Ambulatory Medicine Flashcards
most common cause of secondary HTN in young women
OCPs
most common cause of secondary HTN
renal artery setnosis
main organs HTN causes damage to
heart
eyes
CNS
kidneys
Changes seen in the eyes due to HTN
AV knicking, cotton wool spots , papilledema (ominous finding)
BP meds C/I in pregnancy
Thiazides, ACEI , CCB, ARBs
safe meds for elevated BP in pregnancy
Beta blockers, hydralazine
biggests ADR of thiazide diuretics
Hypokalemia
hyperuricemia, hyperglycemia
secondary causes of hyperlipidemia
hypothyroidism, DM< cushing’s syndrome, nephrotic syndrome, ueremia
what lipid levels does alcohol increase?
TG and HDL levels
how do beta blockers affect cholesterol
Increase TGs and lower HDL
how do estrogens affects cholesterol levels
increase TG levles
LDL goal in all diabetic patients
<100
If a patient has CAD and DM what is the LDL goal?
<70
LDL goal w/ no eastblished CHD
<130
what needs to be monitored whil on statins?
AST and ALT
what cholesterol med should not be used in patients w/ DM
Niacin
how do fibrates (gemibrozil) affect cholesterol levels?
lower VLDL and TG
increase HDL
main ADR of bile acid resins?
GI side affects
C/I with sumatriptan
CAD pregnancy uncontroll HTN basilar artery migraine hemiplegic migraine use of MAO, SSRI or lithium
Prophylaxis for migraines
Amitriptyline propranolol
causes of chronic cough in adults
smoking
postnala drip
GERD
asthma
Antitussive therapy
Codeine
Dextromehorphan
Benzontate (Tessalon Pearles)
tx for common cold
hydration
rest and analgesics (aspirin, APAP, ibupforen)
cough suppressant
nasal decongestant (Neo-synphrine) for <3 days
If patient has a cold beyond 8-10 days or if cold symptoms improve then worsen after a few days what shoudl be considered?
aucte abcterial sinusitis
Sinusitits tx
Saline nasal sprays
Decongestatns (no more than 3-5 days)
amox, augmentin, bactrim, cefuroxime
most common cause of sore throat
viruses
Tx for strep throat
PCN for 10 days, erythromycin if allergic
indications for endoscopy w/ dyspepsia
Weight loss, anemia, dysphagia age >50 recurrent vomitting/ GI bleeding dont respond to therapy systemic illness
lifestyle modifications for dyspepsia
Avoid alcohol, caffeiene, acdic foods
stop smoking
raise head of bed
Med tx for dyspepsia
H2 blocker
sucralfate
PPI
most sensitive and specific test for GERD
24 pH monitoring of the lwoer esophagus
Fibrotic rings common in GERD that narrow the lumen and osbstruction the passage of food
peptic stricture
where the normal stratified squamous epithelium of the distal esophagus is replaced by columnar epithelium. Associated w/ risk of andocarcinoma
Barrett’s esophagus
if food poisoning causes diarrhea when will it occur?
within hours of the meal
Fever + bloody diarrhea could indicate what?
Shigella, campylobacter, slamonella , enterohemorrhagic E. Coli
diarrhea w/o fever or blood is associated w/ what?
Viruses- rotavirus, Norwalk virus, entero toxic E. Coli, food poisoning
how long is chronic diarrhea?
> 4 weeks
Most common med cause of diarrhea
abx
most common electrolyte and acid/base abnormlity w/ diarrhea are what?
metabolic acidosis
hypokalemia
when should you use abx w/ diarrhea
high fever, bloody stools (use quinolone)
stool crowth of a pthogenic oragnism
travelers diarrhea
c. diff (metronidazole)
Antidiarrheal agent that can be given w/ mild-moderate diarrhea. Don’t give to people w/ fever or blood
loperamide
Lab tests w/ constipation
TSH
serum calcium levels
CBC (suspect colon cancer)
electrolytes
Complications of chronic constipation
hemorrhoids
rectal prolapse
anal fissures
fecal impaction
lifestyle modificaitons for constipation
increase physical activity
eat high fiber foods
increase fluid intake
diarrhea that has abomdinal pain, possible fever, tenesmus, fecal luekocytes. Resolves within 4-5 days
Shigella
what exacerabtes IBS
stress and irritants in the intestinal lumen
most common cause of gastroenteritits
enterovirus
if there is bilous vomitus where is the obstruction?
