Blood/endo

Question 1

• Most patients usually only complain about fatigue.
• Bleeding (usually due to thrombocytopenia) occurs in the skin and mucosal surfaces, with gingival bleeding, epistaxis, or menorrhagia.
• gum hypertrophy and bone and joint pain.
• pale and have purpura and petechiae.
• Bone tenderness may be present, particularly in the sternum, tibia, and femur. (long bone)

Answer 1

Acute Leukemia

Patients with ALL may have a mediastinal mass visible on chest radiograph.
The hallmark of acute leukemia is the combination of pancytopenia with circulating
blasts.

(1) Referral to hematologist.
(2) MEDEVAC
(3) Combination chemo and radiation therapy will be the mainstay of therapy.

Question 2

Prolonged aspirin use, or the use of other anti-inflammatory drugs, may
cause GI bleeding even without a documented structural lesion.
(c) Physical Findings
1) Fatigability, tachycardia, palpitations and tachypnea on exertion.
2) Severe deficiency causes skin and mucosal changes, including a smooth
tongue, brittle nails, and cheilosis.
3) Dysphagia because of the formation of esophageal webs (Plummer- Vinson
syndrome) also occurs.
4) Many iron-deficient patients develop pica, craving for specific foods (ice
chips, etc) often not rich in iron..

Answer 2

Iron Deficiency Anemia

Most important treatment is identification of the cause of blood loss,
especially a source of occult blood loss.
Ferrous sulfate – iron supplement
(1 Dose: 325 mg three times daily for 3-6 months, is the preferred
therapy.
Referral to a hematologist should not generally be necessary. Refer the
patient if he or she is not responsive to iron therapy.

Question 3

(1) Painless persistent edema of one or both lower extremities, primarily in young women.
(2) Pitting edema without ulceration, varicosities, or stasis pigmentation.
(3) There may be episodes of lymphangitis and cellulitis.
(1) Aching discomfort with sensation of heaviness or fullness.
(2) Hypertrophy of the limb with markedly thickened and fibrotic skin and subcutaneous
tissue in very advanced cases.
(3) Pitting Edema

Answer 3

Lymphedema.

Lab/Image Findings
(1) MRI
(2) Lymphangiography
(3) Ultrasound to evaluate for Deep Vein Thrombosis
Treatment
(1) Referral
(2) Elevation, especially during sleeping hours
(3) Compression stockings
(4) Diuretic therapy
(a) Furosemide (Lasix) 40mg PO daily
(b) Bumetanide (Bumex) 1 mg PO daily

Question 4

(1)Whipple’s Triad:
(a)Blood glucose measured at <70mg/dl
(b) (confusion, irritability, fatigue,anxiety, sweating, irregular heart rhythm, perioral paresthesia)
(c)Clinical signs and symptoms resolve with appropriate glucose elevation

Answer 4

Hypoglycemia.

Lab: Finger sticks blood glucose
(1)Immediate treatment of hypoglycemia involves provision of glucose.
(2)Patients able to eat or drink can drink juices, sucrose water, or glucose solutions; eatcandy or other foods; or chew on glucose tablets when symptoms occur.
(a)Do not attempt PO interventions on a patient with altered mental status- highaspiration risk.
(3)Adults unable to eat or drink can be given glucagon 0.5 or 1 mg SC/IM or 50%dextrose 50 to 100 mL IV bolus, with or without a continuous infusion of 5 to 10%dextrose solution sufficient to resolve symptoms.
(4)Once patients are alert and safe to do so, they should consume a meal (containingcarbohydrates, proteins, and fats) to prevent immediate hypoglycemia recurrence.

Question 5

• Malar (butterfly) Rash, alopecia is common.
• Joint symptoms in 90% patients.
• Systemic feature: Fever, Malaise, weight loss, anorexia.

Answer 5

Systemic Lupus Erythematosus

Antinuclear antibody test are nearly 100% sensitive for SLE but not specific.
* Educations, emotional support.
* Cautioned against sun exposure.
* Minor joint symptoms rest and NSAIDs.
* Systemic treatment only prescribed by Rheumatologists.

