Deck 2 Flashcards
Giardiasis
prlonged GI illness watery diarrhea, wt loss, camping trip no running water - giardia cysts in water large volume smelly stools Dx: Giardia stool antigen Tx: Prev - boil water
O&P less sensitive
Modified acid staining - cryptosporiduium, isospora, cyclosproa
Asymptomatic VSD as adult
small perimembranous defect No pulm HTN, no chamber enlargment close f/u and observation No abx ppx Dx: TTE (if suboptima CMR)
Tx: iF Qp:Qs >2:1 and evidence of LV overload closure
If 1.5: 1 and net left to right then close
Autoimmune bullous disease
Bullous pemphigoid Tense subepidermal blisters non-mucosal surfaces aw RA, DM, SLE, thyrotitis W/u: Skin bx with immunoflorescence
Delirium in ICU
acute state of confusion - reduced conciouslness, cognititsion, emtional distrubance, , hyperactive, hypoactive
Acute CVA does not cause flucutaing conciousness
Opiods take some time to develop dependence and cause withdrwaal
Risk factors for damaging veins in pts with CKD
If pt with bad CKD - don’t use PICC/central lines if avoidable - stenosis of central veins may make unsuitable for dialysis catheter or av fistula
Limited stage small cell lung CA
No cure
rarely present early enough to have surgical resection
Dz limited to one hemithorax, with hilar and mediastinal adneopathy that can be encompassed in one tolerable radiofield
Tx: Chemo+chest radiation
If good response - ppx brain radiation done
Advaced dz - chemo along
Small cell lung CA (early stage surgically treatable)
mediastinoscopy for staging for suitability for surgical cure
Acute digit ischemia in systemic sclerosis
Warm environment
Pain control
**Vasodilating tx - IV epoprostenol (prostacyclin analgog)
sequelae = raynaud, ptting, ulceration, gangrene
Bosentan - preventing recurrences of digital ulcers
no benefit in treating acute digit ischemia
ACEi - sclerodermal renal crisis
Colonoscopy with inadequate prep
re prep and repeat colonoscopy do not wait
q3yr colonoscopy for: 3-10 adenomas all <1cm) tubular adenoma, low grade dyplasia
q10yr - hyperplastic polyp or none
Manage diabetic ketoacidosis
Admit to ICU - insulin, fluids, serial abd exams
No imaging or testing unless abd pain does not resolve with correction of met acidosis
Can cause elevated WBC, fever, elevated amylase
Manage peripheral verigo
referral for vestibular rehab if epley maneuver fails
improves sx, balance and ADL
Menieres dz
Tinnitis, hearing loss, vertigo - episodic vertigo, not positional
Acute viral hepatitis
Marked jaundice - marked elevation of AST/ALT
short duration on sx (acute)
Fulminant Hepatic failure
hepatic encephalopathy w/in 2 months of jaundice,
abnormal INR
hemochromatosis
chronic liver dz muchlower LFT levels
Primary biliary cirrhosis
chronic liver inflammation - lower LFTs, disproportionaly high alk phos
Chorea gravidarum
self limited chorea during pregnancy
quick muscle jerks in random pattern
(DDX - huntingtons, HIV, encephalidies, poprhyoria etc, etoh, hyperglycem…
Huntington’s - hereditary progressive neurodeg d/o cogniftive decline with chorea - ataxia, dystonia, slurred speech,myoclonus - psych sx halluc, irrit agitation, dyphoria, disinhibition
Tardive diskinsesa
2/2 mes that block dopamine rcts
twitching movememnts, abn postures
choreiform movmeemnt of face
Takotsubo’s CM
Stress CM - transient ST elev, +CE normal coronaries with apical balooning, basal hypercontractility
catecholamine induced
Tx: BB, ACEi
Pericarditis
PR seg depression
diffuse ST elev
Twave changes
CP postional
HYperthyroid in pregnancy
Tx with PTU in 1st trimester -> methimazole after
presence of vilitigo, suggests automimmunte graves
r/o fetal growth retardation, miscarriage, prmature delivery, preeclampsia
Only thyroidectomy if toxic gointer, large malignant thyroid nodule, toxic adenoma
**Hydroxurea cause of macrocytosis
decrease incidence of sickle cell crisis
RNA reductase inhibitor
dec’s DNA synthesis
Cobalamin def - high MCV, glossitis, wt loss, hypersg PMNs, takes years to manifest
Myelodyplastic syndrome =- infeff hematopoesis, transformationi to AML - need to be dificent in all cell lines
Ankylosing spondylitis
Can occur in 20’s
Need radiographic evidence for dx
can be neg in xray
Pain/morning stiffness relieved with ACTIVITY
MRI sarcoilliac jnt - bone marrow edema, synovitis, erosions, CT can’t detect early bone edema (don’t MRI lumbar spine, affected LATER)
Tx: NSAIDS, tnf alpha, phys tx/surgery
Rotator cuff tendonitis/impingement
pain in shoulder began after rpeitive activity
pain occurs in range of abduction only
neg drop arm test
+hawkins test
Acromioclavicular joint degeneration
aw trauma or osteoarthritis - palpapbel osteophytes on xray with deg changes - pain with shouler movememnt up and down after 120 deg
Adhesive capsulitis
thickening of capsule surrounded by glenohurmoral joint
loss of both passive and active ROM
multiple planes and stiffness
slow in onset, near insertion of deltoid
Rotator cuff tear
+drop arm test
weakness, Loss of function
wk external rotation
Manage anemia in CKD pt
Start EPO
CKD pt with Hg <10
r/o IDA, vit B12 def, GI blood loss, hemoglobinopathy
target Hg 10-11
Mild pulm Histoplasmosis
No tx needed in healthy host
ohio river valley/misippi valley
pulm infiltrates mild hilar LAD
If tx needed: ie immunoompromised HIV
Itraconazole
more serious lipid amphotericin B
(NO FLUCONAZOLE)
Pulmonary embolism
Intermediate to high risk - get CTA chest
lack of contraindication and str abn lung (no V/Q scan)
Don’t use D-dimer in intermed to high risk (only to r/o low risk patients)
If contraindictation to CTA chest then get duplex LE US r/o DVT
Mechanical heart valve and microangiopathic hemolytic anemia
elev LDH, dec’d haptoglobin, decreeased Hg, inc’d retics = evidence of microangiopathic hemolytic anemia + schistocytes on smear
10 year old valve with new murmur
TTE to check for valve dysfxn
TTP - adamts-13 assay - would have low plts and more acute course
Not DIC - no signs of sepsis
Direct coombs - warm or cold autoimmune hemo anemia - would show spherocytes
Osmotic fragility test - hereditary spheroctyosis
personal or family hx jaundice, splenomeg, gallstones, spherocytes on smear
Cryptococcal meningitis
In pt with HIV and immune reconstitution inflammatory syndrome
sweating diplopia, left gaze, somnolence
immune response increases dramatically to fight crytococcus - (diss fungal infxn) - CSF (elev lymphocytes, inc’d protein low normal glucose)
Check crytococcal antigen -
Tx: IV amphotericin B then long term fluconazole
CMV also OI in AIDS but with CD4<100, MRI multiple ring enhancing lesions, h/a mental status chagne, focal deficits
Telogen effluvium
common cause of non-scarring hairloss
common in young post partum women
body brings lots of hair from anogen to telgoen phase under stress - hair loss diffuse
No tx required (also cuase by sehorreic dermatiits, psoriasis, IDA, thyroid dz)
Allopecia areata
patches of total hair loss no scarring - autoimmune
Androgenta alopecia
chronic loss of hair in crown positon - male pattern baldness
Lichen planpilaris
scarring alopeicia -
Lupus
chornic cutaneous lupus - would have scaring with dyspigmentation
REfractory temporal lobe epilepsy
Right temporal lobectomy
Unlikely that addition of meds will help
Corpus callosotomy palliateive surgery for kids with syptomatic generalized epilepsy or atonic seizures
Vagal nerve stimulation doesn’t put seizures into remission
Eosinophllic esophagitis
slowly progressive solid food dysphagia in young person with asthma and allergies
food impaction
Mucosal bx with infiltration by EOS >15/hpf
exclusion of GERD by ambulatory pH monitoring or non response to PPI trial
proximal strictures on endoscpy
Tx: swlalowed aersolized corticosteroids
Achalasia - solid and liquid dyphagia aw CP and regurg
(motiiity d/o not mech obstruction)
Esophageal infection - in pts who use swallowed/aero corticosteroids - usually with oropharyngeal candidiasis
Malignancy - less likely in young pt with no wt loss
oropharyngeal dysphagia - difficulty swallowing phase/formation of food bolus
Hypogonadism in pts with obesity
total testosterone >350 excludes hypogonadism
<200 confirms hypogonadism
200-350 is grey zone
Need free testosterone level - obesity can cause DECREASE in sex binding globulins so low total testosterone level can be normal in free testosterone
then need to r/o other caueses ie meds
karyotype not needed -normal FSH/LH (used to exlude klinefletsers)
Pituitary MRI not needed because 2ndary hypogonadism not confirmed
Sperm count not needed as pt with normal sperm count cna have low testoterone and vice versa
Informed consent
- understanding proposed tx
- understanding alternatives
- understanding risks and benfits of both tx and alternatives
Applies to all health care decisions not just procedures
Dx Glomerular hematuria
See dysmorphic erythrocytes (acanthocytes) on urine microscopy (eruthrocytes retain ring shape but have blebs of membrane protruding) - acanthocytes in blood have spikes not blebs)
Then check urine protein-cr ratio - determine degree of proteinuria
If + then check complement, hep panel, bctx, ANA, ANCA, anti basement membrane ab, anti streoptolysin ab, then kidney bx
If microscopic hematuria non-glomerular then check kidney US
UCtx not needed if U/A neg
Amyloidosis in pt with heart failure
heart failure, hepatomegaly,proteinuria, bruising - low voltage on EKG despite LVH - infiltrative process
Serum/urine spep/upep, fat pad bx -> amyloid
Endomyocardidal bx for dx of myocardial amyloid
Giant cell myocarditis
pw significant hf or cardiogenic shock high mortality rate refractory ventricular arrythmias may present over montsh or acutely NOT aw systemic sx
Saroidosis
if inovlves heart - patchy areas of inflammation/fibrosis from granuloma formation - no low voltage (not infitrative)
No pulm dz in this patient or skin fidings of sarcoid
No proteinuria/bleeding abn in sarcoid
Takayatsu arteritis
aorta and major branches
young women
low grde fever, wt loss, fatigue, myalgia, arthralgia, elevated ESR/CRP, mild anemia/thrombocytosis
Fusiform narrowing of involved blood vessels
Bruises -> pulse deficits -> organ/limb ischemia
Adult onset STILLS dz
high eSR, CRP, high spiking fever, serositis, arthritis, RASH
Microscopic polyangiitis
mononeuropathy, glomerulnephritis, pulm hemorrhage, p-ANCA(myeloperoxidase)
Polyarteritis nodosa
aw Hep B
fever, myalgia, HTN, mononeuropathy, abd pain
Polymyositis
elevated CK, prox muscle wk, myalgia, wt loss
Pulmonary mets from Colonrectal CA
Stage II CRC - periodic H&P, exam, CEA
Annual CT surveillance - colonoscopy
Resection of primary mets to lung (limited to lung)
No data on additional chemo/rad
Nochemo/rad as primary tx for lung mets from CRC II
Peripheral manifestations of psoriatric arthritis
Methotrexate - can treat both arthritis and peripheral manifestations of psoriasis
Polyarticular, DIP, nail changes, arthritis mutilans, nail changes, dacylitis,
Rituximab (CD20) may worsen psoriasis
steroids may worsen psoriasis
ibuprophen doesn’t help
sx Multiple myeloma
>10% plasma cells Need evidence of end organ damage 1. Kidney bx - myeloma cast neuroapthy 2. Hyper Ca+ 3. Anemia 4. Bone dz
Abd Fat pad aspiration - dx amyloid - nephrotic range proteinuria, peripheral sensomotor neuropathy, autonomic neuropathy, carpel tunnel, heart failure, macroglossia
Chemotx only if end organ damage
F/u M protein in 12 months only if <10% plasma cells
Erythasma
well defined pink to brown patches, ofthen in moist skin folds, leisons floresce bright coral red under WOOD lamp
Etio - coryneobacterium minitusimum - groin, axilla, intergluteal fold
asx or mild pruritis,
Cutaneous candidiasis
red itchy, inflamed skin, satelite pustules
Inverse psoriasis
psoriasis in intertrignous areas (inguinal, perneienal, genital, axillary) ie not in extensors
No scaling
Tx: topical steroids
Tinea
has ring with clearing center
KOH scraping branching hyphae
Cushing syndrome - secondary cause of DM
DM, HTN, central obesity, hypokalemia, proximal muscle weakness
CHeck 24 hr urine cortisol, overnight dexameth supp,
Other secondary causes - meds, pancreatic dz, genetic conditions
Causes of cushing - corticosteroid use, secrtion of ACTH by pituitary adenoma (cushing dz), hyperfxn adrenal adenoma
Adrenal CT only if non- ACTH dep cushing
Confirm autoimmune type I DM - glutamic acid decarboxylase Ab
Type II DM high normal C-peptide from insulin resisitance
Pancreatic imaging if jaundice, back pain, chronic diarrhea
Screen for CKD in DM pts
CHeck spot albumin creatnine ratio annual testing
Type I Dm - 5 years after dx
Type II DM - immediately upon dx
Microalbum 30-300 - need ACEi/ARB
24 hr urine protein too cumbersome (gold standard)
Kidney US - once CKD dx
Rumination syndrome
effortless regurgitation of undigested food and reswallowing of contents
30min to 1-2 hrs after meals
Rome III criteria - persistent or recurrent regurgistation and swallow/spit, regurgitation not preeceded by wretching, 3-6 months
Tx: deep breathing post prandial
Cannaboid hyperemsis syndrome
h/o marijuana use with recurrent n/v abd pain - better with marijuana cessation or hot bath
Cyclic vomiting syndrome
vomiting and feelin gwell between periods - (less than 1 week), fhx migraine
Gastroparesis
n/v/bloating, postprandial fullness, early satiety, abd discomfort, DM >10 years
Manage pressure ulcer
Stage III (full thickness no bone/tendon/muscle), Stage IV (Muscle/bone/tendon)
Needs debridement
Add abx as needed
moiste wound environment
No role for hyperbaric, EM or US therapy
Neg pressure wound vac - not better than standard tx
Surguical flaps only in refractory ulcers, vit c/zinc don’t work.
