Content Flashcards
Leading causes of death in all ages/genders
Heart disease, CA, chronic lower respiratory disease
Leading cause of death in adolescents
MVA, suicides, homicides
Most common skin cancer
Basal cell carcinoma
SpIn
SPECIFIC test rules IN diagnosis (detects true negatives)
SnNout
SENSITIVE test rules OUT diagnosis (detects true positive)
Screenings, taking daily aspirin to prevent future MI
Secondary prevention
Support groups, education on current disease, rehab
Tertiary prevention
Acute onset severe eye pain, phototobia, tearing, blurred vision in one eye
Herpes keratitis
Elderly with acute onset of severe eye pain with headaches, N/V, halos, decreased vision, cloudy cornea, cupping of optic nerve on fundoscopic exam
Acute angle-closure glaucoma
Refer to ED
Young adult female with new loss of vision in one eye; may have nystagmus; daily fatigue on awakening worse through day; heat exacerbates
Optic neuritis from multiple sclerosis
Refer to neurologist
Acute onset erythematous swollen eyelid with proptosis and eye pain; pain on eye movement; history of recent rhinosinusitis or URI
Orbital cellulitis
Refer to ED
Sudden onset of floaters with looking through curtain and sudden flashes of light
Retinal detachment
Refer to ED
Cauliflower growth on ear and foul smelling ear discharge; hearing loss; TM not visible due to tumor
Cholesteatoma
Tx with antibiotic and surgical debridement
Battle sign
Periorbital ecchymosis and bruising behind ear appearing 2-3 days post trauma
Rule out basilar or temporal bone fracture
Clear golden fluid from nose/ear
Indicates basilar skull fracture
Severe sore throat, difficulty swallowing, painful swallow, hot potato voice; unilateral swelling or peritonsillar area; uvula deviation away
Peritonsillar abscess
Refer to ED
Sore throat, fever, swollen neck
Gray to yellow pseudomembrane of throat
Diphtheria
Contact prophylaxis
Refer to ED
Age related due to decreased ability of eye to accommodate stiffening of lenses
Presbyopia
Normal TM
Translucent off white-gray color with cone of light intact
Bluish, pale, boggy nasal turbinates
Indicate allergic rhinitis
Leukoplakia
White to light gray patch that appears on tongue, floor or mouth or cheek
Aphthous stomatitis
Canker sores
Tx with magic mouthwash–benadryl, viscous lidocaine, steroid
Papilledema
optic disc swelling with blurred edges due to increased ICP secondary to bleeding, brain tumor, abscess, pseudotumor cerebri
Hypertensive retinopathy
Copper and silver wire arterioles, AV nicking, retinal hemorrhages
Diabetic retinopathy
Microaneurysms, cotton wool spots
Opacity of lens, difficulty with glare, halos around lights, blurred vision
Cataracts
Koplik spots
Small red papules with white centers clustered on cheeks
Measles
Ishihara chart
Tests for color blindness
Legal blindness
20/200
When should vision be 20/20
Age 6
Weber test
Tuning fork placed on midline of forehead; normal finding is no lateralization
Rinne test
Tuning fork on mastoid process than at front of ear
Normal is AC > BC
Causes of conductive hearing loss
OE, cerumen, OM, obstruction
Causes of sensorineural hearing loss
Presbycusis, meniere disease, ototoxic drugs, stroke
Acute onset severe eye pain with tearing, feeling of foreign body
Corneal abrasion
Tx of contact lens related keratitis
Topical ophthalmic abx with pseudomonal coverage (cipro, ofloxacin, polytrim) for 3-5 days
Acute onset swollen, red, and warm abscess on eye
Hordeolum
Tx with warm compresses 5-10 minutes BID to TID
Chronic inflammation of melbumian gland on eye; painless and moveable
Chalazion
tx: I+D, surgery, steroid injections
Wedge shaped yellow thickening of conjunctiva due to sun exposure
pterygium
Tx: sunglasses
Sudden onset bright red blood in eye with no pain
Subconjunctival hemorrhage
Resolves on its own in 1-3 weeks
Gradual increase in IOP with gradual change in peripheral vision first
Primary open-angle glaucoma
Tx: timolol eye drops or latanoprost topical prostaglandin
Insidious onset eye pain with conjunctival injection; complication of autoimmune disorder
Anterior uveitis–iritis
Painless loss of central vision
Macular degeneration
Results in blindness
More common in smokers
Chronic autoimmune disorder with decreased function of lacrimal and salivary glands
Daily dry mouth and eyes >3 months
