Commonly encountered things Flashcards
Treatment of post-heretic neuralgia?
There are numerous possible treatments for postherpetic neuralgia, however, gabapentinoids (gabapentin and pregabalin) or tricyclic antidepressants (TCA) are usually the best options for initial management.
What is de Quervain’s Tenosynovitis? Testing and tendon affected?
The most likely diagnosis in this patient is de Quervain disease. de Quervain disease is also called stenosing tenosynovitis of the abductor pollicus longus (APL) and extensor pollicus brevis tendons, but more often involves the APL. It is a common overuse syndrome seen in construction workers and waitresses and has been associated with rheumatoid arthritis. It presents with pain and tenderness at the radial styloid near the anatomical snuffbox. It can be diagnosed with the Finkelstein test, which is elicited by grasping the thumb and deviating the hand toward the ulna. A positive test is extreme pain over the radial styloid. Conservative treatments such as rest, activity modification, and splinting followed by corticosteroid injections are the mainstay of treatment and are successful in many patients. de Quervain disease that is resistant to conservative treatment may be treated with surgery.
What puts you at an increased risk of osteoporosis?
The patient’s history of smoking, heavy alcohol use, and compression fracture of the spine indicate a diagnosis of osteoporosis. There are multiple risk factors for the development of osteoporosis. These include but are not limited to advanced age, cigarette smoking, chronic glucocorticoid therapy, low body weight, previous fractures, history of rheumatoid arthritis, and excessive alcohol intake.
MOA of Sulfonylureas?
The mechanism of action is Stimulates the K-ATP channels of pancreatic beta cells to increase insulin secretion refers to sulfonylureas (glipizide, glyburide, gliclazide). One of the major side effects of sulfonylureas is hypoglycemia due to the stimulation of insulin release. It is important to inform patients of an increased risk of hypoglycemia and to have them take this medication with food. If they have symptoms of hypoglycemia, they should have access to a glucometer and glucagon or an alternative sugar source. Situations in which hypoglycemia is more likely to occur include after exercise, after a missed meal, with doses that are too high, with alcohol intoxication, with impaired renal and cardiac function, and after hospital admission. Additionally, the side effect of hypoglycemia is more common with the long-acting sulfonylureas (glyburide) compared to shorter-acting sulfonylureas (glipizide, gliclazide).
The initial treatment of choice for type 2 diabetes is metformin, with sulfonylureas often being added as a second agent in those in whom metformin is not achieving adequate control. This is usually because the patient cannot afford some of the newer agents that are likely to replace sulfonylureas over the next few years, especially as they become more affordable. These agents include GLP1 agonists and SGLT-2 inhibitors. Clinical indications for initial use of sulfonylureas include contraindications to metformin, severe hyperglycemia, and maturity-onset diabetes of the young (MODY). Initiation of these medications will lower the hemoglobin A1c by 1-2% on average. There is some concern that stimulating increased insulin release leads to more rapid pancreatic burnout and is another reason why some of the newer agents are favored, in addition to causing less hypoglycemia and weight gain. Sulfonylureas should generally be discontinued when insulin is started, as opposed to metformin, which is usually continued along with insulin therapy.
Best ophthalmology test for herpes zoster on face to see if its affecting eye?
The dermatomal distribution of acutely erupted vesicular lesions in an elderly patient prompts the differential diagnosis to include varicella-zoster virus. In this particular distribution, which involves the tip of the nose, one must be concerned about corneal involvement, known as herpes zoster ophthalmicus, involving the V1 branch of the trigeminal nerve. Therefore, the virus also might involve the cornea along with the tip of the nose. The patient may complain of ocular pain, change in vision, and photophobia. When stained with fluorescein and viewed under a cobalt blue light, pseudodendrites appear on the surface. Hutchinson sign might also be present. This is a clinical sign that refers to vesicles on the tip or side of the nose that precede the development of ophthalmic herpes zoster.
Treatment for lateral epicondylitis?
lateral epicondylitis. The most appropriate next step is to have him consider rest (if possible, though this may require time off from work or alternative labor) and the addition of physical therapy focusing on eccentric strengthening exercises and wrist mobility. A counterforce brace would also be a consideration but is not listed as an option. Lateral epicondylitis is a common condition affecting laborers and tennis players and is commonly called “tennis elbow.” It presents with lateral elbow pain that is exacerbated with resisted extension of the wrist.
Metabolic syndrome criteria?
While there are several definitions for metabolic syndrome, the ATP III criteria is most widely used. The ATP III criteria define the metabolic syndrome as the presence of any three of the following five traits:
Abdominal obesity, defined as a waist circumference ≥102 cm (40 in) in men and ≥88 cm (35 in) in women
Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides
Serum high-density lipoprotein (HDL) cholesterol < 40 mg/dL (1 mmol/L) in men and < 50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL cholesterol
Blood pressure ≥130/85 mmHg or drug treatment for elevated blood pressure
Fasting plasma glucose (FPG) ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose
Raloxifene and Tamoxifen contraindications?