Evaluate acute chest pain
Serious 6 ACS Pericarditis with tamponade PE PTX Aortic dissection Esophageal rupture diastolic murmur - poss dissection with aortic root rupture and AI
CHest CT for pt iwth widened mediastinum, CP, and difference in BP L vs R arm and diastolic murmur (not TTE - not good to assess ascending aortic aneursym) - TEE better for that
Posterior EKG - dx of isolated posterior wall MI - would have +myoglibin
No V/Q as pt does not have si sx PE
Critical illness myopathy
Severely ill pt in ICU>7 days - inability to extubate, prox flaccid limb wk - elevated CK
worse iwth use of steroids, hyperglyemia, NMJ agents
Guillane barre similar but NO HIGH CK
Corticosteroid myopathy
prox weakness - normal CK, only mild myopathic findings on EMG
Myasthenia gravis
worse with activity
post synaptic aceetylcholie rct ab
pstosis, diplopia, slurred speech, weakeness incrases with repeated testing (on EMG)
Prosthetic joint infection
prosthetic joint infection not loose and pt doesn’t want replacement - lifelong abx suppression with bactrim (no sulfa allergy)
(IDeally removal of hardware and abx therpay followed by replacement)
Don’t use rifampin - develops resistance quickly
don’t repeat abx regimen already used (IV)
observation with sx relief but no abx will cause extension of local infection/systemic infxn
Stage I rectal CA
Midrectal CA into mucosa but not trhough, no LN mets - surgery ALONE
Low anterior resection - if further staging shows T3-4 or any postive nodes then chemorad/chemo needed
Chemo, radiation or combination not shown to help stage I dz - RFA doesn’t cure CRC primary tumors
Asbestosis
b/l interstitial fiborsis of lung parenchyma 2/2 inhallation of asbestos fibers - latency 10-15 yrs
Crackles on exam
Work in shipyard without adequate respiratory protection
CT with b/l peripheral and basal septal thickening with pleural thickening and calcified pleural plaques
Breathlessness and restrictive pulmonary physiology
Hypercapnic resp failure as lungs can’t expand 2/2 stiff pleura
Tob inc’s risk of lung CA
Hypersensitiveity Pneumonitis
acutely after exposure to antigen - fever, flulike sx, cough waxes and wanes with exposure
Mid upper lung involvement (not basal)
centrolobar nodules (not pleural plaques)
IPF
pt with interstital lung dz
NO exposures
Severe knee osteoarthritis
not responding to conservative mesures and have functional limitations - refer for total knee replacement
No benefit from knee arthroplasty (is good with meniscal injury)
Osteootomy for valgus/varus deformity or younger pts with unilateral
Hyalronate injections only for mild to mod OA
NSTEMI not candidate (or wants) angiography
BB, ASA, plavix, statin, LMWH - TIMI risk =4
would need angiogram but pt does not wish it
Contraindication to LMWH - obesity, kidney dysfxn and need for invasive procedure
Only use CCB when pt contraindicated for BB
Glioblastoma Multiforme
MC and aggressive intraparenchymal brain tumor
ring enhancing lesion with central necrosis and hemorrage
Meningiomas - extraparenchymal / extradural - enhance diffusely with dural tail - slow growing, better prognosis thank gliobastoma MF
Oligodendroglimoas - rare - intraparenchymal lesions - No enhancement, no necrosis/hemorrhage
Schwanomma - tumors of nerve sheath - CN VIII, hearing loss, tinniis, enhancing lesion at cerebellopontine angle - better prognosis than gliomas
Squamous cell CA
malignancy of lips/oral cavity
Risk factors etoh, smoking, sun exposure
red plaques/nodules - crust/erosions
Need bx and excision
Actinic chelitis
chronic erythema and scaling of lower lip - sun damage - PRECANCEROUS - SCC can evolve
Tx: cryothrapy, topical 5FU, Laser ablation
Herpes simplex (orolabial)
cold sores HSV 1 - found around vermillion of lip - prodrome tingling prior to onset of vesicles then crust over
Impetigo
S aureus - yellow crusted surface - tx topical abx or systemic
Lichen planus
lips and buccal mucosa - may ulcerate - Wichham striae - white lacy rash on buccal mucose - r/o evolving SCC
Diffuse esophageal spasm
Chest pain
Corkscrew esophagus on barium swallow (multiple simultaneous contractions on manometry) esophageal dysmotility
dyphagia to solids/liquids both
Tx: CCB
Achalasia - birds beak esophagus - needs surgical myotomy
Eosinophillic esophagitis - multiple rings/strictures - h/o asthma/atopy
Schatzi ring - isolated ring in GE jnc - intermittent dysphagia no CP
IgA nephropathy
gross hematuria, h/o resp/GI illness (recent) and normal complement
Infections precipitate production of Ab - IgA depostis in glomeruli causing injury and bleeding
(ATN from tubular congestion)
Glomerular cresents on kidney bx bad prognosis
Analgesic nephropathy
NOT DUE TO Glomerular damage (chornic interstitial nephritis, renal papillary necrosis)
Post infectious glomerulonephritis
Preceding GI/resp infection weeks before (strep/staph)
Decreased complement
elevated anti steptolycin O ab
Rhabdomyolysis
pigment induced nephropathy
muscle injury releases CK/myoglobin
elevated CK, elevated urine myoglobin
ACEi induced cough
non productive cough after starting ACEi - normal CXR
d/c ACEi (cough from bradykinin)
Substitute ARB + smoking cessation + re-eval in 4 wks
(can consider GERD, asthma, upper airway cough syndorme (post nasal drip))
Babesia
Camping trip new england Tick borne dz Ioxides tick 1. Lyme (borriella burgdorferi) 2. Babeesiosis (Babesia microti) 3. Human granulocytic Anaplasmosis (anaplasma phagoctyophilium)
Only Babesiosis have HEMATURIA
Tx: atovaquone or azithro
severe - exch tx
RMSF - rash no hematuria - blanching erythematous macuoles wrists and ankels -> petechiae
West Nile virus - fever, CNS SX not HEMATURIA
Cardiac sarcoid
Dx with cardiac MR
Echo findings suggestive - restrictive filling, biatrial enlargement,
MR would show delayed gadoinium enhancement in atypical distribtuions for coronary artery disease
MR also looks at pericardial thickness r/o constrictive pericarditis
IF cardiac sarcoid confirmed -> ICD
ENdomyocardial bx warranted if MR neg
TEE only if TTE inadequate
High grade dysplasia in pt with barretts
Pt with Barrett esophagus
High grade dysplasia
Tx: Esophagectomy if surgical candidate
Endoscopic ablation (ie bad heart failure) - alternative
If no precedure - endoscopic surveillance q3m - adenoCA then surgery (high grade-> adeno 6%/yr)
Macroprolactinoma
Dopamin agonist (carbergoline better tolerated than bromocriptine) if no sx (no visual field changes despite being on optic chiasm) will decrease tumor size OCP do not use - may increase tumor size Surgery only with intolerance of dopamine agonist, unstable vision changes Radiation last resort tx
External spinal cord compression by epidural hematoma on warfarin
Pt on warfarin with INR 3
Discontinue warfarin reverse A/C in prep for surgical decompression
Cauda equina syndrome form cauda equa compression 2/2 epidural hematoma
Do not lumbar puncture prior to AC reversal
Without fever and WBC elev, epidural abscess unlikely so no abx
If no signs of inflammaotry process then no need for high dose solumedrol
Staph aureus infection
G+ organisms MCC infectious arthritis
monarticular usually
affect large joints, rapid (1-2 hrs)
Otherwise healthy patient with skin breakdown in trauma
Fever, swollen knee with effusion -> stayph aureus septic arthritis
hematogenous spread of skin infection to knee
Gout rare in healthy young women
Onset of chronic lyme gradual
Patient hospital dispostion options
Skilled nurinsing facility - IV meds, low level rehab - when gets better can reassess for better dispo
Inpatient rehab - intensive physical and occupation therapy - need to be medically stable and able to participate in 3 hrs /day at least
Long term acute care hospital - will need hospital based interventions - need for significant medical monitoring>25 days - overseen by physicians
Hospice care - prognosis < 6 months
Hematuria - low risk patient
Risk factors >40, h/o uro d/o, analgesic abuse, pelvic irrad, UTI, smoking, occupational exposure chem/dyes
(FHx does not increase risk)
Repeat U/A if +
Glomerular - dymorphic erythrocytes (acanthocytes) on urine microscopy, erythrocyte casts
Non-glomerular - isomorphic/normal RBCs on urine microscopy (UTI, bladder/renal CA)
Dx: Upper urinary tract imaging - CT, US, IV uropgraphy (CT Urography best) ->cytoscopy / urine cytology
No Uctx if no WBC no dyuria
Vocal cord dysfxn
inspir and exp wheezing
respiratory distress, anxiety
difficult to distinguish from asthma during exacerbation
Clues: sudden onset and abrupt termination of attacks - lack of response to asthma tx, promient neck discomfort, lack of hypoxemia, lack of hyperinflation
FLow volume loop: Inspiratory (lower) limb cut off 2/2 extrathoracic obstruction - vocal cord - expiratory (upper limb) prserved
TX: speech therapy, relaxation techniques, tx of anxity, post nasal drip, gastroesophageal reflux
Acute asthma
cxr not needed unless doesn’t respond to asthma therapy or evidence of concurrent condition (PNA< HF, PTX)
Bullous pemphigoid
autoimmune bullous disorder
Tx: prednisone initially then transition to steroid sparing ageng (azathroprine, mycophenolate motif)
Dx: skin bx (infection, contact dermatitis, allerigc, drug reaction)
Monitor skin for signs of superinfection (antihistoamien hydroxazien may not help
Manage GI Bleed in patient taking warfarin
Upper endoscopy to be performed right away in pts with UGIB with INR <3
Gnawing pain and characteristic coffee ground emesis = pepcid ulcer dz
Weigh risk of thrombosis from A/C rev against riks of bleeding - in pt with prosthetic valve and recent TIA should NOT reverse or sthop A/C (pt HD stable)
If need to reverse - FFP immediate, oral or IV vit K delayed
Profound hypoglycemia in older patients
Sulfonyureas with longer half lives in older pts
prolonged hypoglycemia
focal neuro signs(coma, hemiplegia), sweating (A1c level HCT if + and within window consider TPA
Prevent varicella zoster in pt with leukemia
Give varicella IgG (VZIG) or IVIG if not available for ppx w/in 96hrs
No varicella vaccine (live vaccine) in leukemia immunocompromized pt (under therapy)
Acyclovir not proven to help for post exp ppx
HTN in pt with DM2
keep < 130/80 - already on arb (irbesartan), HCTZ - add BB or CCB
If GFR <30 and need better diuresis change HCTZ to loop diuretic
Only add spironolactone as 4th drug if 3 drugs already on board at optimal doses
Paroxysmal nocturnal hemoglobinuria
Unprovoked vein thrombosis unusual location (splenic vein)
Hemolytic anemia
mild to mod pancytopenia
Dx: flow cytometry CD55, 59
Direct coombs - to evaluate autoimmune hemolysis, splenomegaly, spherocytosis, reticulocytosis, elevated unconjugated bili, elev LDH, dec’d haptoglobin
Factor V Leiden - thrombophilia
Antiphospholipid syndrome - inc’d risk of arterial and venous TE - correlation to pregnancy loss
dermatitis herpetiformis
aw celiac dz!!!