Sjogrens syndrome
Eye drops TID
Refer to ophthamologist and rheumatologist
Inflammation of eyelid; itching and irritation, eye redness
Blepharitis
Tx: baby shampoo and warm water
May use erythromycin BID to TID
Clear mucus rhinorrhea, postnasal drip, nasal itch, family history of atopy, pale/boggy turbinates, under eye bags, nasal crease, cobblestoning
Allergic rhinitis
Tx: nasal steroids (flonase)
2nd line is topical antihistamines
Decongestants PRN
abrupt onset fever, sore throat, pain on swallowing, enlarged submandibular lymph nodes, purulent exudates on tonsils, enlarged anterior notes, absence of cough
strep throat
Tx: penicillin 500mg BID 10 days
Possible complications of strep throat
Scarlet fever, rheumatic fever, peritonsillar abscess, post strep glomerulonephritis
Most common organisms in AOM
Strep pneumoniae, H. influenzae, M. catarrhalis
Ear pain, muffled hearing, recent cold, afebrile or low fever
AOM
Tx: amoxicillin high dose 5-7 days
Unilateral facial pain with nasal congestion >10 days; purulent nasal/postnasal drip
Acute bacterial rhinosinusitis
Tx: High dose Augmentin BID 5-7 days
Tx of sx: decongestants, guaifenesin, flonase, dextromethorphan, benzonatate
OE due to
Psuedomonas or staph aureus
Tx of OE
Cortisporin otic (polymyxin B-Neomycin-Hydrocortisone) 4 drops QD 7 days Ofloxacin or cipro otic drops BID 7 days
Fever, pharyngitis, posterior lymph nodes, fatigue, hepatosplenomegaly, maculopapular rash
Mono
Tx: symptomatic
Rinne test with conductive hearing loss
BC >AC
Weber test with conductive hearing loss
Lateralization to bad ear
Abrupt onset high fever, chills, severe headache, N/V, phototobia, myalgia, arthralgia followed by 2-5 days fever
Petchiae rash on wrist, forearms, ankles and progressing to trunk
Rocky mountain spotted fever
Tx: doxycycline
Expanding red rash with central clearing (target lesion)
Erythema migrans (Lyme disease) Tx: doxycyline
Sore throat, cough, fever, HA, stiff neck, phototobia, changes in LOC, may have petechial rash
Meningitis
Rifampin prophylaxis if outbreak
Pearly or waxy skin lesion with atrophic/ulcerated lesion that may bleed easily
Basal cell carcinoma
Numerous dry, round, red-colored lesions with rough texture
Actinic keratoses
Pre-cancerous squamous cell carcinoma
Anatomy of skin
Epidermis: no blood vessels–top layer squamous epithelial cells, bottom layer melanocytes
Dermis: blood vessels, sebaceous glands, hair follicles
Subcutaneous layer: fat, sweat glands, hair follicles
Most common skin CA
Basal cell carcinoma
Macule
<1cm, flat
Freckles, lentigo
Papules
Palpable solid lesion <0.5cm
Moles, acne, cherry angioma
Plaque
Flat elevated >1cm
Psoriasis
Bulla
Elevated blister filled >1cm
Impetigo, SJS
Vesicle
Elevated <1cm filled with serous fluid
Herpes
Pustule
Elevated <1cm filled with purulent fluid
Acne
Erythematous/raised skin lesions with discrete borders; wheals
Urticaria–hives
Soft, wart like fleshy growths on the trunk; appear in the middle age
Painless
Seborrheic keratoses
Xanthelasma
Raised, yellow plaques on eyes
50% of these patients have hyperlipidemia
Melasma
Bilateral brown/tan stains on face on pregnant women
Usually permanent
Vitiligo
Hypopigment of skin that spreads over time
Risk factors: autoimmune disease
Tx: steroids, light therapy, avoid sun
Acanthosis Nigricans
velvety thickening of skin behind neck
associated with DM, metabolic syndrome, GI cancer
Avoid what medication in fungal infection
Steroids
Koebner phenomenon
In psoriasis, new plaques develop over sites of trauma
Auspitz sign
In psoriasis, pinpoint bleeding when scales are removed
Pruritic erythematous plaques covered with silvery white scales
Psoriasis
Tx: topical steroids, topical retinoids
For refractory: methotrexate, cyclosporine, biolics
Hypopigmented round macules on chest, shoulders
Tinea versicolor
Tx: selenium sulfide, topica azoles
Multiple small vesicles that rupture; lesions become lichenified from chronic itching
Atopic dermatitis (eczema)
Tx: hydrocortisone if mild, triamcinolone if moderate
Oral antihistamines for itching
Skin lubricants–Eucerin, baby oil
Inflammatory skin reactions due to contact with irritating external substance
Bright red and pruritic lesions that evolve into bullous or vesicles
Contact dermatitis
Tx: if lichenified, use high potency steroids
