3CK PART II Flashcards
Explain relationship between hyponatremia and thyroid
Hypothyroidism can cause hyponatremia due to decreased clearance of free water and increased release of antidiuretic hormone.
Euvolemic hyponatremia.
Algorithm hyponatremia
DO
Postpartum thyroiditis presentation
Is a variant of hashimoto
brief thyrotoxic phase, followed by a self-limited hypothyroid phase and eventual return to a euthyroid state.
If mild, no need of supplementation
If sever needs levothyroxine
patient hypotense, tachycardi and blunt thoracic trauma , next step in management?
FAST! lead to detection of other causes that can be life threatening-pneumothorax, aortic dissection, hemoperitoneum, pericardial effusion leading to tamponade
- FAST is not only in abdomen
- Chest X rays are often done, but FIRST FAST
What are the preferred Chest X rays in trauma?
bedside (ie, anteroposterior) chest x-rays are typically performed as obtaining posteroanterior and lateral chest x-rays requires patients to stand
type I error, definition and ways that it is increased
rejecting a true null hypothesis [false positive]
increases as sample size increases
type II error
probability of failing to reject a false null hypothesis [false negative
2 ways in which Nonresponse increases the potential for bias
when nonrespondents differ from respondents in the outcome of interest; and it contributes to a decrease in statistical power given that the sample size has been reduced. However, a significant nonresponse rate in a study does not necessarily translate into bias.
Patient with alcoholism that after treatment with intravenous glucose, thiamine and fluids develops weakness of arms
Its due to hypophosphatemia ( refeeding syndrome) which can lead to development of rhabdomyolisis due to myopathy.
- check CPK in this setting.
Absolute iron deficiency is defined as
transferrin saturation <20% or ferritin <100 ng/mL.
Causes of anemia in ESDR
MC decreased EPO production BUT ALSO: iron deficiency ( blood loss, frequent blood testing, dyalisis, functional severe hyperPTH( resistance to EPO) Folate deficiency systemic inflammation aluminium toxicity
functional iron deficiency
Can occur in ESRD but these can also have the normal iron deficiency.
In functional-> unable to mobilize iron from stores.
When do you start EPO in ESDR?What considerations are needed before starting it?
Hemoglobin < 10
The goal is to increase hemoglobin by 1.5-2 g/dL over 4-6 weeks to target hemoglobin to 10-11.5 g/dL.
When do you supplement with iron in ESDR?
Iron supplementation is recommended for ESRD patients with transferrin saturation <30% and ferritin <500 ng/mL
** Think on the patient who despite receiving EPO keeps going with anemia.
Stress urinary incontinence tto
Intrinsic sphincter deficiency and urethral hypermobility
Lifestyle modification
Pelvic floor exercises
Pessary
Urethral sling surgery
Urgency urinary incontinence tto
Lifestyle modification
Bladder training
Antimuscarinic medications
Overflow urinary incontinence tto
Intermittent catheterization
Correct underlying etiology
Patients with an underlying neuropathy can develop overflow incontinence when additional risk factors (eg, antihistamines) result in exacerbation of symptoms
t
Overflow incontinence- post void residual volume
> 150
Presentation Genitourinary syndrome of menopause
urinary incontinence PLUS vaginal atrophy dyspareunia, vulvar irritation pelvic organ prolapse
Normal JVD
6-8
notched (bifid) P waves in lead II
left atrial enlargement due to mitral stenosis
Mitral stenosis in women think of
rheumatic fever
hear murmur + dyspnea, orthopnea, hemoptysis , hoarseness
mitral stenosis
Auscultation and ECG findings of MS
Auscultation: loud S1, loud P2if pulmonary hypertension
Mid-diastolic murmur
ECG: notched p wave
atrial tachyarryhtmias, high R’S IN v1,v2
Cardiac manifestations Noonan syndrome
pulmonic stenosis, atrial septal defects, and hypertrophic cardiomyopathy.
Indications of IVC filters
In whom anti coagulation is contraindicated :recent surgery, hemorrhagic stroke, bleeding diathesis, active bleeding
goal of IVC filters
inhibit progression of lower extremity clots through the IVC toward the lungs.
Acute and long term complications of IVC filter placement
acute: acute insertion site thrombosis, hematoma, arteriovenous fistula
long term recurrent DVTs andIVC thrombosis.
IVC filters do not appear to affect overall mortality significantly.
The filter can prevent clot progression to a pulmonary embolism, but it does not prevent future DVTs or treat the underlying thrombotic predisposition.
heteroplasmy - mitochondrial disorders
mom passess diasease to both male and women, but then her female child is the only one able to pass to the offspring.
Stroke + Seizures
MELAS
MELAS presentation
Mitochondrial encephalomyopathy with lactic acidosis and stroke like episodes
- stroke
- seizures
- weakness
- hearing loss
- lactic acidosis
Corrected calcium formula
Corrected calcium in mg/dL = (measured total calcium) + 0.8 (4.0 g/dL - measured serum albumin in g/dL).
calcium concentration decreases by 0.8 mg/dL for every 1 g/dL decrease in serum albumin concentration.
ss hypocalcemia
oral paresthesias, carpopedal spasm, tetany, seizures
tto hypocalcemia
Oral calcium citrate or carbonate mild acute hypocalcemia (corrected calcium of 7.5-8.5 mg/dL) or chronic hypocalcemia.
for symptomatic : Intravenous calcium gluconate
distribution of calcium in the body
albumin-bound calcium (45%), ionized calcium (40%), or calcium bound to inorganic and organic anions (15%).
organism in chagas
PROTOZOAN-Tripanosoma cruzi
Cardiac manifestations of chagas
- Ventricular apical aneurysm in the absence of coronary disease
- Biventricular heart failure (R>L) with cardiomegaly
- Mural thrombosis with embolic complications
- Fibrosis leading to conduction abnormality ( heart block , ventricular tachycardia)
Cardiac manifestations of lyme
atrioventricular conduction block. In rare cases, patients can also develop myopericarditis with dilated cardiomyopathy.
Infection with human immunodeficiency virus has been associated with the development of dilated cardiomyopathy.
T
Diagnostic criteria for C difficile
Characteristic symptoms – Watery diarrhea (≥3 loose stools in 24 hours) with or without lower abdominal pain, low-grade fever, and leukocytosis
AND
Positive stool testing
Positive laboratory testing in the absence of symptoms is not sufficient for diagnosis as asymptomatic carriage is common.
4 RF for C.difficile
PPIs – C difficile spores are acid-resistant, but proton pump inhibitors are thought to alter the colonic microbiome, which increases the risk of C difficile proliferation.
Recent antibiotic use – Antibiotics disrupt the barrier function of normal colonic flora. Fluoroquinolones, clindamycin, and broad-spectrum penicillins/cephalosporins are most likely to cause CDAD.
Hospitalization
Advanced age
Medications related to C. difficile
Fluoroquinolones, clindamycin, and broad-spectrum penicillins/cephalosporins
Newborn with red sac in lumbar spine, dx?
Spina bifida = myelomeningocele
Complications of spina bifida (4)
Motor/sensory dysfunction
Neurogenic bladder/bowel ( urinary retention/constipation)
Hydrocephalus
Scoliosis
tto spina bifida and its complciations
Surgical closure
Clean intermittent catheterization
Scheduled laxatives/enemas
Bracing; correction of deformities
Patients undergo urgent surgical repair, which results in hydrocephalus requiring a ventriculoperitoneal shunt in over half of infants.
Presentation of transverse myelitis
Rapidly progressive weakness of the lower extremities following an upper respiratory infection, accompanied by sensory loss and urinary retention
muscle flaccidity and hyporeflexia, but spasticity and hyperreflexia develop subsequently.
type of patients that can present with epidural abscess
IV drug users
crescent, hypoechoic lesions adjacent to the gestational sac
subchorionic hematoma
abnormal collection of blood between the uterus and the gestational sac
management of subchorionic hematoma
management is expectant; patients can be followed with serial ultrasounds to help provide reassurance.
**DO NOT RECOMMEND HOSPITALIZATION OR BED REST- DOESNT CHANGE ANYTHING, AND INCREASES RISK OF DVT
Kleihauer-Betke test
determines the amount of fetomaternal hemorrhage that occurred due to delivery, maternal trauma, or first-trimester bleeding in an Rh-negative mother.
determines the amount of Rho(D) immune globulin to be administered.
