Ambulatory Flashcards
Goal hyperlipidemia levels in general population and diabetic patients and diabetic plus CAD patients
General population
Total cholesterol: less than 200 (high is 240)
LDL: less than 130 (high is 160)
Triglycerides: less than 125 (high is 250)
Diabetic
LDL less than 100
Diabetic plus CAD
LDL less than 70
Tension headache treatment
Stress reduction possible depression or anxiety
NSAIDs, acetaminophen and aspirin
If don’t respond can use migraine drugs
Cluster headache treatment
Acute attack:
Sumatriptan, O2 inhalation
Prophylaxis
Verapamil drug of choice
Ergotamine, methysergide, lithium and corticosteroids are alternatives
Pseudotumor cerebri diagnosis and treatment
Diagnosis:
Normal CSF, except increased CSF opening pressure
(tetracyclline or isotretenoin use)
Treatment:
Azetazolamide-1st line (can be with furosemide)
If have progressive vision loss: surgical intervention with optic nerve sheath decompression or lumbar peritoeal shunting
Migraine treatment
Acute attacks:
NSAIDs or acetaminophen for mild attacks
dihydroergotamine-sertonin agonist
Sumatriptan
Prophylaxiss
amitryptyline and propanolol (most effective)
verapamil, valproic acid and methysergide
NSAIDs for menstrual migraines
Treatment of postnasal drip
Fist generation antihistamine/decongestant
Allergic rhinitis: loratadine (long acting non-sedating oral antihistamine)
Acute bronchitis treatment
Codeine for symptoms
Bronchodilators (albuterol)
Antibiotics are NOT indicated
Common cold treatment
Adequate hydration-loosens secretions and prevents airway obstruction
Rest and analgesics (aspirin, acetaminophen, and ibuprofen) for releif of malaise, headache, fever and aches
dextromehtorphan, codeine for cough suppression
antihistamines for rhinorrhea/sneezing
Diagnosis and treatment of acute sinusitis
Diagnosis
Cold for more than 8-10 days
purulent discharge from one of the turbinates
Impaired light transmission in maxillary sinuses
tenderness to palpation
Treatment:
Antibiotics and decongestants for 1-2 weeks
Saline nasal spray aids drainage
Decongestants: pseudoephdrine or oxymetazoline-facilitates sinus drainage and relieves congestion-no more than 3-5 days
antibiotics: amoxicillin-clavulanate, TMP/SMX, levofloxacin, moxifloxacin, and cefuroxime
Antihistamines: use sparingly because can increase secretion thickness
Chronic:
broad spectrum penicilinase resistant antibiotic
Refer to otolaryngologist
Diagnosis and treatment of sore throat
Diagnosis:
Throat culture: takes 24 hours but is most accurate
Rapid strep test: takes one hour
Mono suspicion: obtain appropriate blood tests (monospot)
Treatment: strep throat: penicillin for 10 days viral: symptomatic treatment Mono: advise rest and acetaminophen/ibuprofen Symptomatic treatment: Acetaminophen or ibuprofen gargling with warm salt water Humidifier Sucking on throat lozenges, hard candy, flavored frozen desserts
Dyspepsia workup and treatment
Dyspepsia Typical GERD-acid support NSAID use-discontinue Neither-alarm symptoms or >55=endoscopy no alarm symptoms and less than 55=H. Pylori test \+H. Pylori test=treat H. pylori -H. Pylori test=PPI for 4-6 weeks
Alarm symptoms: weight loss, bleeding, dysphagia, persistent vomiting, or early satiety
Also avoid alcohol, caffeine, stop smoking, raise head when sleeping
Diagnosis and treatment of GERD
Diagnosis
Endoscopy with biopsy-test of choice if heartburn refractory to treatment, accompanied by dysphagia, odynophagia or GI bleeding
Upper GI series (barium contrast study) if strictures/ulcerations suspected
24 pH monitoring is most sensitive and specific but normally unnecessary
Treatment:
Phase I: diet (avoid fatty foods, coffee, alcohol, OJ, chocolate, avoid large meals before bed time), sleep with trunk of body elevated, stop smoking
Antacids after meals and at bedtime
Phase II: add an H2 blocker
Phase III: switch to PPI
Phase IV: add promitility agent (metoclpramide or bethanechol)
Phase V: increase dose of PPI and/or H2 blocker
Phase VI: antireflux surgery if medical treatment does not work, respiratory problems due to aspiration, severe esophageal injury (nissen funcoplication)
Indications for diarrhea diagnostic studies
Chronic diarrhea >4 weeks severe illness or high fever presence of blood in the stool Severe abdominal pain Immunodeficiency Signs of volume depletion
Lab tests to order Stool WBCs Stool for ova and parasites Stool culture Stool for C. difficile culture and toxin Stool for Giardia Ag (ELISA)
Indications for hospitalization of diarrhea
dehydration
unable to tolerate or hold down PO fluids
Blood diarrhea
high fever, toxic appearance
Treatment of acute diarrhea
No complications: rehydrate and consider loperamide monitor electrolytes (metabolic acidosis with hypokalemia)
