1 Flashcards
Loss of elastic recoil is characteristic of what kind of COPD
emphysema
increased airway resistance is characteristic of bronchitis
what is the most common sx of emphysema
dyspnea seen with hyperinflation barrel chest increase in AP diameter V/Q matched defects
sxs of chronic bronchitis
productive cough wheezing rales rhonci peripheral edema cyanosis
increased CO2 is characteristic of chronic bronchitis or emphysema
chornic bronchitis
anything over this temp celicius is technically a fever
38
what is the presentation of PUD
dyspepsia that is worse at night
GIB
(MCC of upper GIB)
duodenal ulcers are better or worse with meals
better
MC type of Peptic ulcers
dueodenal (4x)
more common in younger pts
diagnostic test for PUD
endoscopy
what is gastritis
superficial inflammation / irritation of stomach mucosa with mucosal injury
CC of gastritis
. H. pylori MCC
NSAID / ASA / Alcohol 2nd MCC
less common Autoimmune / Pernicious anemia
MC presentation of gastritis
epigastric pain
MC virsu associated with gastroenteritis in adults
what is the most common virus in children
adults –>NORO
children–>ROTA
questions would want to ask if you suspect gastroenteritis
recent travel (e.coli)
recent anbx (C. Diff)
sxs of invasive gastroenteritis
increased fever
blood and fecal leukocytes
large bowel involvement
mimics acute appendicitis
initially watery
sxs of shigella
lower abd pain explosive watery diarrhea mucoid blood febrile seizures
nonivasive gastroenteritis szs
vomiting
increase i voluminous stool
small bowel involvement
copious watery diarrhea “rice water”
grey, no fecal door/blood/pus
severe dehydration
Canned home foods is a RF for this gastroenteririts pathogen
C perfringens
pork and poultry are RF for these gastroenteririts pathogen
Salmonella
shellfish and gastroenteritis think this pathgen
V. Cholerae
picnic and egg salad think this gastroenteritis RF
S. auereus
DO NOT GIVE ANTIDIARRHEAL WITH this type of gastroenteririts
invasive (fever, blood, leukocytes large bowel involvement)
antiemetics that can be used for gastroenteririts include
5HT3 inihibitors
dopamine blockers like reglan (if not heart conditions)
anbx TX for shigella
Trimethoprim-sulfamethoxazole (Bactrim) 1st line if severe
anbx tx for vibrio
tetracyclines, FQ
C. diff tx
metro or vanco
Salmonella tx
FQ
constipation questions to ask
new onset after 50
opiate use
DM
hypothyroid
MS
Labs for constipation
CBC, CMP, TSH
Tx for constipation
bulk forming laxitices (metamucil)
increase fiber 20g
stool softner like sENNA
ROME criteria for constipation
less than 3 BM/ week
with straining
hard or lumpy
sensation of incomplete evacuation
acute pancreatitis causes
gallstones (40%)
ETOH (35%)
sxs of acute pancreatitis
epigastric boring pain that radiates to the back
PE of acute pancreatitis
tachy
necrotizing hemorrhagic
Cullen’s (periubilical ecchy)
Grey turner( flank ecchymosis)
Labs if you suspect acute pancreatitis
increase tg Increase lipase (more specific than amylase)
greater than 3x ULN of amylase
increase ALT: 3x suggest gallstone
dx test of choice for acute pancreatitis
abd CT
can rule out gallstones with abd U/S
Tx for acute pancreatitis
supportive
NPO]
IV
Ranson’s at admission
at admission
glucose >200 age>55 ldh>350 ast>250 wbc>16k
ranson’s w/in 48 hrs
calcium <8 hct>10% fall pO2<60 mmHG BUN>1.8 HCO3<20 fluid sequestration> 6L
chronic pancreatits
ETOH 70%
idipathic 15%
triad of chronic pancreatitis
calcifications on plain ab =d xray
steatorrhea
DM
UC differs from crohn’s b/c
limited to colon
begin in rectum always and contiguous spread
mucosa and submucosa
UC sxs
LLQ colicky MC
bloody diarrhea hallmark
hematochezia
crohn’s dz differs from UC b/c
can be any segment of GI
MC terminal
transmural
crohn’s sxs
RLQ pain
apthous ulcers
Chron’s complications
B12 deficiency
fistual
perianal dz
skipped lesions and cobbles-atoning on colonscopy is associated with
chron’s
string sign
