Ambulatory Flashcards
Medication tx for BPH
1st line = alpha blockers (-sin)
2nd line = 5-alpha reductase inhibitor (prevents T –> DHT; DHT causes hyperplasia) ex. finasteride
Combo if prostate large
Symptoms of BPH
Weak stream Intermittency Straining Emptying incomplete Hesitency Post-void dribbling Nocturia
Indications for BPH surgery
Urinary retention Recurrent UTI Recurrent or persistent gross hematuria Bladder stones Renal insufficiency
Mammogram screening regular risk women
Q2-3y 50-74
No routine clinical breast exam alone or in conjunction with mammography to screen for breast CA
No need to recommend routine breast self-exam
Mammogram screening for high risk women
Q1 yr 40-74
Colorectal CA screening for average risk individual
Begin at age 50
FOBT q1-2yr
Colonoscopy/flex sig q10y
No screening after age 75
Colorectal CA screening for individual with +ve fam hx for HNPCC or FAP
- Genetic counselling and special screening
- HNPCC: colonoscopy q1-2y starting age 20 or 10y younger than earliest case in family (whichever first)
FAP: Sigmoidoscopy annually, starting age 10-12
AAPC: Colonoscopy annually starting age 16-18
Colorectal CA screening for individual with 1st degree relative with CA or adenomatous polyp at age <60 or 2 or more 1st degree relatives with polyp or colon CA at any age
Colonoscopy q5y
Begin age 40 or 10y younger than earliest polyp or cancer case in family
Colorectal CA screening for individual with one 1st degree relative with cancer or adomatous polyp affected at age >60 or 2 or more second degree relatives with polyps or colon CA
Average risk screening
Begin at age 40
Colorectal CA screening for individual with one second degree relative or third degree relative affected
Average risk screening
Begin at age 50
Cervical CA screening
Pap smear age >/= 25 q3y
Once age >/= 70, if 3 normal tests in a row and no abnormal tests in last 10y, can discontinue screening
Cervical CA screening, inadequate sample
Repeat cytology in 3mo
Abnormal squamous cell of unknown significance (ASCUS)
<30y.o. = repeat cytology in 6mo
> 30 = HPV DNA testing
If Positive –> colposcopy
Abnormal squamous cells cannot rule out high grade squamous intraepithelial lesion (ASC-H)
Colposcopy
Atypical glandular cells of unknown significance (AGUS)
Colposcopy +/- endometrial sampling
Low grade squamous intraepithelial lesion (LSIL)
Colposcopy OR repeat cytology in 6mo
Important points for cervical screening
- Pregnant women and women who have sex with women should follow routine cervical screening
- Hysterectomy = total –> only swab vaginal vault if hx of uterine malignancy/dysplasia
= subtotal –> continue regular screening
Routine prostate CA screening
PSA test NOT RECOMMENDED for any age group
Dyslipidemia screening
q1-3y in males >40y.o. and females >40y.o. or who are menopausal
OR at any age with additional dyslipidemia risk factors
Framingham Risk Score
10yr mortality risk
<10% = low risk
10-19% = Moderate risk
>20% = High risk
Target for dyslipidemia tx
=2mmol/L LDL-C or >/= 50% decrease
When to tx dyslipidemia
High risk –> tx all
Moderate risk –> tx if LDL >/= 3.5mmol/L, ApoB >1.2g/L or Non-HDL-C >4.3; or men >/=50 or women >/= 60 with one additional RF (ie. low HDL, impaired fasting glucose, high waist circumference, smoker, HTN)
Low risk –> tx if LDL >/= 5 or familial hypercholesterolemia
Monitor lipids q6-12mo if adequate response on statin
Statin MOA
HMG-CoA reductase inhibitors
Other dyslipidemia tx option
Ezetimibe (cholesterol absorption inhibitor) - post-ACS, combine with statin for reduced mortality benefit
Conditions that automatically require statins
DM (age >40 or >30 with 15yr duration or microvasc complications) CKD AAA Clinical atherosclerosis Very sig LDL or cholesterol fam hx
Contraindications to inactivated vaccines
Hx of anaphylaxis to previous dose of vaccine, or to component of vaccine
Contraindications to live vaccines
Hx of anaphylaxis to previous dose of vaccine, or to component of vaccine, severely immunocompromised pts (ie. HIV with CD4 <200), pregnant patients
ADLs
DEATH Dressing Eating Ambulating Toileting Hygiene
IADLS
SHAFT Shopping Housekeeping Accounting Food prep Telephone/Transportation
Geriatric giants
Immobility
Instability
Incontinence
Intellectual impairment
2 month immunizations
- DTaP, Hep B, Hib, Polio (IPV)
- Pneumococcal
- Rotavirus
- Men conjugate C
4 month immunizations
- DTap, Hep B, Hib, IPV
- Pneumococcal
- Rotavirus
6 month immunizations
- DTaP, Hep B, Hib, IPV
2. Hep A (offered to Aboriginal patients)