Pts with subchorionic hematoma are at higher risk of
Spontaneous abortion Abruptio placentae Preterm premature rupture of membranes Preterm delivery preeclampsia, fetal growth restriction, and intrauterine fetal demise
RF for subchorionic hematoma
Infertility treatment
Anticoagulation
Uterine anomalies
Recurrent pregnancy loss
RF Placenta previa
prior placenta previa.,history of prior cesarean delivery, multiple gestations, multiparity
RF Placenta accreta
previous cesarea
Indication for Fetal fibronectin
cervicovaginal discharge of patients at <34 weeks gestation with preterm contractions
not older than 34
patient third trimester bleeding, fetus ok, next step?
transvaginal US- likely caused by placenta previa
Transvaginal ultrasound and speculum examination are safe in placenta previa as neither the transvaginal probe nor the speculum enters the endocervical canal. DIGITAL EXAM IS CONTRAINDICATED
Woman that after birth- shortness of breath, unresponsive, hypotension
Amniotic fluid embolism:
Cardiogenic shock
Hypoxemic respiratory failure
Disseminated intravascular coagulopathy
Coma or seizures
Management of amniotic fluid embolism
Respiratory & hemodynamic support
± Transfusion
RF for amniotic fluid embolism
cesarean/operative delivery, placenta previa, and abruptio placentae.
Peripartum cardiomyopathy
in the late third trimester or early postpartum period with symptoms of heart failure (eg, dyspnea, orthopnea, hemoptysis, pedal edema)
Initial management of aspiration pneumonia:
blood and sputum cultures with initiation of broad-spectrum antibiotics with anaerobic coverage (eg, clindamycin).
Patient diabetic with sinusitis, next step
depends on glycemic control:
If adequate glucose: amoxi-clavulanate for 5-7 days
If not control ( i.e DKA)- think of mucor - and admit to hospital for antifungals
Acute bacterial rhinosinusitis tto
1st-line therapy: Amoxicillin-clavulanate (5-7d)
Alternate agent: Doxycycline or fluoroquinolones
Supportive care: Analgesics, decongestants, saline irrigation, topical glucocorticoids
Dx Acute bacterial rhinosinusitis
> 1 of the following is present:
Persistent symptoms/signs of rhinosinusitis for >10 days
Severe symptoms, high fever (>39 C [102.2 F]), purulent nasal discharge, and/or facial pain for >3 consecutive days
“Double sickening” - initial improvement of viral upper respiratory symptoms for 5-6 days, followed by clinical deterioration (eg, worsened fever, headache, nasal discharge)
MC organisms in bacterial rhinosinusitis
Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
ST elevation
ST-elevation myocardial infarction (STEMI) is diagnosed by ECG showing >1 mm (0.1 mV) ST elevation (>2 mm in leads V2 and V3) in ≥2 anatomically contiguous leads.
If suspicion of perforated peptic ulcer, next step
Chest and Abdomen X ray
sudden-onset abdominal pain with significant tenderness and guarding
peritonitis
management of peptic ulcer perforation
Fluids, antibiotics with coverage for gram negative, PPIs IN preparation for surgery
cause of small intestinal obstruction in patients with a history of abdominal surgery.
adhesions
Conditions associated with Down Syndrome
VSD/ASD duodenal atresia, Hirschsprung's disease, atlanto-axial instability, and hypothyroidism.
Pts with Down syndrome on the long run are at increased risk of ..
Acute Leukemia Alzheimer ADHD Autism seizure disorder depression
Management of dyspepsia
Age ≥60: Upper endoscopy
Age <60:
Testing and treatment for H pylori
Upper endoscopy in high-risk patients (eg, overt GI bleeding, significant weight loss, >1 alarm symptom)
presentation of dyspepsia
Epigastric pain often described as “burning”
± Nausea, vomiting, epigastric fullness, heartburn
pelvic organ prolapse
Weight loss
Pelvic floor exercises
Vaginal pessary
Surgical repair
rectocele presentation
posterior vaginal mass that increases with the Valsalva maneuver.
pelvic pressure, lower back pain, constipation, and fecal incontinence.
rectocele treatment
Pelvic floor exercises
Vaginal pessary
Surgical repair
What findings are associated with poor prognosis in CLL
lymphadenopathy, organomegaly, and anemia/thrombocytopenia,
erythrocytosis and hematuria
Renal cell carcinoma
lank pain, hematuria, and palpable abdominal mass; h
suspect renal ca, next step
CT scan of the abdomen
JAK2 mutation is seen in which condition
Polycytemia vera
polycythemia vera presentation
Erythrocytosis is the defining feature; patients also often
aquagenic pruritus, hypertension, and arterial or venous thrombus.
CT scan of the abdomen reveals an enhancing mass of the kidney with thickened, irregular septa, raising strong suspicion for renal cell carcinoma, next step
referral to nephrology for nephrectomy!
Polycystic kidney disease tto
ACE inhibitors- reduce risk of chronic renal insufficiency.
management of kidney cysts.
Complex kidney cysts often require surveillance with repeat imaging
viral conjunctivitis, when does it stop to be contagious?
when watery discharge resolves
Other symptoms, such as morning crusting or eye redness, may persist longer than eye discharge but do not contribute to infectivity
Difference between allergic vs nonallergic rhinitis
Allergic:
earlier age (<20) with predominant eye symptoms (eg, watery eyes), sneezing, nasal congestion, and watery rhinorrhea. Patients usually can identify a trigger
PE:normal or pale blue nasal mucosa with pallor and occasionally shows polyps
TTO: allergen avoidance and intranasal glucocorticoids
Non allergic after age 20 with nasal blockage, rhinorrhea, and postnasal drip.. throughout the year.
PE:nasal mucosa can appear normal or boggy and erythematous on examination. topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamine (eg, azelastine).
Tto of allergic and nonallergic rhinitis
aLLERGIC: Avoid trigger, and intranasal glucocorticoids
NON ALLERGIC : topical intranasal glucocorticoids (eg, fluticasone) or intranasal antihistamine (eg, azelastine).
When to consider allergy testing/IgE in rhinitis
reserved for differentiating between NAR and AR in patients who do not respond to initial treatment or in those being considered for immunotherapy.
Elderly woman saying that sexual activity is no longer “pleasurable.” cause?
vaginal atrophy- vaginal dryness and dyspareunia.
*** if they describe interest then is not age-related libido
treatment of postmenopausa
SSRIs, NSRIs ( Venlafaxine)
Considerations before prescribing opioids
evaluate prescription history and use
- Also check the prescription drug monitoring program ( identify undisclosed prescriptiosn, clarify prescription patters and see if patient has obtained prescriptions from multiple providers)
Tto of seborrheic dermatitis
TOPICAL antifungals (eg, selenium sulfide SHAMPOO, ketoconazole)
Topical glucocorticoids
Topical calcineurin inhibitors (eg, pimecrolimus, tacrolimus)
keratolytic agents (eg, salicylic acid)
**Oral could be used but are NOT the first line
organism involved in seborrheic dermatitis
Malassezia
Griseofulvin is used in
tinea capitis
Permethrin is used to
scabies
Crusted scabies can cause large, scaly patches but is not pruritic and occurs most commonly in immunocompromised patients (eg, lymphoma, AIDS).
t
long term management of seborrheic dermatitis/ prognosis
chronic, relapsing condition.
Initial treatment -> significant improvement but no remission.
SO: intermittent re-treatment. Typical regimens include topical ketoconazole or ciclopirox every 1-2 weeks.
factorial design
STUDY arms in RCT
Does psoriasis cause alopecia?
NO, usually no!
well-demarcated, often round, non-scarred patch of complete hair loss
Alopecia areata: can be multiple patches! not only one.
“exclamation point hairs” (hairs which are tapered near the insertion into the scalp), especially at the periphery of an alopecic plaque
Nail pitting associated to alopecia areata
yes
Nail pitting is seen in
Psoriasis
Alopecia areata
prognosis of alopecia areata
self-limited but may be relapsing and remitting or chronic and progressive.
increased risk -> autoimmune thyroid disease, vitiligo, and pernicious anemia.
Tinea capitis vs alopecia areata
tinea capitis: erythema, scaling, “black dot” alopecia (secondary to breakage of hairs near the scalp), pustules, or boggy plaques with posterior
alopecia areata: well emarcated, non-scarred, exclamation points around it.
