Deck 1 Flashcards
Diffuse itching in absence of rash
Do general labs search for systemic cause (TFT, iron, CBC, CMP)
Liver dz, CKD, thyroid, HIV, IDA, age appropriate cancer screening
Psoas sign
pain on extension of hip - lumbar plexus compression from iliopsoas hematoma
FHx of mucocutaneous bleeding, no prolonged PTT, on OCP
vW dz
Newly Dx DM2 - what to do to screen
Urine alb-Cr ratio now
Do not use MDRD (only in pts with CKD - not accurate with preserved glomerular fxn)
Mycobacterium Avium Complex in middle aged woman with no pre-existing lung condition, has discrete nodules - exposed to soil in SW US, no smoking
Need to repeat sputum ctx for MAC - if still positive then BAL or video assisted thoraoscopy for bx
COPD tx FEV<60%
1st recommendation - long acting broncodilator (tiotropium)
don’t use budesonide (ie inhaled corticosteroid) - no benefit compared to long acting broncodilator
Depression screening
screen all adults as long as appropriate support available
Hep B screening
not routinely recommneded except pregnant women
Osteoporosis screening
Women > 65 or high risk (3 month corticosteroid, etoh, low body mass, smoking, dementia, anticonvulsant use)
Screening for H pylori in setting of GIB or PPI current use or abx use
ONLY H. Pylori serology
Cardiorenal syndrome
fluid overload from inpt saline/abx use decreases ability to excrete sodium - heart can’t compensate for inc’d preload in setting of CHF -> IV lasix (even with elev Cr)
Don’t use lisinopril, don’t use BB in setting of acute decompensated HF
Vaginal atrophy - pale walls, petechiae, whiff neg, no clue cells - no response for vaginal itching from lubricants
low dose vaginal estradiol/ring
don’t use oral estrogen (inc’d r/o CVA, CAD, VTE, breast CA)
Bacterial vaginosis
inc’d vaginal pH, clue cells, +whiff test, vaginal d/c
Tx: metronidazole
Yeast infections
thick white d/c, KOH + with hyphae
Tx: vaginal clomitrazole
Posterior mediastinal mass
schwannoma - benign neoplasm from NEURAL tissue - usually located in posterior mediastinum
could also be esophageal tumor/cyst
(cough, venous distention, hoarsness, CP, Back pain, asx)
Usually need removal if sx don’t regress or if dx in question
Anterior mediastinal mass
thyroid, thymus, lymphomas
Middle mediastinal mass
broncogenic cysts, pericardial cysts, LAD
Allergic contact dermatitis
eczema caused by environmental exposure, unusual geographic pattern (ie oval, rectangular patch) -> edematous erythematous then vesices/bullae if severe -> chornic - > lichenified, scaly, hyperpigmented
Ecthyma
saucer shaped ulcers, legs, feet -> strep
Nummular dermatitis
pruritic eczematous - annular coin shaped erythematous plaque - pinpoint vesicles, honey colors serous crusting
Pulmonary valve stenosis
JVD prominent A wave, RV heave, systolic thrill, ejection click (rapid opening of stenotic pulmonary valve leaflets) - click decreases with inspiration but INCREASES systolic murmur (R sided murmurs increase with inspiration) - 2nd LEFT ICS -> left clavicular region, dilated pulmary artery on CXR
ASD
fixed split S2,
Bicuspid aortic valve
with more AS, click less audible, diminished, delayed carotid pulsation (pulsus parvus et tardus), apical impulse sustained, late peaking murmur -> carotids, LVH
MVP/regurg
early systolic click, mid systolic murmur - with valsalva murmur longer but click moves closer to S1
VSD
holosystolic murmur at left lower sternal region
DISH - diffuse idiopathic skeletal hyperostosis
male, obese, DM
calcification of enthesis region (where tendons insert near bone)
Osteophyes on at least 4 contiguous vertebrae (anterolateral)
Ankylosing spondylitis
Younger patients
sarcoilitis
vertical bridging syndesmophytes
Lumbar spinal stenosis
chornic lower back pain
pseudocladication - pain radiating down both legs on walking better with rest - BUT ALSO RELEIVED leaning forward over shopping kart, walking uphill, climbing stairs
Narrowing spinal canal on MRI
Spondylolisthesis
subluxation of on vertebrae over another - lax or damaged ligaments - > anterior posterior movement
Parkinson’s dz - wearing off syndrome
wearing off motor flucutuations, drug induced dyskinesia -> indication for deep brain stimulation (can’t use further meds will cause further wearing off symoptoms and more dyskinesia
Subthalamic nucleus or globus pallidus
DO NOT DO ACUTE DRUG HOLIDAY - can cause acute parkinsonian sx
Functional hypothalamic ammenorrhea
stress, excessive weight loss, excessive excercise
Tumor/infiltrative lesion, lymphoma, sarcoid
Low FSH, normal prolactin, TSH
Neg preg, neg progestin challenge (no withdrawal bleeding - estrogen low)
Pit MRI no lesion
PCOS
look for hyperandrogenism (hirsuitism)
PCOS has good estrogen levels so progestin challenge would cause withdrwawal bleeding
Primary ovarian insufficiency
FSH would be elevated (trying to raise levels of estrogen)
Ceftaroline IV
B lactam abx with activity against CA-MRSA (only 5th gen cephalosporin active against MRSA)
complicated soft tissue infection
Pregnant pt with VTE/PE
LMWH at least 6 months and 6 weeks post partum
NO WARFARIN - teratogenic
Polymyositis
anti-Jo abs
Tx: Prednisone, azathroprine
r/o ILD - need HRCT and PFTs to dx (can have normal CXR)
PFT restrictive defect with decreased DLCO
If HRCT neg then check Echo (RHC) r/o PAH as cause of isolated dec in DLCO
Primary adrenal insufficiency
nausea, wt loss, salt craving
hypontremia, hyperkalemia, low cortisol, high ACTH
hypopigmentation
dec’d production of mineralocorticoid (hyponatremia, hyperkalemia)
Dec’d prodxn androgens (low DHEA)
Random cortisol inappropriately low for level of hypotension
Random cortisol >17 would r/o primary adrenal insuff
If ACTH >100 (random) then confirms dx
Likely autoimmune given fhx thyroid, premature gray hair, scleroderma
don’t need MRI pituitary - high ACTH normal in response to low cortisol/DHEA etc
Tx: hydrocortisone
Calcium oxalate kidney stones
envelope shaped crystals
s/p bypass surgery - dec’d fatty absortion (binds Ca in gut)
inc’d oxalate absorbtion 2/2 dec’d Ca absorption
Tx: low fat diet, CaCarbonate supp to dec oxalate absorbption, aggressive oral hydration
Hypercalciuria
Thiazide diuretics
Migraine with aura
unilateral, pulsatile, mod to severe intensity, nausea, photophobia -> visual sx = aura
tx: if NSAIDs don’t work -> sumitriptan
Propranolol ONLY FOR PPX not tx (>10 attacks/month)
Migraine MRI - white matter hyperdensities
Molluscum contagiosum
Pox virus
firm umbilicated pearly papules waxy surface
sexually active adult
Henderson-patterson’ bodies on bx
Bacterial folliculitis
pustules centered on hair follicles
Large esolphageal varices
Needs ppx
Primary tx: endoscopic ligation (NOT SCLEROTX) and/or non-selective BB (propranolol)
No BB if contraindication (ie asthma)
large varices >5mm despite air insulfation and red whale marks (inc’d r/o rupture)
When to use TIPS
Varicieal bleeding - if no effect with endo ligation
Gastric bleeding - if balloon tamponade ineffective
Prevent surgical site infection
abx 30-60min prior to incision - maintain therapeutic level thru procedure - no reason to continue 24 hrs after procedure
Control/eliminate modifable risk factors - DM, obesity tob use, avoid shaving hair, chorohex prep, minizize traffick, check list
Prevention of neonatal GBS
decolonization of strep in vagina/rectum, no role in sugical site infection prev
hypoactive sexual disorder
Sex therapy
lack of sexual thought, dec’d desire
individual or couples therapy ok
Lofgren sydrome
known sarcoid d/o =- fever, erythema nodosum - hilar LAD - usually spontanous resolution - no need for tissue dx
STEMI
If PCI facility >1.5 hrs away then give thrombolytics unless contraindication: prev IC hemorrheage Known CVA ischemic stroke 3 months suspected aortic dissection active bleeding significant closed head or facial trauma 3 months Relative contraindication HTN >180/110 ichemic strove >3monthas ago CPR/major surgery w/in 3 wks recent internal bleeding (2-4 wks) Previous steptokinase active PUD current use of A/C
Manage life sustaining care in critiaclly ill pt
Pt needs dialysis acutely - said initially that didn’t want to be on long term machines but wants to attend graduation in 3 weeks - wife willing to consent for HD - can always make decsision to stop ethically/legally - also pt can then participate in decision
Obscure GI bleeding aw severe AS (angioectasia) - Heyde syndrome
AVR - mechanical disruption of vWF during non-laminar flow thru stenotic AV
No need to repair diffuse angioectasis - resolves post AVR
Hyperandrogenism in pt with neoplasm
TVUS r/o ovarian neoplasm first
total testosterone elevated DHEA normal
Rapid inc in sx and high testosterone suggest OVARIAN source, if neg then image adrenals (if adrenal mass then likely elevated DHEA
Hemolytic uremic syndrome
microangiopathic hemolytic anemia, low plts, AKI
E coli 0157 H7
Shiga toxin
glomerular damage (erythrocytes/ertyrocyte casts)
Trip to endemic country
inc’d LDH, dec’d haptoglobin, schistocytes
dysentery (bloody diarrhea, dec’d UOP, fever, chills)
Post strep glom nephr
weeks after strep/staph infxn - dec’d complement
Chemotx induced myeloblastic syndrome
ineffective hematopoesis and various cytopenias
multiple chromosomal abnormalities
lack of LAD, HSM
hypercellular marrow, dyerythropoesis
ALL
7th decade - lymphocytosis, neutropenia, anemia, throbocytopenia, LAD, HSM
Parvovirus B19
NOT A/W cytogenic changes
Recurrent Hodgkins lymphoma
2-12 years - palpable mass, lymphomas sx (fever, anorexia, wt loss, pruritis) - NO CHROMOsomal abn
Post infarct VSD
p/w delayed STEMI
acute respiratory distress
New harsh holosystolic murmur LSB palpable thrill (thrill makes VSD more likely than acute MR)
Acute aortic dissection
aw IWMI, asymmetric BPs, early diastolic murmur of AI
Rupture ventricular free wall
electromech dissociation, hemopericardium Risk factors Female First MI Anterior infarct
RV infarct
hypotension, clear lung fields elevated JVP
not likely with AWMI
Acute ischemic MR
prominent V wave in PCWP from inc’d reguritant volume into LA - need TTE
Acanthosis nigrans
DM pt (obese) - asx lesion
velvety, hyperpigmented skin thickening in axilla/neck fold area - multiple skin tags (fibroepithelial polyps)
Tx: wt loss, improved DM control
Tinea corpis
scaling annular patches with erythema - pruritic
Lichen simplex chroicus
thickening of skin with exencuation of normal skin markings - pruritic
Inverse psoriasis
atypical psoriasis areas (axilla/groin) - raw pink patches
Allergic contact dermatitis
pruritis, erythematous, well demarkated border
Chronic thromboebolic pulm HTN (CTEPH)
recurrent small PE over extended time with progressive dyspnea - inc’d PAP, gas tx defect (low DLCO)
Tx: long term A/C, pulm artery endarectomy
NO NEED FOR D-dimer, CTA chest or LE Duplex
Rheumatoid arthrtis
Can present with carpel tunnel syndrome (confirmed with EMG testing)
prolonged morning stiffness >60min
b/l wrist sx
synovitis of wrists can cause entrapment of median nerve
Pregnant women, thyroid dz, DM
Overuse DOES NOT CAUSE carpel tunnel
OA DOES NOT cause wrist sx typically (PIP/DIP)
Renovascular HTN w/u
pt with resistent HTN and inc’ing Cr w/ b/l epigastric bruits
-obtain renal doppler arteries
underperfusion of kidneys - inc’d renin-angiotensin - sodium retention - HTN
ALready on 3 drug HTN tx including a diuretic
(do not do kidney angio - bad for kidneys and can dislodge plaque from aorta)
Restrictive CM
dyspnea, edema, fatigue, Right sided failure, Echo restrictive ventricular filling, atria dilated - systolic fxn preseverved, small to normal size ventricles
Cardiac hemochormatosis
cause of restrictive CM but if iron levels low can be ruled out
Constrictive pericarditis
restrictive filling
less severe atrial enlargement
BNP only mildly elevated
h/o acute pericarditis, TB, malignancy or chest radiation
Male hypogonadism
First step is morning TOTAL testosterone (morning most accurate)
if abn, 2nd test indicated before further w/u
(no reason for free testosterone - not older or obese)
(no reason for testicular US if testicles normal volume)
Subacute cuteanous Lupus erythematosis
Anti Ro/SSA + (or anti la/SSB)
erythematous circular papules with central clearing
neck, trunk, extensor surfaces