12 month immunizations
- Pneumococcal
- Men conjugate C
- MMR
- Varicella
18 month immunizations
- DTaP, IPV, Hib
2. Hep A (offered to aboriginal patients)
4 year immunizations
- DTaP, IPV
- MMRV
- Hep A (offered to aboriginal patients)
Live vaccines
Rotavirus Varicella MMR Nasal influenza Shingles/Zoster
Ventolin
Salbutamol
SABA
Blue puffer
Atrovent
Iptratroprium bromide
SAMA
Salmeterol/SereVent
LABA
Aclidinium bromide
LAMA
Lumbar strain
Acute onset (possibly with injury)
Worse with activity, relieved with rest
Paraspinal spasm/tenderness
Disk herniation
Worse with sitting
Radiation to lower extremities in dermatomal pattern
+ve straight leg raise test
MRI if sx >4wks
Degenerative disk disease
Worse with flexion/sitting
Chronic
Facet disease
Worse with extension, standing, walking
Spondylolisthesis
Leg pain > back pain
Worse with extension, better with flexion
Worse with activity
Spinal stenosis
Relieved with sitting/flexion
Lower extremity parenthesis
Neurogenic claudication
Ankylosing spondylitis
Younger male Morning stiffness, night pain Relieved by activity SI, spinal, hip and shoulder Peripheral arthritis (dactylitics) HLA-B27 2 forms: ankylosing spondylitis (radiographic evidence of sacroilitis) or non-radiographic asSpA
Reactive arthritis
Hx of recent GI/GU infection
Lower extremities commonly infected
Uveitis, arthritis, urethritis
Psoriatic arthritis
Asymmetric and distal joint involvement
SI joint involvement
Common viruses associated with common cold
Rhinovirus** Coronavirus Adenovirus Respiratory syncytial virus (RSV) Influenza Parainfluenza Coxsackie
Mono virus
Epstein barr virus
Mono triad of symptoms
Fever
Tonsillar pharyngitis
Lymphadenopathy
Mono features that distinguish it from strep
Significant fatigue
Posterior cervical chain or generalized adenopathy
Splenomegaly
Mono lab findings
Atypical lymphocytosis
Positive monospot test
Centor criteria for GAS
Cough absent Exudate on tonsils Nodes (anterior cervical chain) Temp >38 young (+1 for <15) OR old (-1 for >45)
0-2 = no swab, no tx 3 = swab, no tx until +ve 4+ = swab, tx with abx prophylactically, stop if -ve
GAS abx choice
Penicillin (or erythromycin for its allergic to penicillin)
Common bacterial causes of otitis media
Strep pneumo (50%) H influenzae (30%) M catarrhalis GAS S. aureus
Otitis media triad
Otalgia
Fever
Conductive hearing loss
1st line medical tx for otitis media
Amoxicillin 75mg/kg/d to 90mg/kg/d divided into TID for 10d
2nd tx for otitis media after failed first line (no improvement in 2-3d)
Amoxclav: amor 90mg/kg/d + clay 6.4mg/kg/d divided into BID for 10d
If amoxclav fails then consider Ceft 50mg/kg IM/IV OD x3 doses
BMI
< 18.5 = underweight 18.5-24.9 = normal 25-29.9 = overweight 30-34.9 = Obesity class I 35-39.9 = Obesity class II 40+ = Obesity class III
Normal waist circumference
Men = 102cm (40in) Women = 88cm (35in)
Weight loss >___% is clinically significant for reducing CVD risk
5
Dyslipidemia: Normal b/w
Total cholesterol <5.2
HDL >1
LDL <3.5
Triglycerides <1.7
Gonococcal disease tx
Ceftriaxone 250mg IM single dose
Azithromycin 1g orally in single dose
If no risk factors, screen 6-12mo post-tx
If risk factors, test of cure (culture 4d post-tx or urine PCR 2wk post tx)
Non-gonoccocal disease tx
Azithromycin 1g PO + Ceftriaxone 250mg IM
Genital herpes tx
Acyclovir 200mg PO 5x/d for 5-10d or Valacyclovir 1000mg PO BID x10d
If recurrent:
Acyclovir 200mg PO 5x/d for 5d or 800mg PO TID x2d
OR valacyclovir 500mg PO BID x3d or 1000mg PO OD x3d
Syphillis
Benzathine penicillin G IM
Continuous F/U until seroneg
Asthenia
sense of weariness, exhaustion
Diabetes screening
> 40y.o., screen q3yrs
PID minimal clinical criteria
- Lower abode pain
- Cervical motion tenderness
- Adnexal tenderness
PID - Inpt tx regimens
- Cefoxitin 2g IV q6h + Doxycycline 100mg PO q12h (switch to oral 24-48h after clinical improvement)
OR 2. Clindamycin 900g IV q8h + gentamicin loading dose 2mg/kg IV then 1.5 mg/kg IV q8h
PID - Output tx regimens
- Ceftriaxone 250mg IM single dose + Doxycycline 100mg PO BID for 14d
IF gonorrhoea not cause: Levofloxacin 500mg PO daily for 14d
Top 3 renal stones
- Ca-oxalate
- Struvite
- Uric acid
Beck’s Triad of cardiac tamponade
- Muffled heart sounds
- Elevated JVP
- Hypotension
Gold standard imaging for PE
Pulmonary angiogram
PE triad of tests for low pre-test probability
- CXR
- ECG
- D-dimer
D-Dimer level suggestive of PE R/O
If <50: <500 U/mL
If >50: < age x 10
Criteria for outpatient PE management
MUST MEET ALL CRITERIA