Bright red/shiny lesions that itch and burn; may have sattelite lesions
Common in obese/moist areas
Superficial candidiasis
Tx: nystatin or topical antifungals
Most common opportunistic infection in hIV patient
Oropharyngeal candidiasis
Tx: oral fluconazole
Acute diffuse pink/red skin poorly demarcated with advancing margins; warm and may form abscess; may have red streals
Cellulitis
Tx: amoxicillin
Folliculitis
infection of hair follicle
Tx: bactroban
Subtype of cellulitis involving the upper dermis/superficial lymphatics
Due to GAS
Erysipelas
Tx for human bites
Augmentin PO BID 10 days
If allergic to penicillin..doxycycline BID, Bactrim DS BID + Flagyl BID
Impetigo
Superficial skin infection due to G+
Tx: severe cephalexin or dicloxacillin
If no bullae, mupirocin
Do not return to daycare until 48-72 hours after treatment
Meningococcemia prophylaxis
Rifampin q12 hours 2 days for close contacts
Tx for meningococcemia
Ceftriaxone 2g IV q12 hours + Vanco IV q8-12
Tx of lyme disease
Doxycycline BID (adults and children)
Labs for lyme disease
ELISA
How long is varicella contagious for
1-2 days before onset of rash until all lesions have crusted over
Fever, pharyngitis, malaise, followed by pruritic vesicular lesions
Chickenpox
Labs for varicella
PCR
Tx varicella
Acyclovir X 5 days or valacyclovir X 10 days
Tx of postherpetic neuralgia
TCAs, anticonvulsants, gabapentin
Tx herpetic whitlow
NSAIDs and acyclovir if severe
Bacterial skin infection of lateral nail folds
Paronychia
Tx: topical mupirocin and soak in warm wate r
Oval lesions with fine scales that follow skin lines with christmas tree pattern
Pityriasis Rosea
Tx of scabies
Permethrin for 8 hours and repeat in 7 days
Tx of tinea capitus
Griseofulvin 6-12 weeks
Baseline LFT and 2 weeks after tx
Nails become opaque, yellow, thickened with scaling under nail
Onychomycosis
Tx: oral terbinafine or itraconazole
Tx mild acne
Tretinoin topical (retin A), benzoyl peroxicde gel, erythromycin/clindamycin topical
Tx moderate acne
Topical/oral abx: tetracycline or minocycline or erythromycin or clindamycin
Tx of severe acne
Isotretinoin
Tx rosacea
Metronidazole gel, azelaic acid gel, low dose tetracycline
Dome shaped papules with central umbilication due to poxvirus
Molluscum contagiosum
Tx of MRSA if allergic to Bactrim
Minocycline, doxycycline, clindamycin
Gradual onset intense and steady chest discomfort and pain produced by physical exertion or eating heavy meal
Acute MI
Acute or gradual dyspnea, fatigue, dry cough, swollen feet, crackles in lung with S3 heart sound
CHF
Fever, chills, and malaise associated with onset new murmur
May have subungual hemorrhages, petechiae on palate, janeway lesions
infective endocarditis
Sudden onset, severe, sharp, excruciating pain in abdomen/flank/back
Dissecting abdominal aortic aneurysm
S3 heart sound
May indicate HF
Always abnormal if >35 years
Normal in children, pregnant women, athletes
Systolic murmurs
Aortic stenosis Pulmonary stenosis Tricuspid regurg Mitral regurg MVP
Grade murmur first time thrill is present
4
Grade murmur when you can hear off of stethoscope slightly off chest
5
Grade murmur when you can hear off of stethoscope
6
Sudden onset heart palpitations with feelings of weakness, dizziness, dyspnea, syncope
A fib
Labs for new onset A Fib
TSH, EKG, electrolytes, renal function, BNP, troponin,
Tx of A fib rate control
Beta blockers, CCB, digoxin
Tx of A fib clot control
Warfarin, direct Xa inhibitors (ravoxaban)
INR goal for A fib
2-3
SE thiazide diuretics
Hypergluycemia, hyperuricemia, hypertriglyceridemia, hypokalemia, hyponatremia, hypomagnesia
SE loop diuretics
Hypokalemia, hyponatremia, hypomagnesia
SE aldosterone receptor antagonists
Gynecomastia, galactorrhea, hyperkalemia, GI upset
CCB CI in
Heart failure, bradycardia, 2nd/3rd degree heart block
Crackles, cough, dyspnea, decreased breath sounds, dullness to percussion
LVF
JVD, enlarged spleen, enlarged liver, edema
RVF
Tx HF
Initial: furosemide 20mg
If stable with htn: ACEI/ARB + beta blocker, spirinolactone
Homan sign
Lower leg pain on dorsiflexion of foot; indicats DVT
Labs: D-dimer, platelets, CVC, clotting time, EKG, US
Tx DVT: hep IV then warfarin 3-6 months
Patient with a history of smoking + Hyperlipidemia complains of worsening pain on ambulation instantly relieved by rest