autoimmune bullous dz
intensly itchy small papulovesicles on scalp, elbows, knees, back buttocks
Skin bx: deposition of granular IgA in dermal papillary tips
Tx: gluten free diet (Dapsone for skin lesions only)
follow TTG ab
will improve anemia
Sarcoid - skin - maculopapular eruption, waxy nodule, erythema nodosum
manage epistaxis
apply uninterupted pressure x 15-30 minutes then avoid blowing nose, stop nasal steroids
Etio (viral/bact rhinositis, nose pickign, dry air, intranasal steroids)
No need for blood count or coags
Cauterization/nasal packing or nasal artery emboliz for sevre cases not responsing to pressure
Only posterior nasal bleeds need ENT
Acute ischemic stroke treatment
Tx with ASA at least 160mg daily
dpeending on size of stroke transition to warfarin
Obesity hypoventillation syndrome
Daytime hypercapnia PCO2>45 (dimineshd ventilaotry drive 2/2 obesity) Pulmonary HTN, polycythemia OSA Sleep study to determine CPAP vs bipap Tx: weight loss
Cheyne stokes breathing - central sleep apena - cresencdo decresendo pattern
men with advanced LV dysfxn
COPD long standing - carbon dioxide retnetion and hypercapnia
Treat aortic disease in patient with bicuspid aortic valve
Sx aortic regurg
-> already indicated for AVR regardless of LV fxn
if aorta > 45mm then repair at time of AVR indicated
Bicuspid aortic valve aw ascending aortic dilation -
Don’t wait on intervention (BB can slow progression of aortic dilation in marfans)
Tennis elbow/lateral epicondylitis
Periarthritic d/o pain at elbow-> forewarm
repetitive motion of forearm injury and inflammation of the tendon - carrying/lifting/grasping objects (overuse syndrome)
Pain on lateral elbow
Tx: counterbrace
Cervical radiuclopathy
pain-> forarm but also aw numbness, tingling, wk
Sx reproduced by bending neck
Olecron bursitis
Pain at the olecron process at tip of elbow aw bursa swellign
etio - trauma, septic (staph aur), gouty
Tx: aspiration
OA of elbow
rare - occurs with prior injury to elbow - pain localized to elbow joint only
Tx Younger pt with AML with high risk features
High risk AML=complex karyotype, 5q deletion
Best tx: allogenic stem cell tx
(no advantage with autologous stem cell tx)
(Azacitindine - high risk MDS)
Favorable young patients - t(8;21), inv 16 - chemo/cytarabine
Radiation induced aortic valve regurgitation
Common in post radiation patients (10-25years) - r/o valve fibrosis
Corrugan pulse (rapid carotid upstroke, rapid decline)
high pitched blowing diastolic decrescendo murmur heard to left of sternum at 3rd ICS
Displaced PMI
Widended pulse pressure (155/43)
Dypnea from inc’d LVEDP from AR
CP from low coronary filling pressures
low diastolic aortic pressure
Constrictive pericarditis
prior radiation with DOE
findings of RV failure (JVD, peripheral edema)
Restrictive CM
signs of RV prossure overload
Tricuspid regurg
large retrograde V waves/hepatojugualar reflux
systolic murmur
Manage non-cardiac chest pain
2wice daily PPI x 8 to 10 weeks if no alarms sx (if so then directly to EGD)
Pt with non-anginal CP with neg stress and neg echo
If PPI unsucessful then endoscopy (r/o erosive esophagitis, achalaisa or manometry (DES/esoph motilitly d/o) ambulatory pH monitoring
MSK CP - focal, sharp localized to one area
Multiple sclerosis
partial demyelinnating myeltis
Cervical cord
Electrical sensation with neck movment (Lhermmete sign)
Prior eposide of vision loss (optic neurtis)
daytime fatigue
Dx: MRI brain ovoid white matter lesions from MS
Not cardioembolic CVA - no language deficit in setting of large motor def/sens def
Not migraine - would have h/a, would caurse subtle neuro deficits only
CVID
h/o recurrent respiratory tract infections with encapsulated bugs, H flu, S.pneumoniae, giardiasis
autoimmunie hemolytic anemia, pernicious anemia (high MCV), RA, d/o of GI tract -> malaborption
r.o sinopulm d/o, lymphoma,
If titers low, check response to protein/protein sacc vacines
If very low then then vaccine response unnecessary
Low total hemolytic complement
complement def
Early compoent of complement - SLE
(recurrent infxn wtih encapsulated bugs or diss neissria
Def in terminal complement - recurrent neisserial infxn, ie meningitis and DIG
NNT
Absolute risk=pt with event in one group/total pt’s in group
ARR=AR1-AR2
NNT= 1/ARR
Primary hyperparathyroidism
h/o fragility fx
inappropriately high PTH in setting of hyperCa+
Need PTHectomy
Indications for PTHectomy
- Sx hyperCa (arrtymias, nephrolithiasis)
- Cr Cl < -2.5
- Ca+ > 1mEq abov normal
- age< 50
- Fragility fx
Bisphosp only if pt refuses surgery
No bone scan, no PTHrP needed
Actinic keratosis
sun exposed areas in older people
Premalignant -> SCC
erythematous scaley macules
Cryotx, 5FU, photodynamic tx
Easier to papate and dx
Basal cell CA
pearly, waxy - fair skin, sun exposure
Sebhorriec kearatosis
brown, warty waxy plaques - stuck on appearance - benign
Solar lengintes
brown macular patches in fair skined with sund damage - benign but could be hiding cancer underneath
Porphorya cutanea tarda
blistering d/o - def o enzyme uroporphyingen decarbox - bullae on dorsum of hands after sun exposre - dyspigmentation, scaring, tender
End stage kidney dz and alport syndrome
GFR 13 -
Xlinked dz collagen synthesis
sensoneural hearing loss, ocular abn, fhx kidney dz and deafness
Kidney tx is only therapy - dz does not recur in tx
(ACE/ARB can slow decline, not tx)
Manage CVD risk in pt with CKD
LDL target in pts with CKD not on HD is < 70
Increase lipitor dose
Lowering PTH in CKD patients not aw dec’d mortality
Keep bicarb >23
Corticosteroid refractory idiopathic tranverse myelitis
Plasmapheresis
PE: bl leg wk, loss of sensation below umbilicus, hyperreflexia LE, leukocytosis in CSF, inflammation in MRI,
Probably autoimmune transverse myelitis
First line tx: high dose steroids
2nd line: plasmapheresis or cyclophosphamide
(NOT MTX)
Glatiramer acetate - Disease mod agent in tx of MS - reducees immune resposes that exacerbate MS
Treat multinodular goiter
thyroidectomy if impinging partially solid and cystic nodules Goiter grows over time FNA rules in or out CA If no CA Growing goiter can compress trachea, esophagus, laryngeal nerve
Ext beam radiation doesn’t work
synthroid will make pt thyrotoxic
No need for PTU/methimazole
Radioactive iodine only used in pts with MN goiter with autonomous fxn
Metastic melanoma
sx brain mets
If symptomatic - resect brain mets or stereotactic surgery
chemo and/or radiation won’t work without surgery
Melanoma relatively radio resistant
Schizophrenia
Neg sx: withdrawal, flat affect, lack of interest
Pos sx: paranoia, hearing voices
Sig/sx at least 1 month
Fhx schzophrenia inc’s risk
Sebhorreic keratosis
flesh colored to yellow, tan, irregularly pigmented
waxy/veruncous intexture
BENIGN - no premalignant potential
Atypical nevi
located on torso more macular (ie flat), lack verruncous texture of seborrhic keratosis
Melanomas
irreg borders, darkly pigmented black lesion
Solar lentignes
completely flat in areas of sun exposure
Dx amiodarone induced pulm toxicity
HRCT
chronic dypnea, dry cough, restrictive lung physiology
temporaly related to start of amiodarone
Chroic intersticital pneumonits, organizing PNA, ARDS, pulm mass,
Risk - inc’d age, dose, duration of tx, pre-existing lung dz
Psoriatric arthritis
various pattern of joint/nail involvement
DIP, enthesitis, dactylitis, tenosynovitis, nail pitting, symmetric polyarthritsi - arthrtiis mutilans, spondylitis - onchymyolysis
Lyme arthritis
med or large joints - NO NAIL CHANGES
OA
DIP no nail findings
RA
usually symmetric - PIP, MCP, NO NAIL CHANGES
Tuberculin skin testing
> 10mm - IVDA, persons from countries with high prev < 5ya, employees of NH, hospit, homeless shelter, mycobacterium lab, ppl with inc’d risk of TB (DM, CKD, siolosis, cancer of head/neck, gastric bypass
> 5mm - recent contact with active TB pt, HIV, fibrotic changes on prior CXR c/w old healed TB, organ tx or other immunocomprimised
Asx person of both groups if cxr neg then need latent TB tx
Afib in setting of HF after MI
Amiodarone
One of few agents safe for sx afib with LV dysfxn
(alternate= dofetilide - ok with afib and HF - monitor QT)
No flecanid - inc’d r/o polymorphic VT
NO disopyramide - neg ionotrope
No dronedarone - inc’d mortality in NYHA III, IV
No soltolol - more BB than amio, bad in HF
Proliferative glomerulonephritis
active SLE and abn urine
new onset HTN/edema
+ANA, dec’d complement, proteinuria, hematuria
Need prompt bx - wil lthen start on high dose corticosteroids + immunosupp agent (cyclophos or mycophenilate moteifil)
Severe COPD
Pulmonary rehab for…
Sx COPD with FEV1t walk, recent MI or UA)
Morphine only for pt with severe dypnea at rest for palliation
O2 only for 88% or lower
Steroids only for acute exacerbation - change in baseline cough, sputum
Cryptococcal meningitis in pt with AIDs
Disseminated cryptococcus - with meningitis
Tx: conventional amphoteriicin B and flucytosine
h/a, skin lesions (molloscum like) - CSF paucity
If pressure>250 then drainage needed
1: induction - amphoter B + fluctyocine
2: consolidation - oral fluconazole x 8 wks
3: maintenanc/suppression
(lipid amphoter for kidney dz pts)
no echiochinocandins - (caspofungin) as no activity against crypto and no CSF penetration
(also amphot B+ fluconazole, flucon along, fluc + flucytocine)
Sx pulmonary valve stenosis
Contraindications to pulm baloon valvulopastic
Sub or supra pulm valvular stenosis
Severe PR
hypoplastic pulm annulus
going in anyway for other cardiac dz - fix valve while in there (need pulm valve replacement)
Sx patients with >50mm instant grad (30mm mean)
Asx pt with >60mm/40mm mean wihtout mod or greater PR
Pulm vasodilator therapy for PAH
Atypical parkinson’s dz
typical parkinson’s responds to high dose levodopa
Sx: resting tremor, bradykinesia, rigidiy, postural instability
absense of olfaction
w/o response to levodopa - more extensive dz
Tremor absent in 30%
Most parkinson’s patients have autonomic dysfxn
Manage pt with secondary iron overload from B thal minor
Hct 25% - can’t do phlebtomy - need iron chelation (deferasirox)
B thal major with iron overload from excessive tx and inefective EPpoesis
elev ferritin and transferrin saturation indication for tx
Complications from second iron overload - HF, liver failrue, arthraligia, pitutiary, islet cell dysfxn
Chronic neuropathic pain
mod to severe
if did not respond to non-opiod meds
transition to sustained release morphine
don’t use tramadol for chronic pain - weak opiod
don’t use methadone in pt with ischemic CM and conduction dz (can cause long QT -> VT)
HTN in black patient with CKD
Stage 3 CKD - add ramipril
blacks with more end organ damage from HTN at any level than other groups
Absense of end organ damage goal < 135/85
+end organ damage - ing diuretic will improve bp but not proetinuria and kidney dz progression)
Tx superficial lacerations in elderly adult
Non-adherent dressing over plain petrolium - cheap and good
Atopic skin (Polymyalgia rheumatica - pain in neck,shoulder, hip aw temporal arteritis - tx with low dose prednisone) Minimize risk of damage to skin with adherent tapes
(no need for hydrocolloid, hydrogel, calcium angonate, foam dressings)
No need for topical abx - risk of allergic contact dermatitis and drug resistance
Don’t leave wound open - escar can form - prolong healing time
Evaluate diarrhea not meeting criteria for irritable bowel syndrome
IBS - abd pain, diarrhea, imporovment with defecation, onset with change in stool frequency,
Dx: flex sig with bx - r/o microscopic colitis
thickened subepithelial collagen band (collangenous colitis) or subepithelial lymophcytic infiltrate (lymphocytic colitis)
Don’t use antispasmotic agents - dicyclomine - GI smooth muscle relaxants -
Pt with normal IgA unlikely to have celiac dz
If needed to use TTG NOT antigliaden ab to dx celiac dz
Don’t give loperimdie without dx
Small intestinal bowel overgrowth
diarrhea, bloating, weight loss Macrocytic anemia 2/2 B12 def Elevated folate (bacteria consume B12, synthesize folate) Pt with sclerosis high risk for SIBO 2/2 intestinal dysmotility Risk factors - altered gastric acid (gastrectomy, achlorohydria, str abn (strictures/diverticula blind loops), intestinal dysmotility (DM, NM d/o) Dx: hydrogen breath test, upper endo with ctx
Celiac dz unlikely with normal TTG
Microscopic colitis - chagnes ONLY in colon so fat absorption should not be affected, vit def not present
Acute sinusitis
tx with anti histamine for mild case, no abx
usually resolves 7-10 days
Abx only for worsening sx and HIGH fever
No need for nasal ctx
No need for imaging - not very sensitive
role of nasal steroids unclear
Hypothyroid in critically ill adult
High TSH, low T3, T4 in ICU pt with PNA
amiodarone also causes hypothyroid
start treating hypothyroid
Adrenal insuff -
Nonthyroidal illness causing hypothyroid - euthyroid sick syndrome - from cytokine inc - TSH shouldn’t be above 10,
TSH secreting tumor inc’d TSH and T3/4
Folliculitis
pustules caused by bacteria around follicles topcial abx (clinda, benzoyl peroxide) or doxy
Acne would have comedones - pustule of acne usually sterile
Miliria - heat rash - erythematous papules occulsion of sweat ducts, no pustules
Rosacea - papules and pustules - central face only!