Raloxifene should be avoided in women with a past history of thrombosis. Raloxifene does not increase the risk of endometrial cancer, unlike tamoxifen. The risk of breast cancer decreases with raloxifene use. There are no definitive data showing raloxifene modifies the risk of ovarian cancer. Raloxifene is a mixed agonist/antagonist of estrogen receptors, acting as an antagonist in breast/vaginal tissues and an agonist in bone. Raloxifene increases the risk of thromboembolism.
What is the dental prophylaxis for patients with history of endocarditis?
The patient is presenting with signs and symptoms consistent with endocarditis. She has sepsis, bacteremia, a history of intravenous drug use, a new murmur, and an Osler’s node on her finger. Patients with a prior history of infective endocarditis are considered to be at increased risk for recurrence due to changes in the valvular epithelium caused by prior infection. These patients should receive endocarditis prophylaxis when undergoing any kind of high-risk procedure with 2 g of amoxicillin, 30 to 60 minutes prior to their procedure. Azithromycin, cephalexin, or clindamycin are alternative options for penicillin-allergic patients. Patients with risk factors, but undergoing low-risk procedures, do not need prophylaxis.
Diagnosis of DM2?
Type 2 diabetes mellitus (DM) is diagnosed with a fasting glucose level greater than 126 mg/dL on 2 separate occasions, a random glucose greater than 200 mg/dL with symptoms of hyperglycemia, or a 2-hour postprandial glucose level greater than 200 mg/dL. The American Diabetes Association (ADA) now suggests using an HbA1c of greater than 6.5% as a criterion for diagnosing diabetes. The preprandial glucose goal for diabetics is 90 to 130 mg/dL, whereas the postprandial goal level is < 180 mg/dL. According to the ADA, the goal HbA1c for diabetics is < 7.0%, but this may vary with other risk factors and age.
What what glucose parameters do we just start Dm2 patients on insulin?
However, acording to the ADA, in the setting of severely uncontrolled diabetes with catabolism, which is defined as fasting plasma glucose levels > 13.9 mmol/l (250 mg/dl), random glucose levels consistently above 16.7 mmol/l (300 mg/dl), A1C above 10%, or the presence of ketonuria, or as symptomatic diabetes with polyuria, polydipsia and weight loss, insulin therapy in combination with lifestyle intervention is the treatment of choice. The reasoning is that some of these patients may have unrecognized type 1 diabetes and others will have type 2 diabetes with severe insulin deficiency. Insulin can be titrated rapidly to better get the glucose levels under control. After any symptoms have resolved and glucose levels have decreased, the patient may be switched to oral agents if tolerated.
Note: Abnormal blood urea nitrogen and creatinine can also be indicative of renal dysfunction that precludes the use of metformin.
When do we give Tetanus Toxoid to injuries? Tetanus immunoglobulin?
The secondary prevention of tetanus can be accomplished after exposure by adhering to guidelines set forth based on vaccination history and wound specifications. All patients, regardless of vaccination history, should receive a tetanus toxoid booster (Td) every 10 years. Tetanus toxoid should be administered intramuscularly to patients suffering from tetanus-prone wounds (those present for greater than 6 hours, deeper than 1 cm, contaminated [dirt, metal debris, clothing], or exposed to saliva or feces, as well as crush injuries), to patients who are less than 7 years of age, or if it has been more than 5 years since the patient’s last booster, as is the case in this patient.
Tetanus immunoglobulin (TIG) should be administered to patients older than age 60, along with patients who have received fewer than 3 doses of tetanus toxoid in their lifetime. If there is any doubt that the patient has had his or her original series of 3 tetanus immunizations, add tetanus immune globulin.
With the evaluation of any wound, basic irrigation and appropriate dressing, closure, or referral are required.
JNC 8 Blood pressure guidelines?
According to the Eighth Joint National Committee (JNC 8) guidelines, the recommendation is to target, as goals, systolic blood pressure of less than 140 mmHg and diastolic blood pressure of less than 90 mmHg in patients who are older than 18 years of age and who have a diagnosis of diabetes mellitus (DM). These blood-pressure goals are based largely on expert opinion.
Hypertension is a major contributor to cardiovascular disease and is more common with increasing age. According to the American College of Cardiology, in adults who are 45 years of age and who do not have hypertension, the 40-year risk for developing hypertension is 93% for African-American adults, 92% for Hispanic adults, 86% for white adults, and 84% for Chinese adults.
Before diagnosing a person with hypertension, it is important to use an average that is based on 2 or more readings that are obtained on 2 or more occasions to estimate the individual’s blood pressure. Rarely, hypertension can be diagnosed with 1 reading if the patient has signs of end-organ damage (chronic kidney disease [CKD] with proteinuria, left-ventricular hypertrophy, ischemic coronary disease, etc.) due to hypertension or if the patient presents with a blood pressure of more than 180/120 mmHg or with hypertensive emergency.