can be aw meds - HCTZ, CCB, ACEi, terbenafine
50% no systemic manifestation of SLE
Levido reticularis
lacy, purple motling of skin - pt with cholesterol emboli syndrome, SLE, raynaud, antiphospholipid syndrome, worse with cold, better warm (decrased local skin blood flow with dilated cappillaries
Colonoscopy screening UC pts
Dx’d with UC beyond rectum
Colonoscopy 8-10 years after dx and every 1-2 years with bx (UC arises from mucosa - inc’d risk of adneoCA)
If flat low grade dysplasia noted - colectomy or at least more frequent surveilalnce colonoscopy warranted
Colonoscopy screening normal
General - age 50 then q10yr
Pt with 1st deg relative colong CA after age 60 (or two 2nd deg relative) - age 40 then q10yr
Pt with 2 first deg relatives with colon CA or one 1st dg relative with colon cA before age 60 - age 40 or 10 years prior to youngest affected relative then Q5yr
HNPCC fhx - 25y or 10 years yonger than youngest affected relative then q2yr up to age 40 then q1yr
FAP - sigmoidoscopy age 12 q1-2 yr
Post colonoic resection for Colon CA - start 1 yr post, then 3yr then q5 yr
UC/Crohns - colonscopy 8yr after dx then q1-2 yrs
Extrapulmonary blastomycosis
Mild disseminated - oral itraconazole - verricus lesion -> central clearing -> scar formation -> depigmentation (broad based budding yeast)
also osteoarticular, genitourinary and CNS manifestations
Severe dz - CNS, mod to severe pulm, disseminated - tx with amphotericin B/lipid formulation
Fluconazole DOES NOT WORK WITH BLASTO
No reason for surgical exicision
Suspected melanoma
ABCDE Asymetry borders irregular Color varied Diameter >6mm Evolving Dx: Excisional bx - breslow depth analysis
Prevent pressure ulcers in elderly
Pressure distributing mattress and position changes
high risk for ulcer - limited mobility, low albumin, ascites
Stage I pressure ulcer - non-blanching erythematous plaque
Tx of pt with acute DVT in post op period with renal insufficiency
Use Unfractionated heparin in pt with low GFR (cleared by reticuloendothelial system not kidneys) and reversible by protamine so good in post op setting)
Only add warfarin after heparin therapeutic since initially aw hypercoagulablity - warfarin skin necrosis
No fonduparinux with low GFR (cleared by kidney)
Enoxiparin - not entirely reveersible so not good in post op setting and 80 BID too high dose for low GFR
DVT dx
Pt with high pre-test probability of VTE given immobility, age, tachycardia so NO D DIMER
CTA Chest high cost and uneccearly exposes to contrast
US Duplex legs best and most cost effective test
Non-dermatophyte (fungus) onchymycosis
thickened yellow or white nail with scaling
DX: KOH
or PAS staining of nail clipping
Candida, yeast
Usual tx terbinafine, fluconazole, itraconazole
Can be non-fungal cause (trauma, psoriasis,lichen planus) so need nail clipping PAS
Aplastic anemia in young patient
Aplastic anemia dx
ANC < 20,
Tx: if age 40yo or no HLA matched or medically fit for tx then tx is anti-thymocyte globulin and cyclosporin/corticosteroid
No growth factors
High risk NSTEMI
TIMI>4 - (age>65, >3 risk factors, ST seg dev, +CE, >2 anginal episodes in 24 hrs, ASA in last 7 days)
A/C heparin, Plavix, ASA, lopressor, SLN + lipitor and IIb/IIIa (eptifiptide - block final common pathway of plt aggregation) and early invasive approach
NO PPX LIDOCAINE (use BB instead)
NO throbolytics with NSTEMI (tenecoplase) - ok for STEMI if no PCI available but no dec’d mortality with NSTEMI
Respiratory failure in pt with COPD
tachycardic, hypoxic despite 6L O2, CP, clear CXR - CTA Chest r/o PE
Evaluate pt for TB that has been treated with BCG for bladder CA, vaccine or unlikely to return for f/u of TB skin test
use IFN gamma release assay
if + then assess sign’s sx and CXR, sputum
Two step TST only in pt with remote TB infection or remote BCG (not recent)
Diagnose secondary h/a
unstable or progressive temporal sx - long h/o migraine with aura - new neuro sx of blurring vision - more frequent recently
Obtain brain MRI
Not medication overuse as pt with new and more frequent sx
Before LP need to r/o mass lesion in brain
Evaluate pt with high BP
If see end organ damage in eye then check EKG check for LVH or q waves, check for microalbumuria
1st line tx without other factors would be thiaizide ACEi, arb, CCB in gen non-black pop
In Blacks thiazide or CCB
Age >60 goal <150/90
Secondary HTN
Primary hyperaldo - spontaneous hypokalmeia - check aldo, plasma renin activity
Chronic pelvic pain - interstitial cystitis
noncyclic pain >6 months
DDX:
Interstitial cystitic
pelvic adhesions - no h/o surgeries or STDs
endometriosis - no masses or TVUS neg, no cyclic pain
Irritable bowel syndrome - no GI sx
Pt here with persistent urinary sx -> interstitial cystitis - Ctx and U/A can be neg
Tx: stress management, diet modification
PT oral meds (TCA, cimididiene, hyroxazine)
Type I cryoglobulinemic vasculitis
monoclonal immunoglobulins complication of monoclonal paraproteins - seen in Sjogren’s pts
+palpapable purpura, mononeuritis complex, low C3/4, immune complex glomerulonephropathy
Microscopic polyangiitis
p-ANCA
No immune depostis
L
Lupus associated Glom nephritis
immune complex GN, dec’d complememnt - need clinical features of systemic lupus
Type II cryoglobulinemic vaculitis
active Hep C (RNA +)
Painful DM neuropathy
better glucose control+ TCA (Desipramine) + capsacin cream Remyelination can occur with better glucose control NO SSRI Nerve conduction studies NOT needed
Acute stroke
even if hemorrhage suspected - Do CTH first
impaired conciousness and h/a suggest cerebral mass lesion with elevated ICP
No LP until mass lesion r/o
Post Roux en Y gastric bypass abn CBC elev MCV
B12 deficinecy
macrocytic anemia
mild neutropenia
low retic
lack of IF production from bypasesed gastric tissue
Monitor b12 post op and supplement (500-1000 oral daily or 1000 q monthly IM)
Also check ferritin, folate, vit D, Ca q6month first 2 years
NO BM bx (too early)
NO suspicion for GIB or CRCA with guiac neg stool,no fhx, MACROcytic anemia
Excercise induced broncospasm
short acting B2 agonist 15 min prior to excerise
Mild intermittent asthma aw excercise only
Normal baseline FEV (>80) with drop after excercise
Inhaled corticosteroids
> twice daily sx, weekly nightime sx
Type A acute aortic dissection
proximal aorta through arch to desecending with diastolic murmur, distant heart snds, CP-> back
Not necesarily divergent BP in arms
Emergency surgery evaluation (not stenting)
Bicuspid Aortic valve aw dilated prox asc aorta - inc’d risk aneurysm or dissection
No IABP - worsens AI
Histoplasmosis
Bat droppings Ohio river valley Hilar LAD with infiltrates SE US/ohio river valley bird/bat droppings Asx, or flu like sx, dyspnea
Blastomycosis
NO hilar LAD
aw soil exposure with decaying vegetation - NOT BATS/BIRD droppings
Ohio river valley
Coccoidomycosis
SW US
Acute pulmonary, erythema nodosum, joint pain
Flat warts
HPV
autoinnoculation from shaving
flat, flesh colored
Actinic keratosis
PRE-cancerous -> SCC
erythematous with overlying hyperkeratosis
irregular edges, gritty
Lichenoid keratosis
inflammed sebhorrhic keratosis (benign - stuck on, do not resolve)
Dermatofibromas
firm dermal nodules - button hole when pinched - legs adult women
Hypoparathyroidism
s/p thyroid surgery
perioral anesthesia - muscle cramping
tx: first oral Ca+
Eventual calcitriol since with lack of PTH no conversion of 25 to 1,25 D3
Treat pt with kidney stone
inc chance of kidney stone 10 mm won’t pass without intervention)
Urine collection and analysis only several weeks after stone passage for w/u of nephrolithiasis
May require intervention if no stone passage after period of time
Cancer of unknown primary site
Tx for GI cancer - primarily abdominal districtuion (liver, ascietes)
NOT germ cell tumor (undiff) if ID’d as adenoCA - platnum chemo
NOT neuroendocrine (would be poorly differentiated) - platnum chemo
NOT prostate (bony mets/ elevated PSA) - anti androgen tx
NOT lung (would be distrubed over diaphragm)
Manage carpel tunnel
EMG and nerve conduction first (+- NSAIDs)
sx - parasthesia hand, weakness grip strength, loss of sensation in median nerve territory, thenar atrophy
Wrist splint/conservative measures
If all this fails and after EMG/nerve studies- consider surgical release
Tx pt with recurrent chemo sensitive diffuse b cell lymphoma
Initial tx - RCHOP
recurrent high dose chemo, autolougous stem cell tx
no radiation, not just recurrent chemo
Hypercalciuric patient with nephrolithiasis
U Ca >300 (normal serum Ca+)
FHx nephrolithisis
Tx: distal reabsorbption of Ca+ with Thiazide
don’t use Ca citrate - will exacerbate calciuria (if want to alkalzye urine - use POTASSIUM CITRATE)
Don’t restrict CA (makes Ca Oxilate worse)
CAP in outpt
Tx with azithromycin (H.Pneumo, H.flu, mycoplasma, chlamydia)
NEVER USE CIPRO (poor activity against S. Pneumo)
Risk factors for drug resistant age >65, B lactam tx in last 3 months, medical comorbidies, immunocompromised
Pt with advanced HF
Pt with end stage cardiac failure refractory to tx - mechanical support and cardiac tx indicated
Relatively young, no other comorbidities
IF QRS OK then no indication for BIVICD upgrade
Pusatile tinnitis
pt with whooshing sound in ear louder when excerciseing - listen over r eye, ear, neck for bruits for vasc abnormality (tumor, stenosis) -> confirm with doppler or MRA
If no cause found - external noise generator
Pull test
quick pull - pt should compensate by stepping backward if not predictive of future falls
Dix Halpike
peripheral vs central verigo
Abnormal proprioception
do not fall backward - have abnormal gait
loss of proprioception - peripheral neuropathy, spinal cord dz, severe hemicranial cortex dz
Rhomberg test
ataxia and proprioception loss - cerebellum, cerebellar, vestibular issue
Utricarial Vasculitis
Lesions that last > 24hrs and resolved with bruising concerning for vasculitis
SKIN BX NEEDED
50% have underlying SLE
No role for RAST (no clear allergin)
Malignant pleural effusion
former smoker - pw sx concerning for malignancy
(cough, wt loss, unilateral effusion)
Pleural fluid cytology used for dx - if neg first then repeat (inc’s with serial taps)
If nothing then pleural bx
Evaluate GIB with endoscopy
Neg NGT does NOT r/o UGIB First resucitate then EGD (first) if neg then colonoscopy then tagged RBC scan then video capsule
PCOS
PCOS - irreguular menses, elevated testosterone, hirsuitism,
tx: estrogen-progesterone OCP - dec’d LH, inc’d sex binding hormone-> dec’s avaiable testosterone
Prolactinoma
tx’d with bromocriptine
Congential adrenal hyperplasia
17 hyroxyprog abn - tx with dexamethasone - reduces hyperplasia and reduces prodxn of testosterone
Non-purulent cellulitis - B hemolyitic strep
B lactam agent - Cephalexin
CAMRSA (doxy/bactrim)
Apraxia
inability to perform previously learned motor task despite intact motor and sensory systems, clear comprehension, full cooperation (need to r/o parkinsons, severe wk etc)
Hemiparkinsonianism
asymmetric rigidity, bradykinesia, dystonia Corticobailiar degeneration (hemiparkinson combined with hand moving independent of voluntary control = alien hand syndrome)
Asomatognosia
pt doesn’t recognize body part as part of himself (R parietal cortex)
Routine f/u in breast CA survivor
Early stage breast CA survivors
Routine clinical f/u - no intensive lab surveillance
H&P, Mammo
in otherwise asx patients
Humoral hyperCa of malignancy
severe hyperCa in setting of lung mass
Tumor prodcution of PTHrP - acts on skeletal Ca release
Usually SCC Lung
Sx PAD tx
Best therapy - supervised excercise program 30 min/day 3 days x 12 wks - inc pain free walking time and distance
Cilastoazole - contraindicted EF<40%
Surgery (bypass) only for limb thretening ischemia - or severe life limiting dz on maximal medical tx
Miliaria
Heat rash - skin get hot and occulded exocrine sweat glands - need active cooling measures - hospitalized pt with rash limited to dependent parts of body (vesicles, papules, pustules)
No need for oral steroids
Fibromuscular dysplasia
Angiogram - beads of strings MC women 15-30 nonatherosclerotic, noninflammatory (suspicious in pt with severely resistant HTN, high renin/angiotensin) TX: PTCA Don't use drugs in this young patient