Acute disseminated encephalomyelitis
inflammatory demyelating d/o young adults
post infectious phenomenon
simultaneous demyelinateing in multiple areas
h/a, fever, ENCEPHALOPATHY (not c/w MS)
lymphocytic prolif in CSF (not c/w MS)
usually SELF limited
CKD patient with HTN
Sodium restriction, keep BP <130/80
Start with CE in CKD patients with proteinuria
nonproteinuric CKD - focus on BP control not specific agent
Nabicarb in pt with CKD and bicarb 15-20
No need to tx mild elev PTH with normal Ca+/Phos
Sarcoidosis
Idiopathic d/o with UPPER LUNG infiltrates (better seen in lateral view)
Non-necrotizing granulomatous infection
Dx requires tissue
Asbestosis, organizing pna iPF all lower lobe predominant
Gestational anemia
red cell mass increases (inc’d EPO)
inc’d plasma
HELLP (hemolysis, elevated liver ezymes, low plts) - RUQ pain, elev LFTs, pre-eclampsia,
Abn blood smear with throbocytopenia, fragmented erythrocytes
No signs sx of IDA, normal smear, normal MCV not IDA
EPO inc’d during preg
Intercritical gout, hyperuremcemia
HCTZ INCREASES serum uric acid levels, inc’s risk of gout
change to urate neurtral or lowering anti HTN agen
Low fat dairy dec’s urate
Fruit inc’d urate, wine is the least gout precip etoh
Pt with HIV exposed to active TB
should get INH/pyridimine regardless of inf gamma/TST testing results/CXR
need pyraxidine with DM, HIV, uremia, etoh, malnutrition, sz d/o, pregnant women
Don’t use rifampin and pryridmime together - hepatoxicity
doxorubicin induced dilated CM
decompensated HF - S3 gallop, pulm crackles
years to decades after chemo
cumulative dose >550
risk factors age >70, other cardiotoxic agent (cyclophosphamide)
Radiation tx to thorax
No cardiac tamponade without JVD, or pulsus >10
No COPD exacerbation without cough/sputum
Radiation induced constrictive pericarditis -RHF signs, relatively normal BNP
potential cardiotoxicity in breast CA requiring trastuzumab tx
HER2+
Check LVEF before initiating for baseline and during tx
No Exc stress test prior to radiation
radiation can lead to premature CAD, valve fibrosis, abn in LV fxn/mass
Dermatomyositis
Elev CK prox muscle wk heliotrope(violacious color eyelids with periorbital edema), shawl sign, V sign, gottron papules (violacious to pink plques with scalling over extensor surfaces of hand joints, knees, elbows Raynauds, perungal erythema, arthritis, pulm/GI involvement \+ANA
SLE - discoid, malar rash
Polymyositis - no rash
MCTD - overlap systemic sclerosis, SLE, myositis
Inclusion body myositis - older pts, both prox and distal wk
SCC in kidney tx patients
immunosupp agents increase r/o cancer
SKin CA, melanoma, SCC, basal cell CA, Kaposi’s
Occur at younger age, more met potential
Thick adherent scale and eroded areas
Fixed drug eruptions
repeated exposure to same agents
rash recurrening at same areas each day
Nummular eczema
circular/coin shaped eczema
Psoriasis
think pink plaque, silvery scale
elbows, gluteal cleft
Tinea corporis
pruritic, annular patch, thin plaque fine scaling
Post hypoxic myoclonus
prolongued cerebral hypoxia/anoxia syndrome of generalized myoclonus shokclike muscle jerks negative myoclonus Cariac arrest with delayed resucitation cortex hyperexcitable after hypoxic injury VPA, levecitram, clonezepam
Cerebellar degeneration
spinocerebellar ataxia
autosomal dominent
40’s
gait unstadiness, uncoordination
Myoclonic epilepsy
generalized tonic-clonic seizures
Wernickes encephalopathy
ataxia, opthalmoplegia, confusion, peripheral neuropathy, seizures
Thiamine def
Etoh abuse, bariatric surgery, fasting, vomiting, TPN without vitamins
Cocaine associated CP
No BB - unopposed alpha
Tx with CCB and lorezepam (benzos)
lower HR, BP and myocardial demand
No thrombolytics if no ST elevation
No nitroprusside - no reason to acutely lower BP
Palliative care
focuses on maintining quality of life not limited to terminal illness
Non-hopsice palliative care DOES NOT exclude tx (just ensure they are what patient wants)
Morphine only with severe dsypnea at rest without reversible cause
Asx hyponatremia
absence of neurofindings
chronic - rapid correction undesired
1st fluid restriction
3% NS if menstal sattus hcange and Na d r/o variceal bleeding
SIADH - (would have high urine Na), use demecyclocine
Secondary hypogonadism
Central hypogonadism - low serum testosterone, FSH, LH
r/o prolactinoma
r/o hemochromatosis - iron/ferritin levels (h/o OA, inc’d LFT)
Reason to suspect inc’d sex biding globulin (obesity, DM, older age)
Karyoytpe and testiuclar US in pt with primary hypogonadism (inc’d gonadotrpin level (inc’d LH/FSH)
Dyspepsia without alarm sx from developing country
Young pt with dypepsia from endemic area for h pylori without alarm sx (wt loss, anemia, dyphagia, fhh/o UGI malig)
Test and treat
h pylori stool antigen - if + then tx h pylori
if neg trial PPI
EGD for pt’s that do not respond to H pylori tx and PPI
or pt’s pw alarm sx
Manage adrenal fxn during critical illness
Need stress dose steroids if appropriate abx not solving fever, hypotension
(repeated steroid injections probably mad adrenally insufficient)
Cortisol level though normal inappropriately low for stress condition ie sepsis
Don’t wait for ACTH stim, don’t add vasopressors before giving steroids
Patient with hypokalemic met alkalosis
net loss of acid
or retention of bicarb
Saline responsive hypokalemic met alkalosis - hypovolemic - corrects with saline
UClt correct with Saline
active diuresis or gnetic tubular d/o - bartter or gitelman
Pirmary hyperaldo - aldo renin ratio 20 to 30
Mineralocorticoid excess - both renin and aldo suppressed
Plasma aldo and renin levels elevated in patients with malignant HTN, renin secreting tumores and renovasc htn
UOsm gap - used in estimating ammonium excretion
Brachioradial pruritis
neuropathic itch
inflammation in cervical spine causes recurrent itching in upper extrem
Response only to cold pack
Skin bx neg - NO RASH
Not histamine related so antihistamine creams don’t help
Tx: gabapentin/pregabalin
Polymorphous light eruption - skin lesion after light exposure - wheals, papules, plaques vesicles
Skin lesions + itch
Prurigo nodularis - itchy skin, licenified nodules where been repeatedly scratched (pickers nodules)
Solar utricaria - sunlight hives
OSA in post op period
pts with mild risk of OSA should be screened pre-op - (Snoring, tired, observed stop breathing during sleep, big neck, BMI>35, male
Pushed over edge by anesthesia and narcotics
Acute severe pancreatitis
Aggressive hydration by IVF - acute necrotizing pancreastitis - avoids end organ damage
No need for broad spectrum abx even with necrosis
no benefit for ppx either
Only abx if pancreatic infection noted with sample
ERCP only if gallstone lodged in pancrease
Post concussion syndrome
somatic, neurologic and psychatric sx after head injury - h/a fatigue, sleep distrubances, diff concentration and memory - depression, anxiety irritability, dizziness, tinnitis
abn on fxn neuroimaging,
Meniere dz
tinnitis, vertigo, hearing loss
Post traumatic stress d/o
cognitive and emotional sx, memory loss, irritabliity, h/a flahsbacks of events
Manage inadequately observed asthma 2/2 improper inhaler technique
Observe pt using inhaler
on observed inhaler sx PFTs improve
reduce sx of oral thrush and dysphagia
Add leukotriene rct antag if using inhaler properly (corticosteroids and long acting beta agonist)
Prednisone therapy only if lung fxn not improved after proper inhaler technique - lots of systemic s/e don’t use if topical/inhaled meds work
Peak flow diary can document loss of asthma control prior to onset of sx
DM related osteomyelitis
vancomycin/meropenum
septic syndrome with limb threatening foot infection
spreading cellulitis far beyond wound/ulcer
staph, strep enteric g neg,pseudomonas, anaeroboes
Bx of deep bone ideal
Need surgical debridement
NOT aztreonma/flagyl - no cov vs step/staph
No cefazolin - no coverage of MRSA
No gentamycin/aminoglycosides - very toxic, little activity in necrotic aorobic environtmnet
Treatment of mild systolic HF (LVF) in black pt
Needs BB and ACEi - NYHA I-II mild HF sx resolved with diuresis
No need for CCB
1st gen CCB inc’d r/o HF
Hydralazine and nitrate only added to all patients intoleratnt of ACEi/ARB - also blacks with NYHA III/IV HF - addition of these two to ACEi reduces mortality
Spironolactone for severe SHF NYHA III/IV added to BB/ACEi - if pt has only mild sx no need for spironolactone
Iron defiicency anemia with anisopoikilocytosis
variation in RBC size and shape (anisopoikilocytossi) inc’d RDW, inc’d central pallor
Iron def anemia (throbocytosis as well)
DOE/chest pain from dec’d O2 carrying capacity of blood
G6PD def - bite or blister cells - MCV normal
eccentricaly located hemoglobin to one side of cell - MCV normal or slightly high 2/2 inc’d recitulocytosis 2/2 G6PD mediated hemolysis
Myelofiboriss - sign sx anemia + night sweats, wt loss - leukoerythroblastic picture - nucleated eruthrocytes and left shift in leukocytes - TEARDROP CELLS, MEGATHROMBOCYTES.
TTP - fragmented erythrocytes (schistocytes) + AKI + MS changes + ecchymoses
Treat chronic HCV infection
Pt with chronic HCV and advanced bridging fibrosis and no cirrhosis
Start peginferon and ribavirin
can progress to HCC
(If Genotyope I HCV - NS3/4A protease inhib)
Candidates for thearpy - detectable virus - some indication of hepatic inflamm - elev LFTs, inhflamming/bridging fibrosis on bx, NO CONTRAINDICATON to therapy - decompensated liver dz (ascietes, hpe encep, jaundice)preg, psych dz, cytopenia
Goal therapy to sustain response - non-detectable virus w/in 6 months - lot of morbidity from tx
Corticosteroid tx for extrahep manifestations of HCV - mixed cryoglobulinemia, lymphoma, skin dz, autoimmune dz (thyroididits), don’t give unless indicated otherwise worsens HCV (inc’s replication)
Liver tx for HCV pt with DECOMPENSATED cirrhosis, -
No reason to wait - should not reeval in 6 montsh - treat now!
ARDS mechanical ventillation
hypoxemia corrected with mech ventillation, suppleemntal O2 and PEEP - limit barotrauma by ventilating 6mL/kg IDEAL body weight prevent ventilator associated lung injury then stepwise dec till pleateau pressure <0.6
IBW= 50Kg +2.3Kg for men each inch over 60 (45.5+2.3 women)
Interpret thyroid fxn test in older pt
observe with TSH 6.5 and low normal T4 (free)
monitor for signs of hypothyroid
Repeat test over months to ensure stability
In pts over 80 elevated TSH no aw adverse outcomes (depression, impaired cognition),
Normal reference TSH 1-7
Don’t give older pts levothyroxine just for mildly elevated TSH without other clinical sx
TPO normal and exam normal except mild fatigue
No advantage of liothyroxine (T3) over levothyroine (T4)
Pyoderma granulosum
uncommon, neutrophilic, ulcerative skin dz - multiple lesions - begin as tender papules/pustules or vesicles -> spontaneously ulcerate to painful ulcers with purulent base with ragged violacious borders
Sharp cliff cutoff face compared to normal skin
Etio - inflamm bowel dz, -> RA, seroneg spondlyloarthritsi, hematologic dz/malignancy - AML
Caliphylaxis
ectopic Ca of arteries feedign skin - always in pts with ESRD on HD in setting of high Ca+/Phos products, - reticulous dusky erthema that then ulcerates from cutaenous ischemia
Ecthyma gangrenosum
perivascular bacterial infection of blood vessel walls with secondary ischemic necrosis, - multple lesions in diff stages of dev - infecting agent psedomonas - in immunocompromised patients that are ill
Necrotizing fasciitis
rapidly progressive infxn of SQ tissue - strep or poly microbial bacteria - pts are critically ill - progresses over HOURS (not days or weeks) - pale dusky skin with creptus - sepsis
Evaluate pt with metastatic non small cell lung CA
Pt with metastatic adenoCA and NO SMOKING HX -
Need Epidermal growth factor rct analysis - can benefit from biologic agents targeting this gene factor
Chemotx + erlotineb/gefitinib (EGFR ab) - sruvival 8-10 months longer than standard chemo
Bx of liver not recommended with multiple mets (only if soltiary lesion because if you can resect can change STAGE of dz)
Medistinoscopy with bx of LN in pts with potentially resectable non-small cell lung cA (not if pt has multiple mets)
Serum chromografin levels in pt with neuroendocrine tumors (carcinod) or small cell lung CA
Manage side effects of corticosteroid use
Alendronate indicated for pts being tx for giant cell arteritis with corticosteroids - if tx >3months >7.5mg/day
Ca+, vit D
No HRT (estrogen or estrog+prog) for prev of chronic dz like osteoporisis in post menopausal woemn - r/o VTE, CAD, CVA
Epididymitis
Pain in superior and posterior aspect of testicle
dysuria, urgency, frequency, gradual onset of pain
fever, leukocytosis
Risk factors - rec sexual activity, heavy exertion, bike riding
55/MSM - ecohli, pseduomonas
Orchitis - direct palpation of testicle gives pain, testicuular enlargmemnt
Acute prostatitis - pelvic pain, lower UTI sx - fever, WBC - TENDER PROSTATE
Indirect hernia - discomfort and fullness in scrotum, unlateral - scrotal mass - NO FEVER OR WBC
Testicuular torision - testicle twists on spermatic cord - acute pain - cut off blood supply - SURGICAL EMERGENCY - n/v high riding testicle
HIV in pregnancy
Zidovudine, lamivudine, lopinavir-rotinavir NOW when HIV detected lowers transmission to 2%
NO EFAVIRENZ - teratogenicity
Do not withhold tx till CD4<500
Postinfectious glomerulonephritis
weeks after staph infection
decreased complement (C3 and 4) - activate classic and alt pathways
acute nephrotic syndrome, edema, HTN, oliguria, erythrocyte casts
Diabetic nephropathy
steady decline of GFR not sudden
IgA nephropathy
normal complement
AKI macro/micro hematuria
within days of staph/strep infxn
Primary membranous glomerulpathy
nephrotic syndrome hypoalbumin NORMAL COMPLEMENT HLD asx protienuria erythrocyes and granular casts NO ERYTHROCYTE CASTs
Acute Severe MR
ruptured mitral valve cord
flail leaflet, severe MR
pulm edema - sx
urgent surgery MVR
BRIDGE could be IABP, IV vasodilator tx
NOT ORAL afterload reducer (captopril)!!