- Vital signs stable
- SpO2 >92% on RA
- Chest pain resolved
- No hx of cardiopulmonary disease
- No syncopal event
PE management
IV UFH (monitor aPTT q6h, keep within 50-90)
ACA infarct
Contralateral leg weakness > arm weakness
MCA infarct
Most common stroke
Contralateral weakness/numbness affecting arm > leg
If DOMINANT hemisphere affected (usually left) = aphasia
Homonymous hemianopsia and gaze preference TOWARD side of lesion
If NON-DOMINANT hemisphere affected = inattention, neglect, extinction of simultaneous stimulation
PCA infart
Its may be unaware of deficits
Motor minimal
Visual abnormalities - homonymous hemianopsia
Light touch and pinprick may be sig reduced
Vertebrobasilar
Crossed neuro deficits (ipsilat CN deficits with contralateral weakness)
Dizziness, vertigo, diplopia, dysphagia, ataxia, CN palsies and limb weakness
Basilar
Severe quadriplegia, coma, locked in syndrome
Cerebellar
Sudden inability to walk or stand (drop attack)
Vertigo, nausea, vomiting, back pain
Lacunar
Pure motor OR sensory deficits
Commonly a/w chronic HTN
TPA absolute contraindications
Intracranial hemorrhage on CT Neurosurg, Sig head trauma or prior stroke in prev 3 mo Symptoms suggest SAH Hx of prev intracranial hemorrhage Intracranial neoplasm, AVM, aneurysm Activei eternal bleeding Suspected/confirmed endocarditis Elevated BP (>185SBP or >110DBP) Acute bleeding diathesis (plt <100; heparin within 38h causing elevated aPTT; anticoagulant with INR >1.7 or PT >15s; use of thrombin or factor Xa inhibitors with elevated lab tests) Blood glucose <2.7
Ischemic stroke treatment
tPA within 4.5h if no contraindications + ASA or clopidogrel in 24h
If tPA window missed/CI, ASA or clopidogrel given right away
Thrombectomy in anterior circulation stroke (within 6h of last seen normal); in posterior circulation stroke no time cutoff
If pt candidate for thrombectomy and thrombolysis, do both
No evidence for anticoags unless secondary prevention in fib and embolic strokes
Goal BP in AAA
100-120 SBP
Acute elevated BP management
- Nitroprusside + Propranolol
OR 2. Labetolol
Auscultation sound for pericarditis
Friction rub best heard at LLSB
Pericarditis ECG stages
1 (hours to days): Diffuse ST elevation in inferior and anterior leads; may have PR depression (pathopneumonic)
2: transiently normal
3: Deep symmetrical T-wave inversion
4: Permanent T-wave inversion or normal
Pericarditis tx
- Pain management - Indocid 50mg q8h +/- corticosteroid if very severe
- Abx +/- surgical drainage
BP d/t pulmonary edema management
Nitro SL 0.4mg; 2 sprays q5min
IV morphine 1-3mg
IV furosemide 60-120mg
Eclampsia BP target
DBP <100
HTN with stroke symptoms BP target
DBP < 115-120
Eclampsia BP tx
IV Mg + IV Hydralazine
HTN with CP or MI BP target
SBP < 170
DBP <110
Hypertensive urgency
Severely elevated BP (sys BP >220 or diastolic >120) with no evidence of target organ damage
Hypertensive emergency
Severely elevated BP with target organ damage
Ulnar gutter
Prox phalanx #D4-5
Metacarpal #D4-5
Boxer’s #
Radial gutter
Prox phalanx #D2-3
Volar slab
Metacarpal #D2-3
Thumb spica
Thumb fractures (phalanx or metacarpal) UCL tear
1st line tx for otitis media
Watchful waiting for 48-72h IF:
- pt >60mo
- no hx of immunodeficiency, chronic dz, abnormality of head/neck, hx of complicated otitis media, DS
- non-severe (fever <39, mild otalgia)
- capable parents
Reasons to start abx for otitis media
- has had abx in past 90d
- does NOT attend daycare
- very unwell (severe otalgia or mod-severe systemic illness)
- unwell after48h analgesics
Reasons to refer to ENT for otitis media
3+ in 6mo or 4+ in 12mo (may require myringotomy & tympanovstomy)
facial paralysis
mastoiditis
Test of choice for pharyngitis
Rapid antigen detection test for strep antigens from throat swab
Management of acute asthma exacerbation
O2 to keep SpO2 93-95%
Ventolin 5mg neb + Atrovent 0.5 mg neb continuous or q20min for 1h
Methylprednisone IV 40-60mg OR prednisone 60mg PO
Mg Sulfate 2g IV over 20min
D/C instructions for acute asthma exacerbation
SABA q4-6h PRN
Pred 40-60mg/d for at least 5 days
Resume/start inhaled GCS
Gonorrhea gram stain
Gram negative diplococci
CT head rule
High risk: Age >/= 65 Basilar skull fracture signs (hemotympanum, battle sign) Consciousness (GCS <15) Depressed or open skull fracture Emesis >/= 2
Medium risk:
Retrograde amnesia >/= 30min
Dangerous mechanism (led hit by vehicle, ejected from vehicle, fall from 3ft or 5 stairs)
Canadian C-Spine Rules
Paresthesias in extremities
Age >/=65y.o.