Tto of normal pressure hydrocephalus
Ventriculoperitoneal shunting
***no eviudence for acetazolamide
Diagnosis of normal pressure hydrocephalus
Marked improvement in gait with spinal fluid removal: Miller Fisher (lumbar tap) test
Enlarged ventricles out of proportion to the underlying brain atrophy on MRI
ppt normal pressure hydrocephalus
Gait instability (wide-based) with frequent falls Cognitive dysfunction Urinary urgency/incontinence Depressed affect (frontal lobe compression) Upper motor neuron signs in lower extremities ( they can have tremor, rigidity-parecido a parkinson)
lumbar tap test (Miller Fisher test)
Is for normal pressure hydrocephalus
evaluates parameters such as gait speed, stride length, verbal memory, and visual attention before and after removal of 30-50 mL of CSF.
red flags for a pathologic etiology in scoliosis
Back pain ( nocturnal awakening- concerning for tumor)
Neurologic symptoms
Rapidly progressing curvature (>10 degrees each year)
Vertebral anomalies on x-ray
** degree of curvature is not associated with etiology
suspect scoliosis, next step
X ray, although MRI is gold standard
Anterior horn cells disorders
SMA
ALS
Paraneoplastic syndromes
Polio
UMN disorders
leukodystrophies
vasculitis
brain mass
vit B12
Pathogenesis of botulism
peripheral nerve endings to inhibit release of acetylcholine into the synaptic cleft.
patient with shock that after resuscitation develops hyperactive reflexes
multiple transfusions can lead to hypocalcemia as Ca joins with citrate .
—-citrate chelates with calcium
hypocalcemia : hyperactive reflexes
relation between hypomagnesemia and reflexes
hyporeflexia
Patient in whom you suspect varicella zoster, next step
Treat with oral acyclovir/valacyclovir
atients with localized herpes zoster who have had lesions <72 hours typically receive antiviral treatment with oral valacyclovir to reduce transmission risk, new lesion formation, and (possibly) risk of postherpetic neuralgia. Analgesics for acute neuritis are also typically required.
No need for testing. testing is reserved for atypical lesions
Healthcare precautions for patients with varicella zoster
Localized infection - standard precautions and lesion covering
Disseminated infection - standard precautions plus contact and airborne precautions
Definition of hypoglycemia
< 60
normal fasting blood sugar range is 70 to 100 mg/dL
The target pre-meal blood sugar level in patients with diabetes is between 80 and 120 mg/dL.
Whipple’s triad
low blood glucose level
symptoms of hypoglycemia
symptomatic relief with the administration of glucose.
Whipple’s triad is strongly suggestive of true hypoglycemia.
Hypoglycemic episodes during exercise
decreasing the insulin dose (NPH, glargine - not the regular that ggoes with each meal ), eating before exercising, and avoiding injections of insulin in the exercising limbs.
unilateral facial nerve palsy, hepatomegaly (>2 cm below costal margin), and lymphadenopathy AND significant fatigue
extrapulmonary sarcoidosis
suspect sarcoidosis, next step
a chest x-ray as >90% of patients have bilateral hilar or mediastinal adenopathy
Löfgren syndrome
SARCOIDOSIS
Erythema nodosum
Hilar adenopathy
Migratory polyarthralgia
Fever
Eye manifestations in sarcoidosis
Anterior uveitis (iridocyclitis or iritis)
Posterior uveitis
Keratoconjunctivitis sicca
CNS/endocrine manifestations
Facial nerve palsy
Central diabetes insipidus
Hypercalcemia
Herpes simplex meningitis presentation
can have focal signs, including nerve palsy but in 90% cases ALTERED MENTAL STATUS
Patients with facial nerve palsy should undergo brain imaging if symptoms do not improve by 3 weeks or resolve by 4 months.
T
Chest x-ray reveals bilateral hilar adenopathy and interstitial infiltrates, next step to confirm diagnosis
excisional lymph node biopsy- noncaseous granulomas
usually a palpable lymph node or skin lesion. When there is no easily accessible lesion, fiberoptic bronchoscopy with transbronchial lung biopsy is often performed.
*** Although ACE levels will be high in 75%, not recommended.
All patients with pulmonary sarcoidosis should undergo pulmonary function testing to evaluate for respiratory impairment
true, but this is not to confirm diagnosis.
Diagnosis after chest X ray: excisional lymph node
Management of bacterial conjuncitvitis
S.aureus, S. pneumonia, moraxella, H. influenza
Erythromycin ointment
Polymyxin-trimethoprim drops
Azithromycin drops
Preferred agent in contact lens wearers: fluoroquinolone drops (pseudomona)
Management of viral conjunctivitis
Warm or cold compresses
± Antihistamine/decongestant drops
When keratitis is suspected, next step
ophthalmology referral
diagnosis of keratitis is made by slit-lamp examination showing corneal ulceration.
cultures are needed
Keratitis can cause scarring or ulceration of the cornea and subsequent blindness if not aggressively treated.
well-defined plaques covered by thick silvery scales
psoriasis
Treatment of psoriasis
Mild-to moderate plaques: TOPICAL high potency steroids ( fluocinonide, augmented betamethasone dipropionate 0.05%)
-topical vit D derivatives
Severe plaques: phtototherapy or systemic agents(methotrexate)
Pt who had runny nose, sore throat, tactile, then develops headache, vomiting confusion and focal neuro signs?
Viral meningoencephalitis
Suspect viral meningoencephalitis
LP followed by vancomycin, ceftriaxone, and ACYCLOVIR
MC causes of meningoencephalitis
enterovirus( coxsackie)
herpes
arbovirus(West Nile)
role of dexamethasone in pneumococcal meningitis.
Prevents neurological complications
loss of consciousness. He was standing in a crowded subway station when he felt lightheaded, had a pounding sensation in his chest, and passed out. On awakening, he felt short of breath for a little while and then was “completely fine.” Causes?
Vasovagal syncope could be
BUT CONSIDER
-Tachyarrhythmia- WPW so look for it in the ECG
Managemetn of WPW
Catheter ablation
Altered mental status in patients with lithium, what to consider
Any new meds? volume depletion? CKD?
Lithium has a very narrow therapeutic index and can interact with many drugs
THIAZIDES ( chlortalidone) , ACEIs, NSAIDs increase levels of lithium.
therapeutic and toxic levels of lithium
Therapeutic lithium levels are 0.8-1.2 mEq/L.
Serum lithium levels >1.5 mEq/L confirm toxicity, and levels >2.5 mEq/L require emergency management.
Drugs that increase lithium levels
THIAZIDES ( chlortalidone) , ACEIs, NSAIDs
Management of lithium toxicity
Lithium levels every 2-4 hours
Intravenous hydration
Bowel irrigation (asymptomatic acute overdose)
Hemodialysis:
>4 mEq/L
>2.5 mEq/L with symptoms or renal failure
Increasing level despite intravenous fluids
presentation of lithium toxicity
Acute
GI: Nausea, vomiting, diarrhea
Neurologic findings occur much later
Chronic
Neurologic: Ataxia, confusion, agitation, neuromuscular excitability (tremor)
Mammogram screening
Mammogram every 2 years for women age 50-74
Screening for patients age 40-49 is based on individual risk factors
Breast cancer screening is not indicated in low-risk patients age <40.
self manual exam is recommended annuallu
FALSE, Breast self-examination does not reduce breast cancer mortality. It has a high false-positive rate and leads to unnecessary biopsies; therefore, it is not recommended at any age.
Management of acute diverticulitis
bowel rest
ciprofloxacin and metronidazole,
Patient with diverticulitis on antibiotics who after 2-3 days persists with fever, abodminal pain, next step
if no improvement after 2-3 days repeat CT to evaluate for complications: colonic abscess, obstruction, and perforation.
MC complication of diverticulitis
Colonic abscess (5-15%)
require percutaneous drainage and intravenous antibiotics followed by elective partial colectomy several weeks later.
When do you recommend colonoscopy in diverticulitis
patients with diverticulitis 6-8 weeks after the complete resolution of symptoms to rule out colon cancer.
pithelial cells that have a stippled appearance but no ferning
Vacterial vaginosis
Bacterial vaginosis
Clindamycin or MTZ
Candida vaginosis presentation
thick, white, clumpy discharge and vulvar pruritus
Why should be treat bacterial vaginosis in pregnancy
To relieve symptoms.