Obese patient needing weight loss
reduce calories by 500-1000/day
1-2 lbs/week
(excercise alone will not work)
(Bariatric only BMI>35 with comorbidity (DM, OSA, joint dz) or >40 anyone
Med supplement is secondary ie orlistat (lipase inhibitor)
Manage acute PE
Unfractionated heparin
Only throbolysis if still hypotensive after fluid bolus (alteplace)
DOn’t use LMWH if with CKD or possible need for revesal (ie if need to thrombolyse)
Dyspepsia
with no alarm sx (wt loss, blood) -> PPI empiric tx
If H. pyori
test and treat ok if no heartburn, alarm sx or area of high h pylori prevenlance
If alarm sx then EGD (onset after 50, aemia, odynophagia, dysphagia, wt loss fhx GI malignancy, h/o PUD, abd mass, LAD)
Thiamine deficiency s/p gastric bypass
wernike’s encephaloptahy (nytagumus, opthalmoplegia, ataxia, confusions) - needs IV thiamine - can have irreversible damage - thiamine depletes quickly much faster than B12 gets deficient (starts with parasthesia/ataxia
CMV after kidney tx
pt with seroneg for CMV, seropositive donor - few months after tx (after CMV ppx completeted) - so CMV is correct
pw low grade fever, body aches, cytopenia, colitis, hepatitis, pneuonitis (CMV), leukopenia, thrombocytopenia
Polyoma BK virus post tx
LATE complication of tx, p/w neuropathy, organ rejection, uteretral strictirues - decoy cells (with intranuclear inclusions)
Listeria mono post tx
usually causes meningitis, h/a, MS change
EBV post tx
usually pw LAD
hemodynamically stable WC tachycardia
regular wctachy with LBBB w/ AV dissociation -> VT (h/o cad or CM) cannon a waves from AV dissociation (atria contracting against closed TV)
Tx: IV amiodarone
-2nd line procainamide, sotolol, lidocaine
If unsuccessful - cardioversion
DO NOT GIVE BB/CCB - > can deteriorate in VT
Will need ICD for 2ndary prevention
Breast CA with mets to brain (>1) and inc’d ICP
corticosteroids and radiation - reduce ICP
h/a sx of inc’d ICP, papilledema on exam
also sz, focal neuro findings, cognitive changes
Will need chemo, not surgery (>1 lesion)
NO LP
Axial spondyloarthritis
Dx: pt with inflamm back pain without radiographic evidence of sarcoilliitis or spondylitis, clean MRI
Dx of spondyloartritis without radio evidence - HLAB27+ and two of the following with elevated CRP, fhx spondyloartritis, good response to nsaids, crohn/UC, dacyliasis, psoriasis,
NO RF + in spondyloartritis
Centor criteria
Fever>100.5, sore throat, tonsillar exudate, tender cervical LAD
2 criteria - obtain rapid strep antigen testing
0-1 risk factors - no abx or culture
2 or 3 - throat culture/antigen test and tx if +
4 or 5 - treat empirically (and get ctx)
Plasma osmolality
Sz caused lactic AG met acidosis
Dec’d breathing from etoh intoxication caused respiratory acidosis + etoh ketoacidosis
If pt improves with supportive measures - no HD or fomizpezole
Fomipezole if pt has methanol or ethylene glycol poisoning (competitive inhibition of etoh dehydrogenase) - prevent conversion to toxic metabolites
2x [Na]+ glucose/18+ BUN/2.8+ ethanol/3.7 if present
Supplemental bicarb if pH <7.15
HD if severe ethylene glycol or methanol poisoning, severe propylene glycol poisoning, severe isopropyl -
Delayed hypoglycemia in pt with Type I DM
Need to eat complex carbs at bedtime to avoid nighttime hypoglycemia after evening excercise - etoh reduced ability of liver to release glucose into blood
(no need to avoid evening excercise, omit insulin in evening or light beer only)
Lichen planus
white reticulated network on buccal mucosa (wickham striae) - does not scrape off - can ulcerate
also affects skin, scalp, nails
incd with liver dz, hcv or drug induced (BB, diuretics, ACE, PCNamine, lasix)
autoimmune
Skin - small violacious papules
Candidiasis
Usually immunocompromised or corticosteroid use
scrapes off
Oral hairy leukoplakia
aw HIV
lateral tongue - adherent doesn’t remove from scraping - no ulceration
MAP
2x DBP + SBP) /3 -
if < 65 -> or CVP < 8-12 - if fluid resucitation does not get MAP>65 then vasoactive agent (norepi) ok
If that doesn’t work - hydrocortisone next step
Invasive aspergillosis in pt with leukemia after chemo
halo sign on CT galactomannan antigen immunoassay + BAL or TT percutaneous bx, VATS Tx: Voriconazole Salvage Tx: amphotericin, itraconazole, caspofungin/micofungin (echinocandin)
Toxic epidermal necrolysis
Drug reaction (bactrim)
Stop bactrim or offending drug
Burn unit - wound care, supportive care
Fluids
Skin bx
DO NOT USE SYSTEMIC STEROIDS - worsens mortality
No role for ppx abx (only if evidence of infxn)
A/C preg pt with mechanical MVR
Warfarin - despite teratogenicity
or LMWH or UFH
VTE after intracranial hemorrhage stroke
UFH low dose or LMWH after day 4 if no ongoing bleeding
IVC filter only if absolute contraindication to heparin
Axial Spondyloarthritis
Inflamm back pain,
Tx:
NSAID (diclofenac)
only after several diff NSAIDS - then try etanercept
Evaluate obscure GIB
If pan endoscopy neg - repeat EGD (or colon) whichever more likely source
If neg then other modality (wireless capsule, single balloon enteroscopy)
Asess for recurrent PE
A/C x 3 months
f/u D-dimer 3-4 weeks after dx
if elevated inc’d risk for recurrent PE
Restart A/C
Manage hyperparathyroid in CKD
CKD with low 25OHD3 and high PTH-> maybe be just vit D deficient
If this does not work and 25OHD3 >30 (normal) with PTH still high then give 1,25OHD3 (calcitriol)
Febrile neutropenia
Begin broad spectrum abx (zosyn, cefepime) - G pos and neg coverage
Only start antifungals after 4-7 days of no response to zosyn cefepime
Chronic pain in elderly
First line tylenol (chronic non-cancer pain) if no underlying liver problems
No TCA
NO NSAID if h/o PUD
Metabolic syndrome
3 of 5 Waist circumference >40 men, >35 F SBP >130>85 HDL< 50 F TG>150 Fasting glucose>110
Tx for severe etoh hepatitis
Should add corticosteroid unless contraindictated
(GIB, kidney failure, active infection (has this - SBP))
Maddrey discriminant score >32
Add pentoxyfyline
Reactive arthrtiis
acute arthritis + urinary symptoms
Despite not being sexually active in one month - check urine for gonnorhea and chlamydia -> symptoms point to DIG
(arthritis, urethritis, conjunctivitis) - sx 2-4 wks after infxn
Sexual partners should be dx and treated
Infection control in pt with strep pyogenes (invasive)
necrotizing fasciitis and TSS
clinda + PCN
CLose contacts can get infected so-> CONTACT PRECAUTIONS needed
PCN ppx for household contacts at high risk (Age>65, DM, cardiac dz, varicella, CA, HIV, coriticosteroid use, IVDA)
Airborne precautions
TB, avian influenza, disseminated zoster, smallpox
Droplet precaustions
> 5micrometer droplets 3 to 10 feet
Neiserria meningitidus, pneumonic plague, diptheria, H flu b, pertussus, influenza, mumps, parvo b19
Erythema Multiforme
INfections or drug rxn target/iris lesions palms, soles, mucous membranes Tx: suppressive acyclovir (doesn't shorten course) (if also respiratory sx then consider mycoplasm pneuoniae -> tx with azithro)
Erythema migrans
hallmark cutaneous lesion of lyme centrifical spreading ring - bullseye much bigger than erythema multiforme lack of mucosal invovlement amoxicillin or doxy
Erythema nodosum
strep infection
PCN tx
Recurrent breast CA with possible bony mets
first bx bone to see HER2neu and hormone status
Tx: IV bisphosphonate -
Hypothyroid during pregnancy
thyroid supp requirement inc’d by 30-50%
Goal first trimester <2.5 TSH (less fetal complications)
AL Amyloidosis
frequently affects kidney and heart progressie HF from restrictive CM Nephrotic syndrome Hepatomegaly (congestion from RHFx painful b/l sensory neuropathy (distal) monoclonal light chain - lambda DX: fat pad bx congo red stain rectal or kidney bx if non dx SPEP/UPEP detect monoclonal light chains 20% have concurrent MM or lymphoprolif dz
Polyarteritis nodosa
fever, abd pain, arthraliga, mononeurtis multiplex, livido reticularis
Occupational lung dz
ground glass diffuse nodules on CT, SOB cough, low grade fevers no exposures, no relief with abx
Always get detailed history of current work exposures, timing of ezposure to symptoms, if co-workers also getting affected, MSDS
Metal workers - lipoid PNA, hypersensitivity pneumonitis, occupational asthma
Cardiovascular risk in elderly women
Start ASA in women 55 to 79 with several risk factors (older age, DM2, HTN) - dec’s risk of stroke, MI, CV death - outweighs risk of GI hemmorhage
Stroke risk reduction
ASA alone
Plavix slightly more effective or if allergic to ASA
ASA + dipyramidole even more effective
ASA + plavix - high bleeding risk
Myopericarditis
Acute pericarditis with +CE unrelated to MI
Regional ST elev with new global or seg WMA
Prodromal URI or other sickness (fever, etc)
could have effusion
Cardiac tamponade
SOB
complication of pericarditis
JVP, pulsus paradoxus
RV/RA collapse during diastole
Post myocardial infarction syndrome
Pericardidits preceeded by cardiac injury (ST e MI)
Does not usually cause HF
Takutsubo’s CM
Chest pain, STE on EKG, LV dysfxn, normal cornoaries - deg of biomarker elev mild compared to myopericardiits - ballooned apex, hypokinetic base
Concurrent primary cancers - cancerization field effect
H&N cancer rare mets to lung - lung mass found can be another early stage primary - need to bx to find out
Chemo and radiation spares voice
Dx Male infertility
1st step: Semen analysis (abstain 2-3 days)
2nd step: if semen analysis abn - FH, LSH, total testosteroine (asess leydig and sertoli cell fxn)
Young woman, mild nephritis, outpt setting
mild flank tenderness, +U/A, fever, dysuria
Tx with floroquinolone ie cipro
(no nitrofurantoin - not good in renal tissue)
Step down therapy for asthma
If asthma sx stable with little need for rescue meds then try step down (ie stopping inhaled corticosteroid - use just rescue short acting B agonist)
Drug induced myopathy
Recent increase in statin or drug that inc’d statin blood levels can cause myalgia (PI, azole anti fungals, macrolides)
Polymyositis
prox muscle wk, elev CK, inflamm changes on muscle bx
Drug reaction with eosinphils and systemic sx (DRESS)
Generalized papular eruption, facial edema, fever arthalgia, LAD, elev EOS, LFTS
Anti-convulsants, sulfa, minocycline, allopurinol
Acute generalized exathematous pustulosis (AGEP)
acute onset pusutules, fever, elev WBC poss EOS
B-lactam, ampicillin, floroquin, anti malarial agents, sulfa, terbafine, diltiazem
Erythema Multiforme
acute recurrent mucocutaneous eruption following acute infection (recurrent herpres simplex), or could be drug related
Erythematous plques with concentric rings of color
Levido retiucularis
pink mottled netlike pattern
aw drug rxn to amantadinie, quinidine, warfarin, minocycline
Pre-op Rheum Arthritis
Pt with longstanting RA need to rule out atlanto axial subluxation -> could cause paraplegia
No need for pre-op spirometry
If pt demonstrates 4 mets no need for stress test
Manage GERD that does not respond to PPI trial
Pt failed PPI trial and has (wt loss, dyphagia, men >5 yrs sx, bleeding, anemia (no need for H2 blocker next)
r/o eosinophilic esophagitis, mlaignancy, stricture, achalsia
When to use ambulatory pH monitoring
After neg endoscopy and still with GERD sx
Functional urinary incontinence
Pt’s with cognitive decline may not be getting to toilet fast enough - prompted voiding
Overflow incontinence
obstruction vs neurogenic bladder
Check residual urine
Stress incontinence
pelvic floor muscle excercises
Urge incontinence
anticholinergic ie tolterodine
Inc’d risk of CV events in CKD pts
CKD pts may not have other risk factors but if symptoms occur then ACS should be ruled out
Unstable angina in pt with contraindication to BB
Diltiazem
(not nifedipine - can inc HR)
contraindic to BB - sx brady, AV block (advanced), SBP<80, shock, pulm edema, sx reactive airway
TCA overdose
can cause arrythmias
blocks fast Na channels, -> VT/VF
Sodium bicarb infusion - narrows QRS dec r/o arrythmia
Procainamide contraindicated (also blocks sodium channel - makes arrythmia worse) Amio also bad - prolongues QT
Sjogren’s associated lymphoma
44 fold inc in incidence of lymphoma
risk factors - dissappearance of RFactor, mixed monoclonal cryoglobulinemia, cutaneous vasculitis, LOW C4
Bx mass!