Complications (blood diarrhea, high fever, severe diarrhea)-ciprofloxacin for 5 days or specific antibiotic for bug
If diarrhea lasts longer than expected: sigmoidoscopy with biopsy
Treatment of shigella diarrhea
TMP/SMX
Treatment of campylobacter diarrhea
erythromycin
Treatment of irritable bowel syndrome
diarrhea: diphenoxylate, loperamide
constipation: colace, psyllium, cisaride
Avoid dairy products and excessive caffeine
Tegasrod maleate (zelnorm) serotonin agonist works in women
Treatment of nausea and vomiting
fluid replacement is first step: use 1/2 Normal saline with potassium replacement
Prochlorperazine (compazine) and promethazine (phenergan)
Liquid diet
Avoid large meals and fatty meals
Nasogastric suction may improve symptoms
Correct electrolytes: metabolic alkalosis with hypokalemia
Treatment of hemorrhoids
painless BRBPR
General: Sitz bath Ice packs Stool softeners High fiber and high fluid diet topical steroids
Rubber band ligation for internal hemorrhoids
Surgery if do not respond to conservative methods-severe prolapse, strangulation, very large anal tags or fissure is present
Goal for hypertension in general population vs diabetic
General population: less than 140/90
Diabetic: less than 135/85
Most commonly injured ankle ligament
anterior talofibular ligament
when are ankle radiographs not necessary
patient is able to walk four steps at the time of injury and at time of evaluation
No bony tenderness over distal 6 cm of either malleolus
Diagnosis of osteoarthritis
Plain radiographs are the initial test-joint space narrowing, osteophytes, sclerosis at end plates, subchondral cysts
MRI is indicated if neurologic findings or before surgery
Treatment:
Avoid activities involving joint
Weight loss, physical therapy (swimming)
Use can or crutches
Acetaminophen is first line
then NSAIDs or celecoxib
intra-articular injections of corticosteroids
Viscosupplementation
Surgery for serious disability: total joint replacement
Osteoporosis diagnosis and treatment
Diagnosis
DEXA scan: women >65, postemenopausal women less than 65 with 1+ risk factors, men with risk factors
If normal repeat in 3-5 years
Treatment: Diet: 1200 g of calcium, 800 international units of Vitamin D Smoking cessation Reduce alcohol intake weight bearing exercise
Pharmacological: postmenopausal women with T score less than 2.5 or fragility fracture, high risk postmenopausal women with score -1 to -2.5
Bisphosphonates: inhibit bone resorption-first line
PTH therapy: max of 24 months
Calcitonin: short term therapy
Diagnosis and treatment of age related macular degeneration
Diagnosis: loss of central vision-peripheral vision preserved
Distortion of straight lines
Treatment
Exudative: sudden visual loss due to abnormal vessel formation (anti-VEGF inhibitors)-Ranibizumab
Nonexudative: atrophy and degneration of central retina-OTC vitamins antioxidant
Open angle glaucoma diagnosis and treatment
Diagnosis: enlargment of optic cup (cupping)
Impaired outflow of aqueous humor
Painless increased IOP
Visual field loos sparing central vision
Tanometroy measures IOP
Opthalmoscopy
Gonioscopy: gold standard visualizes the anterior chamber
Visual field testing: monitors
Treatment
B blocker, a agonist, carbonic anyhydrase inhibitor, and or prostaglandin analog
Laser or surgical treatment if refractory
Closed angle glaucoma diagnosis and treatment
Opthalmologic emergency can lead to irreversible vision loss
Red painful eye
Sudden decrease in visual acuity,, seeing halos
N and V
Pupil is dialted and nonreactive
Diagnosis Tanometry-measures IOP Opthalmoscopy Gonioscopy: gold standard Visual field testing
Treatment
Opthalmic consult
emergently lower IOP
Pilocarpine drops, IV acetazolamide and oral glycerin
Laser or surgical iridectomy is definitive
Viral conjunctivitis diagnosis and treatment
watery discharge, pereauricular lymph node palpable, eye stuck shut
cold compress, strict hand washing, topical antibiotics possible
Bacterial conjunctivitis diagnosis and treatment
Diagnosis: S. pneumo or gram - (gonorrhea)
Mucopurulent discharge with crusting
rapid onset
Treatment
Acute: erytormycin, ciprfloxacin (contacts), sulfacetamide
Hyperacute: one time dose of ceftriaxone IM (gonnococcal) and topical therapy
Amaurosis Fugax
Transient monocular loss of vision
Embolization of cholesterol plaque from the carotid arterial system
Reperfusion established and vision returns
Diagnosis: carotid ultrasonography (duplex study of neck) and cardiac workup
Diagnosis and treatment of obesity
Diagnosis BMI: 19.5-24.9 is normal 25-30 is overweight 30-40 is obese 40+ is morbidly obese
Treatment
Lifestyle modifications
Orilistat can be used for 4 years
Bariatric surgery if BMI over 40 (roux-en-Y bypass)