NO BB - tachy is compensatory and maintaining CO
No sign’s/sx endocarditis so NO ABX
Bacterial meningitis s/p NSx
Empiric tx for NOSOCOMIAL bacterial meningitis
Vanc + agent that penetrates CSF well
MEROPENUM (for g neg bacteria/pseduomonas)
CFtx and bactrim NO EFFECT vs pseudomonas
Gentacmycin doesn’t get into CSF
Flagyl only vs anaorobes
Hypokalmeic distal RTA I
Normal AG with nephorcalincosis
metabolic acidosis and hypokalmeia
can’t acidify urine - > pH alkalotic (>5.5)
Etio: SLE, Sjogrens, RA, lithium, , amphotericin B
hypercalciuria, hyperglobulinemia
Inc’d pH increase r/o kidney stones
Gitleman’s syndrome
hypokalemic met alkalosis
BP low to normal
defect in thiazide channel ie acts like thiazide
Laxative abuse
hypokalmeic normal AG met acidosis
inc’d GI losses - compensted by kidney by urine ammonium prodxn - acid secrition by kidney
Urine amm estimated by UCl gap
15 - decreased acid secrtion
Proximal RTA II
defect regenerating bicarb in prox tubule
normal AG met acidosis
hypokalemia
glycosuria in setting of normal blood sugar
renal phosphate wasting
LMW proteinuria
Distal acidification is intact so pH urine <5.5
No kidney stones
Manage menopausal sx in pt on tamoxifen therapy
Venlafaxine and gabapentin
hot flushes, ameorrhea
NO fluoxetine or paroxeteine (inhibits liver enzymes)
Hormone RT contraindicated in pts with hormone rct + breast CA
No evidence that excerise or herbal meds help
Lambert eaton
progressive proximal muscle wk
depressed dTRs
improve with repeated excercise
Autonomic dysfxn
P/Q Calcium voltage gated ioin channel Ab
Dx: motor nerve conduction studies - inc of potential after stimulation
Myastenia gravis
Acetylcohlinesterase Ab Post synaptic Muscle use and stimuulation WORSENS strength NO AUTONOMIC dysfxn normal DTR
Chronic inflammatory demyelinating polyneuropathy
elevated protein level
progressive prox muscle weakness and hyporeflexia
No autonomic dysfxn
Tx SBP with significant hepatic and kidney injury
+ascitic fluid with >250PMN
Cefotaxime
If Cr >1.5 then also ALBUMIN
If advanced liver dz then also ALBUMIN
DOn’t use diureteic or large volume paracentesis - worsen kidney fxn
Evaluate rheum arthritis
AFter therapy with MTX/biologics get
XR of hands and wrists to reevaluate erosive changes
Don’t use anti CCP for monitoring RA (just to dx)
Only do TB screening yearly
Secondary causes of HLD
LDL and TC really elevated despite statin
statins ineffective in setting of hypothyroid
Check TSH
(sx fatigue, constipation, dry skin)
Also check for DM, obstructive liver dyfxn, nephrotic syndrome
don’t add gemfibrozil to statin unless needed - inc’d conc of statin and inc’s r/o statin induced myopathy
Don’t ever give zocor 80 - change to lipitor or rosuvastatin instead
If fasting glucose and TG normal - don’t need to check HgA1c for now.
Body areas
leg 18%, arm 18%, front torso 18%, back torso 18%, head 9%
Need 30gm topical med to cover body in 70kg person
Tx Myedema coma
IV levothyroxin and IV hydrocortisone
Non-responsive, hypotension, hypoglycemic, hypothermic, bradycardic
tx of sepsis - /PNA - ventillation tx of cardiac issues
With severe hypothyroid also hypopituitarism - need IV hydrocortisone(glucocorticoid) replacement also
Check for adrenal insufficinecy as tx occurs
Don’t use liothyroxine (T3)
Hypotension in pt with Hypertorpic CM
Stop dopamine
cw IVF
START PHENYEPHRINE
LVOT obstruction from SAM
Worsen with ionotropic agens (dob/dopamine)
WOrse with volume depletion, vasodilators, sustained atrial arrythmia and sinus tach
Worse with withdrawwal of BB, CCB
Phenylephrine alpha agonist - raises afterload by peripheral vasoconstriction
Esmolol decrases dynamic outflow tract obstruction raising SBP
DOn’t use milronone - vasodilator effect worsens obstruction of LVOT
Treat central sleep apnea in pt with HF
Cheyne stokes breathing/Central sleep apnea
2/2 HF
Needs diuresis
improvement in cardiac fxn 2/2 dieuresis improves CSA
If CSA persists after medical optimization of HF - adaptive seroventillation (ASV)
CPAP only if obstructive element to sleep apnea
If O2 low then supplement only
Oral appliances only with obstructive sleep apnea element
Dx SLE
Anti- DSDNA Ab
\+ANA arthritis ulcer photosensitive rash livido reticularis - antiphopholipid Ab
ANti ro/SSA, anti la/SSB - Sjogrens, slcerosis , RA
Anti U1-ribonucoprotien (RNP) - MCTD - features of systemic slcerosis, polymyositis, SLE
c-ANCA (antiprotienase 3 ) - granulomatosis weith polyangiitis (wegeners)
necrotizing vasculitis lungs and kidneys
Tx pt with acute VTE
LMWH 5 days overlapped with warfarin INR 2 or more x 24hrs or risk of recurrent thromboembolism
cellulitis
rapidly spreading subcutaneous infection
warmth, swelling, tenderness, erythema, fever chills
Strep
Never b/l
Risk factors - h/o cellulitsi, chronic leg ulceration, varicose veins, DM, thrombophlebitis, lymphedema, obesity, tinea pedis, onchymycosis
Bullous tiniea - inflammatory and erthematous
scales in mocassin distriubtion
localized to foot -> ankle
Contact dermatitis - swelling erythema, warmth - also PRURITIS, - can get secondarily infected
Stasis dermatitis - usually b/l NOT TENDER
Suspected SAH
sudden onset severe h/a
Neg HCT
Need LP to dectect xanthochromia
No use for MRI, MRA, repeat HCT with contrast (if mass lesion large enougth for headache would have shown up without contrast)
Primary biliary cirrhosis
Tx: ursodeoxycholic acid
women >25yo
cholestatic liver enzymes - alk phos 1.5x, AST/ALT 1:40 (bigger is more +)
Tx: monitor with alk phos reduction
don’t give ursodeoxycholic acid with bile binders (cholestyramein)
Screen for HIV infection
HIV ab enzyme immunoassay
HIV screening for all those 13 to 64 once
with risk factors annually
confirm + with HIV western blot (if EIA is +)
(don’t use HIV wetern blot as initial screen)
If acute sx and suspect in window phase -> HIV nucliec acid amplication (PCR)
Graves opthalmopathy
Thyroidectomy + local measures,/steroids
proptosis, diplopia, chemosis, conjuntival injection - optic nerve compresssion can cause blindness
WIth graves dz - surgery for those severe allergy or intol of anti-thyrod drugs (methimazole, PTU, iodine), large obstr goiters or opthalmopathy
If oral iodine taken reduces TFTs but without antithroid drug will cause hyperthryoid
Don’t use PTU if adverse rxn to methimazole
**Don’t use radioactive iodine for graves -> worsens!!
Dronedarone
increases Cr BUT DOES NOT DECREASE GFR
(partial inhibition of tubular tx of creatinine itself)
measured value shoudl be new baseline on dronedarone
DO NOT USE DRONEDAREONE with CHF NYHA IV or NYHA II-III with recent decompensation and hospitalization
de Quervain tenosynovitis
swelling/stenosis of abductor pollicus longus/brevis tendons at level of wrist
Etio - repetive motion of thumb
Pain and swelling over radial syloid
Pain with resisted thumb flexion and extension
Finklestein +
Carpometacarpal arthritsi - pain at base of thumb during gripping - tenderness on doral and palmar joint surface
loss of ROM/joint stiffness
Older patients
Ganglion cyst - in tendon shealth from inflammation following TRAUMA
Scaphoid fx - h/o injury with wrist dorsiflexion
Dx type II DM
HgA1c dx of DM, FBS not - so recheck test dx of dm - ie HgA1c
(has risk factors - fhx CAD, DM, obesity)
If both tests dx’d DM then no reason to repeat either
Manage influenza during outbreak in community
Mild illness otherwise healthy - does not need tx
Those at high risk for influenza - CVD, active CA, CKD, chronic liver dz, hemoglobinopathy, immunocompromise - neurologic dz impairing handling of resp secrtions - ]
Agents should be given with 48hrs
(Oselamavir, zanamivir)
Don’t use amatadine, rimanitidine (high reistance)
Dermatomyositis
heliotrope rash - erythema of malar area, nasolabial fold, periorbiatl skin
gottron sign - erythema over extensor joint spaces
Gottron papules - pink t skin colored papules DIP/PIP, lacy or reticulate erythema of v-neck - shawl sign
Exacerbated by sun
Psoriasis -pink papules, silvery scale - elbows/face
improved withsun exposure
RA - a/w rheum nodules - SQ nodules over ext joints - no muscle weakness
SLE - malar rash - NO MUSCLE weaknes, no guttron papules
Tardive dystonia
facial grimacing, akasthesia(restlessness) induced by dopamine rct agoneists - (metocloproamide) and antipsych drugs
Tx: slowly taper off offending agent, antichol or dopamine rpeleting agen and botox injections
Huntington - familial d/o - generalized chorea, dementia, behavioral changes
Juvenile parkinsons - in child
Wilson’s dz
copper accum in basal ganglia and liver - progressive parkinsons or dystonia. onset in teens - keisher flyscher rings
Stage IIB lung CA
Surgical candidate - isolated, growing nodule
Calculating lung fxn post op - take percentage of lung removed and multiple by FEV1 and DLCO if >40% then ok
neoadjuvant chemo good too
No need to bx as high probability that patient has malignancy
Pt with BRCA gene and inc’d risk for ovarian CA - sister ovarian CA young
b/l salpingoooprhectomy and ppx b/l mastectomy
(multiparity and OCP protective against ovarian CA)
(Pelvic exams, CA125 screening only in pts declining surgery)
Hepatic encephalopathy
neuropsych d/o (minmal MS change to coma/confusion)
Oral lactulose was stnadard tx
Rifaxamin equiv or superior to lactusose
(infection, dehydration, electrolyte disturbances, GI bleeding, constipation and use of narcotics)
No dose adjustement for kidney needed
DO NOT PROTEIN RESTRICT - causes malnurtrition and further infxn
Kidney fxn decline in pt with HTN
ARB/ACEi may lead to inc’d serum cr and uncover previously undx kidney dz -
Pt had kidney dz when started ACE/ARB but treatment decrease GFR from efferent vasodilation - inc’s serum Cr (renal perfusion pressure maintained by inc’d angiotensin)
Peripheral manifestations of inflammatory bowel dz (UC/Crohns)
IBD arthritritis
1st NSAIDs
Can’t use NSAIDs 2/2 GIB
first line = sulfasalazien (also treats diarrhea, tenesmus)
2nd line if sulfasalazine does not work: MTX
3rd line - biologic (TNF alpha - etanercept, infliximab adulimabib)
No corticosteroid for long term…
Premature CAD in CA survivor s/p radiation therapy
typically in ostial/prox sites - fibrous
intimal prolif
poor candidates for PCI 2/2 fibrous nature
Antiphospholipid syndrome - prolonged aPTT - inc’d r/o VTE/arterial thromboembolism and preg loss - aw SLE
Cocaine induced vasospasm - more likely ST elevation and only in case of +cocine labs
Kawasaki dz - fever, conjunctivitis - eyrthema oral mucosal mem, ertyma of LE, cervial LAD, coronary aneurysm /throbmosis of Coronaries- childhood
MS related fatigue
Amantadine or modafnil
exacerbated by hot weather
need to exclude anemia, sleep d/o, hypothyroid, depression,
Adeuqte rest and physical exc importnat too
DON”T USE MEMANTIDINE
only change therapy to INFN beta if relapse (fatigue is not relapse)
Dx acute kidney injury
If BPH with suprapubic illness - suspect obstructive uropathy and get kidney US
h/o irradiation, pelvic tumors, congential urinary abn, prostate enlargment all inc risk
Don’t rely on U/A - FENA may be variable (low in early obst but high later on with tubular damage) - can cuase hyperkalmic metabolic acidosis -
Kidney bx only for kidney injury of unknown cuase
Rhabdo can cuase AKI but need h/o crush injury, muscle pain, meds that cause rhabdo etc
Aortic coarctation
discrete aortic narrowing distal to subclavian artery - discrpance in UE & LE BP - UE HTN, delayed/diminished femoral pulses -