Sjorens sx - dry mouth (pilocarpine), inflamm sx - arthritis, cytopenia, vasculitis (steroids), arthrisits - hydroxychloroquine
Ectopic ACTH
Cushing syndrome - hypercortisolism, melanonchya) - signs of malignancy wt loss, temporal muscle wasting, new onset DM (excess mineralocorticoid), HTN, met alk, excessive urine K+ loss
Ectopic ACTH secrtion from lung CA (small cell)
NOT pituitary adenoma - ACTH levels lower
Adrenal adenoma/CA
suppressed ACTH
Autism spectrum d/o
impair communication, impaired social interaction, restrictive, repetitive stereotyped behaviors and interests
learning disability or mental retardation, high functioning autism or Asberger variant
Obsessive compulsant d/o
recurrent obsessions and compulsions at least 1 hr per day that cuase marked distres or functional impairment, peristnt idea, thoughts, impulses, images
Schizophrenia
psychosis, delusions - hallucinations, disorganized speech, catatonic behavior
At least 6 months of sx, 1 or more month of active sx (hallucination, delusion, d/o speech) and neg sx (flat affect)
Social anxiety d/o
severe/persistent fear of social or performance situation
Severity of acute pancreatitis
Dx: amylase/lipase
Predictiing severity : BUN
Allergic contact dermatitis
Delayed type allegic rxn - red edematous, weepy, crusted
Dx: Patch testing
Pinprick and RAST only for immediate type hypersensitivity rxn
Migraine without aura
Migraine 4-72hrs pulsatile unilateral mod - sev aggreva by activity
N/V or photophobia
No neuroimaging if stable h/a sx for years
Tx with triptan (sumatriptan)
Locally advanced high risk cervical CA
Pelvic radiation with chemo
Surgical resection then adjuvant chemo/radiation
HPV now would not help
Pelvics every 3-6 months for 2 years, then q6 m x 3 years then annually + serial CT scans
Incidental high risk gallbladder polyp
High risk >10mm, gallstones >3cm, porceline gallbladder
Cholecystectomy
Risk factor for gallbladder CA, cholelithiasis, fhx gallbladder CA,
If < 10mm then serial imaging
Manage prostate CA screening
Start with informed discussion risks/benefits of prostate CA screening
Screening would be DRE+PSA (after discussion)
Tuberculous pericarditis
Treat TB (rifampin, INH, ethambutol, pyrazinamide) Add prednisone to decrease recurrence (indometh/colchisine only viral/idopathic pericarditis) if recurrent effsuinons then periocardial window or pericardectomy
Dx obstructive lung dz in coal miner
Coal dust can activate inflammatory cascade
Check PFTs first
Asx patients should get imaging q5yrs
Recurrent pericarditis
colchicine, ASA
Pleurtic CP worse supine partially relieved leaning forward - pericardial friction rub, h/o acute pericarditis
avoid corticosteroids (more recurrence)
3rd line azathroprine/cyclosporin
CT Chest if suspect constrictive pericarditis (RHF JVD, pedal edema etc)
Sickle cell pain episode
Treat iniitally with IVF, spirometry and IV morphine
If stroke/acute chest -> erythrocyte exchange tx
avoid if possible in this patient has multiple alloantibodies
NO meperidine - low sz threshold, short half life
Basic Calcium phosphate deposition dz
destructive inlfammaotory arthritis aw milwaukee shoudler
Pain, large non-inflamm effusion after trauma
destruction of articular cartilage ROM limited
Dense Ca on Xray
BCP crystals NOT seen under polazized light - only alizarin red staining
Calciphylaxis
soft tissue calcium deposition - ESRD pts
CPPD
see postivelty biregringent crystals
(Gout neg birefringent crystals)
OA fluid <2K WBCs
Hep C associcated cryoglobulinemic vasculitis
HCV Viral load elev, Low serum C4, elevated RF
Palpable purpura
+cryoglobulins - cold precip immunoglob - tend to occur in periphery extrem
Skin bx: leukoplastic vasculitis
Can also aw CTD, waldenstogm, MM
Henloch-schoen purpura
cutaneous small vessel vasculitsi (leukocytoclasic vasculitis)
young children after strep infxn
Porphorya Cutanea tarda
vessicles/bullae on sun exp skin - 50% aw HCV
Necrolytic acral erythema
discrete erythematous to hyperpigmented plaques with scale/erosion in HCV pts, aw zinc def
Hypokalemic metabolic alkalosis from Gentamycin
Diuretics, gastric fluid loss, gentamycin toxicity, gittleman/barrtler
Gentamycin toxicity - barrtler like - mimick effect of LOOP diuretic
Urine pot/cr ratio 50 -> c/w urine potassium losses 2/2 tubular dysfxn
Without elevated BP, primary hyperaldo less likely
If Urine potasium/Cr ratio < 15 then might be seroquel induced shift of K to intracellular space, no met alkalosis
Vancomycin induced nephrotox -> aw HYPER K+
Acute exacerbation of multiple sclerosis
High dose IV methylprednisolone (NOT PO)
If refractory - plasmaphereiss
Phyical/occup/speech therapy
Dermatomyositis (can occur without myalgia)
Need age appropriate cancer screening
poikilodermatous erythema
inc’d abd girth, fhx ovarian CA - need TVUS
only bx if has myalgia - blind bx low yield
Patient presenting late with STEMI
Primary PCI (NOT EMERGENCY CABG) No thrombolytics >12hrs STEMI
Fundic gland polyps
Need colorectal eval for Familial Adenomatous polyposis
Multiple small 1cm
COPD pt immunizations
Can have both influenza and pneumococcal vaccines same visit diffierent sites
Pneumococcal vaccine in routine pts >65yo
At any age if COPD, asthma, DM, liver dz (chronic), etoh, fxn/antomic asplenia, immunocomprimizing conditions, smokers, NH
One time revaccination for those vacc >5ya or <65 at time of vacc
Only influenza vacc aw decrease in mortality
Antiepileptic in pt who wants to get pregnant
Carbamazepine, lamotrigine, levetiricem
No VPA, phenobarb or phenytoin
Risk factors for RA
Smoking increases risk of developing RA
No change with etoh, obesity, excercise
Dec’d risk with OCP
NSAID induced nephropathy in MM patient
MM pts particularly vulnurable to nephrotoxic meds ie NSAIDs, IV dye
Pt’s particulary vul baseline CKD, vol depletion, hyper Ca
Cast nephropathy - filtered light chains intratubular obstruction/precipitation - unlikely if severe AKI but improved cast burden
Palmidronate AKI - low indcidnece
Focal segmental glomerular sclerosis +proteinuria
Renal amyloidosis - highly unlikely as would have significant non-selective proteinuria
Nonpurulent cellulitis outpt therapy with systemic symptoms
Clindamycin active against CA MRSA and B hem strep
risk factors for le cellulitis - DM, leg ulcers, tinea pedis, obesity, phlebitis
Doxy/bactrim NO B hem strep coverage - if used need amoxicillin
No rifampin - lots of resistance
Minimal change glomerulonephropathy
aw lithium use - fusion of podocytes on EM, no immune depostis, massive proteinuria
aw mono, malignancies, NSAIDs, lithium rifampin
Hep C ass glomeruloneph, lupus nephr, membran glomeruplopneph - > immune deposits
Benign positional vertigo
breif severe vertigo with position change
episodes 1min and VERTICAL (not horizontal)
Menieres - vertigo (nonpostional), unlateral hearing loss, tinitis
Vestibular neurontis - aw viral infxn, more extended sx
Pustular psoriasis
pinpoint pustules coalescing into lakes of PUS
h/o psoriasis
Fever
sheets of pustules
Erythroderma - generalized erythema >90% skin - drug eruptions, psoriasis, atopic dermattis, cutaneous T cell lymphoma (high risk psoriasis tx by corticosteroids)
Tx: underlying dz, general supportive care
Candida
localized in immunocompromized
erytmmatous base with white stuff
Sweet syndrome
acute febrile neutrophillic dermatosis (neutrophil granulocytes on histo)
+arthralgia, myalgia
Edematous red-purple plaques in trunk/extremites
Can be aw AML
Tx: corticosteroids
Reactive syndrome preeceding viral syndrome (resp/GI)
Toxic shock syndrome
diffuse erythroderma resembling sunburn
Nasal packs, wound care
Dx Celiac dz with IDA
if upper/lower endoscopy neg and pt still anemic (pt with down syndrome)
even if TTG neg - repeat endoscopy with small bowel bx r/o celiac dz, capsule endoscopy if neg
Meckel diverticulum - pw acute bleeding, ft’s of obstruction,
Normotensive acute ischemic kidney injury (ATN)
Pt with vascular risk factors and HTN now with lower than normal BP - renal hypoperfusion
Elevated FENA, granular casts on u/a, normal kidney US
Acute intersitial nephritis
1 week after offending drug
hypersensitity rxn
rash
WBC, erythrocytes in U/A
Cholesterol emboli syndrome
after conoary angio
bland urine sediment
Pre-renal azotemia
h/o fluid losses, dec’d fluid intake
FENA >2%
FE uria >50%
Osteoarthritis
subchondral sclerosis, asym joint space narrowing, osteophytes
No h/o inflamm attacks - not gout
RA would have symmetric joint space narrowing, no subchonral sclerosis or osteophytes
Calcium pyrophosphate deposition dz
chondrocalcinosis - in fibrocartillage (menisci)
Agitation and confusion in pt with alzheimers
r/o occult infextion, head trauma, CVA, meta abnormality
If w/u neg
D/c sedatives/anticholinergics
don’t need risperodone yet (not indicated for delirium)
Donezepil , acetycholinesterase inhib, rivasstigmine - tx alzhemiers but not delierum
Hyperprolinemia
pt with h/a and low libido-pituitary MRI r/o mass (Sellar)
Eventual tx with cabergoline (dopamin agonist)
No need for testosterone tx - secondary hypogonadism
Acute cervical radiculopathy
without evidence of weakness or myelopathy - conservative tx with analgesics and avoidance of triggering activity ok
(neck collars, corticosteroids, cervical traction don’t show any superiority)
EMG only if surgery being considered to pinpoint what nerve
If wk/hyporeflexia then CT/MR myelograpy needed
Malaria -
Plasmodium falicparum - most malaria cases Can be from resistance or non-compliance fever, cyclical every 48-72hrs Giemsia blood smear Banana shaped gametocytes, ring forms
Plamodium Maraliae
fevers q72hrs
band form - trophozite
Plasmodium ovale, vivax
trophozoit, schizont forms - Shuffer dots inside enlarged RBCs
COPD exacerbation with NIPPV
reduces mortality, need for intubation (if has mental status or risk of aspiration) if RR<88%
Evaluate asx heart murmur
check TTE for any systolic lout (3 or >/6, any diastolic or continuous
MVP (click) - reduction in LV volume, valsava prolongs murmur, shortens S1 to click
inc in LV vol and preload by squatting dec’s murumur, delays systolic click
Calciphylaxis
ESRD patients on HD
elevated serum Ca, Phos
Elev PTH
Purpuric non-blanching patches associated soft tissue nodules -> bullae->ulcerate->escar
From metastic calcium deposit in skin, vesicular CA - skin necrosis
Nephrogenic systemic fibrosis
yellowish thickened papules, and nodules, progressive skin tightening and sclerosis - pt with ESRD on HD exposed to GADOLINIUM
Polyarteritis nodosa
reticuloform purpura and SQ nodules - not aw ESRD
Pyoderma granulosum
p/w ulceration no SQ nodules, violacious, overlying edge, NOT AW ESRD
Inaccurate HgA1c
may be postprandial hyperglyemia if all preprandial and fasting FBS are normal and HgA1c elevated
HgA1c falsely high with inc’d survival of RBC - untreated iron, B12, folate deficiency
HgA1c falsely low survival of RBC (shorter) - hemolytic anemai, tx’d for B12, iron or folate def
Manage giant cell temporal arteritis