Initial care: Check for antibodies with ANA. If positive referred to Rheumatologist.

Question 6

• Impaired fasting glucose (100-125mg/dl)
• Borderline Hgb-A1C elevation (5.7-6.4%)
• 2-hour post-prandial glucose (140-199 mg/dl)

Answer 6

Prediabetes

(1)Weight loss if overweight/obese
(2)In obese patients there is evidence Metformin 850mg BID may lower risk ofdeveloping Type 2 Diabetes by 30%. This is less effective in thin or elder patients.
(3)Increased physical activity / exercise

Question 7

• Polyuria / Polydipsia
• weight loss
• Plasma glucose of 126 mg/dL or higher after an overnight fast, documented on more than one occasion.
• Ketonemia / ketonuria - inadequate insulin leads to inadequate glucose within muscle cells which promotes fat metabolism (the source of ketones).

Answer 7

DM type II.

Labs(a)Urine Screening
Random glucose of 200mg/dL or higher.

Question 8

• Hyperglycemia > 250 mg/dL
• Acidosis with blood pH < 7.3
• Serum positive for ketones
  Symptoms
• Rapid deep breathing and a “fruity” breath odor of acetone.
• May begin with a day or more of polyuria, polydipsia, marked fatigue, nausea and vomiting and, finally, mental stupor that can progress to coma.
• Abdominal pain and tenderness in the absence of abdominal disease

Answer 8

Diabetic Ketoacidosis

• Volume repletion is the initial management priority. 1 L of 0.9% normal saline to (lactated ringer’s is fluid of choice if available). Once improvement (Improve vitals, >250 mg/dL
• Insulin plus fluid and electrolyte replacement is the mainstay of therapy (Consult MO) MEDVAC

Question 9

Goiter

Answer 9

(a)Serum T4 and TSH generally normal
(b)Thyroid Radioactive Iodine Uptake is elevated

(a)Addition of potassium iodine to table salt.
(b)Adults with large goiter may require thyroidectomy for cosmetic reasons,compressive symptoms, or thyrotoxicosis.

Question 10

**

• Weakness, cold intolerance, constipation, depression, menorrhagia, hoarseness, dry skin, bradycardia. (a)Thin, brittle nails
  (b)Thinning of hair (b)Puffiness of face and eyelids
  (c)Thinning of outer eyebrows
  (d)Tongue thickening, Goiter
• Delayed return of deep tendon reflexes.

Answer 10

Hypothyroidism.

TSH, T4, T3. CBC, cholesterol,liver enzymes, creatine kinase, prolactin
Treatment
Levothyroxine (T4), TSH tests every 4 to 6 weeks for medication titration until TSH is at goal.
MEDEVAC: Depends on signs and symptoms, May retain if no major issues.

Question 11

Sweating, weight loss, heat intolerance, menstrual irregularity, tachycardia, tremor, stare. Graves’ disease: Goiter (bruit), Ophthalmopathy,* Thyroid storm: delirium, severe tachycardia, vomiting, diarrhea, dehydration, very high fever. Lab:

Answer 11

Hyperthyroidism

TSH, T4, T3. CBC,
Graves’ disease
* Propranolol (beta blocker): symptomatic relief of tachycardia, tremors, diaphoresis, and anxiety.
MEDEVAC

Question 12

Thyroid Nodule

Answer 12

Malignancy if
* Hoarseness or vocal cord paralysis
* Nodules in men or young women
* Nodule that is solitary, firm, large, or adherent to trachea or strap muscles
* Vocal cord paralysis
* Enlarged lymph node(s)
* Distant metastatic lesions
Lab: T3, T4, TSH

Imagining: Neck ultrasound indicated for all palpable nodules, preferred over CT and MRI.
Treatment
* Refer to endocrinology.
* Ultrasound guided fine-needle aspiration (FNA) biopsy of suspicious nodules.
* MEDEVAC if suspected or referral to Endocrinology if nodule is suspected to be benign

