

1. Murmur (Assessment) - Cardiac murmurs possess distinct characteristics that are pivotal in their evaluation. These attributes encompass the intensity (grade), timing, configuration (time course), frequency (pitch), and location of the murmur. Systolic murmurs exhibit several variations. The midsystolic murmur (MSM) is commonly linked to benign flow murmurs, elevated flow rates across normal semilunar valves, and aortic valve sclerosis. Aortic valve stenosis generates an abnormal MSM that is often most pronounced at the right second intercostal space and radiates to the carotids. The presence of an MSM alongside a single S2 indicates severe aortic stenosis. Holosystolic murmurs arise from conditions like mitral regurgitation, tricuspid regurgitation, and certain ventricular septal defects. Early systolic murmurs, on the other hand, are associated with conditions such as acute severe or mild chronic mitral regurgitation, primary tricuspid regurgitation with normal right ventricular pressures, and specific ventricular septal defects. Late systolic murmurs are commonly linked to mitral valve prolapse and may be accompanied by a tricuspid valve prolapse murmur. Moreover, ischemic mitral regurgitation, often occurring due to infarction or ischemia, typically manifests as a late systolic murmur.

Diastolic murmurs are diverse as well. Early diastolic murmurs usually originate from aortic or pulmonic regurgitation. Mitral stenosis gives rise to middiastolic, late diastolic, or combined murmurs. Tricuspid stenosis, depending on the rhythm, leads to either late diastolic or middiastolic murmurs. Furthermore, continuous murmurs have distinct origins, emerging from conditions like patent ductus arteriosus, aortopulmonary window, certain shunts, arteriovenous fistulas, and coarctation of the aorta.

https://www.uptodate.com/contents/auscultation-of-cardiac-murmurs-in- adults?search=murmur&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H15 52124

2. Murmur (Planning) - The management of heart murmurs hinges on their underlying etiology and impact on the patient's health. While many heart murmurs are innocuous and necessitate no intervention, certain murmurs triggered by underlying heart issues or medical conditions may require treatment. Innocent heart murmurs, characterized by their non-adverse effects on patient health, typically do not warrant any treatment. These murmurs are considered physiological and are often detected during routine examinations. In such cases, close monitoring suffices without the need for therapeutic intervention. For heart murmurs arising from specific cardiac problems, a tailored treatment approach is paramount. The root cause of the murmur directs the treatment strategy. Heart murmurs resulting from septal defects might necessitate surgical intervention. Surgical repair or correction is often employed to address these anatomical issues effectively. When heart murmurs stem from valvular defects, a multifaceted approach is taken. Antibiotic prophylaxis is administered prior to certain surgical or dental procedures to prevent potential infections. In cases of severe valve damage, surgical procedures may be required to repair or replace the affected valves, restoring cardiac function.

Heart murmurs attributed to an underlying medical condition are managed by addressing the primary health issue. Effective treatment of the causative condition, such as anemia or hyperthyroidism, typically results in the resolution of the murmur. Once these conditions are successfully treated, the associated murmur often dissipates. The treatment pathway for heart murmurs is individualized, aligning with the specific circumstances of each patient. Factors such as the murmur's origin, its impact on cardiac function, and the overall health of the patient play pivotal roles in determining the appropriate course of action.

Milto, L. D., Frey, R. J., & Atkins, W. A. (2020). Heart murmurs. In J. L. Longe (Ed.), Gale encyclopedia of medicine (6th ed.). Gale. Credo Reference: https://go.openathens.net/redirector/westcoastuniversity.edu?url=https%3A%2F%2Fsearch.credoreference.co m%2Fcontent%2Fentry%2Fgalegm%2Fheart_murmurs%2F0%3FinstitutionId%3D8049

3. Peripheral Artery Disease (PAD) (Diagnosis) - Diagnosing Peripheral Artery Disease (PAD) requires a comprehensive approach considering risk factors, symptoms, and examination findings. Typically, a history of risk factors or PAD symptoms, combined with physical examination results, is sufficient to establish a diagnosis. However, for patients with unclear symptoms or equivocal pulse examination, the ankle-brachial index (ABI) test can diagnose arterial obstruction if it's ≤0.9. For patients showing apparent abnormalities in pulse examination, experiencing rest pain or tissue loss, the presence of PAD is strongly suggested, particularly when other vascular causes are ruled out. The identification of any bruit or pulse abnormality during examination significantly increases the likelihood of PAD. While the history, symptoms, and ABI test provide strong diagnostic hints, they might not be sensitive or specific enough to assess disease severity or pinpoint the obstruction site accurately. Depending on the clinical presentation, additional physiologic tests or vascular imaging might be needed. For patients with exertional leg symptoms, formal vascular laboratory testing is recommended, and exercise testing might aid in differentiating arterial claudication from non-arterial claudication. Patients with tissue loss require individualized testing. In most cases, formal vascular laboratory studies are recommended before intervention. Patients diagnosed with PAD through screening should undergo confirmatory testing for disease severity and level. An ABI ≤0.9 is highly accurate in detecting arterial stenosis ≥50% using arteriography. However, nonatherosclerotic diseases causing arterial occlusion should be differentiated. There is a correlation between symptoms and severity of PAD estimated from the ABI. In patients with unclear symptoms but suspected PAD, exercise testing can provide diagnostic data. Using standardized protocols and a treadmill, this aids in evaluating functional limitations and guiding treatment response. While vascular imaging is generally not required for diagnosing PAD, it's useful to differentiate from other causes if needed. Contrast arteriography is the gold standard for evaluating the affected limb and identifying suitable targets for intervention and post-intervention monitoring.