AW bicuspid aortic valve - early systolic click 2/6 murmur RUSB - pt can also have aortic regurg with diastolic murmur
ASD
Fixed split S2 (inc’d L->R R vol overload, pulm HTN)
holosystolic murmur with flow across TV (TR)
Mitral valve prolapse
midsystolic clikc - late systolic murmur DECREASE with squat - if regurg with LVH - displaced PMI
VSD
harsh holosystolic murmur inc’s with isometric exc (inc’d afterload)
+thrill
Inflammmatory muscle/joint pain aw systemic sclerosis
Methotrexate
systemic digit swelling in pt with GERD, systemic sclerosis, dilated nailfold capillaries
pruritis/skin induration - scl-70
MSK features - dcSSc - symmetric synovitis - peripheral joints, tendon sheaths, mild inflamm myopathy
Cyclophosphamide - alveolitsi (low DLCO) aw dcSSc
Hydroxychloroquine - tx SLE - need to be dx with anti DS DNA ab or anti smith -
NSAIDs - no effect with inflammatory myopathy or dermal inflammation
Manage constipation with alarm sx
Colonoscopy
change in bowel habits with recent blood in stool or wt loss, Fhx colon CA or age of onset >50yo
Fiber supplement for uncomplicated constipation without alarm features
Don’t check TSH if TSH already normal
Anorectal mamometry - suspected pelvic floor dyfxn (sensative of blockage in anorectal region), paradoxical contraction of anal sphincter)
No stool guiac if blood on finger…
Chronic Fatigue Syndrome
medically unexplained fatigue that persists for 6 months or greater - subjective memory impairment, sore throat, tender LN, muscle or joint pain, h/a, unrefreshing sleep, post excercise malaise>24hrs
No dx test for CFS - check sleep hx, r/o OSA, frequent limb movements during sleep (restless leg syndrome) - check for depression, check for hypothyroid (if dx of hypothyroid) - CBC r/o anemia/lymphoma, r/o DM, CKD
Don’t test for EBV, parvo B19
Pitted keratolysis
caused by kytococcus sedenarius in ppl with hyperhidrosis warmth, moisture, occlusion Malodor, smelliness of skin Pressure bearing areas (balls of feet)
Ecthyma
Superficial sausage ulcers with overlying crusts
legs and feet
Staph aureus - IVDA and HIV pts at higher risk
Tinea pedis
silvery scale and dull erythema of whole foot, interdigit scaling and maceration
Kertadoerma blenorrhagia
hyperkeratotic skin lesions on palms and soles
aw reactive arthritis
Murcomycosis in pt with DKA
rhino-orbital murcomycosis - emergency surgical debridement and amphotericin B
Posaconazole as steop down to ampho B (or salvage)
Inhalation of spores - can proceed rapidly from orbit to brain - high mortality rate if not treated
Periorbital edema with escar in nasal turbinate
Rhino orbtial or rhino cerebral infxn
DO NOT USE zosyn (no fungal activity)
High altitude periodic breathing
cyclic central sleep apneas and hyperapenas during sleep aw ascention to high altitude
hypoxemia stiulates ventillation
resolves with acclimatization >2500m
dyspnea, waking from sleep, poor sleep quality
Not asthma - no cough or wheeze
HIgh altitude cerebral edema - exterme of high altidudie sickness - encephalopathy in response to brain swelling
High altitude pulm edema - capillary leak in response to hypoxia - no cough or signs of pulm edema
Chronic myeloid leukemia
Sx: fatigue, night sweats, wt loss, early satiety
BASOPHILIA on smear
-> CML
Dx: t(9,22) in situ hybridization
Flow cytometry
good for dx malignancy with homogenous cell population
ALL, CLL, NHL, AML
Check for specific CD markers
Heterophile ab test
infectious mono
check for pharyngitis, LAD
JAK2 Mutation
95% P Vera
60% essential thombocytosis, primary myelobfibrosis (tear drop cells, nucleated cells)
End stage COPD
Palliative/hospice care Dypsnea - Etio PE, PNA, lung mets continue broncodilators if on them MORPHINE for relief of dypnea
Transfusion only severely anemic
Benzos only for anxiety
Oxygen for pts with hypoxemia
Acute UNCOMPLICATED diverticulitis
Oral abx - cipro and flagyl (if able to tolerate oral intake)
obstruction of diverticula neck with fecal matter
mucous/bacterial overgrowth
LLQ pain, n/v
inc’d WBC, mild fever tachy
DO NOT DO COLONOSCOPY RIGHT AWAY - r/o malignancy in 6 weeks
CT guided percutanous bx if peridivertiucular abscess >4cm
Hospitalization and IV abx only with peritonitis or significant comorbidies or no oral intake tolerating
Surgical consultation if unresponsive to abx therapy
or COMPLICATED - abscess, fistula, obstrction, peritonitis/stricture
Dural sinus venous thormbosis
Magnetic resonance venography
h/a worse in AM and valsalva, c/w inc’d ICP
h/a, papiledema, visual problems, focal neruo, MS changes, Sz
NOrmal MRI, h/o tobacco and OCP use -> dural sinus venous thrombosis
Tx: d/c OCP, tob and systemic A/C x 6 months
No lupus A/C if coag panel normal
Adverse effects of glaucoma drugs
Pt brady and low energy/libido inc'd IOP Timolol should be d/c'd decreases inflow of aqueous humor and generally well tolerated - broncospam, depression, mood swings
Amlodipine - s/e hypotension, peripheral edema, dizziness, h/a,
Carbonic anhydrase (Dorlozamine) - acidosis, malaise, diarrhea, hirsuitism, bloody dyscrasia
lantoprost - flu like sx
ACEi - cough hyperkalemia, kidney failure.
Low solute intake
h/o anorexia/wt loss
clinical eurvolemia
low plasma AND urine Na/osmolarity
hypotonic hyponatremia
NOT hypovolemia - no postural chagnes - if hypovolemia, urine OSM would be high as ADH would decrease free water diuresis
Pseduohyponatremia
low serum sodium due to measurement in falsely large volume -
Inc’d LIPIDS and PARAPROTEINS
shows lower than real measure of serum sodium
If no osmal gap then no pseuodohyponatremia
Hyponatremia with primary adrenal insuff
mineralocorticoid and inc’d vasopressin
hypotension, hypovolemia, hyperkalemia, low morning cortisol
Sx Severe TR
Tricuspid valve replacement either sx or signs of
RV overload dilation, reduced fxn
Severe RH failure - dyspnea
Pulm HTN
Don’t cardiovert as TC annullar dilation will preceipate flutter
Don’t treat RHF with digoxin
Don’t treat with abx for endocarditis - no fever wbc etc
Tx chronic venous insufficiency
Knee high compression stockings 20-40mmHg/leg elevation
persistent venous HTN caused by venous incompetence or occlusion
Edema, hyperpigmentation, stasis dermatitis, varicose veins, cellulitis,ulceration
avoid bx (non-healing wound)
Etio also meds CCB/thiaziediones -> dependent edema
Elevation of leg and comrpession
avoid compression with PAD, decompensated HF
Abx only if signs of infection
Diuretics only if systemic signs of volume overload
Patch testing only if allergic contact dermatitis (disrupted skin barrier or use of multiple topical meds)
Immunizations prior to administration of biologic anti-inflammatory therapy
Rituximab
Give IM flu shot prior
No live attenuated in immunocompromised, pregnant women, chornic met dz, DM, kidney dysfxn, hg opathy
prolbem with respiratory secretion handling
Biologics may blunt dendritic or b cell fxn in terms of vaccine response (antigen presentation or ab formation)
Only contraindication is egg allergy, vaccine intolerance
Anti flu tx (oseltamavir, zanamavir) - bridge to therapy with vaccine in immunocompromised
Assistd living during outbreak, close household contact, heathcare works
Delayed hemolytic reaction
Sickle cell anemia pt
Blood tx 1 week ago
jaundice, inc’d indirect bili, lower Hg - worsening pain crisis
If pt with new alloantibody then at risk to develop more
5-10 days later
(not IgA - would have had anaphylaxis)
Tranfusion related acute lung injury (TRALI)
pulm edema/infiltrates
antibodies against neurtrophils in donor plasma
fever/hypotension
HLA alloimmunization
rxn from plt exposure
new plt tx doesnt inc level appropriately
Pt with adrenal insufficiency with mild illness
increase hydrocortisone dose to avoid addison crisis x 3 days
Hospitalization only if hypotensive and not taking oral meds/fluids
Don’t need mineralocorticoid (flucortisone)
Manage implanted cardiac device infection
PPM generator eroded thru skin
extraction PPM and leads needed EVEN WITH NO SIGNS OF INFECTION
visible generator means entire PPM system infected
(microbes track down leads)
temp wire if ppm dep abx for at least 72hrs
Neg BCx followed by 7-14 days abx directed by cultures from PPM pocket
coagulase neg staph, staph aureus MCC
With endocarditis or bacteremia better to wait longer b4 replant (extend abx therapy)
Prior to explant abx may be used to limit systemic spread of infection but still need explant
In pts with localized pocket inflammation but no erosion DO NOT ASPIRATE could spread infxn
TEE if bacteremia present check for lead or valvular veg
DO NOT JUST CLOSE EROSION
Early stage ductal breast CA - breast conservation tx
Excision of primary tumor, sentinal LN bx, radiation
overall survival same with lumpectomy vs mastectomy but better cosmetic results
Sentinel = first LN draining after cancer site (inject blue dye and radioactive colloid into tumor)
If sentinel LN neg then further nodes likely no mets
NO FURTHER SURGERY
If sentinel LN + then axillary node dissection done to determine number of LN involved
If pt with scleroderma, prior chest wall radiation - can’t have breast conservation tx - NEED MASTECTOMY and LN bx/radiation
Always do sentinel LN bx not just surgery - for decision on adjuvant chemo
Most pts undergoing mastectomy don’t need radiation therapy unless large tumors (>5cm)
Validity of medical study
Primary threat to validity in CASE SERIES is NO CONTROL GROUP to compare tested intervention to…
Also randomization not possible
Balkan nephropathy
chornic tubulointerstitial condition of unclear cause in patients of southeastern european origen (Balkan region)
?aristolocholic acid - plant alkaloid from region etio?
Dec’d GFR, urine protein <1gm /day, relative with same dz
CKD, minimal proteinuria, benign urine sediment
Analgestic nephrophathy - h/o analgestic heavy use over years
HTN nephrophathy - long h/o poorly controlled HTN
IgA nephoropathy at later stage of kidney dz should have hematuria and more proteinuria
Venous stasis ulcers
provide compression, minimze vascular HTN, minimize edema -> promote healing
(Unna boot)
medial maleolus classical area
surrounding skin thickened with hemisderin deposition
venous stasis dermatitis
No arterial vasc - not PAD (ABI 0.9) - arterial ulcers at LE affected limb cool with poor cap refill, pulses may not be palpable - over bony prominances or post calf
contact casing - redistribute pressure in neuropathic feet
cellulitis should have fever/ inc WBC and should respond to abx
Hyperaldosteronism diagnosis
Biochemical evidence of hyperaldo: HTN, hypokalemia
No cushings featers (so not cushing syndrome) so no dexamethasone suppression or 24 hr urine cortisol
No CAH features (no hirsuitism, amenorrhea) -
No pheo sx so no plasma catecholamines
DX: check aldo to renin ratio (except if on spirono/eplero)
(should be inc’d aldo, suppressed renin
No need for imaging yet
Behcet’s dz
vasculitis in multiple organs mucous membrane ulcerations occular involvement GI, pulm, neuro manifestations erythema nodosum, arthritis, pan uveitis, retinal vasculitis, pulm artery aneurysm
Granulomatosis with polyangiitis (Wegeners)
small blood vessel involvememnt
NO aneursyms
h/o upper airway dz (sinusitis, epistaxis) and glomerulonephritis
Polyarteritis nodosa
medicum size vessel vasculitis
mesenteric/renal arteries - intestinal ischemia and renovasc HTN
aw Hep B
Sarcoidosis
arthritsi/uveitis
CXR hilar LAD
no aneurysm
Pt on multiple NSAIDS wtd?