Distal to ampulla of Vater
vomitting of undigested food indicated what?
esophageal problem, achalsia, stricture, diverticulum
what can projective vomiting indicate?
increased intracranial pressure or pyloric stenosis
most common electorlyte abnormality after severe vomitting
hypokalmeia w/ metabolic alkalosis
best fluid replacement to use w/ dehydration from vomiting
1/2 NS w/ K+ replacement
meds used to help w/ N/V
prochloperazone (comparzine)
promethazine (phenergan)
what type hemorrhoids are more painful
external
Risk factors for hemorrhoids
constipation pregnancy portal HTN obesity prolonged sitting
when are extneral hemorrhoids painful?
when they are thromboses where there is painful swelling w/ ulceration, blood. Can do surgery on
non-med treatment for hemorrhoids
sitz bath ice packs stool softeners high fiber, high fluids diet topical steroids
Surgical tx used for internal hemorrhoids
rubber band ligation
3 most common causes of LBP
musculoligamentous strain, degnerative disk disease, facet arthritits
factors that exacreabate disk herniation pain
Coughing/ sneezing
foreward flevsion
how long must LBP exist for it to be considered chronic
> 12 weeks
LBP + bladder dysfunction, saddle anesthesia
cauda equina syndrome
TX for cauda equina syndrome
surgical emergency. Need MRI ASAP
risk facto for chronic LBP
obesity, older age, sedentary work, physically strenuous work, low education, worker’s comp
patient has leg pain on back extension and pain worsense w/ standing or walking
spinal stenosis
foreward slippage of cephalad vertebrae on the caudal vertebra. Most common at L4-L5 and L5-S1. Often co-exists w/ spinal stenosis – neurogenic claudication
spondylolisthesis
Tx for lumbar disc ehrniation
anti-inflammatory meds, PT, epidural steroid injections.
when is spinal stenosis worse
when walking, relieved with sitting. foward flexion improves symptoms
what can multiple compressoin fractures in the spine lead to
kyphosis in the thoracic spine
At what spine level is the nerve for hip flexion
L2
at what spine level is the nerve for ankle platna flexion
S1
what what spine level is the nerve for knee extension
L3
at what spine level is the nerve for great toe dorsiflexion
L5
When should you get imaging for low back pain
progressive neuro deficieits osteoporosis or prolonged stoeroid use constitutional symptoms (fever, weight loss) IV drug use recent trauma
when can surgery be a good option for neck pain
with radicular arm symptoms
what is the most common cause of cervical radiculopathy
cervical spondylosis (osteoarthritits) and disc herniation
Best test to diagnose nerve root compression of neck
MRI of cervical spine
Tx for cervical radiculopathy
NSAIDs, time, PT, epidural injections
Neurologic dysfunction secondary to spinal cord compression in the cervical spine.
Cervical myelopathy
earliest symptom of cervical myelopathy
gait disturbance , an have loss of hadn dexterity, bowel and bladder dysfunctiona re late findings
treatment for cervical myelopathy
surgery to decompress the spinal cord
Most common cause of knee pain in older patients
osteoarthritits
if a patient presents with patellofemolar pain (anterior knee pain) how should it be treated?
PT to strength and stretch quads/ hamstrings
syndrome typically seen in athletes w/ overuse injuries. Patients ahve pain along medial patella and feel snapping with walking and intermittent effusion.
Plica syndrome
Tx for plica syndrome
PT, Anti-infalmmatories, steroid injections. Can do arthroscopic release of plica if that fails
most common ankle ligametn injuired
ATFL- anterior talofibular ligament
3 ligaments on the lateral side of the ankle
ATFL (anterior talofibular ligament)
calcenofibular ligament (CFL)
posterior talofibular ligament
Are medial ligament (deltoid ligaments) injured in an ankle sprain?