Peripheral artery disease
Dx: ABI <0.9
Tx: aspirin + smoking cessation
Chronic and recurrent episodes of color changes on fingertips in symmetric pattern
Raynauds Phenomenon
Tx: avoid triggers, smoking cessation, nifedipine
Abx prophylaxis for endocarditis
Only if previous hx of prosthetic valves–amoxicilin 2g PO 1 hour before procedure
S2 click followed by systolic murmur
MVP
Tall/thin female with fatigue, palpitations, light headedness aggravated by heavy exertion
MVP
Tx: beta blockers if palpitations
Older adult with sudden onset of dyspnea/coughing may be productive or pink tinged; feeling of impending doom; history of A fib, estrogen, smoking, surgery, immobility
PE
Breath sounds in lower lobes
Vesicular
Breath sounds in upper lobes
Bronchial
PE in emphysema
Increased AP diameter, decreased breath sounds, pursed lip breathing, weight loss, hyperressonance percussion, tactile fremitus decreased
Tx COPD
Cat A: SABA PRN + short acting anticholinergic
Cat B: LABA or long acting anticholinergic
Cat C: LAMA or LAMA + LABA
Cat D: Refer to pulminologist
Acute onset fever, purulent sputum and wheezing in a patient with COPD
Susoect H Influenzae pneumonia
Tx: Bactrim, Doxy, Ceftin BID 10 days
The only treatment known to prolong life in COPD
O2
Bacteria that causes the most deaths in outpatient CAP
Strep pneumoniae
Most common pathogen in CF patients with CAP
Pseudomonas
PE in CAP
Rhonchi, crackles, wheezing, dullness, increased tactile fremitus
Tx CAP if no co-morbidity
Azithromycin for 5 days
Tx CAP if co-morbidity
Respiratory fluoroquinolone ALONE
OR Augmentin + Azithromycin
CURB criteria for CAP
Confusion, BUN >19, Resp >30, BP <90/60
Poor prognosis
Young adult with several weeks of fatigue and severe paroxysmal coughing that is nonproductive
Atypical pneumonia
Due to mycoplasma pneumoniae usually
Tx: Doxy, azithromycin or levaquin
Coughing >14 days, inspiratory whooping
Pertussis
Tx: azithromycin
Chest X ray in TB
Cavitations and adenopathy with granulomas
Fever, anorexia, fatigue, night sweats, mild nonproductive cough which progresses to hemoptysis with weight loss
TB
Tx: Rifampin, INH, ethambolol, pyrazamide
PPD positive results
> 5mm: HIV, recent contact, chest X ray positive, immunocompromised
10mm: recent immigrant, IV drug user, health care worker, homeless
15mm: no risk factors
Asthma treatments step 1-4
Step 1: FEV1>80%; daytime sx <2 days per week; use SABA
Step 2: FEV1<80%; daytime sx >2 days per week but not daily; SABA PRIN + low dose ICS
Step 3: FEV1 between 60 and 80; use SABA PRN + low dose ICS + LABA
Step 4: FEV1 <60; Daily symptoms; use SABA PRN + Medium dose ICS + LABA
Acute onset saddle anesthesia, bladder incontinence, fecal incontinence, and BL leg weakness
Cauda equina syndrome
Within first 48 hours of exercise injury
Do not exercise, use ice, do not do any ROM exercises
McMurray Test
+ suggests injury to medial meniscus
Lachman test
+ suggests ACL damage
Tx shin splints
RICE, compression bandage, low impact exercise
Inflammation of digital nerve of foot between third and fourth metatarsals
Mortons neuroma
Early morning joint stiffness and with inactivity
OA
Tx: first line is Tylenol
Woman complains of maculopapular butterfly rash in middle of face
SLE
Do a UA to look for proteinuria
Tx: steroids, plaquenil, methotrexate, biologics
Education: avoid sun and cover with sunblock
Gradual onset daily fatigue, low grade fever, body aches, myalgia, generalized joint pain, early morning stiffness, warm and tender swollen fingers
RA
Tx: NSAIDs, steroids, methotrexate, sulfasalazine, cyclosporine, hydroxychloroquine
Gold standard for diagnosing gout
Joint aspiration of synovial fluid
Tx acute: indomethacin or naproxen or NSAID + colchicine
Maintenance: Allopurinol
Tx of ankylosing spondylitis
NSAIDs
Acute onset high fever, muscular rigidity, mental status changes, hyperreflexia and uncontrolled shivering
Hx of taking SSRI
Acute serotonin syndrome
Atypical antipsychotics
Olanzapine, risperidone, quetiapine (Seroquel)S
SE: obesity and DM
Typical antipsychotics
Haldol, chlorpromazine
SE: increased lipids, malignant neuroleptic syndrome
SSRI
Paroxetine, fluoxetine, citalopram, sertraline, escitalopram
SE: anxiety, insomnia, impotence
SNRI
Duloxetine, venlafaxine
SE: may precepitate acute narrow angle glaucoma