Question 13

• Weakness, abdominal pain, fever, confusion, vomiting.
• Low blood pressure, dehydration.
• Skin pigmentation may be increased.
• n elevated serum potassium and low sodium.
• hypoglycemia.
• Dehydration and hypotension may result in poor kidney perfusion

Answer 13

Adrenal Crisis

• Refer to Medical Officer
• Dexamethasone can be used if hydrocortisone is not available, dose is 4 mg IV every 12 hrs. Goal is still to transition patient to hydrocortisone as soon as possible,

Question 14

Fatigue, Decreased strength, Poor libido, Hot flushes
Erectile dysfunction, Gynecomastia, Infertility, Small testes

Answer 14

Hypogonadism

SHOULD ONLY BE INITIATED WITH GUIDANCE FROM MEDICAL OFFICER
Lab: Hematocrit (HCT), Prostate Specific Antigen (PSA). Total Testosterone. If low, obtain LH, FSH, and Prolactin.
Medication: Transdermal Testosterone (preferred), Intramuscular Testosterone (longer acting), Alternate routes for Testosterone (Buccal, implantable, intranasal).

Question 15

Gynecomastia

Answer 15

True gynecomastia will be localized to subareolar region only.
Red Flag: Asymmetry, Density located away from subareolar region, Nipple retraction, Nipple bleeding or discharge, unusual firmness.
Examine testicles for size and masses. All masses or presence of beta hCG warrant testicular ultrasound.
Lab: Free testosterone with SHBG, LH and FSH. Liver function panel, Renal panel, Beta HCG (not the pregnancy test), Estradiol, Thyroid function panel, Prolactin.

Treatment
Pubertal gynecomastia is generally self-resolving. Referral to family practice or internal medicine for initial evaluation.

Question 16

Constellation of 3 or more of the following:
* Abdominal obesity
* Triglycerides 150mg/dl or higher
* HDL <40mg/dl for men or <50mg/dl for women
* Fasting glucose of 110mg/dl or higher
* Hypertension

Answer 16

Metabolic Syndrome

Management: Risk Factor Modification!
* Obesity is the most important modifiable risk factor. Diet or physical activity.
* Nutrition referral advised for tailored dietary counseling.
* Metformin may be considered if impaired fasting glucose is present.
* Blood pressure medications depending on comorbidities.

Question 17

• Mild : Nausea, Malaise.
• Moderate: Headache, Lethargy, Disorientation.
• Severe: Respiratory arrest, Seizure, Coma, Permanent brain damage, Brainstem herniation, Death.

Answer 17

Hyponatremia

• Initial step: Restriction of free water and hypotonic fluid intake, less 1-1.5 L/day.
• Patients with minimal free water clearance: More severe free water restriction.
• Patients with negative free water clearance: Hypertonic saline
  Complication: Most serious complication of hyponatremia is iatrogenic cerebral osmotic demyelination from overly rapid sodium correction. Generally catastrophic and irreversible.

Question 18

• Dehydration patient: Orthostatic hypotension, Oliguria.
• Early signs: Lethargy, Irritability, Weakness
• Severe: Hyperthermia, Delirium, Seizures, Coma

Answer 18

Hypernatremia

Treatment
* Correcting the cause of the fluid loss, replacing water, replacing electrolytes (as needed)
* Administered over a 48 hr, serum sodium correction of approximately 1 mEq/L/h.
Complication: Rapid correction of hypernatremia may cause cerebral edema and potentially severe neurologic impairment.

Question 19

• Mild to moderate: Muscular weakness, Fatigue, Muscle cramps
• Severe (< 2.5mEq/L): Flaccid paralysis, Hyporeflexia, Hypercapnia, Tetany (involuntary contraction), Rhabdomyolysis.
  Lab: Serum potassium < 3.5 mEq/L
  Rad: ECG: Decreased amplitude and broadening of T waves, PVC, ST Depression.

Answer 19

Hypokalemia

Treatment
* Oral potassium supplementation: fest and easiest treatment for mild to moderate deficiency. 40-100 mEq/day over a period of days to weeks.