No
Tx for ankle sprain
RICE and PT
What is the ATFL ligament located?
anterior tip of distal fibular
what is the most common cause of shoulder pain
Supraspinatus (rotator cuff) tendinitits- impingement syndrome
Where is pain w/ impingement syndrome
Subacromially on the lateral aspect of teh shoulder with arm in abduction
Tx for impingement syndrome
PT, subacrominal steroid injection
Caused by inflammation/ degeneration of the extensor tendons of the forearm which originates ont eh alteral epicondyle
Lateral epicondyliitits (“tennis elbow)
What causes tennis elbow
excessie/ repetitive supination/ pronation
Tx for lateral epicondylitits
spinting the forearm (counterforce brace) Don’t wrap the elbow itself!! PT often helpful
pain distal to medial epicondyle htat is caused by overuse of the flexor pronator muscle. Exacerbated by wrist flexion
Medial epicondylitits (golfer’s elbow)
Where does pain w/ hip osteoarthritits often present
groin pain
Pain at the radial aspect fo the wrist (espeically w/ pinch gripping) in region of radial styloid. Common for pain to radiate to elbow or into thumb
De Quervain’s disease
What causes De Quervain’s disease
Inflammation of the abductor pollicis longus and extensor pollicis brevis tendons
What is the Finklestein’s test (for De Quervain’s disease)
have patient clench the thumb under the other fingers when making a first then ulnarly deviate the wrist.
Tx for de Quervain’s disease
Thumb spica splint and NSAIDs. local cortisone injections can be helpful
common cause of lateral hip pain. Greater tronachter is exquisitely painful on palpation
Trochanteric bursitits
Tx for trochanteric bursitis
NSAIDs, activity modification. Local cortisone injections may be helpful
caused by median nerve compression leading to numbness and pain in the mdian nerve distrubtion
Carpal tunnel syndrome
Tap median nerve at wrist crease , will lead to paresthesias in the mdian nerve
Tinel’s sign
Palmar flexion of teh wrost for 1 minutes causes paresthesias in the mdian nerve
PHalen’s test
Definitive diagnosis of CTS
EMG and NCV
TX for CTS
wrist splints worn at night during sleep to prevent wrist flexion, NSAIDs, local corticosteroidsteroid injections, surgical release
degeneration of cartilage due to wear and tear and by hypertrophy of bone and articular margins
Osteoarthritits
Risk factors for OA
age, obesity, excessive joint loading, trauma, altered joint anatomy, hemophilia
X-ray findings in osteoarthritits
Joitn space narrowing, osteophytes, subchondral sclerosis, subchondral cysts
Bony overgrowth and significant osteoarthritic chagnew at the PIP
Bouchard’s nodes
Bony overgrowth and significant osteoarthritits changes at the DIP
Heberden’s nodes
Tx for OA
avoid excessive use of joint
weight loss, PT
use canes or cruthces to reduce weight on joint
APAP is 1st line
cortisone injecitons (up to 3-4 per year)
if a patient has left knee pain which hand should the cane be in?
right
Causes of secondary osteoporosis
Excess steroid therapy/ Cushing’s syndrome, immobilization, hyerpthyroidism, long term heparin, hypogonadism in men, mit D deficiency
mainstay of therapy for osteoporosis
Exercise program with calciu, Vit D
fracture in distal radius usually due to fall on an outstretched hand
Colles fracture
ostoepenia T score
_1.0 to -2.5
t score less than or equal to -2.5
osteopororsis
indications for DEXA
women 65, postmenopausal women <65 w/ one or more risk factors
when should DEXa scan be repeated if normal
3-5 years
labs to r/o secondary causes of osteopororisi
calcium, phosphorus, alkaline phosphatase, TSH, vit D, free PTH, creatinine, CBC
bisphosphonate indications for osteopororsis
T score 2.5 or less of fragility fracture
ADRs of oral bisphosphonates
reflux, esophageal irritation and ulceration
most common causes of visual impairment in developed countries
diabetic retinopathy (65 years)
cataracts
glaucoma
loss of central vision, blurred vision and scotoma.