IF suspected GCA with neg bx on one artery - repeat bx on other side needed
Don’t use MRI with GAD in pt with CKD - npehrogenic systemic fibrosis
Cough variant asthma
Chronic cough - cough triggered by cold air and excercise
Bronchial challange can exclude asthma if neg
Pertussis - tx with macrolide/floroquinolone
HFPEF
preseved EF with HF sx
LVH on ekg
Tx: diuretics and ARB (candesartan) - reduced hospitalizations
No digoxin in HFPEF
Normal Pressure hydrocephalus
gait shuffling, urinary incontinence, cognitive change
-check Brain MRI - look for ventriculomegaly
Hormone Rct + breast CA pre-menopausal
Tamoxifen x 5 years if ER/PR + in PRE-menopausal
S/E endometrial CA, , VTE, hot flashes, cataracts
Aromatase inhibitors if hormone + POST=menopausal woemn (anastrazole, letrozole)
DCIS - no chemo needed
Raloxifene - no study indicating for adjuvant tx - just prevention of cancer in pt with high risk/osteoporosis
HTN in women of childbearing age
d/c lisinopril - > start labetolol No spironolocatone(anti androgenic) and does need SOME antiHTN med
ACEi-> cardiac abn, kidney abn, death
Short bowel syndrome
surge of gastric acid after small bowel resection - incactivaes pancreatic lipase - > diarrhea
Need suppressive PPI tx
No cholestyramine - will worsen diarrhea by binding remaining bile salts
Palliative care discussion
Early referral preferred, emphasize NOT withdrawal of care, just improving quality of life
Longer mean survival in study in patients with SCLC
Hypoactive sexual desire d/o
persistent lack of sexual desire/thoughts
Tx: sex therapy
Tx: post menopausal dryness vaginal estradiol
Dysparenunia - infx, cystitis, pelvic adhesions, endometriosis,
Sexual Aversion d/o - aversive response to any genital contact, nausea, SOB,
Vaginismus - involutary spasm of vagina
Beau lines
transverse lines on nails in setting of systemic stress ie chemo or sepsis (disruption of nail natrix prodxn)
Lichen planus
pitting, onchyolysis, longitiudinal ridging
Median nail dystophy
longitudinal (not transverse) depression in center of nail and traverses whole length of nail - one or two nails - trauma
Psoriasis
Nail changes like pitting, oncylolysis
Concussion management
Grade 1 - Amensia/MS change < 15 min no LOC - may return to competetion if ok same day
Grade 2 - Amnesia/MS change >15 min no LOC - remove from competition that day
Grade 3 - Brief LOC - remove from competition and for 1 week asymoptomatic
CT for grade 2 or 3 if sx return within week
Hospitalization if traumatic findings on neuroimaging or persistent abn on physical exam
GERD
If no alarm sx (weight loss, dysphagia, bleeding, melena, anemia) then PPI trial first for GERD
inc’d r/o GERD with obesity, tob use, OSA
Reassss in 6-12 wks
Ambulatory pH monitoring if fail PPI trial and neg EGD to confirm dx GERD
Fundoplication if still GERD after PPI trial and neg EGD
Smallpox
Variola - respiratory tract infxn initially - high fever, vomiting, buccal/pharyngeal mucosa (Kolip spots) - > hands/face same stage maturation - contagious till all scabs crusted/shed
Give smallpox vaccine for exposure of health worker
CHicken pox - lesions in crops
Cidofovir - outbreak of smallpox
NSTEMI/UA pt
If no stent - ASA + plavix x 1 month to 1 year (ideally) aw OMT
Severe asthma exacerbation
ICU - PCO2>42, FEV1<40% despite broncodilator
TSH secreting tumor
Hyperthyroid - elevated radio iodide uptake - Thyrotoxicosis with inappropriately elevated TSH -> TSH secreting tumor -> pituitary MRI needed NSx resection No thyroiectomy, methimazole, PTU
HTN pregnant pt
HTN before 20 weeks - presence of chronic HTN NOT HTN aw pregnancy
Cr usually falls during pregnancy so does BP
Gestational HTN - after 20 wks no proteinuria
Pre eclampsia - HTN and proteinuria after 20 weeks
G6PD
Acute hemolytic anemia after oxidative drug (Bactrim)
Bite cells on smear
also dapsone and primaquin
Cold agluten dz - high MCV - agglutination of erythrocytes
Hereditary spherocytosis - no central pallor spherical on smear
Thallesemia - target cells on smear
Older pt with seizures
Lamotrigine best tolerated
Complex partial seizures/generaized
Don’t use carbamazepine (hyponatremia) phenytoin (dizzinesslethargy gait instability)
Selective IgA deficiency
Chronic/recurrent resp tract infections
Atopic disorders (eczema)
autoimmune dz (RA, SLE)
Anaphylaxic rxn to blood products/immunoglobulin - > ab vs IgA
C1 Inhibitor def
Hereditary angioedema
fhx angioedema - subcut edema
Terminal complement deficiency
susceptible to neiserrial dz - meningiococcal
Uninterpretable ABI
ABI 1.4 - uninterpretable -
need great toe pressure or <0.7 = PAD
Spinal stenosis
leg discomfort with walking relieved lying down or waist flexion
Kawasaki dz
LN syndrome particularly with HIV infxn
fever, nonexud conjunctivitis, desquamanting erythematous rash, mucositis, LAD - vasculitis of med vessles
Tx: Immunoglobulin + salicylates - > corticosteroids
TSS
bacterial toxins - septic shock
hypotensive, fevrile, diffuse malar rash, severe myalgia, elevated CPK, hyperemia, AKI, acute liver injury
Newly dx breast CA with risk of BRCA
Counseling and genetic testing
Pt with h/o ovarian and breast CA
decide on local surgery vs ppx mastectomy/BLSO
Keloid tx
Intralesional triamincolone (several injections over weeks) claw like beyond confine of area of trauma - tender or itchy, do not resolve on own - nodule like laser excision/radiation if recalcitrant
No abx, oral steroids don’t work, topical steroids don’t work
Hypertrophic scars at surgery site/trauma - flatten out and resolve over 2 years
Hypothyroid after central hypopituitarsim from surgery/radidation
Fatigue and wt gain - suspect hypothyroid, check free T4
with central hypothyroid - have low TSH since it is produced in pituitary
Tx: levothyroxin
Morning cortisol will be low because pt taking glucocorticoid replacement
OCP will lower LH /gonadotropin levels
Check IGF-1 to assess GH deficiency (GH directly measure is bad - GH is surge hormone)
Hyperkalemia in setting CKD worsening
Hyperkalmemia - tx with gluc/insulin, calcium carbonate,
If peaked twaves or other signs of cardiac conduction abn in setting of hyper K -> needs emergent HD
Don’t use lasix in setting of AKI and low UOP
Pt with hyperkalmeia, hypovolemia and met acidosis -> sodium bicarb
No kayexalate with recent bowel surgery risk of interstitial necrosis
Recently resolved acute diverticulitis
AFter therapy with abx and settling period of few weeks->
Colonoscopy - r/o crohns/adenoCA
Elective colon resection not warranted with one attack of diverticuosis
Acute Angle closure glaucoma
narrowing or closure of anterior chamber angle - impedes trabecular drainage - elevated IOP/ optic nerve damage
Ophthalmic emergency
Sx: halo eyesite, decreased visiual acuity, pain on eye, n/v, sluggish mid range pupil, corneal cloudiness, cupping of optic nerve
Tx: Topical B adrnergic agents, pilocarpine, carbonic anhydrase inhibitor
Central rentinal artery occulsions
50-70yo painless unilateral vision loss
embolic/thrombotic event
afib
(No red eye, pain, n/v)
Occular migraine
Fhx/pmhx migraine
flahsing lights, visual blurring/unilateral vision loss
<40yo
Temporal arteritis
Pt older than 50
severe new h/a
visual loss PAINLESS
(no red eye, n/v)
Chronic severe MR
Surgical indications
preserved LVEF with New onset afib
concurrent maze/PVI
+warfarin for afib
(Rhythm control with amio, DCCV, not likely to work)
OSA therapy
Apnea/hypopnia index
5-15 = mild
16-30 = mod
>30=severe
CPAP for anyone with OSA + sx (daytime somnolensce)
Mild to mod can use oral device (not as effective)
Surgery if nasal sept dev, polyps, tonsillar enlargement, retrognathia (not willing to do CPAP)
Acute pseduogout
Positively biregfringent - rhomboid shaped crystals
linear calcium dep in cartilage (chondroCA)
Pt with DM, CKD, PUD
Tx: best= intraarticular steroids
don’t want oral steroids 2/2 DM, don’t want NSAIDS 2/2 PUD
No abx as infection not likely (neg gram stain, low wbc in synovial fluid)
Drug induced erythema nodosum
Non-specific inflammatory cutaneous rxn - inflamm in fat pads - septal panniculitis - red brown nodules in anterior shins
Etio - infections (Hep C, TB, EBV, cat scratch), drugs (OCP, PCN, sulfa), systemic dz’s (IBD, behchets, sarcoid, NHL
Tx: D/c OCP
Tx infection
Wilson’s dz in young pt
Presents with parkinson's rigidity, bradykinesia cramped handwrited, masked faces psycomotor retardation, depression Dx: CHeck serum ceruloplasmin Slit lamp exam kleiser fliester rings
Other causes parkinsonianism in young ppl
CO poisoning, trauma, brain tumor, hydrocephalus
Pt with breast CA and h/o VTE
Pt with hormone rct + breast CA but contraindication for aromatase inhibitor (h/o VTE)
Tx: Ovarian ablation
ONly use trantuzumab in HER2Neu + patients
Thyroid storm
temp elevation, tachycardia, HF, abd pain, diarrhea, n/v, jaundice
Can be from non-compliance with anti-thyroid meds or precip by surgery, truama or radiocontrast
Tx: PTU/methimazole, BB, iodine solution
Myxedema coma - hypothyroid - hyponatremia, hypoventillation how T3, T4
Subacute (de Quervain) thyroiditis
transient destructiono f thyroid tissue - release of pre-formed T3/T4 - initially hyperthyroid then hypotheyroid
s/p viral infct, tender thyroid
Budd Chiari syndrome
hepatic vein thrombosis risk factor PCVera (also have TIA, MI/CVA, erythromyalgia Dx: Doppler US check for hepatic flow Tx: A/C - oral diuretics if not fully controlled - TIPS -> liver tx
Splenic vein thrombosis - isolated gastri varices no tender Hepatomegaly or ascites
HTN in pt with CKD
Thiazide diuretics less effective than loop diureteics if GFR < 30
(resistent HTN - 3 agents diff classes including diuretic)
Change HCTZ-> loop
Dx Acute retroviral syndrome
Pt with high risk features for HIV
HIV test neg, strep and mono neg
Check HIV RNA to dx HIV
Manage AC for pt with mech AVR preop
Short term risk small
D/C warfarin 3 days before surgery and restart evening of surgery
Risk factors = afib, more than one valve, valve position, hypercoag state, LVEF<2, stop 4 hrs prior to surgery then restart after with warfarin until INR therpautic
If needs emergent surgery then use FFP to reverse coumadin
Henloch Schloen purpura
Palpable purpura of legs after strep pharyngitis
(raised violacious non-blanching papules)
Cutaneous small vessel vasculitis
elevated risk of kidney dz
Disseminated gonnococcal infxn
fevers, tenosynovitis, arthritis, skin lesions - hmorrhagic pustules -
Sweet syndrome
neutrophillic dermatosis - bright erythematous well demarcated papules
Idiopathic or aw underlying dz (hem malignancies)
Treat carpel tunnel syndrome
avoid repetitive wrist motions
start wrist splinting
Local corticosteroid inj for 3 months releif not durable
->contraindicated with thenar hypertrophy, lot of sensory loss, acute carpel tunnel
NSAIDS not effective
Surgical intervention if medical/nonpharm tx fails - progresive sensory and motor defects, severe EMG findings
Manage sellar mass
Incidental sellar mass
Check for hormone hypersecretion