Question 20

• Impairs neuromuscular transmission, Muscle weakness.
• Flaccid paralysis (reduced muscle tone)
• Ileus (intolerance of oral intake due to inhibition of the GI propulsion)
  Rad: ECG: Prolongation PR interval, Peaked T waves, QRS widening, Bundle branch block, AV Block. Bradycardia. Ventricular fibrillation and -cardiac arrest are terminal events.

Answer 20

Hyperkalemia

• Reviewing medications and dietary potassium intake, reduce exogenous potassium,
• Emergent treatment is indicated: Cardiac toxicity, Muscle paralysis, Severe hyperkalemia > 6.5 mEq/L.
• Insulin (MUST give glucose), bicarbonate, and beta-agonists
• Loop diuretics: Furosemide (Lasix) 40-80mg or Bumetanide (Bumex) 1 mg IV. inadequate urine output in 30 minutes then repeat the dose.

Question 21

Febrile patient or acute neurologic illness with recent exposure to mosquitoes during the summer months in WNV endemic areas. 70-80% of human infections are subclinical/asymptomatic.
* An acute systemic febrile illness may be accompanied by: Headache, weakness, myalgia, or arthralgia, Gastrointestinal symptoms, Transient maculopapular rash.
Neuroinvasive: < 1%
* Meningitis: fever, headache, and nuchal rigidity. Brudzinski, Kernig.
* Encephalitis: fever and altered mental status, seizures, focal neurologic deficits, tremor.
* Acute flaccid paralysis: poliomyelitis, respiratory paralysis requiring mechanical ventilation. isolated limb paresis or paralysis

Answer 21

West Nile virus mosquito

Lab: Diagnosis via identifying IgM in serum or CSF (Neuroinvasive) lumbar puncture, ELISA is used to detect IgM antibody.
Treatment
* No specific treatment, Vigorous supportive measures are the first line management protocol.
* MEDEVAC

Question 22

can develop as early as 7 days after mosquito bite to months.
* Uncomplicated: Paroxysmal (cyclical) fever, Influenza-like symptoms, Jaundice & mild anemia secondary to hemolysis.
* Severe : Small blood vessels infarction, capillary leakage and organ dysfunction, Altered consciousness, Hepatic failure & renal failure, Acute respiratory distress syndrome, Severe anemia.
Paroxysmal fevers: Cold stage (1 hours) - Febrile stage (2-6 hours) - Diaphoretic stage where fever drops (2-4 hours) - Patient then returns to normal. Cycle repeats itself in 48 – 72 hours.

Answer 22

Malaria mosquito

Treatment MEDEVAC
* Uncomplicated Malaria: Chloroquine phosphate 1g PO, 0.5g in 6 hours, 0.5g daily for 2 day. Chloroquine resistance, Malarone (Atovaquone 250mg/Proguanil 100mg) 4 tabs PO QD for 3 days.
* Severe Malaria: Artesunate 2.4mg/kg IV at 0, 12, 24, 48 hours, Followed by Doxycycline 100mg BID x 7 days after parenteral therapy.
* Treatment of P.ovale: ADD primaquine 52.6mg PO QD x 14 days. Added to regiment for hypnozoites.

Do not use the same or related drug to treat Malaria as was used for chemoprophylaxis

Question 23

Puerto Rico, Virgin Islands, US-affiliated Pacific Islands. Outbreaks occurred in FL/HI/TX.
Predisposing Factors: Urban environments, outdoor during spring & summer; mosquito bites. 3 phases:
Febrile phase (2–7 days): severe headache; retroorbital pain; muscle, joint, and bone pain; & transient maculopapular rash. Minor hemorrhagic manifestations, including petechiae, ecchymosis, purpura, epistaxis, bleeding gums, hematuria, or a positive tourniquet test result.
Critical phase (24–48 hours): Most patients clinically improve during this phase and move on to recovery & convalescence phase. substantial plasma leakage develops severe dengue as a result of a marked increase in vascular permeability (cardinal feature).
Critical phase: Narrows pulse pressure (diastolic blood pressure increases), severe plasma leakage will have pleural effusions or ascites, hypoproteinemia, and hemoconcentration. Dengue Shock Syndrome: once hypotension develops, systolic blood pressure rapidly declines, and irreversible shocks. Hematemesis, bloody stool, melena, menorrhagia, especially in prolonged shock.
Convalescent phase (Recovery stage)
Two hallmarks of are infection-induced capillary permeability (leaky capillaries) and diminished blood clotting.
Tourniquet Test: determination of a patients’ capillary fragility or hemorrhagic tendency. Count petechiae below AC fossa. A positive test is 10 or more petechiae per 1 square inch.