↑ Risk of preterm birth, BUT NOT IUGR
lung cancer screening
55-80
Patient has ≥30-pack-year smoking history
AND
Patient is a current smoker or quit smoking within the last 15 years
lung Ca screening termination
Age >80
OR
Patient successfully quit smoking for ≥15 years
OR
Patient has other medical conditions that significantly limit life expectancy or ability/willingness to undergo lung cancer surgery
Smoking cessation reduces the risk of developing lung cancer and COPD exacerbations, even in long-term heavy smokers.
true
What organism is most commonly cultured from corneal foreign bodies in the eyes?
Staph aureus
Other: Strep, hemophilus, pseudomona
treatment for all foreign-body associated corneal abrasions
empiric broad-spectrum antibiotic eye drops or ointments (e.g., erythromycin, sulfacetamide, ciprofloxacin, ofloxacin).
Pt comes for blood in urine, next step
hx of trauma or suspected stone: CT/US
IF no: urianalysis
even if you think is bladder cancer or you know the etiology need to confirm first
The first step in evaluating hematuria is
urinalysis and culture
acute onset of flushing, a throbbing headache, palpitations and abdominal cramps, after 30 min eating fish. Dx?
Scombroid poisoning
can also have bitter taste
skin erythema, wheezing, tachycardia and hypotension.
Pufferfish poisoning
prominence of neurological symptoms (perioral tingling, incoordination, weakness, etc).
Scombroid poisoning
acute onset of flushing, a throbbing headache, palpitations and abdominal cramps after 30 minutes of eating fish
can also have bitter taste
skin erythema, wheezing, tachycardia and hypotension.
Carcinoid syndrome
characterized by diarrhea, flushing, dyspnea, and wheezing – may occur if a serotonin-producing tumor has metastasized to the liver, bypassing first-pass metabolism. Elevated 5-HIAA in the urine helps to establish the diagnosis
Recommendations on exercise for pt with cerclage
Contraindicated
Contraindications of exercise during pregnancy
Patients at risk for preterm delivery
Cervical insufficiency
Preterm labor during current pregnancy
Preterm premature rupture of membranes
Patients at risk for antepartum bleeding
Placenta previa
Persistent second- or third-trimester bleeding
Patients with an underlying condition that could be exacerbated by exercise
Severe anemia
Hypertensive disorders of pregnancy (eg,
preeclampsia)
Restrictive lung disease
Severe heart disease
prognosis of night terrors
typically occurs between ages 4-12. The condition is usually benign and self-limiting, resolving spontaneously over 1-2 years.
low-dose BZD at bedtime if episodes are frequent, persistent & distressing
non-rapid eye movement (NREM) sleep disorders
night terrors, sleep walking ( do not remember)
REM sleep-related behavior disorder
acts out the dreams
MOA of SGLT2 inhibitors for DM
proximal tube, exchange sodium for glucose. So inhibit re absorption glucose
canagliflozin, dapagliflozin, and empagliflozin
SE SGLT2 inhibitors for DM
Vulvovaginal candidiasis
Polyuria
UTI
* In the setting of glucosuria
canagliflozin, dapagliflozin, and empagliflozin
canagliflozin, dapagliflozin, and empagliflozin are what type of drugs
SGLT2 inhibitors for DM
Dipeptidyl-peptidase 4 (DPP4) inhibitors
sitagliptin, saxagliptin, linagliptin, and alogliptin.
increase incretin levels (GLP-1 and GIP)–> inhibit glucagon release, which in turn increases insulin secretion, decreases gastric emptying, and decreases blood glucose levels.
DDP4 inhibitors SE
Pancretatitis, may cause hypersensitivity ( ie. angioedema)
Schizoaffective disorder
Major depressive or manic episode concurrent with symptoms of schizophrenia
Lifetime history of delusions or hallucinations for ≥2 weeks in the absence of major depressive or manic episode
Mood episodes are prominent & recur throughout illness
Schizoaffective disorder vs Major depressive or bipolar disorder with psychotic features:
Schizoaffective disorder: has concurrent mood symptoms with psychotic symptoms, PLUS ≥2 weeks of psychotic symptoms in the absence of a major depressive or manic episode.
In the other disorder: Psychotic symptoms occur exclusively during mood episodes
Schizoaffective disorder is distinguished from schizophrenia by
the presence of mood symptoms lasting a significant portion of the illness.
treating friends and family is not always unethical
true, there may be emergency cases in which is needed
Friend asking for a prescription of opioid, what to say
” I would like to help you but I feel uncomfortable prescribing to someone I do not treat
Women in 50s with symptoms of amenorrhea, and increased vaginal bleeding, next step?
endometrial biopsy
her bleeding is anovulatory, and there is risk of endometrial cancer due to unopposed estrogen production.
ALL WOMEN>=45 with anovulatory bleeding need to have endometrial biopsy
Indications for endometrial biopsy
- ALL WOMEN>=45 with anovulatory bleeding
- Women < 45 with RF ( POS, Obesity), failed management, persist with abnormal bleeding.
Why does menopause occur? At what age? How is diagnosis made?
- loss of ovarian function (oocyte depletion, and abnormal follicular development)
- oocytes fail to produce progesterone
Usually by 51
Dx with >=1 year of amenorrhea
Treatment of anovulatory bleeding in transition to menopause
First - do an endometrial biopsy! If normal: Other options: Cyclic progestin Low dose OCP DIU
Is measure of FSH needed for diagnosis of menopause?
NO! Menopause is a clinical diagnosis and FSH is not required to confirm.
MCC of viral meningoencephalitis
Enterovirus (Coxsackie)
Herpes (HSV)
Arbovirus( West Nile Virus)
presentation of viral meningoencephalitis
fever, headache, altered mental status, nuchal rigidity.
West Nile infection - time of the year and presentation
Summer and early fall
meningitis, including fever, headache, photophobia, nuchal rigidity, and/or signs of encephalitis, such as confusion and focal neurologic findings (eg, hyperreflexia).
- Rash can be present but not always
patients may have excoriated mosquito bites,
Dx of West Nile virus
West Nile IgM antibody in the cerebrospinal fluid
Does Lyme cause encephalitis?
NO, most commonly meningitis, CN palsy, or peripheral neuropathy.
Presentation of Duchenne
2-3 years old, X-linked myopathy
developmental delay ( can have speech delays, late onset walking)
proximal lower extremities weakness (unable to run, walk, jump) for a long time
Dilated Cardiomyopathy
Scoliosis
Waddling gait
pseudohypertrophy of calves – as fat replaces degrading muscle.
THEY CAN HAVE HYPOREFLEXIA of achilles tendon
First step when suspecting Duchenne’s myopathy
CK levels
GOLD standard or CONFIRMATORY study for Duchenne?
Genetic testing showing deletion of one or more exons of the dystrophin gene
Not muscle biopsy
Most accurate diagnostic tool for Parkinson disease?
Clinical- physical examination
Striatal dopamine transporter scan ( DATscan) can be considered when the diagnosis of Parkinson’s disease is equivocal.
Management of Parkinson
Initial treatment:
< 65 : pramipexole, bromocriptine ( dopamine agonists)
>65 : levodopa
Levodopa concerns with prolonged use. It hastens destruction of substantia nigra cells and worsen symptoms in the long-term.
Role of entacapone in parkinson
Entacapone by itself not helpful for PD. It helps prolong the effect of levodopa.
Patients with untreated celiac disease are at high risk of
enteropathy-associated T-cell lymphoma (EATL) in the jejunum – poor prognosis - 10 months.
Foodborne illness- primarily emesis
S. aureus, B cereus
Norovirus (Norwalk)
Foodborne illness-predominant watery diarrhea
C. perfringes Enterotoxin E.coli Enteric viruses Cryptosporidium Cyclospora Intestinal tapeworms
Foodborne illness-predominant inflammatory diarrhea ( bloody)
- Shigella
- Salmonella
- Shiga toxin E.coli
- Campylobacter
- Enterobacter
- Vibrio parahemolyticus
- Yersinia
Foodborne illness- Ciguatera toxin
paresthesia
Foodborne illness- Scombroid
Flushing, urticaria
Foodborne illness- Listeria
Meningitis
Foodborne illness- Vibrio Vulnificus
Cellulitis, sepsis
Foodborne illness- Brucellosis
Arthtralgias, fever
Norovirus ( 3 types of presentation)
- Asymptomatic infection
- Fever with watery diarrhea - non-inflammatory small-bowel process
- Severe illness - fever, vomiting, headache, and other systemic symptoms
Symptoms usually start suddenly and last 48-72 hours. Diagnosis is generally clinical, and most patients improve with supportive care. If needed, diagnosis can be confirmed by polymerase chain reaction or nucleic acid-based testing.