Dangerous mechanism (Fall from >/=3ft/5 stairs, axial load injury, high speed MVC, bicycle collision, MVC)
Low risk: Sitting upright Ambulatory at any point Late onset neck pain no midline tenderness Simple rear-ended MVC
Preferred regimens for urethritis/cervicitis
Cefixime 400mg PO single dose
Ceftriaxone 125mg IM + doxy 100mg PO BID for 7 days
Azithromycin 1g PO single dose
Preferred regimens for chlamydia/gonorrhea
Cefixime 800mg PO single dose + doxy 100mg PO BID for 10d
Ceftriaxone 250mg IM single dose + doxy 100mg PO BID for 10d
Ofloxavin 300mg PO BID for 10d
Meniere’s disease
Vertigo, fluctuating hearing loss that eventually results in permanent hearing loss, tinnitus and aural fullness
Trauma IV fluid resuscitation
Adult: 2L
Child: 20cc/kg over 10min
Trauma acute hemorrhagic resuscitation
Adults: 2U pRBCs
Children: 10cc/kg pRBCs
Cardiac Arrest - VTach or VFib ACLS algorithm
Defibrillate (120-200J if biphasic; 360J if monophonic) –> CPR for 2 min –> Epi 1mg q3-5min –> Amiodarone or lidocaine
5Hs and 5Ts of cardiac arrest
Hypoxia Hypovolemia Hypo/hyperkalemia Hypothermia Hydrogen ion (acidosis)
Tamponade Tension pneumo Thrombosis pulmonary (PE) Thombosis cardiac (MI) Toxins
ACLS Bradycardia algorithm
Look for cause but don’t delay tx –> Airway if needed –> monitor HR and rhythm and BP –> if hypotensive/shock –> atropine 0.5mg q3-5min to 3mg –> if not working, use transcutaneous pacing or dopamine infusion or epi infusion
Common causes of altered mental status
TIPS AEIOU Trauma Infection Psych SAH, stroke, space occupying lesion, shock
Alcohol/drugs Endocrine, electrolytes, environmental, epilepsy, encephalopathy Insulin Oxygen Uremia
DONT cocktail for coma
D50W (50ml of 50%) - give to all unless confirmed glucose is ok with glucometer
Oxygen
Naloxone (if suspected overdose - unresponsive, hypoventilation, pinpoint pupils) - titrate from 2mg to 0.4mg or less IV/SC to avoid precipitating acute withdrawal
Thiamine (100mg IV) for patients at risk for vitamin B1 deficiency (EtOH, malnourished) to tx and prevent acute Wernicke’s encephalopathy
Wernicke’s encephalopathy is caused by ____ deficiency
Vitamin B1
Benzodiazepine antidote
Flumenazil (rarely used in OD setting as can cause withdrawal and lower sz threshold)
Mostly used in pt that normally does NOT use benzos
Additional therapy for Na+ ch blocker induced dysrhythmia
Sodium bicarb
Additional therapy for digoxin induced dysrhythmias
Digoxin antibodies
Additional therapy for theophylline (PDE-I inhibitors) induced dysrhythmias
Beta blockers
Examples of Na+ ch blocking drugs
Tricyclic antidepressants (= most common)
Type Ia antiarrhythmics (quinidine, procainamide)
Type Ic antiarrhythmics (flecainide, encainide)
Local anaesthetics (bupivacaine, ropivacaine)
Antimalarials (chloroquine, hydroxychloroquine)
Dextropropoxyphene
Propranolol
Carbamazepine
Quinine
Big 3 causes of bradycardia
BB
CCB
Digoxin
Toxin-induced seizure management
Benzos
Barbiturates
Propofol
Paralyzation and general anesthesia
Isoniazid
ABx to tx TB
Isoniazid seizure antidote
Pyridoxine
Antiviral drops for herpes simplex keratitis
Viroptic 1% drops q1h up to 9/day for 7-14d
Zovirax 800mg 5/day for 10d
Classic finding for herpes simplex keratitis
Fluorestein staining showing dendritic keratitis
Alcohol intoxication treatment
Benzos
Thiamine
Anticholinergic antidote
Physostigmine (inhibits acetylcholinesterase)
Anticholinergic toxidrome
Altered mental status, hallucinations, tachycardia, dilated pupils, dry/flush skin, decreased bowel sounds, urinary retention
Cholinergic toxidrome
SLUDGE
Salivation, lacrimation, urination, defecation, GI upset, emesis
Cholinergic antidote
Atropine
Opiate toxidrome triad
Respiratory distress, depressed mental status, small pupils