Rule out what with depression
Thyroid issues, Vitamin B12 deficiency, anemia, autoimmune disorders
Korsakoff’s syndrome
Complication from chronic alcohol abuse
Hypotension, visual impairment, coma
Tx: thiamine
Gold standard for sleep apnea
Sleep lab (polysomnography)
Tx of anti-depressant induced sexual dysfunction
Bupropion
Best SSRI for elderly
Citalopram
Avoid what in patients with anorexia
Wellbutrin due to increased seizure threshold
Most common SSRI to cause ED
Paxil (Paroxetine)
Hypoglycemia
FBG<50; weakness, syncope, hand tremors, anxiety
more common in type 1 DM
Peak diagnosis of type 1 DM
age 4-6 and then 10-14
Thyroid CA
Hoarseness and dysphagia, nodules on upper 1/2 lobe
S/S pheochromocytoma
Headache, diaphoresis, tachycardia, hypertension
Hypothalamus secretes
TRH, GnRH, CRH, GHRH, somatostatin
Anterior pituitary secretes
FSH, LH, TSH, GH, ACTH, Prolactin, melanocyte stimulating hormone
Posterior pituitary
ADH and oxytocin
Primary hyperthyroidism
Thyrotoxicosis
Very low TSH with increase in free T4 and T3
Most common cause is Graves
Medications for hyperthyroidism
PTU and methimazole
SE: skin rash, aplastic anemia, thrombocytopenia, hepatic necrosis
Beta blockers for palpitations
Goal TSH with hyperthyroidism
<5
Drugs that can induce hyperthyroidism
Lithium, amiodarone, high doses of iodine, inter feron alfa, dopamine
Primary hypothyroidism
High TSH and low free T4
Most common cause is hashimoto’s thyroiditis
Myxedema
Severe hypothyroidism
Tx hypothyroidism
Levothyroxine 25-50mcg; increase until TSH normalizes
-Start with lowest dose for elderly
Check TSH every 6-8 weeks
Microvascular damage of DM
Retinopathy, nephropathy, neuropathy
Macrovascular damage of DM
Atherosclerosis, CAD, MI
Pre-diabetes labs
A1C between 5.7 and 6.4%
FBG between 100-125
2 hour OGTT 140-199
Diabetes labs
A1C >6.5
FBG >126
Random BG >200
Routine labs if have DM
A1C every 6 months, lipid annually, random urine for microalbuminemia annually
Dawn phenomenon
Increase FBG in the morning between 4 and 8am due to increase in GH
Increase evening dose of insulin
Somogyi effect
Severe nocturnal hypoglycemia causes glucagon release causing increase in FBG by 7am; decrease evening dose of insulin
Diabetic retinopathy
Neovascularization, microaneurysms, cotton wool spots, soft/hard exudates
1st line tx DM
Biguanides: metformin
Decreases gluconeogenesis + decreases insulin resistance
CI: renal, hepatic disease, alcoholics, hypoxia
Monitor renal function and LFT
Increased risk of lactic acidosis
Sulfonylureas
Glipizide, glyburide, glimepiride
Stimulates beta cells to secrete insulin
SE: hypoglycemia and photosensitivity
May cause weight gain
Thiazolidenodiones
Pioglitazone
Enhances insulin sensitivity in muscle tissues and decreases hepatic glucagon production
Take with breakfast
CI: HF (water retention)
Rapid acting insulin
Lispro, aspart, glutisine
Short acting insulin
Insulin humulin R
GLP-1 mimetics
Exanatide, liraglutide
Once a day SC
GLT2 inhibitors
-Flozin
Increases glucosuria
Lantus
Basal insulin; once a day
Order of rx diabetic meds
Metformin 500mg QD, increase dose of metformin, + sulfonylurea, + 3rd agent + basal insulin
Abx causing c diff colitis
clinda, fluoroquinolones, cephalosporins, penicillins
Zollinger Ellison syndrome
Gastrinoma on pancreas; stimulates high levels of acid production–development of ulcers
RUQ
Liver, gallbladder, ascending colon, right kidney
LUQ
Stomach, pancreas, descending colon, left kidney
RLQ
Appendix, ileum, cecum, right ovary
LLQ
Sigmoid colon, left ovary
Psoas sign
Flex hips 90 degrees and ask patient to push against resistance and straighten leg
Obturator sign
Inward rotation of hip
Rovsings sign
Deep palpation of LLQ results in referred pain to RLQ
McBurneys point
Tenderness indicates appendicitis
Murphys maneuver
Press deeply on RUQ during inspiration
Barretts esophagus increases risk of
Esophageal squamous cell cancer
1st line tx of GERD
Lifestyle changes
Meds for GERD
H2 blockers: ranitidine, famotidine, rizatidine
PPI: omeprazole
Long term use of PPI
May cause hip fractures, pneumonia, C diff
Do not D.C abruptly
Tx IBS
Fiber (metamucil)
Antispasmodics (dicyclomine)
Diarrhea (loperamide)
Labs for PUD
CBC and FOBT
tx H Pylori PUD
Clarithromycin + amoxicillin (or flagyl) + PPI
Tx of diverticulitis
Cipro 500mg BID + flagyl 500mg TID X10-14 days