https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-lower-extremity-peripheral-artery- disease?search=Peripheral%20Artery%20Disease&source=search_result&selectedTitle=1~150&usage_type=def ault&display_rank=1#H20

Dermatology

1. Atopic Dermatitis (Pharm) - Atopic dermatitis a chronic skin disease that is more common in children however also affects adults. Clinical manifestations include skin dryness, scaling, erythema, oozing, crusting, and lichenification. Pruritis or itching is a hallmark symptom and is reason for burden. Management of atopic dermatitis involves assessment of disease history, extent and severity. Also, the provider will assess the impact on the patient’s quality of life and family burden. Then, the provider will educate the patient about skin care, the elimination of triggers and/or exacerbating factors, and the safe use of topical corticosteroids. The provider will instruct the patient to use emollients liberally, multiple times per day. For mild disease, a low-potency topical corticosteroid may be prescribed for use on affected areas once daily for 2-4 weeks. After 2-4 weeks, the provider will assess the skin to check for improvement. If improved, the patient will maintain treatment with emollients and intermittent use of topical corticosteroids. If no improvement, the patient will continue the low- potency topical corticosteroid or switch to a topical calcineurin inhibitor. At this time, the provider will assess for adherence to treatment and check for triggers. For moderate to severe disease, a medium to high potency topical corticosteroid may be prescribed for use on affected areas once or twice daily for 2-4 weeks. In addition, a low to medium potency topical corticosteroid or topical calcineurin inhibitor may be prescribed for use in areas at increased risk of skin atrophy.

https://pubmed.ncbi.nlm.nih.gov/24813302/

2. Bites, Insect (Evaluation) - Insect bites may be considered minor nuisances or may be lead to serious medical problems. Insect stings refer to venom injecting into the victim. There are different types of reactions to insect and arthopod bites. There are three categories of insect bites: piercing-sucking, chewing, and sponging. The most concerning form are the piercing-sucking mouthparts. Common arthropods that bite humans include: mosquitoes, ticks, kissing bugs, bed bugs, black flies, etc.

Local reactions are normal reactions in which there is an inflammatory reaction at the site of the punctured skin, accompanied by erythema and edema. Treatment for local reactions include washing site with soap and water, cooling with ice or a cold pack, application of topical creams/gels/lotions for itching, and oral antihistamines. Another type of reaction is papular urticaria. This refers to recurrent and/or chronic itchy papules on the skin. Treatment for papular urticaria includes nonsedating antihistamines, topical corticosteroids, and reassurance. Another type of reaction includes a systemic allergic reaction. Treatment includes epinephrine.

Insect and other arthropod bites - UpToDate

3. Cat Scratch Disease (Planning) - For patients with uncomplicated lymphadenitis as the sole manifestation of CSD, a single-drug therapy approach is recommended. This is typically achieved through a five-day course of azithromycin, an antibiotic that has shown promising results in reducing lymph node volume. Clinical studies have demonstrated that individuals treated with azithromycin had an 80 percent decrease in lymph node volume during a 30-day follow-up period, highlighting the potential benefits of antimicrobial intervention. In cases of more severe CSD infections, which may involve hepatosplenic disease, neurologic complications, or ocular manifestations, a combination therapy approach is suggested. This regimen often includes rifampin in addition to the primary antibiotic. Combining antibiotics can enhance their effectiveness and target different aspects of the infection, providing a comprehensive therapeutic strategy.

In certain scenarios, adjunctive therapies like corticosteroids and lymph node aspiration may be considered. These options are particularly relevant for managing neuroretinitis and refractory lymphadenitis, where conventional antibiotic therapy alone might not yield optimal results. The decision to include adjunctive treatments should be based on individual patient factors and the overall clinical picture. While many patients with lymphadenitis experience gradual symptom resolution without antibiotic intervention, the administration of antimicrobials is aimed at minimizing the risk of complications. The potential for dissemination and the statistical prevalence of this outcome underscore the importance of timely intervention.

https://www.uptodate.com/contents/treatment-of-cat-scratch- disease?search=Cat%20Scratch%20Disease&source=search_result&selectedTitle=2~84&usage_type=default&di splay_rank=2#H4276501801

4. Dermatophytosis (Diagnosis) - Cutaneous dermatophyte infections present a diagnostic challenge due to their overlapping clinical features with various other skin conditions. To ensure accurate identification and treatment, clinicians typically rely on a combination of physical examination and diagnostic tests. This examination enables the recognition of skin manifestations that are consistent or inconsistent with the suspected infection type, such as tinea pedis, tinea corporis, and tinea cruris. Given the potential coexistence of multiple dermatophyte infections (e.g., tinea pedis and tinea cruris), a comprehensive skin assessment involving the skin, hair, and nails can reveal additional sites of infection, enhancing diagnostic accuracy. The confirmation of dermatophyte infections hinges on appropriate diagnostic tests tailored to the type of infection under consideration. For infections affecting the epidermis, such as tinea pedis, tinea corporis, and tinea cruris, a potassium hydroxide (KOH) preparation is the primary diagnostic method. Detection of segmented hyphae in a KOH preparation is a hallmark of dermatophyte infection. It is crucial to distinguish this from other findings, like Candida infection, where budding yeasts and pseudohyphae are observed, or tinea versicolor, characterized by short hyphae and yeast cells. Polymerase chain reaction (PCR) tests are progressively playing a role in dermatophyte infection diagnosis.