Answer 23

Dengue Fever ‘Breakbone fever’ mosquito

Treatment MEDEVAC
* No specific antiviral agents exist for dengue.
* Ensure patient stays well hydrated and avoid aspirin, aspirin containing drugs, and NSAIDS because of their anticoagulant properties.
* Invasive medical procedures such as NG intubation, intramuscular injections and arterial punctures are avoided due to bleeding risk.
* Fever should be controlled with acetaminophen (Max 4g in 24 hrs.)
* Febrile patients should avoid mosquito bites to reduce risk of further transmission.
* Maintenance of the patient’s body fluid volume is critical for severe dengue care.

Question 24

Early illness (days 1-4): Fever, HA, GI symptoms, myalgias, edema around eyes & back of hands, and rash. Rash typically presents 2-4 days after fever onset, begins as small flat pink macules on wrists, forearms and ankles that spreads to trunk, Can also involve palms of hands & soles of feet.
Late illness (day 5 or lainfects endothelial cells that line blood vessels, causing vasculitis and bleeding or clotting in the brain or other vital organs. Neurological deficits, Damage to internal organs (respiratory compromise, renal failure), Vascular damage requiring amputation.
Rash: begins as small flat pink macules on wrists, forearms and ankles that spreads to trunk, Can also involve palms of hands & soles of feet. petechial rash does not typically appear until day 5-6 of illness. Every attempt should be made to treat before petechiae develop

Answer 24

Rocky Mountain Spotted Fever (RMSF) Tick

Treatment
* Doxycycline 100mg PO BID for 5 – 7 days; or for 3 days AFTER fever subsides.
Prevention
* Wooded and brushy areas with high grass and leaf litter, When: Spring/summer/fall.
* Treat gear & clothing with products containing 0.5% permethrin.
* Perform tick checks at 12-hour intervals when training or operating in RMSF endemic areas. Never let your personnel go > 24hrs without a check.
* MEDEVAC

Question 25

• Early Localized Stage: Flu-like symptoms—Malaise, headache, fever, myalgia, arthralgia, Lymphadenopathy. 1 Weeks Erythema migrans (Red ring-like or homogenous expanding rash “bullseye/target” lesion).
• Acute/Early Disseminated Stage: Constitutional, Cardiac Manifestations (Myocarditis, pericarditis), Neurologic Manifestations ( Bell’s palsy, Meningitis, Encephalitis)
• Late Disseminated Stage: Plus Rheumatologic Manifestations (Transient, migratory arthritis and effusion in one or multiple joints, Migratory pain in tendons, bursae, muscle, and bones).

Answer 25

Lyme disease Tick

Lab: Serologic tests should NOT be performed for: Asymptomatic patient in endemic areas or after Ixodes tick bite, Patient with non-specific symptoms (subacute myalgias, arthralgias, or fatigue)
Two-tiered serologic testing algorithm: Acute (Acute/Early Disseminated: 2 ELIZA test, Late Disseminated: Either 2 ELIZA test, or 1 ELIZA test followed by 1 Western blot)
Treatment:
* Early Lyme (Erythema migrans): Doxycycline 100mg PO BID x 14 days
* Early disseminated (Bell’s Palsy): Doxycycline 100mg PO BID x 14 days
* Late disseminated (Arthritis): Doxycycline 100mg PO BID x 28 days

Question 26

• Trismus or lockjaw, followed by nuchal rigidity, dysphagia, and rigidity of abdominal muscles
• Muscle spasms may occur frequently (q10-15 min) and may last upwards of several minutes each episode.
• Hyperthermia, diaphoresis, hypertension, and episodic tachycardia
• Late: Periods of apnea, Fracture of long bones/ vertebrae during muscle spasms. Death typically occurs secondary to respiratory arrest.