Dx of campylobacter
Stool culture
Pathogen of Traveler’s diarrhea
Enterotoxigenic E coli
The most common cause of gastroenteritis in children and adults
Norovirus
Tto of asymptomatic bacteriuria or cystitis in pregnancy
Nitrofurantoin, Cephalexin, amoxi-clavulanate, or fosfomycin
3-7 days
Are fluoroquinolones CI in pregnancy
Yes, risk of cartilage damage in the fetus
First line of treatment for cystitis in non-pregnat
TMP-SMX
In pregnant: Cephalexin, amoxi-clavulanate, or fosfomycin
Why is Trimethoprim-sulfamethoxazole CI in pregnancy
irst trimester has been associated with neural tube defects due to the folate antagonist
Late third trimester associated with kernickterus
Management of pyelonephritis during pregnancy
Ceftriaxone, Cefepime IV
Once afebrile can be transitioned to 10-14 days of oral antibiotics.
After treatment completion- daily suppressive therapy (eg, low-dose nitrofurantoin or cephalexin) is initiated and is maintained until 6 weeks postpartum to prevent recurrence.
Outpatient management of pyelonephritis is not recommended in pregnancy due to risk of complications ie. pulmonary edema
true
Cholestatic pattern in labs
high conjugated bilirubin, high cholesterol, high ALP.
Algorithm for high ALP
Check GGT,
If GGT Normal- then ALP is likely bone origin
If GGT elevated- liver
If liver– RUQ US and AMA!
Suspect of primary sclerosing cholangitis, next step
ERCP intra and extrahepatic sclerosis- strictures alternating with dilation and beading.
Primary biliary cholangitis/cirrhosis with AMA + or US abnormal , next step
Liver biopsy
Complications of Primary biliary cirrhosis/cholangitis
Osteomalacia ( despite vit D levels normal), malabsorption, ADEK deficiencies
PPT of Primary biliary cirrhosis/cholangitis
Fatigue & pruritus (most common) Inflammatory arthritis (40%-70%) Hyperpigmented skin (25%-50%) Right upper quadrant discomfort (10%) Xanthelasmata (10%) & xanthomata (5%)
Alpha-1 antitrypsin deficiency
cirrhosis (with significant elevations in hepatic transaminases) and emphysema.
Anti–smooth-muscle antibodies
type 1 autoimmune hepatitis, which typically causes elevation of hepatic transaminases. Alkaline phosphatase is usually normal or only mildly elevated.
ppt hemochromatosis
elevations in transaminases, and often has additional findings including hyperpigmentation, diabetes mellitus, arthropathy, and cardiomyopathy.
Treatment of primary biliary cholangitis
ursodeoxycholic acid , if not liver transplant
Ca and Vit D supplementation
Management of asthma exacerbation
Mild to moderate ( PEF or FEV >=40): SABA ( up to 3 doses in 1 hour), PO corticosteroids if no reposnse to SABA or prior response to Corticosteroids. O2 if Sat <90
Moderate to Severe ( PEF or FEV<40): SABA +ipratropium in 1 hour , PIV or pO corticosteroids, O2 for Sat<90
Impending or actual respiratory distress - SABA +Ipratropium -IV corticosteroids + Mg - +/- SQ terbutaline or epi \+/- intubation and admission to PICU
Inhaled short-acting beta agonists are the first-line treatment IN ASTHMA regardless of severity.
TRUE
Treatment of CML
tYROSINE KINASE INHIBITOR– IMATINIB
Management of chronic urticaria
nothing! unless systemic ss
80-90% of urticaria is idiopathic
Presentation of chronic urticaria
Episodes of urticaria > 6 weeks
episodes of rash that can worsen over min to hours, and resolve really fast
INTENSE PRURITUS that can extend throughout the night.
40% may associate with angioedema ( mast cell activation extends to subcutuaneous tissue and deeper layers)
Causes of chronic urticaria
80-90% idiopathic physical stimuli - cold, skin pressure NSAIDs stress systemic disorders ( vasculitis, autoimmunde diseases)
C1 esterase inhibitor levels
hereditary angioedema
angioedema of the throat, tongue, or lips without urticaria. Patients can also have abdominal pain due to angioedema of the intestinal mucosa.
When do you do biopsy in urticaria
NOT RECOMMENDED,
ONLY with lesions that last >24 hours, are painful, have associated petechiae or purpura, associated systemic symptoms (eg, fever), elevated erythrocyte sedimentation rate/C-reactive protein, or do not respond to treatment.
1st and 2 nd generation H1 blockers
diphenydramine , chlorphenidramine
and others for motion sickeness: mezicline hydroxycine, promethazine.
2nd generation :cetirizine, loratadine, desloratadine
Management of acute urticaria < 6 weeks
Mild: 1st or 2nd generation H1
Moderate h1 +h2 blockers
Sever: oral steroid
Management of chronic urticaria > 6 weeks
daily 2nd generation H1 blocker
If no improvement in 2 weeks consider increasing dosing, add a first generation, add a H2 blocker, anti-leukotriene, brief course of oral steroids.
If no improvement consider hydroxycloroquine, omalizumab or tacrolimus.
H2 BLOCKERS EXAMPLE
Ranitidine , cimetidine
prognosis of chronic urticaria
most patients have spontanoeus resolution within 1-5 years . 1 (50%), at 5 years 70%
Causes of acute pericarditis
Viral or idiopathic TB Uremia Autoimmune ( SLE) Post MI ( early ( Peri infarct)< 4 days, late ( Dressler))
Management of peri infarct pericarditis vs. viral/idiopathic pericarditis
Peri-infarct pericarditis: high dose aspirin 650 mgTID
- small effect on myocardial healing
Pericarditis idiopathic or viral: NSAIDs and colchicine
NSAIDS to be avoided in peri-infarct as impair myocardial healing and risk of wall rupture .
Long term prognosis of pulmonary sarcoidosis
Asymptomatic patients often require no treatment
those with symptoms or pulmonary function impairment usually receive 12-24 months of oral glucocorticoids
Most cases (~75%) resolve over time and do not recur.
TB screening
Can be done with the tuberculin skin test or Interferon Gamma
Interferon Gamma preferred in patients who had BCG.
Patient tested positive for TB, asymptomatic and nothing on X ray
latent TB
6-9 months of isoniazid ( daily) OR
Rifampin 4 months
PFTs in asthma
In patients with active ss: obstructive pattern (reduced FEV1 and a reduced FEV1/FVC ratio (total lung capacity and diffusing capacity of the lungs for carbon monoxide [DLCO] are typically normal or sometimes elevated). In these patients, a bronchodilator (eg, albuterol) can be administered and should result in significant improvement in FEV1 (eg, >15% from baseline).
In pts without ss- normal PFT findings. The administration of methacholine in these patients is likely to cause >20% reduction in FEV1,
( so normal test but an obstructive pattern following methacholine challenge)!
Mild, moderate, and severe lead toxicity . values
5-44
45-69
> =70
TTO lead poisoning
5-44- no meds
45-69 - Meso-2,3-dimercaptosuccinic acid (DMSA, succimer)
> =70Dimercaprol (British Anti-Lewisite)
plus
calcium disodium edetate (EDTA)
Indications of statins
Atherosclerotic cardiovascular disease ( CABG, TIA, etc)
LDL>=190
Age>-45 with DM
10 YEAR RISK OF CABG is >7.5-10%%
cholestyramine, colestipol, colesevelam - what class
bile acid sequestrants
5 Types of lipid lowering agents
- Statins
- Bile acid sequestrans ( cholestyramine, colestipol, colesevelam)
- Ezetimibe
- Fibrates( Gemfibrozil, fenofibrate)
- Niacin (B3)
MOA statins
Inhibit conversionof HMG-CoA to mevalonate, a precursor of cholesterol.
Decreases mortality in CAD patients
EA statins
Hepatoxicity (increases LFTs)
myopathy ( particularly when used with fibrates, or niacin)
MOA Bile acid sequestrants
Prevent intestinal reabsorption of bile acids, liver must use cholesterol to make more
EA Bile acid sequestrants
GI upset, decreased absorption of other drugs and fat soluble vitamins
MOA Ezetimibe
Prevent cholesterol absorption at small intestine brush border
EA Ezetimibe
Rarely increased LFTs, diarrhea
Fibrates MOA
Upregulate LPL–> TG clearance.