Opiate antidote
Naloxone - quick response diagnostic
If no response, consider antipsychotic or clonidine OD (presents similarly)
Sympathomimetic toxidrome
Hyperactivity, agitation, mydriasis, tacky, HTN, diaphoresis, hyperthermia
Sympathomimetic OD treatment
Benzos, possibly antipsychotics for sedation
If dehydration and rhabdo, treat with IV fluids
If hyperthermia, require cooling
Blood toxicology orders
Acetaminophen Salicylates Electrolytes AG ECG
Major ECG changes for Na+ ch blockade OD
QRS widening
RAD
Sinus tachy
Triad of wernicke’s encephalopathy
Altered mental status
Ataxia
Ophthalmoplegia
Malignant hyperthermia tx
Dantrolene
Characteristic symptom of isoniazid OD
Seizures
Tx with Pyridoxine
Characteristic symptom of Iron OD
N/V
Acetaminophen antidote
N-acetylcysteine
Salicylate antidote
Sodium bicarb infusion, dialysis
TCA antidote
Sodium bicarb
Enhanced elimination often used for phenobarbital and salicylate
urinary alkalization with sodium bicarb in D5 and 20mmol of KCl
NAC time window for acetaminophen OD
> 4h but <24h
Best if within 8h
Administer regardless if acetaminophen level and AST/ALT elevated
Bacterial conjunctivitis treatment
Tetracycline 250mg q4h for 2-3 weeks
If pregnant/infant, erythromycin
Most common cause of mucopurulent conjunctivitis
- S. pneumonia
- S. aureus
+ Hemophilus, proteus, klebsiella
Most common cause of purulent conjunctivitis
N. gonorrhoea
Treatment for traumatic iritis
Cycloplegics
Topical steroids
Clinical finding in iritis
Positive contralateral photophobia test
Acute iritis clinical finding
Many cells in anterior chamber and little flares
Chronic iritis clinical finding
Increased flares and few cells
Special note about herpes simplex keratitis
AVOID STEROIDS
Causes of iritis
Sepsis (TB, H. simplex, H. zoster, adenovirus) Inflammatory joint disease Malignancy Post-trauma Idiopathic
Normal intraocular pressure
10-22mmHg
Needs to be <40mmHg for iris perfusion
Timolol MOA
Decreases production of aqueous and causes IOP to fall within 30 minutes
Needs to be taken with miotic
Diamox MOA
Decreases aqueous production
Acute closed angle glaucoma immediate tx
Timolol (0.25 or 0.5% one drop into affected eye; repeat once in 10min)
Diamox (500mg IV and 250mg q6h)
Pilocarpine (2% for blue eyes-4% for brown eyes, one drop q15min for 1-2h)
Drugs that can be treated with dialysis
salicylates, lithium, ethylene glycol, methanol
Drugs that can treated with whole bowel irrigation
Best used for pts ingesting toxins poorly bound to AC (iron, lithium, lead), medications that dissolve slowly (CCB, Lithium, theophylline, or meds that clump in GI tract (enteric coated aspirin)
Whole bowel irrigation
Polyethylene glycol
Wound management
Inflammatory - 0-5d phagocytosis of bacteria and dead tissue (help with debridement)
Epithelialization - 0-5d watertight covering forms in 24-48h
Proliferation - 5-15d fibroblasts cause wound contraction (affected by host factors)
Maturation - 15d-18mo (collagen reorganization)
Pathognomic injury from shaking trauma
Retinal hemorrhage
Failure to thrive
Decrease in growth parameters >2 STDEV or do not follow normal growth curve
Failure to thrive order of losses
Weight > height > head circumference
Croup AKA
Laryngotracheitis
Pertussis clinical picture
Wheezing, inspiratory/expiratory stridor, SOB, post-tussive emesis, post-jussive whooping
Peds bronchitis
Wheezing in infant <2yo
Typically RSV
Asthma mild, mod severe based on PEFR
Mild >80%
Mod 50-80%
Severe <50%
Treatment of moderate asthma
3 doses of Ventolin + Atrovent MDI
Supp O2 if sat <92%
Prednisone 1mg/kg PO
Cont prednisone for 5d post-d/c
Treatment of severe asthma
3 doses of ventolin + atrovent MDI
Supp O2
IV access, lytes and blood gases
Admit!