barium enema of chron’s
TX for IBD
5-ASA (oral mesalamine)
sulfasalazine (UC)
prednisone
immune modifying
anti tnf
MC sx of diverticulitis
GIB and LLQ pain
labs and diagnostics with diverticulitis
CT scan fat stranding and increased WBC
guiac +
diverticulosis tx
high fiber
diverticulitis tx
clear liquid diet abx (cipro or bactrim +falgyl)
MCC of small bowel obstructions
post surgical adhesions
HX of small bowel obstructions
Cramping abd pain
▪ Abd distention
▪ Vomiting
▪ Obstipation (no stool/passing gas)
early small bowel obstruction expect
▪ hyperactive bowel
▪ high pitched tinkles
▪ visible peristalsis
ABD XRAY in small bowel obstruction expect
Abd XR: air fluid levels in step ladder pattern, dilated bowel loops
initial tx of SBO
- aggressive fluid resuscitation (very dehydrated)
- electrolyte repletion
- NG tube (evacuate air & fluid)
Four Cardinal signs of strangulated bowel:
1) fever
2) tachycardia
3) leukocytosis
4) localized abd tenderness
Hep A symptoms
hepatomegaly
jaundice
RUQ pain
HepA contagious until
1 week after jaundice
HepA test
IgM anti HaV positive
Gallstones in gallbladder, no inflammation
Cholelithiasis
Cholelithiasis sxs
Biliary “colic” episodes
▪ abrupt RUQ/epigastric pain, nausea
▪ 30min to 1hr
▪ precipitated by fatty/large meals
Cholelithiasis tx
Asymptomatic = observation
Symptomatic = elective cholecystectomy
GB cystic duct obstruction by gallstone → inflammation / infection
Acute cholecystitis
cholecystitis MC pathogens
E. coli MC
Klebsiella
Enterococci
SXS and physical of cholecystitis
RUQ/epigastric pain
▪ precipitated by fatty/large meals
Physical exam:
▪ fever
▪ enlarged, palpable gallbladder
(+) Murphy’s: inspiratory arrest
(+) referred pain R-shoulder/scapular d/t phrenic nerve irritation
eferred pain R-shoulder/scapular d/t phrenic nerve irritation
seen in cholecytitis is known as
Boas sign:
dx tests of cholecystitis
Initial test → US
Gold standard → HIDA scan
↑ WBCs with left shift
cholecystitis TX
NPO, IVF, Abx (Ceftriaxone + Flagyl) → laparoscopic cholecystectomy for acute (within 72h) and chronic
stone obstruct cystic duct)
stone obstruct cystic duct)
stone obstruct cystic duct)
choledocholithiasis
stone causing biliary tract infection)
stone causing biliary tract infection)
Transient relaxation / incompetency of Lower esophageal sphincter
associated with what sxs
GERD
Heartburn (pyrosis) hallmark
Worse with supine (flat) position
regurgitation
dysphagia
RF for GERD
Weight gain
Fatty food
Caffeinated or carbonated drinks
Alcohol, tobacco, drug use
Lifestyle modifications
elevate head of bed 15cm (6 inch)
- avoid eating 2-3hr before bed - avoid strong stimulants (coffee, alcohol, smoking) - avoid fatty food, chocolate - weight loss
tx for GERD outside of lifestyle modifications
▪ H2RA (-tidine) then upper endoscopy
stage 3 use prazole PPI
drugs that lower LES pressure and can casue GERD (6)
Anticholinergic ▪ Antihistamine ▪ TCA ▪ CCB ▪ Progesterone ▪ Nitrates
TX for IBS
smoking cessation, low
fat/unprocessed food
▪ Exercise, antibiotics, antispasmodics, peppermint oil, and probiotics appear to improve symptoms
ESOPHAGITIS causes
- MCC GERD (Reflux)
▪ mechanical or functional abnl of LES - Eosinophilic / atopic dz → esophagitis
- Pill induced esophagitis
▪ bisphosphonates
▪ NSAIDs - Infectious cause in immunocompromised
▪ Candida
▪ CMV
▪ HSV
esophagitis common sx
odynophagia -hallmark of infx
dysphagia
retrosternal CP
dx test for esophagitis
upper endoscopy
Achalasia
Loss of Auerbach’s plexus →
increased LES pressure
leads to lack of persitalsis
dx test for achlasia
Double contrast barium swallow →
“Bird’s beak” appearance of LES
esphageal manometry
tx for achlasia
botox injection
nitrates
CCB
LES
test for suspected rotator cuff injury
▪ Hawkins: elbow/shoulder flexed with internal rotation
▪ Neer: pronated arm, pain with forward flex
▪ Jobes: pain with “empty can”
questions for differentiating arthritis
when is it worse?