put on PPI
h/o PUD
>65, high dose NSAID, use of ASA also, AC or steroids
Enteric coated ASA doesn’t really help GI ppx
Don’t d/c ASA in CAD pt s/p MI
Subdural hematoma
Pt with recent head/neck trauma
SDH (unlike epidural hematoma) require only mild injuries to cervical spine or head
Disruption of bridging veins - sx incidious in onset
Older pts, use of AC
(mental cloudiness, dizziness, ataxia, h/a)
IMAGE HEAD (HCT)
cyclobenzaprine only helps with neck spasms
Meclizine - only helps dizziness of vestibular origin
Flu ppx in pregnant pt
use inactivated trivalent flu vaccine
dont give if allergy to eggs or h/o guillan barre
osetlamavir zanamavir and amantadines only effetive in prev after exposure in close contacts
Can use osteltamavir or zanamavir in pregnancy if confirmed flu infection
NO LIVE flu vaccine for preg women or chornic met dz, DM, Hg opathy, immunosupp, CKD
Manage patients with etoh abuse
connect drinking with negative consquences physical or psychosocial harm serious illness, DWI needs f/u and reassessment identify barriers
Adjunct - disulfuram, AA, pscyh
Etoh abuse >14 drinks/wk, 4 drinks per occasion (3 for women)
Suspected advanced stage testicular CA
orchiectomy and chemo (platnum based good with germ cell tumors and mets)
Lung mass and pleural effusion in young pt with testicular tumor is likely mets
High AFP/HCG= nonseminoma
Platnum, etopside, bleomycin
do chemo before resecting mets
Churg Strauss
+eos, migratory pulm infiltrates, purpuric skin rash, mononeuritis multiplex, glomerular nephritis, alveolar hemmorrage
Antecedent asthma, allergic rhinitis, sinusitis
pANCA (MPO)
fever, arthralgia, myalgia
Granulomatosis with polyangiitis
Wegeners c-anca (antiproteinase 3) necrotizing vasculitis resp/kidney inflitrates/nodules CXR, pulm hemorr No eos, no antecedent asthma/allergic rhinitis/sinusitis
Microscopic polyangiits
necrotizing vasculitis lungs/kidney
RPGN
pulm hmorrhage
No eos, no antecedent asthma/allergic rhinitis/sinusitis
Polyarteritis nodosa
Hep B fever abd pain, arthralgia, wt loss mononeurtiis multiplex nodules, ulcers, purpura, erythema nodosum No lung invovlemnt ANCA NEGATIVE
Exclude PE with d-dimer
low risk patietn neg D-dimer no need for further testing
strong h/o asthma - may have come back
check peak flow
No physical signs of abd issue so no need for CT abd
Systolic HF tx with BB
Can start with systolic HF
DO NOT START IF IN ACUTE Decompented HF
B1 selectives (metoprolol, biosprolol)
Don’t replace MV if 2/2 to dilated CM in decompensated HF
Epleronone should replace spironolactone if +gynecomatia
BIVI ICD upgrade - NYHA III/IV, EF120
Malaria ppx pregnant pt
NO DOXY during pregnancy
Mefloquin better in africa (chloroquin resistant strains)
No atovaquin-proguain in pregnant women
Dx Nephrolithiasis
Non contrast helical CT
sx of renal colic
pain rad to testicle or labia majora
Can ID all stones
KUB only with Ca containing stones
follow stone burden or pre-op planning
No further use for IV pyelography with non contrast helical CT
Testicular US if abn of testicle, turmor hernia abscess
Grover dz (acantolytic dermatosis)
transient rash
self limiting, waxing and waning chronic
50yo
pruritis when hot and sweaty
bx acantholysis - dissociation of keartinocytes in epidermis
Tx: reassurance, cooling measures, mild topical steroids,
Miliaria
red papules on skin without scales - occlued and hot such as neonates and hospitalized patients - eruption can be asx, pruritic, burning, stinging - self limited and would not persist
Pityriasis rosa
spring/fall
pink oval shaped plaque - thin collarette of scale (herald patch)
christmas tree pattern of smaller plaques
asx/mildly itchy
4-10 weeks
Tinea versicolor
Malasezzar Furur
scaly slightly hyperpigmented or hypopig macules on trunk/ torso, don’t itch typically don’t itch
Dx complications after SAH/repair
CT angiography urgent
Early complications - aneursymal re-rupture, hydrocephalus
Late complications (5+ days) - cerebral artery vasospams - decline in neuro exam, - cerebral infarction -
CT Angio can show cerebral vasospam -tx with intraarterial CCB or angioplasty of spasm vessel
EEG if CT angio net - r/o status epilecticus (conv/non-conv)
Lumbar pct to measure ICP or r/o post surgery meningitis but neuroimaging first to r/o mass effect (don’t want cerebral herniation)
MRI - cerebral infarction - less accurate for vasospasm AND slow…
Pituitary tumor apoplexy
Bleeding into tumor in pituitary - ie pt on A/C for afib - high risk
Need to give glucocortocoid supp immediately (acute ACTH def) (hypotensive) and surgery to remove tumor
Pan hypopit hx - wt gain, ED, hyponatremia
Acute h/a, neck stiffness - hemmorage
Insulin tolerance test - adrenal insuff, GH insuff
Prolactin - r/o proloactinoma
Lumbar pct - meningitis or SAH for xanthochromia
Arrythmogenic RV dysplasia (ARVD) with syncope
disorder of desmosome fibrofatty infiltrate of myocardium syncope 2/2 monomorphic VT from RV Syncope=ICD placment!! discourage competitive sports - increase in sudden death from mech stress on RV, inc'd sympathetic tone - RV strech progresses dz RV failure/LV failure eventually
No need for pre-icd EPS but VT ablation option to decrease indicdence of VT
Ambulatory holter - >500 PVCs in 24 hrs = ARVD no need if already dx’d
Can use BB (sotolol) to reduced VT and ICD shocks but still need ICD
Advanced symptomatic follicular lymphoma
chemo - rituximab, vincristine, dobxorubcin, prednisone- > reituximab maintenance
If relapse - hemtopoetic stem cell tx
Acute adrenal insufficiency
hemorrhage - trauma, A/C, emboli (afib) sepsis Sx: b/l flank pain, hypotension, fever, n/v - hyponatremia, hypokalemia low hct Tx: IVF, hydrocortisone replacement - Abd CT confirm dx
TB Drug s/e
Pyrazinamide - hyperurecemia/gout (inhibits tubular excretion of urate), hep, rash, GI upset
Norvasc - peripheral edema, muscle pain, nausea, palpitations, dizziness
INH - hep, rash, peripheral neuropathy, lupus like syndorme
Rifampin - rash, hepatitis, GI upset, ORANGE BODY FLUIDS, - enhances renal excretion of urate
Isolated triglyceridemia
very high >500
fenofibrates
Non-HD chol=total chol - HDL chol
Covelesam - ok for preg pts
can raise TG
nicotinic acid - red tg and inc HDL
-precip gout
Omega 3 fatty acid - lower TG - reduce hepatic secrtion -
Tuberculous arthritis of spine
immunosupp’d pt (HIV no meds)
area where TB endemic
Vertibral bx to dx
can have normal CXR
CT Mycelography - only for demonstrating compression after dx made
Tn 99 bone scan - areas of inflamm no microbiail dx -
TsT too slow
Space occupying cerebral infarction
surgical decompression (mannitol could be first) w/in 48hrs of stroke
No ASA
Dexamethoasone and steroids could help with mass effect of tumores and inffection
ICP monitoring after surgery
No lumbarpnct in pt with mass effect
Constipation predominant irritable bowel sydrome
First laxatives and fiber
Lubiprostone - Cl Ch acitivator - secretes salt water into intestine
Hycoscyamine - IBS as antisposmotic blocks acetylcholine at GI smooth muscle - CAN WORSEN constripation
TCA for abd pain in IBS but anticholilnergic effects worsen constipation
Metochorlproamide - only for gastropariesis
HTN emergency
ENd organ damage - encephalaopathy, AKI, retinal hemorrhage, exudates, papiledema,
Decrase BP 25% in 1st hour
Lentigo maligna
slow growing melanoma
pt with signfiicant sun exposure
prolonged radial growth phase - can be present for many years before vertical invasive phase
Actinic Purpura
well demarcated smooth violacious red patches in elderly pt with sun damaged skin - skin fragility - arise from trauma - may heal with post inflamm hyperpigmentation
Actinic keratosis
PREMALIGNANT
in sun damdaged areas
may be pigmented and be mistaken for lentigo malgna
progreses to SCC
Sebhorreic keratosis
barnicles of the old
Benign
brown scaly waxy
Solar lentignes
brown macules and patches occur in elderly pts sun damaged areas - more homogenous pigmentation and lighter color than lentigo malgna
Acromegaly after transspenoid surgery
elevated IGF-1 and sx of acromegaly
Octreotide
Don’t just observe
Reactive arthrtis
Tx: sulfasalazine (after NSAIDs/steroids fail)
inflamm arthritis that occus within 2 months of bacterial gastroenteritis or non-gonoccoal urethriis or cervicitis
arthritis, uveitis, conjunctivitis
Usually self limited - 25% develop chronic arthrtiis
(refractory to NSAIDS or steroids)
Sulfasalazine also useful in peripheral arthritis forms of IBS associated arthrtis, psoriatic arthritis, ankylosing spondylitis
No colchicine - only for crystal arthropathies
No glucosamine - OA
No role for abx
Carcinoid tumor
low grade malignancy Young, never smokers evidence of bronchial obstruction recurrent PNA tx: surgical resection
AdenoCA is most frequent CA in non-smokers but INFREQUETN cause of endobrochial obstrution
Small cell and SCC do cause endobronchial obstruction but rare in young non-smokers
Cat Scratch Dz
Bartonella Henslae
red papules then tender LAD near site of scratch
AZITHROMYCIN
(or doxy, rifampin, clarithro, bactrim, cipro)
Linezold/dicloacillin - G+ activity - not good again gram neg
Sporotrochosis - itraconazole is tx
Chronic stable angina
If BP and HR can tolerate increased BB then increase
CCB - 1st line antianginal if contraindication to BB
can be added if maximal at optimal dose of BB/nitrates
Ranolazine added if optimal doses of BB, CCB, nitrates
don’t give with hepatic impairment, baseline long QT,
Don’t cath if not medically optimiezed
Bed bug bites
itchy - topical steroids/antihistamines
grouping in linear pattern, don’t need ivermectin or topical permethrin or doxy as dont infest skin..
Manage pt with asymptomatic advanced follicular lymphoma
NHL - if asx and normal blood counts then watchful waiting
If sx develop - rituximab, chemo, prednisone
No LN radiation (just circulate and come back)
diarrhea predomiant IBS
Test for celiac dz
also correlation between celiac, DM1, autoimmune thryoitiis
Smoking cessation
If pt needs nicotine replacement and failed one form then try another form
Can add bupriprion BUT NOT WITH SEIZURE HISTORY
No need for benzoes - need nicotine replacement
Acute bell’s palsy
could be 2/2 human herpes virus type I
Upper and Lower face - inability to close mouth AND raise eyebrows
antecedent viral infection
dry mouth, impaired taste, pain/numbness in ear
abrupt onset over 1-2 days
Tx: PREDNISONE within 72 hrs
No role for acyclovir
High dose IV steroids for MS not bell’s (if this was MS would have history of recurrent neurologic epsisodes)
Migraine associated weakness upper face spared…
Tx pt with resistent HTN and systolic HF
Pt already on ACE, BB, diuretic and HR 50
Add norvasc (doesn’t lower HR)
not 1st line as neutral in mortality effect for HF (but other CCB - diltiaem, nifedipine, verapamil are neg ioniotrpes so worsen mortality)
So norvasc/feldopine only used for HTN or angina in pts with systolic HF when pt already optimized on ACE/BB
Post op VTE ppx in high risk patients (cervical Ca hyster)
5 weeks enoxaparin
High risk = prior VTE, orothopedic surgery, cancer (esp gyn malig) - extended ppx
Non-pharm therapy - in all post surgical pts
(early ambulation, compression stockings, SCDs) - only when very low risk (outpt surgery) or bleeding risk (neuroscurgery)
IVC in high risk patients with known VTE or who can’t get ppx 2/2 bleeding risk
SQH is ok but in high risk pt LMWH better and needs to be after d/c also
warfarin only in perioperateive stting in ortho pts
Hirenadrnous suppurativa
(acne inversa)
Painful, recurrent chronic sterile abscesses - sinus tract formation, scarring of axilla/inguina, perianal, inframmammory area
Tender SQ nodules tha tcoalesce and rupture - deep dermal abscesses - can become secondarily infected
AW smoking and obesity
Not acne - double comedones and sinus tracts
No pyogenic gangrenosum - bright red friable papules - resulting from capillary proliferation and NOT infection
Sweet syndrome - acute febrile neutropenic dermatosis - middle aged women after URI
fever arthraliga, myalgia and cutanous lesion - salmon colored papules/plaque trunk, neck extremities
Intrahepatic cholestasis of pregnancy
2nd or 3rd trimester
mildly elev bili and alk phos (maybe ast/alt)
generalized prurutis
sex hormone induced inhibition of bile salt export from hepatocytes
tx: Ursodeoxycholic Acid
Acute fatty liver of pregnancy - 3rd trimester - need early delivery - liver failure adn coagulaopathy
HELLP - microangiopathic hemolytic anemia, elevated liver enzymes and low plt - 3rd trimester - early delivery
Hyperemesis gravidum
1st trim - unrelenting n/v - elev LFTs but resolve when sx abate
Travelors diarrhea
enterotoxogenic e coli - self limited, mild diarrheal illness
Sx treatment, no testing
from eathing fruits - ingestion of unprocessed water
Stool ctx only if diarrhea >72hrs (esp if tenesmus, fever, blood instool)
Ova & Parasite dx - if >7 days sx
No role for fecal leukocytes
Opiate induced secondary hypogonadism ie methadone
Downregulates GnRH, low FSH, LH, decreased testosterone
Anabolic steroid use pts typically c/o infertility - may have pusutular acne and are big not thin
Citalopram cuases low libido but DOSE NOT DECREASE TESTOSTERONE levels
Spinal cord compression in pt with parkinsons
Compressive cervical myelopathy
MRI cervical spine
acute onset of leg weakness in pt previously able to walk, ankle clonus HYPER reflexia,upgoing toes, leg weakness (arm strength normal)
-> suggest spinal cord compression
Not CT myelography - harder to perform, worse images
No inc’d carvidopa/levodopa
Acute interstitial nephritis
hypersensitivity to a medication presentation variable - dependent on type of med - Fever, rash eosinophilia 10% only leukocytes or leukocyte casts on U/A PPI induced AIN is subacute
Bisphosphonats - ATN - muddy brown casts, no leukocytes
Glomerulonephritis - dysmorphic erythrocytes, erythrocyte casts, proteinuria
TTP - cancer/chemotx agents - cyclosporin, tacrolimus, quinidine - ticlodipine, quinine
AKI can happend but with hemolytic anemia and low plts, elev LDH
Inflammatory anemia
normal or low normal iron, low TIBC, ELEVATED FERRITIN - microcytic hypochromic anemia
Elevated hepcidin in response to inflamm cytokines from inflamm dz (SLE, Tb, OM, malignancy, colagen vasc dz)
Tx: Treat underlying condition