Answer 26

Tetanus

Treatment
* Immediate transfer to nearest MTF (Urgent MedEvac), Clean/debride wounds as best as possible, Supportive therapy and airway protection.
* Antibiotics: Metronidazole 500mg IV Q6-8H for 7-10 days, Pen G 2-4Mil Units IV Q4-6hrs (alternate), Tetanus Immune Globulin (TIG, HTIG). 500 units IM at different sites from the Tetanus Toxoid, part of the dose should be infiltrated around the wound.

Question 27

• Erythematous or exudative pharyngitis or Tonsillitis. (often misdiagnosed)
• Malaise, Fever, Cervical lymphadenopathy (posterior), Splenomegaly (post infection).
• Generalized maculopapular rash in patients treated cillin-class antibiotics for strep pharyngitis.Lab: CBC: leukocytosis with lymphocytosis is most often seen.

Answer 27

Infectious Mononucleosis:

Lab: CBC: leukocytosis with lymphocytosis is most often seen. confirmed with a Monospot test (positive within 4 weeks after symptom onset.)
Treatment
* Treated symptomatically: Bed rest, Acetaminophen or NSAIDS, Saline gargles 3 – 4 times daily,
* Avoid the use of antivirals, Steroids should only be used in cases where airway obstruction is possible due to tonsillar enlargement.
Disposition:
* Placed SIQ until acute symptoms subside, Fever resolves within 10 days. lymphadenopathy and splenomegaly may persist upwards of 3 - 4 weeks. Isolation is not necessary.
* Light duty with no physical contact sports for 3 – 4 weeks
* A MEDEVAC may be advised in severe cases where airway issues.

Question 28

• Pain & paresthesia at the bite site are often the first symptoms of disease.
• rapidly from a nonspecific, prodromal phase with fever and vague symptoms to an acute, progressive encephalitis.
• Spasms of swallowing muscles can be stimulated by the sight, sound, or perception of water (hydrophobia); and delirium and convulsions can develop, followed rapidly by coma and death. Hydrophobia: Most characteristic feature; Patient becomes afraid of water due to involuntary pharyngeal muscle spasms when they attempt to drink.

Answer 28

Rabit

Patient should be referred to a higher echelon of care (via routine MedEvac) whether they have signs/symptoms of rabies or not.
Any suspected case of clinical rabies should be evacuated with extreme haste to a major MTF with critical care capabilities.
Treatment
* Non-Immunized: Wound Cleansing, RIG (IF possible, not the same as vaccine), Vaccine HDCV or PCECV 1.0ml IM. Day 0, 3, 5, 7, 14.
* Immunized: Wound Cleaning, NO RIG, Vaccine HDCV or PCEVC 1.0ml IM. Day 0, 3.

Question 29

• Initially: Flu like symptoms (Fatigue, fever, muscle/joint pains).
• Within 1-3 weeks, jaundice & RUQ pain develops.
• Hepatomegaly, Dark or brown colored urine, Gray/clay colored stool. Scleral icteru
  UA: Proteinuria and dark urine (bilirubinurias.

Answer 29

Hepatitis

Lab: Hepatitis panel serologic testing IgM/IgG, UA: Proteinuria and dark urine (bilirubinuria). Liver function Test (LFT): Viral hepatitis = ALT>AST; Alcoholic hepatitis = AST>ALT. CMP.
Treatment
* IDC-level care consists of supportive/palliative interventions & patient monitoring.
* Med Advice, Medevac as soon as operational conditions allow, however, typically does not require emergent evacuation.
* Ensure proper hydration & nutrition, and place patient SIQ.
Low fat, high carbs diet, Small but frequent mealsno EOTH, SIQ Activity conservation.
HEP A and B vaccinations, requirement for ALL military personnel