Fever of unknown origin in child
Daily temp >/= 38.5C for >2 weeks without discernible cause
Common: EBV, osteomyelitis, Lyme dz, HIV, malignancy, inflammatory d/o
Most common organism a/w occult bacteria in children
Strep pneumonia
Tx of occult bacteremia in neonates
Ampicillin & gentamicin or cefotaxime
Tx of occult bacteremia in >1mo
Vancomycin & cefotaxime
UTI tx for >2mo, non-toxic, well-hydrated child
IV ceftriaxone –> 3rd gen oral cephalosporin (ie. cefixime)
Highest bacterial risk causing meningitis
Strep pneumo
Bacterial meningitis LP findings
WBC >1000
High protein
Low glucose (<50% serum glucose)
Viral meningitis LP findings
WBC <300
Normal protein
Normal glucose
Ischemic optic neuropathy
Swelling of optic disc**
Vision loss**
Visual field loss
Splinter haemorrhages
Homonymous hemianopsia
Occlusion PCA causing occipital lobe infarction
Always order MRI/CT
Cortical blindness
Normal pupillary reflexes and normal fundoycopic exam but complete vision loss
Acute angle closure glaucoma clinical picture
Red, teary eye with hazy cornea and fixed mid-dilated pupil
Pain, nausea, coloured rainbows/halos around light
Eyes feel firm to palpation
Examining for glaucoma
q2-4yrs for patients >40y.o
African Americans q3-5 yrs between 20-39y.o.
P/E of glaucoma
Cup:Disc ratio > 0.5
Disc hemorrhages also possible sign of glaucoma
Cup:disc asymmetry of >0.1 between 2 optic nerves
Age-related macular degeneration
Drusen
Degenerative changes in RPE
Choroidal neovascular membranes
Hemorrhage
Tests to identify choroidal neovascularization in wet AMD
Fluoroscein angiography
Ocular Coherence Tomography
Uveitis clinical picture
Blurred vision, pain, photophobia
Keratitis clinical picture
Blurred vision, pain, photophobia
Bacterial conjunctivitis clinical picture
Tearing, exudate, eyelids stuck together
Viral conjuncitivitis clinical picture
Tearing, foreign body sensation, photophobia, may have viral symptoms
Rainbow/coloured halos around a point of light should make you think of…
corneal adema secondary to abrupt rise in IOP (acute glaucoma)
Avoid topical corticosteroids in which eye disease
Herpes simplex keratitis
Fungal keratitis
Other dangers of topical corticosteroid use in eye diseases
Can lead to cataract disease
Can increase IOP –> optic nerve damage
Scleritis/uveitis tx
Refer to ophtho for steroids
Binocular diplopia
Trauma –> muscle entrapment or CN palsy
CN palsy
Thyroid eye dz
Orbital inflammation
Monocular diplopia
Refractive error
Dry eye
Cataract
Intraocular lens subluxation
CNIII palsy
Eyelid ptosis
Dilated pupil and poorly reactive
Eye loses ability to elevate (SR), depress (IR), and adduct (MR) = eye is turned OUTWARD and slightly DOWNWARD
Undergo MRI/CT imaging
Horner’s Syndrome
Loss of SNS tone d/t carotid dissection, cavernous carotid aneurysm and apical lung tumour
Small pupil (myosis) + ptosis + anhydrosis
Dx with apraclonidine drops (alpha agonist) –> elevation of eyelid and dilation of pupil
PTs should get MRI
Argyll Robertson Pupils
Tertiary syphillis affecting midbrain –> small, irregular pupils in response to light, still ok on accommodation
CN IV palsy
Vertical diplopia, especially on downgaze
CN VI palsy
Horizontal diplopia
INO
Slow and weak adduction of one eye and nystagmus of abducting eye in lateral gaze
INO causes in adults, young adult, children
Adults - brainstem microvascular disease (recovers in weeks or months)
Young adults - trauma, demyelinating dz, brainstem hemorrhage
Children - pontine glioma
Always get MRI and consider myasthenia gravis
3 most common forms of nystagmus
At extremes of lateral gaze
Pt on nystagmogenic meds (ie. anti-epileptics, barbiturates, sedatives)
Searching/Pendular nystagmus (congenital)
Characteristics of ischemic optic neuropathy
Sudden, painless, unilateral loss of vision
Orbital floor is made up of…
Maxilla
Zygoma
Palatine
Ophthalmologic changes during pregnancy
Lowering of IOP
Transient loss of accommodation
Decreased corneal sensitivity
Anterior uveitis
Inflammation of iris and ciliary body
Posterior uveitis
Inflammation of choroid
Most common rheumatoid conditions a/w dry eyes
SLE
RA
Sjogren’s
PPRF lesion
Slow/absent horizontal saccades towards side of lesion
Topiramate (anticonvulsant) ocular S/Es
Closed angle glaucoma d/t ciliary body swelling
near sightedness
Macular folds
Anterior uveitis
Ethambutol ocular S/Es
TB abx
Optic neuropathy
Prenisone ocular S/Es
Precipitates ocular HSV
Increased IOP
Open angle glaucoma
Posterior subcapsular cataracts
Sildenafil ocular S/Es
Colour vision disturbance
Ischemic optic neuropathy
Tamsulosin ocular S/Es
Floppy iris syndrome - relaxes iris dilator
RAPD
Optic nerve lesion on the affected side
Muscle and innervation that closes eye
Orbicularis oculi
CN VII
Affected in Bell’s Palsy
Muscle and innervation that opens eye
Levator palpebrae
CN III
Cone cells
Colour vision
Centre of retina (concentrated in fovea)
Function in bright light
Rod cells
Night vision/peripheral vision
Peripheral of retina
Function in dim light
Anticholinergic drops
Tropicamide, atropine, homatropine
Causes pupillary dilation, cycloplegia (paralyzes iris sphincter and ciliary body)
Used for ophthalmoscopy, iritis tx
Open angle glaucoma tx