Acute pancreatitis can be due to
Alcohol abuse, gallstones, triglyceridemia and infections
S/S acute pancreatitis
Acute onset fever, N/V, abdominal pain radiating to midback, + cullen sign and grey turner sign
Labs in pancreatitis
Increased amylase, lipase, trypsin
IgG anti-HAV positive
Antibodies present, no virus, not infectious
Hx of HAV vaccine
IgM anti-HAV positive
Acute infection, patient contagious
Increased ALT indicates
liver inflammation
More specific than AST
Increased alkaline phosphatase may be due to
Healing fractures, osteomalacia, bone malignancy, vitamin D deficiency
Most common cause of liver cancer
Hepatitis C
R/O for headaches
subarachnoid hemorrhage, leaking aneurysm, bacterial meningitis, brain abscess, brain tumor
Most common pathogens in bacterial meningitis for adults
Strep pneumoniae, N. meningitides, H. Influenzae
Tx bacterial meningitis in infants
ampicillin + 3rd gen ceh
Tx bacterial meningitis in adults
3rs gen ceph + chloram phenicol
Prophylaxis of bacterial meningitis
Rifampin or ceftriaxone
Abortive tx for migraines
NSAIDs, codeine/hydrocodone
Sumatriptan (rule out CV disease first)
Prophylactic tx of migraines
Beta blockers: propranolol
TCA: amitriptyline
Anticonvulsants: gabapentin, valproate
Mean age of dx for temporal arteritis
72
Gold standard dx test for temporal arteritis
temporal artery Biopsy
Tx temporal arteritis
High dose steroids (prednisone)
bilateral joint stiffness and aching in shoulders, neck, hips, torso
Polymyalgia rheumatica
Sudden onset severe and sharp shooting pain on one side of the face; triggered by chewing, eating cold foods
Trigeminal neuralgia
CN 5
Tx: high dose anticonvulsants and muscle relaxants
Wake up with one side of face paralyzed; difficulty chewing and swallowing food
Bells palsy
CN 7
TX: high dose steroids, acyclovir if herpes suspected, eye lubricant
R/O what with bells palsy
Stroke, TIA, mastoid infection, bone fracture, lyme disease, tumor
Prophylaxis cluster headache
Verpamil
Tx cluster headache
High dose O2 and sumatriptan
Risk factors for carpal tunnel syndrome
Hypothyroidism, pregnancy, obesity
Acute onset high fever, chills, dysuria, frequency, unilateral flank pain
Pyelonephritis
Abrupt onset oliguria, edema, weight gain due to fluid retention, loss of appetite
Acute renal failure
Smoker and painless hematuria
Bladder cancer
Average daily UO
1500mL
Oliguria
<400ml/day
Dx for UTI in UA
> 10^5 colony of bacteria
Hematuria seen in
Kidney stones, pyelonephritis, cystitis
Tx UTI in female 18-65
Bactrim BID X3 days Nitrofurantoin BID X3 days Augmentin BID 5-7 days Alt: Cipro or Levaquin X3 days Pyridium BID X 2 days PRN for pain
Tx UTI complicated
Minimum 7 days
Cipro 500mg BID or levaquin 750mg qD
Bactrim 500mg BID or Cefixime 400mg BID
Prophylaxis UTI
Bactrim 500mg QHS
UA in pyelo
Large amount of leukocytes, hematuria, WBC casts, proteinuria
TX pyelo
Fluoroquinolone or ceftriaxone 1g IM
Second line: augmentin or Bactrim
Majority of kidney stones
Ca Oxalate
High oxalate foods
Rhubarb, spinach, beets, chocolate, tea, meats
Best measure of kidney function
eGFR
How much blood loss reuslts in orthostatic hypotension
> 15%
How long after acute hemorrage do hct and hgb levels decrease
24 hours
Increase in reticulocytes
Vitamin b12 deficiency
Gradual onset peripheral neuropathy, ataxia, impaired memory, dementia
Cancer of B cells, night sweats, fevers, pruritus, painless enlarged lymph nodes ,weight loss
Hodgkins Lymphoma
Fatigue, weakness, bone pain, bence jones protein in urine, hypercalcemia
Multiple myeloma
Easy bruising, bleeding gums, nosebleeds, hematuria
Thrombocytopenia
normal hgb
14-18 men
12-16 women
What may cause polycythemia
Long term high altitude or chronic hypoxia, smoking
normal hct
42-52% men
37-47% women
Normal MCV
80-100
Most sensitive test for iron deficiency
Serum ferritin
Decreased in iron deficiency
Increased in thalassemia trait
normal WBC
5000-10,000
Gold standard test ot diagnose sickle cell, thalassemia
Hemoglobin electrophoresis
Pallor of skin, conjunctiva and nail beds; daily fatigue; exertional dyspnea; glossitis and angular cheilitis, pika
Iron deficiency anemia
Most common cause of iron deficiency anemia
Blood loss
Tx iron deficiency anemia
Ferrous sulfate 325mg PO TID between meals for 3-6 months