morning–> rheumatoid
later in the day–> osteo
what is classically spared in rheumatoid arthtritis
DIP
prodrome of constitutional sxs are classically seen in this form of arthritis
what are they
rheumatoid arthritis has prodrome
fever
fatigue
wt loss
anorexia
what dx test do you need to confirm RA
ccp antibodies
can also look at rheumatoid factor
XRAY
osteoarthritis dx tests
xray
tx of osteoarhtritis
NSAIDS
elderly with bleeding risk –> actetome
what is reactive arthritis
autoimmune response 1-4 s/p chlamydia
seen with conjunctivits or urethritis
sinusitis -what is it
symptomatic inflammation of ≥1 paranasal sinuses of <4 weeks’ duration resulting from impaired drainage and retained secretions accompanied by obstruction, facial pain/pressure/fullness, or both. Because rhinitis and sinusitis usually coexist, “rhinosinusitis” is the preferred term.
three important features of sinusitis
Inflammation and edema of the sinus mucosa
Obstruction of the sinus ostia
Impaired mucociliary clearance
most cases of sinusitis are due to
vast majority of cases
(rhinovirus; influenza A and B; parainfluenza virus; respiratory syncytial; adeno-, corona-, and enteroviruses)
bacterial sinusitis can be differentiated from viral how?
More likely if symptoms worsen within 5 to 6 days after initial improvement
No improvement within 10 days of symptom onset
> 3 to 4 days of fever >102°F and facial pain and purulent nasal discharge
hx of sinusitis
Worsening of symptoms >5 to 6 days after initial improvement
Persistent symptoms for ≥10 days
Persistent purulent nasal discharge
Unilateral upper tooth or facial pain
Unilateral maxillary sinus tenderness
Fever
associated sxs of sinusitis
Headache
Nasal congestion
Retro-orbital pain
Otalgia
Hyposomia
Halitosis
Chronic cough
sxs with sinusitis requiring immediate attention
Visual disturbances, especially diplopia
Periorbital swelling or erythema
Altered mental status
PE of sinusitis
Fever
Edema and erythema of nasal mucosa
Purulent discharge
Tenderness to palpation over sinus(es)
Pain localized to sinuses when bending forward
Transillumination of the sinuses may confirm fluid in sinuses (helpful if asymmetric; not helpful if symmetric exam).
tx for sinusitis
Pseudoephedrine HCl
Phenylephrine nasal spray (limited use)
Oxymetazoline nasal spray (e.g., Afrin) (not to be used >3 days)
when would you suspect strep throat
pharyngitis sxs with high fever
viruses associated with pharyngitis
Rhinovirus
Adenovirus (associated with conjunctivitis)
Parainfluenza virus
Coxsackievirus (hand-foot-mouth disease)
Coronavirus
sxs associated with pharyngitis
Sore throat
Difficulty swallowing (dysphagia) or pain on swallowing (odynophagia)
Cough (uncommon in GAS pharyngitis)
Hoarseness; “hot potato” voice
Fever
Anorexia
Chills
Malaise; fatigue
Headache
Dysuria and arthralgias (suggest gonococcal etiology)
Sick contacts with similar symptoms or confirmed diagnosis
PE of pharyngitis
Enlarged tonsils with or without exudate
Pharyngeal erythema
Unilateral tonsillar swelling (“frog’s belly”) or uvular deviation (concern for peritonsillar abscess)
Trismus; stridor; drooling (concern for peritonsillar or retropharyngeal abscess)
Cervical adenopathy (anterior suggestive of GAS, posterior most commonly associated with infectious mononucleosis)
Fever (higher in bacterial infections)
Pharyngeal ulcers (CMV, HIV, Crohn, other autoimmune vasculitides)
Scarlet fever rash: Punctate erythematous macules with reddened flexor creases and circumoral pallor suggests streptococcal pharyngitis.
Tonsillar/soft palate petechiae and hepatosplenomegaly suggest infectious mononucleosis (EBV/CMV).