beta blockers --> decreased aqueous production carbonic anhydrase inhibitors (dorzolamide, brinzolamide, acetazolamide, methazolamide) --> decreased aqueous production PG analogues (latanoprost, travaprost, bimatoprost) --> increases uveoscleral outflow
Right optic nerve lesion
Right monocular vision loss
Chloroquine ocular S/Es
Corneal deposits and retinopathy
Irreversible
Bull’s eye macular lesions
Common fungus in seborrheic dermatitis
Malassezia pityrosporum
CREST syndrome
Limited cutaneous forms of systemic sclerosis Calcinosis Raynaud's Esophageal dysfunction (acid reflux) Sclerodactyly Telangiectasia
Pathognomonic finding in dermatomyositis
Gottron Papules
Mild acne treatment
- Cleansing with
a) Benzoyl peroxide (antibacterial)
b) salicylic acid (desquamating agent) - Topical retinoids - comedone tx and sebum production
Moderate acne treatment
- Oral abx (max 12 weeks) - tetracycline, doxycycline, minocycline
- Oral OCP for females
- Oral retinoic acid - accutane
- Intralesional steroid injections
Severe acne treatment
Oral reinoic acid
4 different types of rosacea
- Erythematotelangiectatic rosacea - permanent erythema (vasc dilation)
- Papulopustular rosacea - papules, pustules with NO comedones
- Rhinophymatous rosacea - sebaceous gland hyperplasia at nose, CT hypertrophy, rhinophyma
- Ocular rosacea - conjunctivitis, blepharitis, iritis, keratitis (+/- cutaneous)
Rosacea tx
- Avoid triggers (sun, heat, alcohol)
- Telangiectasia/erythema- laser, electrodessication + brimonidine gel (alpha adrenergic agonist)
- Papules/pustules - topical metronidazole, azeleic acid (antibacterial), systemic abx or isotretinoin
- Phymatous - systemic tetracyclines/isotretinoin, surgical debulking
Slapped cheek disease
Parvovirus B19
DRESS
Drug reaction with eosinophilia and systemic symptoms
3rd week after starting medication
SJS
Steven-Johnson Syndrome
<10% of body surface area
Within 8 weeks after drug onset
TEN
Toxic Epidermal Necrolysis
>30% body surface area
Within 8 weeks after drug onset
SJS/TEN common culprit drugs
SATAN Sulfa Allopurinol Tetracyclines Anticonvulsants NSAIDs
Erythema multiform
Target skin lesions typically affecting distal extremities (including palms and soles)
Non-Bullous Impetigo
Staph aureus > GAS School-aged children Erythematous papule developing to vesicles/pustules --> honey coloured crust Topical abx --> mupirocen PO Abx --> Cephalexin
Bullous Impetigo
Staph aureus Neonates Thin-roofed bull that slough and leave exposed dermis PO abx --> cephalexin IV abx --> cefazolin MRSA-risk --> Vanco
Erysipelas
GAS of upper dermis, superficial lymphatics
Commonly affects face
PO abx - penicillin, amoxicillin
IV abx - penicillin, cefazolin
Cellulitis
GAS of dermis and subcutaneous tissue Commonly affects lower extremities PO: Cephalexin, penicillin IV abx: Cefazolin Complicated: Pip-tazo and vanco
MRSA+ skin infection tx
IV Vancouver
PO doxy, clinda, septra
Facial nerve parasympathetic function
Lacrimal gland
Parotid gland
Facial nerve sensory function
Taste in anterior 2/3 of tongue
Some sensation near pinna
Facial nerve motor function
Facial expression Stapedius muscle (dampens sound to inner ear)
Bell’s Palsy Treatment
Corticosteroids (Prednisone PO x 10 days)
+/- Valacyclovir (poor evidence)
TRAP of parkinsonism
Tremor (resting)
Rigidity
Akinesia/Bradykinesia
Postural instability
3 types of action tremor
Postural
Kinetic
Intention
AIDS definition
- HIV+
2. Either (a) CD4+ T-cell count <200cells/uL OR (b) AIDS-defining opportunistic infection
Cervical cancer screening in HIV patients
PAP smear at time of diagnosis, repeat in 6 mo
Annually after that if normal
Colles #
Distal radius #
Beware of shortening, dorsal displacement and dorsal angulation
Dinner fork deformity of wrist
Often a/w ulnar styloid #
PCP, Toxoplasmosis, MAC and respective CD4 counts requiring prophylactic abx
PCP = CD4+ <200; Tx = TMP/SMX Toxoplasmosis = CD4+ <100; Tx=TMP/SMX MAC = CD4 <50; Tx = Macrolide (clarithromycin) or rifabutin
Neutropenic febrile of unknown origin
Neutrophils <500
Epididymitis
Most common cause of testicular pain
Cefixime 800mg PO single dose + Doxy 100mg PO BID for 10d
Anterior nosebleeds
90% of nosebleeds
Kisselback’s Plexus or Little’s Area
Tx = cauterize with silver nitrate +/- 4% cocaine
If brisk bleed, pack nose with vaseline gauze
If diffuse ooze, apply gel foam or avitene to pack nose and remove in 24-48h
Posterior nosebleeds
Woodruff’s plexus
Tx = foley catheter to balloon tamponade, inflate with 10-15mL saline
Place anterior pack to complete procedure
3 symptoms and 2 signs to dx sinusitis
3 symptoms:
- Maxillary tooth ache
- Poor response to nasal contestants
- History of coloured nasal discharge
2 signs:
- Purulent nasal discharge
- Abnormal transillumination
Most often location of sinusitis
Maxillary
Sinusitis tx
Amoxicillin for 10 days
TMP-SMX for penicillin allergies
Peak ages of otitis media
6-36mo, and again in 4-7yrs
Ethylene glycol antidote
Ethanol
Fomepizole
Pernicious anemia
AI disease where parietal cells do not produce intrinsic factor needed to bind to B12 in duodenum for absorption in TI
Grade 6 vaccinations
HPV
Varicella
Grade 9 vaccinations
TdaP booster
MenC
Tetanus booster required…
q10y
Petrus booster required…
Once over age 25
Age range for live nasal influenza vaccine
2-59y.o.