IGF-1(to measure GH fxn), morning cortisol AND prolactin
IF inc’d prolactin - > dopamine agonist tx
DMSupp
used to locate tumor in ACTH dependent cushings
SIADH
check serum and urine sodium
Acute ischemic stroke with HTN
initial stroke >3-4.5 hrs out - no Tpa
no end organ damage (no LVH, ACS, kidney dz, encephalopathy, preeclmapsia, CHF, aortic dissection
keep BP<220/120
No oral meds (dysphagia risk)
Inpt with risk for VTE
immobilized and two risk factors for VTE
low dose HSQ
(not ASA, warfarin 1mg) - don’t use SCDs unless contraindication for HSQ
Complicated parapneumonic effusion
pleural fluid cw exudate
Complicated = large effusion, loculation, +pleural fluid g stain, pleural fluid glucose < 60, pH tube thoracostomy)
Esophageal candidasis
Oral fluconazole
plaques in mouth and dysphagia
Nystatin swish/swallow only in pt with oral dz and NO dysphagia (indicating esophageal inovlvment)
Do not d/c inhaled steroids yet - tx candidasis
Kidney bx contraindication
Uncontrolled HTN (r/o post bx hemorrhage) <160/95 (take all antiHTN preprocedure - short acting BB/clonidine during procedure also mild sedative (lorezepam)
Other contraindication - coagulaopathy, low plt, hydronephrosis, atroptic kidney, kid cyst, acute pyelo
Hereditary hemochormatosis
C282Y mutation - risk factors ferritin >1000, age>40
r/o cirrhosis - if dx then liver bx to r/o cirrhosis
-> r/o HCC
If cirrhosis - > EGD r/o varices, HCC
Tx: phlebotomy
Observation only if ferritin low <50, no end organ damage
Yearly checkups for iron level and labs
If genetic hemochormatosis with iron overload wihtout end organ damage still needs phlebotomy
Reactivation of HSV by UV radiation
latent HSV in trigeminal nerve
activated by sunlight UV - immunosupp by UV
localized cluster of vesicles on vermillion border of lip - vesicles rupture and heal
tx: oral acyclovir, lip balm with sunblock
Actinic chelitis
premalignant in people with significant sun exposure
on lip - ulcers, vermillion border
Contact dermatitis
from lip balm usually pruritic
Coxsackie
hand foot mouth dz intraoral, palmar, plantar lesions oval flesh colored papules with erythema rim fever/sore throat Spare lips - different than HSV
HLD tx in pt wants to get pregnant
colesevelam (welchol)
bile acid sequestrant - dec CV mortality
Risk factors for CVD - DM, HTN, HLD, FHx MI
s/e constipation - binding and dec absorbtion of other drugs
No ezetimeibe (doesn't dec mortality and preg cat X) Gemfibrozil not efficiacious enough No statins (cat x)
Clinical manifestation of sickle cell TRAIT
Only hematuria, risk fo splenic rupture high altidute, VTE, sudden death during extremem condidtions, renal medually CA
Hematuria - renal papillary necrosis (local microinfarcitons) - painless gross hematuria
Need well hydration during strenous excercise
r/o stones/urinary tract neoplasms
Pt with SC trait don’t get acute chest, bone/joint sx, LE swelling
Treatment of Tic d/o
If no effect on social /academic or occupational fxn no need to treat
Tourette’s syndrome
No ADHD or O/C d/o
If does disrupt ADL - block dopamine with clonidine, pimozole, haldol
Lymphangiolyomyomatosis (LAM)
rare cystic lung dz rare in women of childbearing age aw tuberous sclerosis Spontaneous PTX/chylothorax Young woman with dyspnea and chest CT with cystic findings/hyperinflation on CT Diffuse think walled cysts Etio - smooth muscle cells in lung infiltrating lung with inactivating TS gene tx: sirolimus
Organizing PNA
sx over 4-6 wks no more than 6 months
patchy airspace dz, ground glass, consoidation (no cysts)
Repsiratory bronciolitis associated ILD
smokers
centroloar nodules, air trapping scatterd gound glass
Sarcoidosis
reticulonodular abn in central distribution
along lymphatics
b/l hilar and mediastinal LAD
Padget’s dz of bone
osetitis deformans
focal abn of bone metabolism - compromoised bone integrity
Dx: confirmed by plain Xray - coarsened bone trabeculae
elev alk phos (bone isoform)
traumatic / pathoogic fx, hearing loss impringemneet CN VIII,
bone bx, audiology after confirmation or denial of padgets
Diffuse cutaneous systemic sclerosis
Pt’s w/ SCL70 - antitopoisomerase +
high risk of ILD - check HRCT chest (low dlco, restrictive pattern (low FEV1))
ILD w or w/o alveolitis
No risk factors for PE, no RH strain
No RHC if normal TTE
Achalasia
Tapering esophagus - birds beak
surgical myotomy
No endoscopic dilation in young pt (recurs and r/o rupture)
No botox injection - only temp relief - only if not candidate for surgery or endo dilation
No medical tx - no consistent results
Cardiac monitoring for INFREQUENT arrythmia episodes
Implantable loop recorder
concern for arrythmia given occupation
Up to 3 years
when shorter duration monitors non-dx
Lead nephrotoxicity
Pt with normal lead levels but still suspect lead poisoning
Use chelation mobilization testing - measure in urine
Lead nephrotoxicity - chronic intersititial nephorlithiasis - low grade proteinuria, - Fanconi like syndrome - glycosuria in normal glucose, hyperurecemia, hypophosphatemia, aminoaciduria
Erythrocyte protoporphy measurement - acute lead exposure
Lead lines - long bone radiography - only in kids
Basophilic stippling in peripheral smear - non-specific
Colonscopy screening ulcerative procitis
if confined to colon then like general population (q10yr)
Coccoidomycosis
SW US/S/Central america
Pulmonary infxn, joint pain, erythema nodosum
Blastomycosis
Mississipi/Ohio river valley, great lakes
Histoplasmosis
ohio river valley
Hilar LAD with pulm infiltrates
Bird/bat droppings
Sporotrochosis
rare cuase of PNA - can have erythema nodosum, cavitations, lung nodules, hilar LAD
Ischemic stroke treatment
Contraindication for TPA - DM, ischemic stroke hx
Tx: not candidate for tPA (keep BP < 220/120)
Use high dose statin
Adrenal fxn during critical illness
Random cortisol >12 makes adrenal insuff unlikely in pt with hypoalbumin/ critically ill
continue current therapy abx/IVF
Cosyntropin stim not useful in setting of sepsis (stressful arleady)
No reason for morning cortisol in pt with sepsis as maximally stimulated all day
No need for hydrocortisol
Lentigo malina
Melanoma in situ
uniformly pigmented light brown patch in area of sun exp skin grows slowly over years
Broad shave biospy
Not an excisional bx because lesion is large and likely lentigo maligna and NOT melanoma so likely minimally invasive
High risk myelodyplastic syndrome
Refractory anemia with excess blasts 10-19%
tx with azacitidine (nucleoside analogue)
Abnormal cytogenetics
TTP
thombocytopenia microangipathic hemolytic anemia fever kidney impairment neurologic deficits \+schistocytes on smear
MM and AKI
MM - production of abnormal immunoglobulin (paraprotein)
Pw bone pain, hyperCa, anemia, AKI - precipitation of paraproteins in kidney
Clue: Urine dipstick low protein (only measures albumen)
Total protein HIGH
Use SPEP/UPEP to dx MM
If was ANCA vasculitis then u/a would be active
Disseminated gonnoccocal infection
Young, sexually active adults
prodrome tenosynovitis, polyarthralgia
Cutaneous lesions papule/macule -> pustule, frank arthritis, gram stain/ctx usually neg
tendinitis, PAPULOPUSTULAR skin lesions
Staph arthritis
usually monoarhritiss
no tenosynovitis or skin findings
Thromboembolic ppx after afib ablation
First 2-3 months ALL pts take warfarin
AFter that period give according to CHADS2 (don’t know if pt having asx pAF)
NOAC not studied in post afib ablation setting
Symptomatic BPH
combination therapy with alpha blocker (tamsulosin, doxazosin, terazosin) and 5 alpha reductase inhib (finasteride) - shrink prostate takes time
(no reason to change 5 alpha red i, or for abx
Meralgia paresthetica
Nerve entrapment of lateral femoral CUTANEOUS nerve
BURNING, numbness - anterolateral thigh
PURELY sensory
DM, obesity, wearing of tight fitting pants/belts
dysthesia/hypothesia in distribution of lateral thigh
No tenderness to palpation
Greater trochanteric bursitis
Pain in region of greater trochanter worse on affected side
Pain to palpation
Illiotibial band syndrome
pain in anterolateral knee
worse with running/cycling
absent in rest
pain to palpation of femoral lateral epicondyl
L5 radiculopathy
back pain -> lateral thigh
weakness in foot all three (eversion, inversion, dorsiflexion)
+straight leg test
Dopamine agonist induced COMPULSIVE behavior
excessive repetive tasks 2/2 dopamine agonist meds
dysregulation of brains dopamine rewards system
Tx: reduce dopamine agonists
Demntia with lewy bodies
80% parkinson’s pt affected
cognitive decline, parkinsons
Bizarre visual hallucinations
Frontotemporal dementia
apathy, impulsivity, hoarding, disinhitibtion
obsessionality
Prevent ventillator associated PNA
48-72 hrs after intubation
maintain head of bed 30 deg
daily wheening assessment
chorohexadine mouth washes
No need for early trach, chorlox baths,
Symptomatic rapid afib
hemodynamically unstable -> DCCV
(hypotension, pulm edema, - loss of atrial kick dec’s BP and CO) - recent sx development - no A/C needed
Adenosive to dx SVT
Amiodarone only for cardioversion of stable afib pt or long term afib prevention
No metoprolol or diltiazem in setting of acute HF and unstable afib
Lofgren syndrome
anterior uvietic, fever, acute lower extrem arthritis, erythema nodosum, -> check for hilar LAD on CXR to confirm Lofgren without tissues bx
Granulomatosis with polyangiitis
Wegeners - arthritsi, uveitis, pw URI - glomerulonephritis and mononeuritis multiplex,
Disseminated gonnococcus
fever, tenosynovitis - usually no uveitis
No erytema nodosum
Pityriasis rosea
young ppl
single pink oval shaped plaque (herald patch) -> surrounded later by smaller lesions (christmas tree pattern)
Pruruits
Tx: none - self limited (only mild low dose topical steroids if pruritic)
Fungal
Expanding ring like lesion central clearing
scrape and KOH lesions
Treat vent failure 2/2 opiods
Non-focal neuro exam, pinpoint pupils, RR < 12, - needs escalating doses of naloxone
Stroke less likely given non-focal findings
Hepatorenal syndrome
Setting of SBP doubling of Cr Cirrhosis with ascites No concurrent nephrotoxic drugs Tx: Albumin
(no benefit of octreotide or vassopressin)
Diabetes inspidis
Central DI: Urine Osm < 200 in setting of hypernatremia
Response to ADH/despmospressin UOsm>600
CMV
Nephrogenic DI: foscarnet tx, lithium
Desmopressin does not inc UOsm
Cerebral salt wasting
HYPOnatremia, HYPOvolemia
Pt with DVT and cancer
LMWH (not coumadin, not UFH (needs labs))
No IVC (no contraindic for A/C or failed A/C)
Acute utricaria likely 2/2 levofloxacin
cetirzizine, ranitidine, diphenylhydramine (h1, h2 tx)
No concerning features (stridor, eyelid swelling, breathing comfortably - these would warrant admission to hospital)
Topical corticosteroid impractical
NO NSAID - mast cell degranulation - worsen utricaria
Spasmodic torticollis
focal dystonia of neck
occupational overuse syndrome
characterized by directionality
Tx: botox injection
Elevated chol in pt with DM
With DM - LDL goal LDL<70