Active PPAR alpha to induce HDL synthesis
EA Fibrates
Mypathy ( if given with statins), gallbladder stones
Niacin MOA
Inhibits lipolysis in adipose tissue , reduces hepatic VLDL syndthesis
SE Niacin
Red, flushed face, which is decreased by NSAIDs or long term use
Hyperglycemia, Hyperuricemia
Which of the lipid lower agents decrease the most the TRG
Fibrates
Which of the lipid lower agents increased HDL
Niacin
1st degree block
constant PR prolonged.
2nd degree block MObitz I
PR prolonges before dropped beat
2nd degree block MObitz Ii
Constant PR dropped beat
Treatment of mobitz II and 3rd degree AV block
pacemaker
Suspect appendicitis in pregnancy next step
graded compression abdominal ultrasound
NO CT
Appendicitis in pregnancy
atypical presentation, including right-sided abdominal pain with no peritoneal signs or McBurney point tenderness.
abdominal pain, fever. high clinical suspicion
Pylephlebitis, what is
infective suppurative portal vein thrombosis (THROMBOSIS, INFECTED)
rare but devastating complication of untreated appendicitis or other intraabdominal or pelvic infections (eg, diverticulitis)
pyelephlebitis is a rare complication of appendicitis or intraabdominal pathology.
TRUE
negative predictive value
probability of not having a disease given a negative result on that test.
likelihood ratio (LR)
expression of sensitivity and specificity that can be used to assess the value of a diagnostic test indepedently of prevalence.
positive likelihood ratio (LR+)
represents the value of a positive test result. It is the probability of a patient with the disease testing positive divided by the probability of a patient without the disease testing positive.
lR value
The smaller the LR, the less likely it is that the disease is actually presen
negative likelihood ratio (LR-
he value of a negative test result.
Psychosis can be the first presentation of SLE
Psychosis due to SLE may be treated symptomatically with antipsychotics, but symptoms usually respond well to oral steroids within 2-4 weeks.
Metabolic causes of psychosis
Urea cycle disorders Acute intermittent porphyria Wilson disease Renal/liver failure Hypoglycemia Sodium/calcium/magnesium disturbances
Systemic disorder causing psychosis
Systemic lupus erythematosus
Thyroiditis
Labs in SLE
leukopenia!!, anemia, and/or thrombocytopenia
Management of allergic rhinitis
Allergen avoidance is the first step! Intranasal corticosteroids ( fluticasone spray)
Cat scratch disease
papule, nodule
fever < 50%
1-2 weeks tender and erythematous LAD
Treatment Cat scratch disease
Azithromycin
Mild cases in healthy patients often self-resolve within 1-4 months; but azithro reduces severity and lenght.
But if not very sure add clindamycin as empiric tto for s. aureus and strep
standard caloric intake recommended for enteral feeding
30 kcal/kg/day, with a lower amount of calories and higher protein can be used for patients with severe preexisting malnutrition in order to prevent refeeding syndrome.
A 1g/kg level of protein is appropriate for most patients.
Leriche syndrome
lower-extremity claudication, absent or diminished femoral pulses, and ED.
Erectile dysfunction- no erections in the morning
Ankle-brachial index
highest ankle SB pressure/highest arm SBP
=<0.9 abnormal
0.9-1.2- normal
>1.2-suggestive of calcified or uncompressible vessels.additional vascular studies needed
patients with testosterone deficiency can usually still achieve nocturnal penile erections.
true, and Testosterone deficiency can lead to a decrease in libido and erectile dysfunction
Patients with Erectile Dysfunction and atherosclerotic risk factors should receive appropriate diagnostic testing (eg, ankle-brachial index, cardiac stress testing) prior to initiating specific therapy for sexual dysfunction.
T
patient on chronic prednisone, advice for bone loss
Calcium and vit D
If there is no osteoporosis, no need for alendronate
How do corticoid cause bone loss
- Decrease Ca absorption in the gut
- Increased Renal Ca wasting
- Anti-anabolic effect on bone
- Decrease GnRH release– central hypogonadism.
stones, bones, groans, psychiatric overtones
“Stones” refers to kidney stones, nephrocalcinosis, and diabetes insipidus (polyuria and polydipsia). These can ultimately lead to renal failure.
“Bones” refers to bone-related complications. The classic bone disease in hyperparathyroidism is osteitis fibrosa cystica, which results in pain and sometimes pathological fractures. Other bone diseases associated with hyperparathyroidism are osteoporosis, osteomalacia, and arthritis.
“Abdominal groans” refers to gastrointestinal symptoms of constipation, indigestion, nausea and vomiting. Hypercalcemia can lead to peptic ulcers and acute pancreatitis. The peptic ulcers can be an effect of increased gastric acid secretion by hypercalcemia.[1]
“Thrones” refers to polyuria and constipation
“Psychiatric overtones” refers to effects on the central nervous system. Symptoms include lethargy, fatigue, depression, memory loss, psychosis, ataxia, delirium, and coma.
Left ventricular hypertrophy may also be seen.[2]
Causes of PTH independent hypercalcemia
Malignancy High vit A, VIT D Granulomatosis Milk-alkali syndrome Excess intake Ca immobilization thiazides thyrotoxicosis
Causes of priamry hyperPTH
high urine Ca
- Adenoma, hyperplasia, cancer ( high ALP,cAMP)
- Osteitis fibrosa cystica
- familial hypocalciuric hyperCa
- Lithium
Causes of secondary HYpert PTH
Renal failure ( high PO4) Vit D deficiency (low PO4) pseudohypoPTH Tumor lysis syndrome pancreatitis sepsis
Causes of 1ary hypoPTH
Surgical resection
Polyglandular autoimmune syndrome
Infiltrative disease ( Wilson, hemochromatosis, metastasis)
DiGeorge.
Corrected Ca
measured calcium + 0.8 x [4 – albumin]
Bisphosphonates are useful in decreasing bone resorption and may preserve bone mass in patients who are immobilized for extended periods.
t, can decrease bone turnover and preserve bone mass
Saw palmetto, what is it, and what is it used for
herbal preparation, benign prostatic hyperplasia. Its use has not been shown to significantly improve urinary symptoms or flow measures. In addition, saw palmetto does not appear to affect prostate-specific antigen levels or prostate size.
Kava kava, what is it, and what is it used for
anxiety and insomnia; however, its use is not recommended due to the potential risk of severe liver toxicity.
St. John’s wort ,what is it, and what is it used for
treatment of depression,insomnia,
SE:Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin
Hypertensive crisis
SE of saw palmetto
bleeding
mild abdominal discomfort
Ginkgo biloba, what is it, and what is it used for , SE
memory enhancement, SE is bleeding
Ginseng,what is it, and what is it used for , SE
improved mental performance, SE is bleeding
Black cohosh,what is it, and what is it used for , SE
Post menopausal ss(hot flashes & vaginal dryness)
SE: Hepatic injury
Licorice,what is it, and what is it used for , SE
Stomach ulcers
Bronchitis/viral infections
SE: Hypertension
Hypokalemia
Echinaceawhat is it, and what is it used for , SE
Treatment & prevention of cold & flu
sE:
Anaphylaxis (more likely in asthmatics)
Ephedra
Treatment of cold & flu
Weight loss & improved athletic performance
Hypertension
Arrhythmia/MI/sudden death
Stroke
Seizure
Cells for diagnosis of Spontanoeus bacterial peritonitis
250 cells/mm3
Hepatorenal syndrome
Patients with cirrhosis develop decreased peripheral vascular resistance secondary to splanchnic vasodilation, which can cause the decreased renal perfusion of hepatorenal syndrome.
Suspect hepatorenal syndrome, next step?
A volume challenge would be an appropriate next step to confirm a diagnosis of hepatorenal syndrome in this patient. A failure to respond would be consistent with hepatorenal syndrome
octreotide and midodrine or norepinephrine if no response
albumin for 1-3 days.
test of choice for evaluation of tension pneumothorax in the acute setting (eg, trauma bay, intensive care unit).
Bedside US- allows visualization of the parietal and visceral pleura; inability to detect lung sliding, the 2 pleural layers moving against one another during respiration, is consistent with pneumothorax.