Increase fiber and fluids and iron rich foods
Check reticulocyte and CBC 2 weeks later
Meds that can decrease hgb
ARB and ACEI
Thalassemia minor
bone marrow produces abnormal hgb; results in microcytic/hypochromic anemia
Majority asx
No tx required
Anemia of chronic kidney disease
Due to decreased EPO in CKD
Gold standard test for aplastic anemia
Bone marrow biopsy
How long does body supply of B12 last
3-4 years
Pernicious anemia
Autoimmune; decreased IF and decreased absorption of B12
Paresthesia of feet and hands occur first
Tx: B12 injections weekly X 4 weeks and then monthly for a lifetime
How long does body’s supply of folic acid last
2-3 months
Sickle cell anemia has increased risk of death from
S. pneumoniae, H. influenzae
Due to hyposplenia
dx test for sickle cell
Hgb electrophoresis
If pt has MCV <80…
Test TIBC, Ferritin, serum iron
If ferritin and iron are low: iron deficiency
If ferritin and iron normal: thalassemia
If pt has MCV >100
Order folate and vit B12
Foods high in folate
Leafy green vegetables, grains, beans, liver
Risk factors for priapism
Sickle cell, ED meds, cocaine, quadriplegia
Wake up with abrupt onset painful/swollen red scrotum with N/V
Affected testicle is higher and closer to the body
Testicular torsion
Cremasteric reflex missing
Must be corrected within 6 hours
Doppler US with color flow study
Blue colored round mass on testicular surface resembling a blue dot
Torsion of appendix testis
Where does spermatogenesis take place
Seminiferous tubules of testes
Require 3 months to mature
Testes function
Production of testosterone/androgens stimulated by LH
Spermatogensis stimulated by testosterone and FSH
Epididymis
Located in posterior aspect of testis; storage area for immature sperm
Vas deferens
Transport sperm from epididymis to urtethra
This is cut in a vasectoy
Cremasteric reflex
Testicle elevates up in response to stroking thigh
Absent in testicular torsion
Risk factors for prostate CA
> 50, AA, obesity, family history
Tx for BPH
Alpha blockers : terazosin or tamsulosin
-Watch for orthostatic hypotension
5-alpha-reductase inhibitors: finasteride
–Work directly on prostate gland to shrink it; cat X drug
Chronic bacterial prostatitis
> 6 weeks
due to E coli or proteus
Perineal discomfort with dysuria, nocturia, frequency
UA normal, urine mixed with prstate fluid + for E coli
Acute onset high fever and chills, perineal pain may radiate to back, UTI sx
Acute prostatitis
DRE: extremely tender prostate that is warm and boggy
LABS: leukocytosis with left shift, increased WBC in UA and hematuiia
Tx acute prostatitis
<35: ceftriaxone IM + doxy X10 days (tx like STD)
>35: cipro or levaquin 4-6 weeks
Acute onset swollen red scrotum painful with unilateral testicular tenderness with urethral discharge green and purulent
Acute bacterial epididymitis
Relief of pain with scrotal elevation
tx acute bacterial epididymitis
<35: doxy and IM ceftriaxone (tx like STD)
>35: Ofloxacin or levaquin X 10 days
Scrotal elevation + bed rest
Chronic scaly red rash resembling eczema starting on nipple and spreading to areola
Paget disease of breast
No period for 6-7 weeks, lower abdominal/pelvic pain worse when supine
Ectopic pregnancy
Where is majority of breast CA located
Upper outer quad of breasts: tail of spence
Heavy bleeding, pelvic pain, bleeding between periods
Fibroids
Usually benign
Acne, hirsutism, oligomenorrhea, insulin resistance
PCOS
Palpable ovary in menopausal woman
always abnormal
Order US
Follicular phase
Days 1-14
FSH stimulates eggs to produce estrogen which stimulates growth of endometrial lining
Ovulatory phase
Day 14
LH produces ovulation ; follicle migrates into fallopian tube
Luteal phase
Days 14-28
Progesterone produced; sitimulates stability of endometrial lining
Menstruation
Estrogen + progesterone drop dramatically
Drugs that decrease efficacy of birth control
Phenytoin, phenobarb, griseofulvin, itraconazole, ampicillin, tetracyclines, rifampin
Depo return of fertility
Can decrease for up to 1 year due to severe uterine atrophy
Low dose OCP contains how much estrogen
20-25mcg ethinyl estradiol
Mefenamic acid
NSAID very effective against menstrual pain
Tx PCOS
OCP, spirinolactone, metformin (induces ovulation)
Tx osteoporosis
Biphosphanates: alendronate
-Take with full glass of water sitting up and do not chew tablets