Immunocompromised patient vaccines
Pneumo 13 if >50 and immunocompromised Pneumo 23 if >65, or earlier if immunocompromised (incl DM, CKD, liver dz, asthma, EtOH/drug/smoker) HiB Hep A Meningococcal quadrivalent
Shingles vaccine and C/I
>60 (can get >50 but may not protect for long enough) Live attenuated C/I: - Immunodeficiency (incl transplant) - Breastfeeding - Pregnancy or planning pregnancy within 3 mo - Severe neomycin allergy - Active untreated TB
Diphtheria booster required
q10y
Aspirin use recommendations
The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.
A1c monitoring
q6mo if stable and reaching goals
q3mo if therapy changing/unstable
Diabetic nephropathy workup
eGFR and ACR
If eGFR<60mL/min and/or ACR >2mg/mmol, repeat eGFR in 3 months and order 2 repeat random urine ACRs over the course of the next 3mo. If findings reconfirmed (eGFR <60 and/or 2/3 ACRs >2) = CKD
Triglyceride levels
> 10-11 = risk of pancreatitis and correlation with CVD risk
Start treating when TG >11.3
Isolated hypertriglyceridemia does NOT increase CV risk
Elevated triglyceride treatment
Fibrate (do not use with statin)
Fish oil
Nictonic acid
Dog bite common bacteria
Beta hemolytic strep Staph Eikenlla corrodes Pasturella canis Capnocytophagia Canimorsus
Cat bite common bacteria and treatment
Pasturella multocida (gram neg cocobacillus) Penicillin, clavulin, 2nd and 3rd gen cephalosporins, tetracycline, cipro
Cat scratch fever bacteria and treatment
Bartonella Henelae
Tx = Doxy
Wound risk stratification
Crush > puncture > laceration > abrasion
Hand/foot > legs/arms > trunk > head/neck
Cats > humans > dogs
Most important factor in animal bite care
High pressure syringe irrigation
Prophylactic animal bite abx
Amox-clav
Doxy if penicillin allergy
Rabies prophylaxis only required for _____ in BC
Bat bites (+/- skunks, racoons, foxes, coyotes)
Most important venomous insect in BC
Hymenoptera stings (ie. bees, wasps, sawflies, ants)
Zones of thermal burn injuries
Zone of coagulation
Zone of stasis
Zone of hyperaemia or inflammation
Key distinguishing features from heat stroke vs heat exhaustion
- Core body temp >40.6 (not essential)
2. Neuro symptoms (essential) - confusion, delirium, seizures, coma
Tissue resistance to electricity
Nerves < blood vessels < muscles < skin < tendon < fat < bone
Water LOWERS resistance so wet skin is more vulnerable
Alternating current vs direct current
Alternative current MORE dangerous than direct
AC causes tetany = increased time of contact; can cause VFib
DC = single strong flexion that thrusts victims away from source; can cause systole
Virchow’s triad
Stasis
Hypercoagulation
Vascular injury
Characteristic ECG pattern for PE
S1Q3T3
Deep S in 1, Q in 3, inverted T in 3
Stages of hemorrhagic shock
I: Up to 750cc, <15% blood loss, HR <100, normal BP, RR 14-20
II: 750-1500cc, <30% blood loss, HR100-120, normal BP, RR 20-30
III: 1500-2000cc, <40% blood loss, HR 120-140, low BP, RR 30-35
IV: >2000cc, >40% blood loss, HR >140, low BP, RR >35
Fluid resuscitation for burns
Ringers lactate
2-4cc x kg x %TBSA
Cushing reflex
Irreg respiration, bradycardia, increased systolic BP