At PE will present with hyperresonance and no fremitus
if highly suspected–tto is needle decompression or chest tube placement.
What is the best screen question for unhealthy consumption of alcholo? - single item
how many times in the past year have you had 5 (4 for women) or more drinks/day?
CAGE
Have you felt you should cut down on your drinking?
Have others annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever taken a drink first thing in the morning (eye-opener) to steady your nerves?
Audit C screen alcohol
How often do you drink alcohol?
How many drinks do you have on a typical day when you are drinking?
How often do you have 6 (4 for women) or more drinks on 1 occasion?
DX sicca syndrome
secretory deficiency (e.g. Schirmer test) Anti Ro-, la, RF, ANA
tto of Slipped capital femoral epiphysis
surgical pinning
Delay in treatment (>24 hours in unstable SCFE) can lead to avascular necrosis and femoroacetabular impingement, which increase the risk of future degenerative arthritis.
Dx scoliosis
Posteroanterior and lateral x-rays
TTO scoliosis
treatment is generally unnecessary, and no follow-up is required for mild/moderate scoliosis (Cobb angle <40 degrees, as in this patient).
severe scoliosis (Cobb angle ≥40 degrees) : orthopedic referral for surgical evaluation – high risk of chronic pain, neuro ss, pulmonary complications
Palivizumab ( Sinagis ) for prevention of bronchiolitis indications:
Preterm birth <29 weeks gestation
Chronic lung disease of prematurity
Hemodynamically significant congenital heart disease
policies for physicians sponsored by pharmacy, lecturers vs. those who just attend to conferences.
Physicians attending conferences cannot accept subsidies from the industry for travel costs, lodging, or other personal expenses.
However, it is permissible for faculty physician lecturers to accept reasonable honoraria and/or reimbursement for reasonable travel expenses.
- They should full disclose conflicts of interest
Causes of serotonin syndrome
- Serotonin drugs, especially in combination ( SSRIs, SNRIs, TCA, Tramadol)
- Serotonin drugs in combination with MAOis ( phenelzine) or LINEZOLID
- Drug overdose with Serotonin drugs
- MDMA
presentation of serotonin syndrome
Altered mental status
Autonomic dysregulation( mydriasis, agitation, tachycardia, HTN, vomiting, diarrhea) can have fever
tremor, hyperreflexia, myoclonus, rigidity
difference between serotonin syndrome and NMS
SS: serotonin drug ( SSRIs, SNRIs, TCA, tramadol) + MAOs( phenelzine) or linezolid, or intoxication with SSRIs.
altered mental status, autonomic dysregulation, hyperrefelxia, tremor, rigidity
NMS: with antipsychotics ( haloperidol, risperidone). - dopamamine antagonists.
bradykinesia and generalized “lead pipe” muscular rigidity,. NO INCREASED IN REFLEXES.
Tto of serotonin syndrome
Discontinuation of all serotonergic medications
Supportive care, sedation with benzodiazepines
Serotonin antagonist (cyproheptadine) if supportive measures fail
to avoid serotonin syndrome how is the washout period to introduce MAOis in a patient who was previously on SSRIs
5 weeks
Dx of osteomyelitis
MRI with contrast of the bone
Diabetic ulcer with polymicrobial swab detected and osteomyelitis, next step in treatment
bone biopsy with culture and sensitivity to guide treatment
antibiotics > 6 weeks
TTO of Diabetic ulcer with osteomyelitis
glucose control,
surgical debridement, weight off-loading,
revascularization (if needed),
antibiotic therapy for >6 weeks.
Serial inflammatory markers (eg, erythrocyte sedimentation rate) can help confirm treatment response.
Blood cultures are often negative (>60%) in patients with osteomyelitis;
true
TTO of sporotrichosis
cultures from aspirate fluid are typically obtained. Treatment with 3-6 months of itraconazole
Diagnosis of Hirshprung’s
Rectal suction biopsy-absence of ganglion cells
after a contrast enema that delineates theobstruction
What is associated with Hirshprungs
Up to 25% of patients with HD have another congenital anomaly (eg, renal) and approximately 10% of patients with HD have a chromosomal defect (eg, Down syndrome).
pyloric stenosis,
nonbilious emesis without abdominal distension in infants age 4–8 weeks.
Abdominal US
Dx malrotation with volvulus
Upper gastrointestinal series
Complication of compartment syndrome
AKI - rhabdomyolisis– myoglobin
How is myoglobin from rhabdomyolysis toxic for kidney
The released myoglobin is filtered and degraded in the kidney. Heme pigment from myoglobin degradation:
Is directly toxic to proximal tubular cells
Combines with Tamm-Horsfall protein to form tubular casts
Induces vasoconstriction, reducing medullary blood flow
Nex step if suspect compartment syndrome
lower extremity tissue pressure:
Pressure >30 mm Hg or delta pressure (diastolic blood pressure − compartment pressure) <20-30 mm Hg indicates significant CS.
tto compartment syndrome
fasciotomy
CK needed in compartment syndrome?
NOT PRIORITY Creatine kinase (CK) levels may be elevated in patients with crush injury with or without CS and may be helpful for predicting possible renal injury. However, waiting for CK level results may unnecessarily delay the more important diagnosis of CS.
SE of amlodipine
edema
preferential dilation of precapillary vessels (arteriolar dilation), which leads to increased capillary hydrostatic pressure and fluid extravasation into the interstitium.
other side effects of DHP CCBs: flushing headache edema
Rinne and Weber tests interpretation
see phone
Sudden hearing loss, no trauma, normal neuro exam
urgently by otolaryngology with a formal audiogram, MRI, and corticosteroid therapy.
CI tPA (6)
Presence of active internal bleeding
Bleeding diathesis (eg, platelets <100,000/µL)
Hypodensity in >33% of an arterial territory on CT scan
Presence of intracranial hemorrhage on CT scan
Intracranial surgery in the last 3 months
Blood pressure >185/110 mm Hg
Window for tPA
3-4.5hrs
ancillary studies for patients with stroke
Magnetic resonance or CT angiography of head and neck , OR dupplex carotid
EKG ( arrhythmia)
TEE Echo(presence of an intracardiac thrombus.)
** Hypercoagulability studies are NOT indicated in all patients with acute stroke. They should be ordered in those with a personal or family history of hypercoagulable disease, in young patients with no apparent etiology for stroke despite evaluation for vascular and cardiac sources, and in patients with clinical findings that suggest systemic lupus erythematosus.
labs dermatitis atopic
High serum IgE
Eosinophilia
management for atopic dermatitis (AD)
oral antihistamines, emollients to maintain skin hydration, and avoidance of excessively hot or dry environments.
Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone).
low potency and high potency topical glucocorticosteroids. in atopic dermatitis
Low-potency agents (eg, hydrocortisone) may be adequate for mild symptoms. More significant symptoms may warrant moderate- to high-potency glucocorticoids (eg, triamcinolone, betamethasone).
severe AD may require UV light.
Topical glucocorticoids are relatively contraindicated for Atopic dermatitis on the face, eyelids, or flexural areas;
calcineurin inhibitors (eg, tacrolimus) may be considered for use in these areas
Indications for parathyroidectomy in tertiary hyperparathyroidism
- Persistently elevated calcium (eg, >10.5 mg/dL), phosphorus, or PTH (eg, >800 pg/mL) levels
- Soft tissue calcification or calciphylaxis (vascular calcification with skin necrosis)
- Intractable bone pain or pruritus
How CKD leads to secondary hyperparathyroidism
CKD leads to 1. Decreased conversion from 25 hydroxyvit D to 1,25 hydroxyvit D. 2. Decrease PO4 clearance.
If low vit D, decreased absorption of Ca in the gut. And decreased clearance then increase PO4 that binds to calcium in the serum
aLL THESE LEAD TO LOW Ca IN SERUM AND THEN COMPENSATORY pth ELEVATION
secondary hyperPTH
elevated PTH levels, low/low-normal calcium levels, and low 1,25-dihydroxyvitamin D levels (despite adequate 25-hydroxyvitamin D stores).
tertiary hyperparathyroidism
result of prolonged secondary hyperPTH
autonomous PTH secretion unresponsive to rising calcium levels, resulting in hypercalcemia with very high PTH levels.bone disease with bone pain and an elevated bone-specific alkaline phosphatase (due to high bone turnover).
Stroke patients, particularly those with symptoms of dysarthria, are often at risk for oropharyngeal dysphagia.