Tx bacterial vaginosis
Metronidazole X 5 days
Tx candidal vaginitis
Monistat OTC or diflucan 1 dose
Tx Trich vaginitis
Flagyl X 7 days
Treat partner also
Growth charts
WHO until 2 years old and then CDC
Microcephaly with shortened palpebral fissures with epicanthal folds and flat nasal bridge and smooth philtrum
FAS
Cryptorchidism
Undescended testes
Increased risk of testicular CA
Tx chalmydia pneumonia
Erythromycin X2 weeks
White 1-2mm papules commonly on nose or cheeks that resolves spontaneously
Milia
Small pustules surrounded by red base that resolves spontaneously
Erythema toxicum neonatorum
Faun tail nevus
Tufts of hair on spinal column; may be sign of spina bifida
Order US
Nevus flammeus
Port wine stain
Weight gain 0-6 months
6-8oz per week and 1in per month
Weight gain 6-12 months
3-4oz per week and 1/2in per month
Caput succedoneum
Crosses midline
Normal
Cephalohematoma
Does not cross midline
Abnormal
White papules found on gum line resembling an erupting tooth
Epstein’s Pearls
moro reflex disappears by
3-4 months
Step reflex disappears by
6 weeks
Rooting reflex disappears by
3-4 months
4 month development
Social smile, holds head steady, rolls front to back
6 month development
Palmar grasp, reaches, passes objects, sits independently, rolls both directions, consonants
9 month development
Pincer grasp, waves, feeds self, pulls self to stand, crawls and cruises, peek a boo, stranger anxiety
12 month development
Sippy cup, stands, walks, 2-4 words, knows name
15 month developemnt
Feeds self with spoon, drinks from cup, 4-6 words
18 months
Turns pages of book, walks up steps, points to 4 body parts, 10-20 words
Physiologic jaundice
Neonatal unconjugated hyperbili
Bili >5
Starts after 24 hours and clears within 2-3 weeks
Breast milk jaundice
Onset >7 days
Can take 2-3 weeks to clear
Due to decreased breast milk production
Tx: phototherapy
Dx for coractation of aorta
Absence of femoral pulse when compared to brachial pulse
Ortolani test
Click or clunk sound is + finding
Barlow test
Clunk sound on palpating trochanter
Abdominal mass that is fixed, firm, irregular
Frequently crosses midline
Neuroblastoma
50% present with metastasis
Imaging: US
May have weight loss, fever, racoon eyes, bone pain
Asymptomatic abdominal mass that is nontender and smooth
Rarely crosses midline
Nephroblastoma–Wilms tumor
Most common renal malignancy in children
Palpate GENTLY
Prophylaxis for epiglottitis
Rifampin
Top 3 CA in children
Leukemia, brain or nervous system, neuroblastoma
2 year old development
2-3 word sentences
Stacks 6 cubes
Can copy straight line, runs, jumps, climbs, temper tantrums, says no
3 year old development
3-5 word sentences
Knows age and sexual identity
Magical thinking
Copies circle, throws ball, stacks 9 cubes, rides tricycle
High fever and enlarged lymph nodes in neck, bright red rash, conjunctivitis, strawberry tongue, edema
Kawasaki disease
Tx kawasaki disease
High dose aspirin and gamma globulin
Follow up in cardiologist for several years
Extreme fatigue and weakness, pale skin, easy bruising, petechial bleeding, bleeding gums and noses
Leukemia
Most common type of leukemia
ALL
Hx of febrile illness with salicylate intake
Reyes syndrome
Mortality rate of reyes syndrome
50%
Stage 1 reyes syndrome
Sever vomiting, diarrhea, lethargy, increased AST and ALT
Stage 2 reyes syndrome
Personality changes, aggression
Stage 3-5 reyes syndrome
Confusion, delirium, coma, death
Large head circumference, mental retardation, delayed physical development, hyperactive
Fragile X
Acute onset fever, severe sore throat, HA, multiple small blisters on hands and feet; ulcers in mouth and on tonge
hand foot and mouth
Initial test for testicular torsion
Doppler US
Precocious puberty girls
<8 years
Delayed puberty girls
No breast development by age 12
Precocious puberty boys
<9
Delayed puberty boys
No testicular growth by age 14
Tanner stages boys
2: Testes enlarge
3: Penis elongates
4: penis thickens and increases in size
5: adult
Tanner stages girls
2: breast bud
3: breast mound
4: areola/nipples separate to form 2nd mound
5: adult
Primary amenorrhea
No menarche at age 15; usually due to chromosome disorder
Secondary amenorrhea
no menses for 6 months; most common cause is pregnancy
other: ovarian disorder, stress, anorexia, PCOS