Gray oral pseudomembrane suggests diphtheria and occasionally infectious mononucleosis (EBV/CMV).
Characteristic erythematous-based clear vesicles suggest HSV or coxsackie A virus infection (herpangina).
Conjunctivitis suggests adenovirus.
ddx of pharyngitis
Viral syndrome
Streptococcal infection
Allergic rhinitis/postnasal drip
GERD
Malignancy (lymphoma or squamous cell carcinoma)
Irritants/chemicals (detergent/caustic ingestion)
Atypical bacterial (e.g., gonococcal, chlamydial, syphilis, pertussis, diphtheria)
Oral candidiasis (patients typically complain mostly of dysphagia)
Epiglottitis (associated with stridor, drooling, and progressive respiratory distress)
how to decide whether or not to test for stre
+1 point: tonsillar exudates
+1 point: tender anterior chain cervical adenopathy
+1 point: absence of cough
+1 point: fever by history
+1 point: age <15 years
0 point: age 15 to 45 years
−1 point: age >45 years+1 point: tonsillar exudates
+1 point: tender anterior chain cervical adenopathy
+1 point: absence of cough
+1 point: fever by history
+1 point: age <15 years
0 point: age 15 to 45 years
−1 point: age >45 years
once you have your
If 4 points, positive predictive value of ~80%; treat empirically.
If 2 to 3 points, positive predictive value of ~50%, rapid strep antigen; treat if GAS-positive.
If 0 or 1 point, positive predictive value <20%; do not test; treat empirically with follow-up as needed.
viral pharyngitis sxs that would not warrant testing for GAS
cough, rhinorrhea, hoarseness, oral ulcers, diarrhea, conjunctivitis, rash) (1)[A]
tx for viral pharyngitis
Salt water gargles
Viscous lidocaine (2%) 5 to 10 mL PO q4h swish/spit
Acetaminophen 10 to 15 mg/kg/dose q4h PRN pain or fever (pediatric). In adults, do not exceed >3 g/day.
NSAIDs for pain or fever (more effective than acetaminophen for GAS pharyngitis)
Anesthetic lozenges
Cool-mist humidifier
Hydration (PO or IV)
anbx for GAS
Antibiotics (particularly penicillin) are chosen primarily to prevent complications.
60–70% primary care visits by children with pharyngitis result in antibiotic prescriptions (4). Empiric therapy results in antibiotic overuse.
Treatment duration generally 10 days (1)[A]
Antibiotics do not reduce risk of poststreptococcal glomerulonephritis.
Antibiotics shorten duration of symptoms by approximately 16 hours (5).
Antibiotics may prevent pharyngitis/fever by day 3 (NNT 4 if GAS-positive, 6.5 if GAS-negative, 14.4 if untested) (5)[A].
GAS COURSE
Streptococcal pharyngitis runs a 5- to 7-day course with peak fever at 2 to 3 days.
Symptoms will resolve spontaneously without treatment, but rheumatic complications are still possible.
how long does influenza last
7 days, followed by additional days of cough and fatigue
how long does URI last
3-14 days
when would you not want to use HCTZ, Chlorthalidone
DM or gout
presentation of arrhythmias
▪ Palpitations MC ▪ dizzy ▪ lightheaded ▪ syncope ▪ SOB
LDL target
LDL cholesterol levels should be less than 100 mg/dL. Levels of 100 to 129 mg/dL are acceptable for people with no health issues but may be of more concern for those with heart disease or heart disease risk factors. A reading of 130 to 159 mg/dL is borderline high and 160 to 189 mg/dL is high
Triad of lupus
▪ joint pain (90%)
▪ fever
▪ malar “butterfly rash”
cardiac ROS
Chest pain? • Palpitations? • Dyspnea on exertion DOE? o SOB on exertion? • Orthopnea? o SOB when lying down? • Paroxysmal nocturnal dyspnea PND? o Do you awake in the middle of the night and feel like you have to run to the window to get air? • Leg edema? o Swelling in legs? • Hx of cardiac problems? (HTN, MI, CHF, rheumatic fever, heart murmur)? o **Move to PMH if positive • Ever had/last EKG? o **Move to HM: Screening • Ever had/last heart tests (echo, stress tests)? o **Move to HM: Screening • Cardiac procedures (cath, stent) o **Move to PMH: Surgeries if yes