In the setting of acute stroke, such patients should be given nothing (eg, food, drink, medications) by mouth until a swallow evaluation can be performed.
Patient with stroke passed the tPA window. Management?
evaluate swallow study
aspirin
Low-dose heparin or low-molecular-weight heparin to prevent stroke/DVT - particularly in those who have dense hemiparesis.
Types of necrotizing fascitis
Type I : underlying diabetes and peripheral vascular disease. It is generally a polymicrobial infection; some commonly isolated organisms include Staphylococcus aureus, Bacteroides fragilis, Escherichia coli, group A Streptococcus, and Prevotella species. - here you see more crepitus ( anaerobic)
type II: MC! usually occurs in individuals with no concurrent medical illness. Many patients report a history of laceration, blunt trauma, or a surgical procedure as a predisposing factor. It is typically caused by group A Streptococcus (Streptococcus pyogenes).
Microorganisms causing necrotizing fascitis
usually due to minor trauma or underlying disease( DM, glucocorticoid use, alcohol or drug abuse)
- S.pyogenes ( MC if no underlying disease, and just minor trauma)
- S aureus
- Polymicrobial
- C. perfringens ( MC in diabetics or PAD)
Presentation of necrotizing fascitis
Systemic ss: hypotension, fever, tachyardia
severe pain out of proportion
erythema
can have crepitus ( if c. perfringens or B. fragilis)
BULLAE
Tto necrotizing fascitis
debridement and antibiotics.
Drunk person who threat with suicide and now says no.
When there is concern that the patient may be suicidal, the physician must observe the patient and perform a suicide assessment when the patient is completely sober. Speaking with the boyfriend and contacting family members for collateral information would also be advisable.
Lead poisoning ss
anorexia, decreased activity, irritability, vague abdominal pain and insomnia, PICA behavior
if suspicion of lead poisoning
CBC, serum iron and ferritin levels, and reticulocyte count.
actinic keratosis (AK) tto
due to sun exposure
Topical 5FU cream for a period of 3–6 weeks.
other include: cryotherapy or surgical excision
Untreated AK is associated with?
Untreated AK has up to a 20% risk of progression to squamous cell carcinoma. For this reason, any AK lesions that are detected should be removed or destroyed
selective deficiency of IgG3
more common in adult females and is associated with recurrent sinopulmonary as well as gastrointestinal infections.
Alpha-1-antitrypsin deficiency
emphysema and liver damage, but does not increase the risk of recurrent infections.
Cystic fibrosis manifests earlier in life and does not cause gastroenteritis.
defect in the CFTR gene leads to impaired chloride and water transport this causes viscous secretions in the respiratory tract exocrine pancreas sweat glands intestines genitourinary tract Associated conditions nasal polyposis infertility in men and subfertility in women pancreatic insufficiency
ss in cystic fibrosis
a productive cough
respiratory symptoms are more prominent in adulthood
recurrent pulmonary infections
S. aureus is more common in pediatric patients (treat with vancomycin)
Pseudomonal spp. are more common in adults (treat with amikacin, ceftazidime, and ciprofloxacin)
chronic sinusitis
chronic productive cough
dyspnea on exertion
bronchiectasis
gastrointestinal symptoms are more prominent in infancy
chronic and frequent diarrhea
greasy stool with flatulence from malabsorption
secondary to pancreatic insufficiency
can lead to rectal prolapse
meconium ileus in infants (15%)
How do you measure respiratory status in Guillain Barre
frequent measurement of vital capacity and negative inspiratory force. Tidal volume.
Approximately 30% of patients with GBS ultimately require mechanical ventilation.
Patients with GBS should receive plasma exchange or IVIG if:
Nonambulatory
Within 4 weeks of symptom onset
Those who are ambulatory and recovering generally do not require treatment.
tto botulism
equine serum antitoxin and antibiotics.
course of disease in Guillain Barre
The manifestations of Guillain-Barré syndrome (GBS) tend to evolve as follows:
2 weeks of progressive motor weakness that can lead to paralysis
2-4 weeks of plateaued symptoms
Slow, spontaneous recovery over months
prognosis Guillain Barre
slow recovery
weakness may resolve spontaneously but treatments shortness the time needed for recover.
Measures to decrease rate of transmission
Contact precautions
hand washing with soap and water is more effective in C difficile spore elimination than alcohol-based sanitizers.
cleaning the patient’s environment (eg, room, medical equipment) and limiting the use of certain antibiotics (eg, clindamycin, fluoroquinolones, cephalosporins).
tto giardia
Metronidazole
tto giardia outbreak
Symptomatic individuals require metronidazole therapy.
Symptomatic students with positive stool do not need to be restrained from schoolunless they are incontinent.
NO Recreational water venues. until symptoms have resolved for 2 weeks.
Immune thrombocytopenia pathogenesis
Anti GpIIb/IIIa antibodies. Spleen macrophages consume the platelet-antibody complex. Commonly in viral illness.
ITT pathogenesis
inhibition or deficiency of ADAMS13 ( vWF metalloproteinase)- so decreased degradation of vWF.
large vWF –> increased platelet adhesion–>increased platelet aggregation and thrombosis
Labs: schystocytes, LDH,
ITT presentation
neurologic and renal ss fever thrombocytopenia microangiopathic hemolytic anemia. Petechial rash, abdominal pain
ITT tto
plasmapheresis, steroids.
Pregnancy is associated with an ADAMTS13 deficiency that becomes more pronounced with increasing gestational age and persists into the postpartum period and can precipitate TTP
t
stress fx appear in X ray
Possible abnormalities on x-ray may take up to 4 weeks to become apparent and include bone sclerosis, cortical thickening, periosteal elevation, and visible fracture line
tto of stress fracture
pneumatic splinting, reduced weightbearing, and a graduated exercise program. Most patients may resume full-intensity exercise within 12 weeks,
Hungtington disease
CAG triplet repeat expansion in one allele of the HD (huntingtin) gene on chromosome 4
severity depends on the number of repeats > 39 repeats: full penetrance allele
anticipation: number of repeats may increase with generations, presenting earlier.
Involuntary movements ( chorea, ataxia, tics) cognitive deterioration ( memory, language disability) psychiatric ss)
atrophy of caudate and putamen, as well as general cerebral atrophy
fatal. death 20 years after ss onset.
Treatment lyme
Doxy: non pregnant and children >8 years
Amoxi or cefuroxime: pregnant, lactant or children < 8
no congenital defects from lyme to baby
Types of lyme
Early localized:days to 1 m ( erythema migrans, headache, myalgias)
Early disseminated days to months (carditis AV block, cardiomypathy, VII palsy, encephalitis, meningitis, migratory arthritis, conjunctivitis, )
Late or chronic m to years ( arthritis, polyneuropathy)
why serology is not recommended in Lyme
very insensitive. IgM usually develop 1-2weeks and IgG antibodies typically after within 2-6 weeks.
BUT SEROLOGY SHOULD BE PERFORMED IN PTS WITH SIGNS OF EARLY DISSEMINATED OR LATE DISEASE
Indications for Lyme tto
must meet all 5
1.attached tick is adult or nymphal Ixodes scapularis
2. tick attached for >=36 hrs or engorged
3.prphylaxis started within 72 hrs of tick removal
4. endemic area >20%
no contraindications to doxy
iron def anemia
hemoglobin <11 g/dL, often accompanied by low mean corpuscular volume (MCV), elevated red blood cell (RBC) distribution width, and a low RBC count.
Differentiate thalassemia from iron def anemia
Mentzer index (MCV/RBC) >13 is also suggestive of iron deficiency and can help differentiate it from thalassemia;
Alpha and beta thalassemias are also microcytic but characterized by a Mentzer index <13
Mentzer index
Differentiate thalassemia from iron def anemia
Mentzer index (MCV/RBC) >13 is also suggestive of iron deficiency and can help differentiate it from thalassemia;
Alpha and beta thalassemias are also microcytic but characterized by a Mentzer index <13
testicular torsion
elevated, transverse testi
is erythematous, edematous, firm, and tender
elevating the scrotum does not tend to relieve the pain
absent cremasteric reflex
Timefram for surgery in testicular torsion
ideally within 6 hours
Epididymitis,
commonly due to chlamydia in sexually active boys, causes scrotal pain and swelling, with increased blood flow to the inflamed epididymis evident on Doppler ultrasound.
experience pain relief with scrotal elevation (Prehn sign),