To dec LDL always try to inc statin if possible (other drugs do not dec mortality)
Mild congential asymptomatic neutropenia
ANC 1000-1500 common among certain groups
able to do ADL
NOT aw inc’d infections
No tx needed, repeat CBC in 2 months
(If need to r/o autoimmune neutropenia then antineutrophil Ab assay)
BM aspirate if neutropenia worsesns
(Flow cytometry only in lymphoprolif d/o)
Tb tx
With meningitis - 9-12 months 4 drug regimen
(meningeal involvement on CT)
CSF lymphocytic pleocytosis, dec’d glucose
Regular pulm/extrapulm TB - 6 to 9 months
INH, rifampin, ethambutol, pyrazinamide
2 months of all 4 then 4 or 7 more months depending on pyrazinamide or not during first 2 months
> 12 months for drug resistance
Non etoh steatohepatosis
Wt loss, excercise, agressive control of lipids, BP, glucose
Nodular lung infiltrates suspected vasculitis
lung infiltrates with hemoptysis, p and c ANCA +
rapidly progressive GN
Need lung bx for dx (nasal/rhin tissue dx insufficient, no indication for kidney bx if no protein in urine)
Secondary Osteoporosis
Fragility fx r/o causes of osteopenia
Check for hypogonadism, vit D def, pirmary PTH, Ca malabsorbtion, Ca+ malaborb, MM
H/o IDA with low urine Ca - possible celiac dz
start bisphosphonates when dx certain
Upper airway obstruction 2/2 angioedema from ACEi
No signs and sx of anaphylaxis or allergic rxn (no role for steroids or epinephrine)
Need intubation
Generalized anxiety d/o
excessive anxiety and worry about Variety of events on most days for at least 6 months
fatigue, irritability, restlessnes, insomnia
SOmatoform sx (high utilizer of heathcare)
Major depressive d/o
5 or more depressive sx in 2 week period
Bipolar d/o
manic or hypomanic mood epsisodes and depressive ones (manic = delusions of granduer, elevatd mood, dec need for sleep,, hypersexual, spending sprees)
ADHD
inattention in childhood, hyperactivity, impulsivity in work/home/school (2)
Chronic stable angina
despite optimal medical therapy and no options for revascularization
(already on BB, nitrate, CCB)
Ranolazine
(don’t give to long QT pt, inhibits met of dig/zocor, dose ajust with Kidney dz, )
Primary glomerulous nephropathy
Nephrotic syndrome
Microscopic hematuria, no erythrocyte casts
HBC, HCV, SLE, malaria, syphillus, malignancies (breast, lung, kidney, stomach, colon, NSAIDS, ACEi, RA, DM
Kidney bx:
LM: diffuse glomerular thickening, no inc’d cellularity
Immuno: granular IgG C3 deposits along capillary loops
EM: mod foot process effacement
Asymptomatic gallstones
Observation unless symptomatic
(or undergoing procedure that will make syptomatic)
Most asx gallstones benign course
Superior vena cava syndrome
Need tissue dx - mediastinoscopy and bx
can be caused by lymphoma, mediastinal germ cell tumors, lots of pt with malignancy have this as presentring syndrome
Progressive dyspnea, facial swelling, distention of neck/veins, facial edema, mediastinal widening, pleur eff
Dx Vit D deficiency
Pt with osteoporosis, high PTH, low Ca+ and Phos -> secondary hyper PTH 2/2 vit D deficiency
Check 25OHD3
Chronic fatigue syndrome
unexplained fatigue that lasts more than 6 months - subj memory impairment, sore throat, tender LN, h/a, unrefreshing sleep
tx: CBT, graded exc, sleep hygene,
Osteomyelitis
Deep bone bx cultures more accurate
Sinus tract drainiage could be contaminated from surface
Discoid lupus
dyspigmented atrpohic patches on scalp/ears, black women, hair loss, leave scars usually no systmeic SLE
Allopeica areata
NON-scarring process - no skin changes in ears
Tension headaches
Non disabling h/a 30 min to 7days Need brain imaging - done, net b/l steady, unaffeted by physical activity, no photopobhia, n/v Tx: NSAID> ASA or tylenol (no role for TCA, cyclobenzaprien,
Early Rheum arthritis
CRP, +CCP, +RF, lots of joints, early morning stiffness >60min,
Tx: DMARD (MTX)
(NSAIDs, shoe inserts and colchicine NOT better)
Adult with repaired tetralogy of fallot (pulmonary infundibular stenosis, Overrding aorta (AV connected to both L&R Ventricle), VSD, RVH) pw sx afib
Pulm valve replacement, TV repair, Maze procedure (afib)
MC post op problem - afib from severe PV Regurg 2/2 patch over RVOT - well tolerated for years but causes RVH, TV annular dilation, TR, dilation of RA causing afib
RFA/DCCV won’t work without fixing PV/TV
Tx onlywith biventricular failure
Treat anaphylaxis
IM/SQ epi for anaphylaxis and inhaled albuterol for wheezing
need high flow o2, cardiac monitor, IV access,
No IV epi - only treats hypotension (r/o MI, HTN, CVA, r/o arrhythmia)
Antihistamines or corticosteroids won’t help anaphylaxis
Mechanical ventillation only in drooling, stridor, facial/tongue swelling, inability to talk
Nephrogenic systeic fibrosis
(nephrogenic fibrosing dermopathy, scleromyxedema like illness of renal dz)
Seen in some pts with ESRD on HD after MRI with GAD,
Progressive tightening and thickening of skin, fleshy/yellow plaques/papules, pruritis,
Skin bx CD34, dermal fibroblasts
Lipodermatosclerosis
Significant venous insufficiency
darkly pgimented indurated skin
+venous ulcers, dependent edema
Scleroderma
should be in face, periooral, fingers, +SCL70, +anticentromere Ab
Scleromyxedema
widespread ertyemaouts, indurinated skin with fleshy papules, face, fingers, extremities, aw serum paraprotein seen on SPEP
Parapneumonic effusions
Pt’s with CAP and large pleural effusion (>1/2 hemithroac or 1cm lying) - should undergo prompto thoracentesis,
exclude complicated parapneumonic eeff (pH<60, G stain +) Delay may cause loculation and need for VATs
Small pleural effusions do not require drainage
Cancer of unknown primary
symmetric around midline mediastinum and retroperitonium - poorly diff CA
LIKELY Extragonodal GERM CELL TUMOR (given young man)
Check AFP, HCG
Tx: Cisplatin chemo
Palliative care discussion with family of cancer pt
Communicate with family to assess understanding of patient’s condition
Don’t start with advanced directives
Don’t say cure intent is futile
Overcorrection of hypotonic hyponatremia
Correct 4-6 meq in 24hrs if more then need to correct backward with 5% dextrose
(high UOP suggests rapid water diuresis which will worsen correction)
Tolvaptan would also block ADH which would make overcorrction worse (same with fluid restriction, NS) - cells shrink, water out, central pontine myelolysis
Generalized convulsive status epilepticus
jerking all 4 extremities tonic clonic >5 min
First Lorazepam (benzo)
Then Phenytoin/fosphenytoin
Acute complication - rhabdo, hypoxia, met acidosis
Chronic - cognficitve defects, future seizures
CTH needed
levecitram (keppra) not used in general convulsive status epilepticus
Fungal arthritis
In immunocompromised (ie DM)
subacute monoarthritis
gardener scraping knees (sporothorax)
Synovial fluid culture, synovial bx
Basic calium Phophate dz
usually chronic
crystals invisible in polarized light
alizen red stains them
should have Ca+ seen on xrays
Fasting hypoglycemia in pt without DM
Pt with lab documented HYPOglycemia
inappropriately high insulin level (without inappropriately high C-peptide)
-> hypoglyemia due to EXOGENOUS insulin injection
-> needs PSYCH eval
also r/o sulfonyurea
If suspect insulinoma - abd CT
Gastric emptying delay rarely causes SEVERE hypoglycemia (also with h/o altered Gastric anatomy ie bypass) - no need for gastric emptying study
Pt with active TB that discontinued all meds on 2 month initial regimen
If meds d/c’d more than 2 or more weeks in initial 2 month tx then restart from beginning with SAME meds
If < 2 weeks missed then continue regimen as long as all planned doses taken within 3 months
REgardless if sputums neg pt needs initial 2 month phase followed by 4 month continuation phase
SInce all meds dc’d at once no reason to change meds suspecting resistance
Acute exacerbation of IPF
Some patients with IPF develop acute exacerbation
Dx criteria - unexplanined worsening of dyspnea in < 30 days, CT new GG appearance, consoldation
Only intervention = lung tx
Diffuse alveolar damage on bx - pt age and lack of comorbid condition - good tx candidate
Diffuse alveolar hemorrage can show as ground glass on CT however would show blood in BAL
PJP PNA - would show organisms on BAL, pt should be immunocompromised
Pulm edema 2/2 tachy - would have S3, elevated BNP, JVD
Myasthenia gravis
immune attack on post-synaptic nm jnc Ab vs acetylcholin rect Muscle spectific tyrokinase rect ab CT chest r/o thymoma - needs surgical resection Tx: plasma exchange or immunosuppression
If muscle sp tyros kinase Ab + then less responseive to pyrostigmine
Ephodrium - check if clear cut muslce strengthening after injection -> dx MG not good with just opthalmic and mild limb weakness
Manage white coat HTN
White coat HTN with no evidence of end organ damage (no LVH on EKG, normal Cr/labs)
Dx: 3 sep office measurement above 140/90 and two at home below
f/u q6month, continue HOME measurements - still at risk for sustained HTN
No benefit to pharm tx of white coat HTN
Normal labs, normal ekg no need for TTE or urine studies
Nocturnal hypoglycemia
HgA1c lower than avg blood sugars measured - so i hypoglycemic at unmeasured times of day
70/30 insulin peaks 6-8 hrs
h/a, morning fatigue, sweating in DM I pts
Dawn phenomenon
Elevated glucose 4-8am with morning cortisol surge (co release with GH) - dx with perisistent hyperglycemic morning readings
Somogyi phenomenon
the lower the glucose at night, the higher the rebound hyperglycemia in AM
Risk of death for women
Greatest problem is cardiovascular dz more than all other cuases (ie cancer) combined
Post menopausal, HTN, obseity, inc’d waist circumference, (CAD, PAD, CVA)
Even women with DM will diet of CAD or CVA not DM
Tinea corporis
asx or puritis/burning Often annual growing circumferentially Topical steroids reduce temporatily but do not tx condition and will recur dx: KOH skin scraping Tx: topical antifungals
Atopic dermatitis
would not be worse when cream d/c’d
FHx atopy - eczema, asthma, seasonal allergies, atopic deramatisi - on flexor areas
Nummular Dermatitis
coin shaped eczematous lesions - pruritic - well demarkaced - can be acutely inflammed and weeping - dx by skin bx if needed
Psoriasis
round scaled lesions thicker scale - removal causes pinpoint bleeding (Auspitz sign)
Sclerodermal renal crisis
setting of diffuse cutaneous systemic sclerosis
etio - acute HTN, AKI - microangiopathic hemolytic anemia
Tx: ACEi
Bosentan - tx pulm HTN or digital ulcers in pt wit syst sclerosis
Plasma exchange for TTP, HUS
Sildenafil - PDE inhib, Pulm HTN/ raynauds
Sycope in elderly male
Cardiac causes of syncope have high mortality - inpt cardiac monitoring needed
likely with prodrome of palpitations and immediate recovery
Neuro etio of syncope rare - no need for HCT or carotids
NO TTE unless suspect structural heart dz
Risk of ampullatory adenoCA in pt with FAP or Peutz Jehurers
Need regular upper endoscopy even after colon resection r/o ampullary CA
Tx: whipple
DOn’t just monitor LFTS - when elevated likely too late!