What is Sciatica? presents with?
This patient is presenting with symptoms of sciatica, or compression of the sciatic nerve. Sciatica is a very common pathology that affects males more than females. Incidence peaks in the fourth or fifth decade of life. Other risk factors include obesity, cigarette smoking, diabetes, and sedentary lifestyle. Most patients present with low back pain (not required) that radiates unilaterally down one leg for a few months and is exacerbated by increased intra-abdominal pressure or Valsalva (sneezing, coughing, or laughing), sitting, or standing and at nighttime. Patients may get relief when bending backward. Examination may reveal non-midline tenderness in the lumbar region, positive straight leg raise test, decreased or absent reflexes, weakness, or numbness and tingling. Workup should include plain radiographs and magnetic resonance imaging to evaluate for spinal cord compression. Treatment includes reduced activity for a few days (strict bed rest is no longer recommended), avoiding heavy lifting, physical therapy to strengthen abdominal muscles, and nonsteroidal anti-inflammatory medications. If pain persists, other interventions may be considered such as steroidal epidural injections or surgery.
What is the diagnostic criteria for Osteoporosis?
A T-score of less than -2.5 is diagnostic of osteoporosis. The T-score is calculated by comparing the bone density measurements produced by DEXA to the mean bone density of a young, healthy adult of the same sex. A T-score of -1.0 or greater is considered normal bone density, and a T-score of -1.0 to -2.5 is characterized as osteopenia. Patients with osteoporosis are at risk for fragility fractures, which are fractures that occur due to minor or no trauma and would not otherwise be expected in those with normal bone density. These fractures are commonly seen in the hip as well as the spine, wrist, humerus, ribs, and pelvis. Any fracture without a clear inciting incident should raise concern for underlying osteoporosis.
What is the initial treatment of an acute uncomplicated anal fissure?
The initial treatment of an acute, uncomplicated (no inflammatory bowel disease) anal fissure is supportive with the administration of fiber, sitz baths, topical analgesics, and topical vasodilators, such as nifedipine or nitroglycerin. If constipation is the main cause, that should be treated aggressively with stool softeners and laxatives. In this patient, oral iron is likely worsening her constipation and she should be placed on long-term stool softeners to help with the side effects of iron administration.
Acute anal fissures often present with anal pain that is exacerbated by defecation and can be present at rest. This pain may be severe for hours after defecation, which can be debilitating. Additionally, these fissures will often bleed, which can lead to patient distress and may be the presenting complaint. Anal fissures are often misdiagnosed as hemorrhoids, usually due to inadequate examination. Hemorrhoids, unless thrombosed, are not usually nearly as painful as anal fissures. An anal fissure should appear as a longitudinal tear of the anoderm. It can look like a paper cut or superficial laceration. Chronic anal fissures may have raised edges and may have associated skin tags from inflammation.
Treatment of lower extremity venous stasis?
The best management of uninfected lower extremity venous stasis wounds includes general prevention and treatment of venous stasis (such as elevation, compression, exercise, and barrier protection) as well as specific ulcer-related therapy such as gentle debridement and dressing.
Long term venous stasis can lead to?
Long-term venous stasis is associated with the development of fibrosing panniculitis of the subcutaneous tissue that can be recognized as taut skin. The classic appearance of the legs is that of an inverted champagne bottle due to the fibrosis of the distal legs. The development of these pathological changes and associated phenotype is called lipodermatosclerosis and is caused by chronic venous insufficiency. The fibrotic skin changes and underlying inflammation with continued venous hypertension often lead to the development of skin ulceration and breakdown.
BPH most commonly occurs in what zone?
Benign prostatic hyperplasia (BPH) most commonly occurs in the transitional zone of the prostate, and may not be detected on digital rectal exam (DRE)
Osteoporosis cut off and treatment options?
This patient has osteoporosis based on her T score of -2.6. Osteoporosis is diagnosed with a T score below -2.5. The preferred pharmacologic therapy for postmenopausal women with osteoporosis is a bisphosphonate. Most bisphosphonates are oral, readily available, and well tolerated (alendronate and risedronate). Contraindications to oral bisphosphonates include esophageal abnormalities, history of bariatric surgery, inability to sit up straight, and esophagitis. Given this patient’s history of achalasia, she would not be a candidate for oral bisphosphonate therapy. The best therapy for her would be a longer-acting intravenous formulation, such as zoledronate (zoledronic acid).
When to bring Nephrology on for T2DM?
While this patient does present with microalbuminuria and minimally decreased GFR, guidelines typically suggest nephrology evaluation if the patient’s GFR drops below 30 mL/min/1.73m2 or when albuminuria exceeds 300 mg/g.