Age- related macular degeneration
risk factors for ARMD
female gender, causcasian race, smoking, HTN, family hx
2 categories of ARMD
exudative (wet) and nonexudative (dry)
what type of ARMD causes sudden visual lause due to leakage of serous fluid and blood as a result of abnormal vessel formation under the retina
exudative ARMD
what type ARMD has rusen under the pigemnt epithelium and can be seen with an opthalmoscope
nonexudative ARMD (dry)
Tx for chronic open angle glaucoma
Beta blocker, alpha agonist, carbonic anyhydrase inhibition
Tx for acute angle closure glaucoma
Laer or surgical iridectomy
most common organism for viral conjunctivitis
adenovirus
most common cause of bacterial conjunctivitits
S. pneumoniaea
Tx for bacterial conjuncitivits
Erythromycin, ciprofloxacin, sulfacetamide
Sudden, transient monocular loss of vision due to emboliation of cholesterol plaque from teh carotid arterial system
amaurosis fugax
Workup for amaurosis fugax
carotid US, cardiac work up (lipid profile, ECG)
risk factors for OSA
obesity (espeicailly around neck), enlarge tonsils, uvula, nasal polyps, dviated septum, family hx, hypothyroidism
Features of OSA
snoring, daytime sleepiness, intellectual function decreased, HTN, cardiac arrhythmias , morning headaches, polycythemia
diagnosis of OSA
polysomnography
Tx of mild to moderate OSA
weight loss, avoid alcohol and sedatives, avoid suprine position during sleep
For severe OSA what is the tx
CPAP to present occlusion of the upper pharynx, resmoval of redudant tissue in the oropharynx , tracheostomy is last resort
loss of muscle tone that generally occurs w/ intense emotional stimuli
cataplexy
tx for narcolepsy
methylphenidate (Ritalin), planed naps during the day
what causes conductive hearing loss
lesions in external or middle ear that interference w/ mechanical reception or amplification fo sound
what causes sensorineural hearing loss
lesions in the cochlea or CN VIII (auditory branch)
most common cause of conductive hearing loss
cerumen impaction
bony outgrowths of external auditory canal related to repetitive exposure to cold water
Exostoses
gradual, symmetric hearing loss accosiated w/ aginging
prebycusis
drugs that can cause hearing loss
aminoglycoside abx, furosemic, cisplatin, quinidine
sensorineural hearing loss, (U/L), pressure in ear, tinnitus, vertigo
Meniere’s disease
Tx for meniere’s disease
for vertigo- dietary salt restriction and meclizine. hearing los is progressive
tx for cerumen impaction
irrigation after several days of softening w/ carbamide peroxide, or triethanolamine
for conductive hearing loss where will sound laterize on the Weber test
To the affected size
In which type of hearing loss will the RInne test be abnormal
ocnductive loss
In snesorinueral haering loss which side will the Weber test lateralize to?
The unaffected side
what is the most common king of incontinence in eldelry patients
urge incontinence
in women <70 what is the most common type of incontinence
stress in continence
increase intra-abomdinal pressure (cough, laugh) causes urine loss
stress incontinence
what causes urge incontinence
detrusor instability
sudden urge to urinate, loss of large volumes of urine w/ small postvoid residual
urge incontinence
management of urge incontinence
bladder training exercises. Meds include anticholinergic med (oxybutynin, TCAs (imipramine)
managemetn of stress incontinence
Kegel exercises, estrogen replacement therapy, use of a pessary, surgery
Who is overflow incontinence common in
patient w/ neurologic disorders- have inadequate bladder contractions
Tx for overflow incontinence
intermittent self cath, cholinergic agents (bethanechol), alpha blockers to decrease sphincter resistance
most common cause of fatigue
depression or anxiety
risk factors for ED
HTN, smoking, hyperlipidemia, DM
what causes wernicke’s encephalopathy (nystagmus, ataxia, ophthalmoplegia, confusion)
thiamine deficiency, seen in alcoholism
partial agonist at the alpha4-beat-2 subunit of the nicotinic Ach receptor used for smoking cessation
Varenicline
what vaccinations fo asplenic patients need
Hib vaccine, meningococcal and puneumococcal vaccines
who should get the pneumococcal polysaccharide vaccine?
Adults >65, sickle cell disease, asplenia, chronic medical problems
who should get the shingles vaccine?
adults >60