Manage early septic shock
Empiric abx therapy - within 1 hr of dx sepsis (after cultures obtained)
crystalloids to maintain preload
O2 to prevent hypoxia
Vasoactive agents if persistent hypotension after IVF - go with epi first
Tx of PRBC if needed (if Hct < 30 or CVO2<70%
Salicylate toxicity
respiratory alkalsosis
tinnitis, tachpnea, confusion, fever
AG met acidosis (salicylate anion and lactic acid/ketoacid)
Alk of serum pH to decrease cellular uptake of salicylate
IV glucose to stop salicylcate induced neuroglycopenia
correct hypokalmeia to prevent salicylate absorption in distal tubule
Don’t use acetazolamide - decreases serum pH which increases cellular uptake of salicylate/toxicity
HD if salicylate >80, AMS, AKI, pulm edema,
Avoid mech ventillation if possible - decreases serum pH increasing salicylate tox/uptake
Dx Scabies
confirm with scraping and microscopy mites, eggs, feces
KOH/oil
unexplained itching and rash
finger web spaces, wrist, nipples, axilla,
small excoriated papules, vesicles, linear burrows
EOS is non specific
Serum TTG - r/o dermatitis herpetiforms aw celiac dz
No need for skin bx
MEN I
Parathyroid, Pituitary, pancrease - genetic
(gatrin secreting pancreasic neuroendocrine tumor
Autoimmune polyglandular syndorme
chronic mucocutaneous candidiasis, autoimmune hypoPTH, adrenal insufficiency
MEN II
parathyroid, Pheo, medullary thyroid CA
Convulsive syncope
cardiogenic/vasovagal syncope
similar events in past - prodrome during blood draw
Reassurance - no tx needed
No anti epileptic drugs needed
Even if seizures - only if has risk factors or focal findings on EEG/MRI
Acute chest syndrome in Sickle cell dz
New pulmonary infiltrates on CXR
CP
temp t use lasix - can increase sickling
Hydroxyurea only for prevention of acute chest not tx
Risk factor management in pt with CAD
Smoking cessation best risk factor modification
approach non-smoker status after 3 years
excercise at least 3x/wk 20min/day
<70 if CAD+DM
Botulism
symmetric descending flaccid paralysis with bulbar palsies, (diplopia, dyarthria, dyphagia), normal body temp, clear sensorium
Injestion of botulism toxin from home canned foods, wound contamination 1-5 days of ingestion respiratory dysfxn (Diaphragmatic wk) Detect toxin in stool, serum No abx needed
Guillane barre
oculomotor dysfxn - h/o antecedent infection (GI illness from campylobacter), ASCENDING paralysis, paresthesia,
Paralytic shellfish poisoning
ingestion of filter feeeders clams, oysters…
sx few minutes to hours
Tingling lips, paraesthia hand/feet, loss of contrl of arms/legs
Tick paralysis
ASCENDING paralysis, large muscles
Colonoscopy screening
Nonsyndromic colon CA
1st deg relative with colon CA age 54
Get screened age 40 or 10 years prior to 1st deg relative dx (whichever earlier) - ie 40
Manage ADHD inadult
not paying attendtion, impulsivity, motor restlessness
manifest social/academic dysfxn at least in 2 settings
If few sx then drug holiday q2yr for reassessment warranted
If needs drug after holiday - atomoxidene warranted
other SSRI not shown to help
Guillane barre
Plasma exchange and IVIG to prevent respiratory failure
acute inflammatory demyelnating polyneuropathy
Not phrenic nerve pacing (only with high C spinal injuries)
No cpap - bulbar dyfxn r/o aspiration
No benefit with steroids
Thyroid lymphoma
older pts h/o hashimotos presents as enlarging neck mass
Local , systemic sx
Local compression (dyphagia, stridor, JVD, facial edema)
B symptoms
Bleeding of thyroidd would show cystic mass
no h/o trauma
Thyroid CAs grow slowly
Atopic hand dermatitis
pts with atopic eczema prolongued contact water/harsh substances pruritic skin conditioin intermittent flares skin bx non sp
Keratoderma blenorrhagica
hyperkeratotic skin condition
erythem scaley plaque palms and soles aw sponyloarthropathy
Scabies
intnese itching
burrows interdigital web space, wrist, nipples
Tineas Mannum
infect stratum corneum (epidermis)
Pigment nephropathy from rhabdo
CK>5000
heme + urine, few RBCs (dipstick detects myoglobin)
High urine sodium High FENa/granular casts suggests intrinsic renal damage
Hx suggestive of muscle damage
Acute interstitial nephritis - suspicious mediciine exposure
Hepatorenal - liver dz, low urine sodium
Intrabd compartment - surgery or massive fluid rescuitation
Ambulatory arrythmia monitoring
Presyncope few times a month
Looping event recorder - will record pre-sx rthym but store when pt indicates feeling sx
Holter (continueous 24 hr) - good for frequent asx arrythmia
Post symptoms event recorder - No preeceeding rhtym - takes a while to place and record
Creutzfeld Jacob rapidly progressive dementia
progressive dementia aw myoclonus rapdi deterioration of mental status no trauma, infxn, fever Prion d/o Spongioform incephalopathy without inflammaotry signs - neg neuro imaging
Frontotemporal dementia time course longer
herpes simplex encephalitis - fever, hemicranial h/a, memory impairment, seizures - neuro imaging with edema, hemorrhage in temporal lobes b/l temporal involvmenet -> pathomnemoic for HSV enceph
Henloch scholen purpura
Purpuric rash lower extrem arthritis, abd pain, hematuria Skin bx: Iga Depostis, leukocytoclasic vasculitis aw solid tumors or MDS
Churg Strauss
vasculitis - h/o asthma
peripheral EOS
p-ANCA
Microscopic polyangiitis
small arterioles
glomerulonephritis and purpuric skin lesions
NO IMMUNE deposits
+ANCA
Polyarteritis nodosa
small to med vessel vasculitis
renal artery involvement and HTN
No immune depostis
Subacute cutaneous lupus
maculopapular rash,
anti ro/SSA
no glomerulonephritis
Preg pt with VTE and aquired protein S deficiency (anticoagulant)
dec’d protein S activity
dec’d free protein S Ag
normal TOTAL protein S antigen
During preg (or warfarin use) conc of C4b binding protein inc’s - binding free protein S Ag - dec’ing protien S activity -> hypercoag state - > more VTE
Congneital protein S def shows just dec in protein S activity
Periop risk assessment
3 or more cardiac risk factors (Revised Cardiac Risk index)
unable to achieve 4 mets
If above met - proceed to surgery
Dx severe CAP
Urine antigen for S pneumo and legionella
Treat hospitalized patient with DM and basal insulin
Type I DM should have basal insulin + premeal (aspartate)
Don’t resume pre-mixed 70/30 basal /bolus
Manage patietn with rhabdo
First trial of NS (rapid infusion)
Inc’d sodium delivery to tubules will also excrere K+
No immediate need for HD as no EKG changes
Manage pt with Vfib arrest
after defib shock - CPR x 2 min - 5 cycles of 30 then 2 breaths then rnythem check
CPR @ 100/min
IV epi, after 2nd dose then IV vassopressin
If multiple shocks then amio /lido considered offer ICD if survives arrest
Manage meds in pt who MAY become pregnant
Metformin ok for DM (class B) IF becomes preg then prossibly change to insulin
No ASA, ACEi, zocor (ACEi/statin class X)
Localized impetigo
Bullous impetigo = staph aurueus
-use mupirocin if not systemic
If systemic use cephalexin
Complex liver cyst
Complex=irregular, septations
REfer for surgical resction (r/o malignant transformation)
heaptic cystadenoCA
Cyst asp not appropriate
Do not just observe or repeat US
Asx hyperurecemia
mod elev serum urate NO sx
Dietary/lifestyle mod only
(avoid meat, shellfish, etoh)
inc dairy, wt loss
Don’t use HCTZ - inc’d reabsorp urate, inc’s r/o gout
Gout drugs
Allopurinol XO inhib - urate lowering
Probeneicid - inc’d urate excetion
Colchicine - anti-inflamm
Treat elevated BP after IC hemorrhage
IC hemorrhage after HTN, cocaine and ASA
BP goal with IC hemorrhage - 160/90
(if ICP elev <140/90)
Pt on cocaine so IV labetolol (not lopressor)
IF unconcous or AMS - ventricular drain
Idiopathic pulmonary fibrosis (IPF)
Progressive dypnea with worsening dry cough >6mo
smoking hx, inspiratory crackles
dust exposure (ie wood)
CT septal thickening, honeycombing, traction
bronciectasis
No COPD - normal FEV1/FVC
Hypersensitity pneumonitis
allergic inflamm lung dz
exp to airborne antigens
sx w/in 4-12 hrs
Clenched fist injury pt allergic to PCN
Person bite
Augmentin if NOT PCN allergic
Clindamycin/moxifloxacin if PCN allergy
Alt is bactrim with flagyl
ethylene glycol intoxication
envelope shaped crystal (Ca Ox)
flank pain, kidney failure, coma, seizures, noncardio pulm edema,
Tx: fomipezole (competitive inhib of etoh dehydrogenase - presents converstion to more toxic compount) and hemodialysis to REMOVE present toxic compounds
Metabolic acidosis (AG) with resp alkalosis and met alk (vomiting)
psychogenic nonepileptic seizures
Dx with inpt EEG video monitoring
2-7 days - continuous monitoring
Antiepileptic drugs withdrwan
Patient with cyanotic heart disease and anemia
With cyanotic HD - goal Hg 60-65%
In this pt Hct 52 but ferritin low
Iron therapy needed
Atrial septostomy - ES pulm htn tx without intracardiac shunt
Pulm vasodilator tx if still sx after iron therapy
Advanced stage ovarian CA in complete remission after initial adjuvant chemo
H&P, pelvic and CA125 q4month x 2 years -> restart chemo if relapse
No role for surveillence CT
Fuliminant liver failure
Refer for liver tx
hepatic encephalopathy in setting of jaundice without pre-existing liver dz
MCC FLF - medication (esp tylenol), viral infxn
No need for FFP unless bleeding
No ERCP - bile ducts NOT dilated
Pulmonary artery HTN in pt with MCTD
MCTD - sx of SLE, high ANA and RNP ab PAH occurs \+Raynauds Isolated low DLCO Elev PAP on TTE Needs RHC
CA-MRSA skin infection
Bactrim
Large pustular abscess with purulencea nd drainage
Azithro, augmentin no activ vs MRSA
Rifampin - rapid resistance
Prevent DM2 in overweight pt
Weight loss, excercise
impaired fasting glucose 100-125
Acute HIV infection
nonspecific consitutuional sx
non specifici morbiliform exanthum/rash
trunk/prox exttrem
oral ulcers
Typhoid fever
fever, constitutional sx 1 -3 weeks afgter ingesting contaminated food/water
faint salmon colored rash
diarrhea, abd pain
Dx: salmonella typhi in blood, urine
EBV
heterophile Ab test
pharyngitis and LAB (cerv)
mailaise, h/a
Rash RARE
parvovirus B19
Flu like sx, rash/arthralgia, slapped cheeck rash,
No oral ulcers or gen LAD
Parvoviurs B19 ab titers
Lymphocytic Hypophysitis
uncommon autoimmune d/o
enlargment of sellar contents
central adrenal insuff (low ACTH), central hypothyroid, central hypogonadism
Tx: glucocorticoid replacement - mass should decrease
surgery if visiual field defect
Craniopharygioma
rare mixed solid cystic lesion WITH CALCIFICATION
aw panhypopit and DI
Sheehan syndrome
pituitary infarction in setting of hemorrhage during complicated delivery
Prolactinoma
with such large lesion likely would have much higher prolactin =- inc’d size pituitary in preg does not cause sx or mass effects