Warm antibody mediated hemolysis - small spherecytes
Microcangiopathic hemolytic anemia - schistocytes
Suspected osteoporotic fracture - young pt on steroids
SLE/steroids - high risk for osteoporosis and fx
avoidane of sun
Even if XR neg -> CT thoracic spine r/o fx
Tylenol and NSAID for pain
PT after fracture r/o and pain controlled
NO BEDREST
DOn’t continue cyclobenzaprine - can cause dependence
Cutaneous T cell lymphoma (indolent course)
erythematous eruption >90% body= ERYTHRODERMA
etio: drug eruptions, psoriasis, atopic dermatidis, cutaneous t-cell lymphoma
Patches, plaques, tumors, allopecia, nail dystrophy, thickening palms and soles
Bx skin
Drug hypersensitivity - usually acute in onset 3-6 weeks,
MCC allopurinol, anticonvulsants, dapsone, NSAIDs, sulfonamides, - also facial edema, LAD, HSM
Pustular psoriasis - h/o psoriasis tx’d with steroids - erythrodermic flarie days to weeks after d/cing steroids
SSSS - children or adults with immunosupp, AKI - have peiroral crusting, fissuring - confirm with isolation of staphy (dx clinical)
Serologic testing for lyme (borreilia burgdorferi)
vague constitutaional sx of several months duration - non-focal, nonsp - not suggestive of lyme
Initiate further eval for faigue and weakness
Lyme +IgM, neg IgG - clinical correlation
If findings <1 month after sx then delayed seroconversion - repeat testing in one month
Do not treat for lyme
OMT for severe HF
SHF 2/2 peripartum CM - during preg start BB, digoxin, diuretics
Start acei after delivery
Also with severe sx will also need spironolactone
If after OMT and is euvolemic still with symptoms - and LVEF < 35%, QRS>120 - Cardiac resyncronization tx
Can’t titrate BB up if HR low
Endomyocardial bx only if suspect infiltrative process (amyloid, hemochromatosis, sarcoid) - no LVH, no low voltage
New onset crohns dz
mod to severly active crohns (transmural)
weight loss and significant sx
Treat aggressively with Anti-TNF (infliximab) with or without immunomodulator (azathropine or 6MP)
Abx only if associated abscesses/wound infections
5ASA (mesalamine) more effective in UC (mucosal) than in crohsns (transmural) - used in mild dz for crohns
DOn’t just use corticosteroids - may improve some sx but most pts need maintenance
Surgical eval only if performation, abcess, obstruction or medically refractory dz
Cryptogenic ischemic stroke
when infarct appear embolic suspect pAF
will need prolonged cardiac monitoring
25% cryptogenic ischemic stroke have pAF
No reason to close PFO - no diff in stroke risk vs OMT (ASA)
Warfarin only if pt in pAF
Estimate GFR in low risk healthy person
Use chronic kidney disease epidemiology collaboration equation -
MDRD UNDERESTIMATES GFR at higher (normal) values
(especially with patients of normal or higher muscle mass)
Crockfeld gault ALSO UNDERESTIMATES GFR at normal values
Only need 24 hr Cr urine collection or radionuclide kidney clearance scanning when evaluating living kidney donor candidates
Hypoglycemic unawareness
Reduce insulin dosages
HgA1c below target
adrenergic response blunted after hypoglyemic episode for 2-3 days - inc’d likelihood of 2nd hypoglyemic episode
Don’t increase carbs - on healthy diet, wants toget pregnant and could cause weight gain
Alpha lipoic acid helps with painful Dm nephropathy no effect on hypoglycemic awareness
Pramlintide - analogy of amylyn decrases stomach emphyting speed - promotes satiety - inc’d r/o hypoglycemia
Treat dypnea at end of life
end of life dypnea common
cardiopulm pathology - ie pleural eff, HF, COPD, PE, PNA, lung mets
If underlying lung dz on broncodilator - c/w those and ADD MORPHINE
Abx and steroids won’t immediately help - not c/w comfort only measures
Benzos don’t always help
Diagnose Rheum Arthritis
Anti-CCP - dx 40-60% RA including pt with neg RF
95% specific for RA
Synovitis >1hr in AM
Anti mitox ab
autoimmune hepatitis - can have arthralgia but also with LFT abnormalities
ANCA+
granulomatosis with polyangiitis (wegers), microscopic polyangiitis, Churg strauss, drug induced vasculitis - woul dhave some other systemic involvement
ANA
suspicion for autoimmune dz ie SLE
women of child bearing age,
Respiratory muscle weakness
NM dz - reduced TLC - increased residual volume due to inability to fully exhale
Restrictive pattern, no obstruction
increased RESIDUAL VOLUME -
Dypnea as presenting sx for NM dz
COPD - would have increased residual volume but also inc’d TLC,
HF - no JVD, no edema, abn cardiac exam
ILD - reduction in both TLC and residual volume
Diagnose brain death
Apnea test only test required to dx brain death
Cerebral hemorrhage
coma, absense of motor response, pupillary resonse, corneal reflex, jaw jerk, gag reflex, rxn to pain, cough while suctioning trach, suckign or rooting reflex
Initiate apnea test when PCO2 40-60, pt normothermic and off sedation
Pt off vent to obtain baseline PCO2, O2 supp by other methods, serial blood gasses and observe spontaneous resp
POSITIVE APNEA TEST: if pCO2 inc’d by >20 without spontaneous respiration
No CT angio when brain death dx - even if find hematoma expansion no reason to tx with severe neuro damage
EEG/Transcranial doppler - not required unless apnea test tolerated
Manage asx ostium secondum ASD defect
ASD closure in asx pt (TTE 2/2 murmur) indicated with R side chamber enlargement, no evidence of pulm HTN
Also if sx attributable to ASD - afib, paradox embolism, cyanosis (L-> R shunt) - pt also has mild inc in RV pressure
Device vs surgical ussualy physician preference but if no associated CV dz device closure better tolerated, faster recovery
ASA can be used to prevent paradox embolism in pt with PFO or ASD (Small)
No warfarin unless pt has afib or has paradoxical embolism
Don’t just observe - needs closure - pt already has enlarged right sided chambers - inc’d risk of complications (arrhythmias)
Preop care of pt with COPD and intermedicate risk procedure
Incentive spirometry - reduces risk of peri op pulm complications (or deep breathing)
begin pre op
Risk factors chornic lung dz, older age, spinal or general anesthesia, surgery arond diaphragm
Positive airway pressure only for pts who can’t do incentive spirometry (MSK or NM limitations)
CXR pre or post op without any clinical suspsicon of lung issues does not help
PFTs only when cause of dypnea unknown (pt known to have COPD)
Manage newly dx HIV
combination HAART now (tenofovir, emtricitabine, efavirenz) since CD4< 500, HIV nephropathy, co-infct HBV, pregnancy, CV dz or Hep C
No Viral load indications (just CD4)
Hypercalcemia Tx
Severely sx hyperCa in setting of metastatic breast CA
polyuria, polydipsia, dry MM, low bp, tachy- dehydration -
START normal saline
High Ca impairs nephorons to concentrate urine - need to restore euvolemia with saline diuresis - aids in delivery of calcium to distal tubule which will excrete excess Ca with excess Na from NS
HyperCa of malignancy induces skeletal resorbtion - liver mets likely secreting PTHrP - need control of tumor with chemo
Bisphosphonate may be needed if hyperCa+ after normal saline - also IV lasix may also be needed after euvolemic
Glucocorticoid also can lower Ca if bisphosph don’t work.
Drug induced SLE
d/c offending agent (HCTZ) drug or light induced
HCTZ commonly implicated drug in SLE
anti histone Ab+
ANA titer +
Anti Ro/SSA, Anti La/SSB (photosensitive conditions)
onset of rash after drug starts
annnualar polycyclic erutyenatous scaling patches in sun exposed areas with sharp cutoff at clothes
No MTX as drug induced lupus usually not systemic - normal other labs
CK and aldolase not needed as pt does not have signs of polymyositis or dermatomyositis
(heliotrope rash - violacious dusky erythem rash periorobial with or without edema
, goutrrons papules - violacious scaley papules over bony prominances MCP, PIP, DIP
, prox muscle wk)
Topical terbinafine - KOH neg not fungal - only needed if tinea corporis
Laxative abuse
normal anion gap metabolic acidosis
kidney ability to exrete acid correlates with urine ammonium (hard to measure)
Urine anion gap estimates ammonium excretion
Urine amm=UAG/2
UOsm= 2x UNa + UK+ + Uurea/2.8+ Ugluc/18=176(no gluc)
UAG=176, UAmmonium = 88
UAm >80 = extrarenal losses of bicarb
UAm < 30 = primary kidney losses of bicarb (
Chronic diarrhea from laxative abuse dumps bicarb - causing systemic acidemia - kidneys try to dump extra acid by making ammonium so ammonium levels increase, increasing UAG
Diuretic abuse and surrepticious vomiting are metabolic alkaosis - Vomitting is cloride resopnsive - so UCl- < 10
Diuretic abuse is chloride unresponsive so UCl>20
Hypokalemic RTA (distal type I) - renal tubular acidosis - impairment of urine ammonium excretion (can’t acidfy urine) pH>6, urine ammonium levels >30
Long term f/u for Stage III colon CA
Physical exam, CEA monitoring q3-6 months
Annual CT for 3-5 years (dx relapse tha tis potentially curable)
Colonoscopy 1 year after resection and then q3-5 years
PET only if abn seen on CT
Inclusion body myositis
MC form of myositis >60yo
proximal AND distal muscle wk (can be assymetric)
quads, wrist, finger flexor muscles
incidious onset, modest CK elevation (<1000)
No autoAb (ANA neg)
Dermatomyositis - symmetric prox muscle wk, +autoab and rash (gottrons papules, heliotrope rash), shawl sign
Polymyositis - younger pts, MC women, + autoab/+ANA
symmetric prox muscle wk - extramusc manifestations (fever, pulm inovlvmenet)
Statin induced myalgia - asx CK elevation or myalgia, rhabdo -
ONset of muscle pain tenderness/cramping - withini 6 months of starting statin, resolve 2 months after stopping - dose related
Evaluate 2cm calcified lung nodule in smoker
Smooth bordered, centrally calcified - c/w granuloma
Benign : nodules with smooth borders, popcorn, lamellar, cetral and diffuse Ca
Malignant: spiculated borders - ecentric/off center CA - needs further w/u
Bronchial carcinoid tumor - low grade neuroendocrine neoplasm - pw hemoptysis - bronchial obstruction or asx
Central airway location
SMOOTH BORDER, not calcified
Lung mets - breat, head/neck, colon, thyroid, kidney
Usually multiple and smoothly bordered - NOT calificied
NSCLC - Calcium within nodule unusual - if there would be eccentric
Chronic tubulointerstitis nephritis 2/2 lithium use
Ideally change lithium to other agent
If not possible then add amiloride - decreaes lithium uptake in renal tubule cells decreasing damage
Lithium - decreased GFR - distal renal tubular acidosis - partial nephorgenic DI - high urine output inability to concentrate urine - lithium is uptaken in renal cells along with sodium so concentrates and causes damage
DO not fluid restrict - will make hypernatremia worse in lithium Nephorgenic DI
Prednisone only if tubulointersitial nephritis not improved by dc ing offending agent or adding amiloride
Tolvaptan - hypervol or euvolemic HYPOnatremia -in chronic HF, cirrhosis, SIADH - blocks effect of ADH and causes free water diuresis
Basal cell CA
MC type cutaneous malignancy
Head and neck of older ppl
Sun exposed areas
Smooth, pearly, asx telecangiectatic papules - grow slowly but cause siginficant tissue destruction if not removed - rarely metastasize - bleed when traumatized
Actinic keratosis - PRECANCEROUS sun damdaged skin - large numbers -> SCC flat with prominent scale easier to plpate than see
Epidermal inclusion cyst
firm SQ nodules with prominent central punctum
copious amount of keratinaceous material - malodoorous when extruded
Melanoma - malignancy of pigment producing cells of epidermis - darkly pigmented - ABCDE (assymetric, irreg border, color variation, diameter >6mm, evolution/enlargment)
SCC - scalier, grow radipidly, tender lack pearliness/teleangietatic features areas of sun damage but cna co=exist with BCC lots in immunosuppressed Higher tendency to metastasize
Manage impending respiratory failure in patient with asthma with intubation
Life threatening asthma exacerbation despite aggressive B2 agonist (16 puffs) - pulse 132, RR 32, accessory muscle use - only speak 1 word at a time, reduced breath sounds
Intubate to avoid respiratory arrest
Continuous nebs only with MODERATE broncospam
Not just IV steroids - will take 4-6 hours to fully work- still need intubation
Don’t use lorezepam - will likely exacerbate respiratory acidosis
Treat PFO
Platypnea-orthodeoxia - positional sx cyanosis/dypnea when patient sitting up - resolve when sitting down Sitting up changes shunt to R->L when sitting up 2/2 deformation of atrial septum and redirection of shunt - all 2/2 pneumonectomy CLOSE PFO (is an indication)
Ambulatory O2 may relieve sx but won’t fix problem
Warfarin not indicated as pt has not has paradox embolism (even if he did -> ASA then PFO closure if recurs)
No diuresis as no signs of volume overload
Capgrass syndrome - delusional thinking as primary sx of dementia
Capgrass syndrome - bleieves daughter is imposter replaced by imposter, delusions fixed, false ideas, paranoid aspect, delusional misidentifiaction, believe home is not really his house
Right hemisphere lesion = role in recognition and emotioinal familiarity
Can also occur in alzhimers with diffuse neurogeneration
Tx: antipsychotics (reassuance wont work)
Anosognosia - hemiplegia or vision
Confabulation - disortorded or invented statements WITHOUT intent to deceive (brain fills in detials at random) - retrograde amnesia
Etio - etoh induced korsakoff
Reproductive paramnesia - opposite of capgrass - delusion of familiarity in which pt in hospital bed insists they are at home
Evaluate patient with osteomyeltis and contraindication to MRI
USE CT SCAN if +ICD (MRI would be ideal) when xray normal but still suspicious of OM
local pain/fever, h/o trauma
If xray neg and still suspicious -> MRI or CT
Nuclear imaging ok but can have false + from bone healing, inflammation from non-infx cuases ie trauma, neoplasm, deg bone dz,
Gallium scans stick to neurtrophils and goto site of inflammation or infection
Three phase bone scan not as good as MRI or CT
Primary ovarian insufficiency
Must exclude turner syndrome - pt has elevated FSH and no period
Check karyotype
if + r/o AV dz, aoritic dilation, coarct, renal malformation(horseshoe kidney), autoimmune d/o, thyroid dz,
Short stature, stocky build, square chest, webbed neck
Pelvic US not needed yet - elevated FSH indicates low estradiol prodxn from ovaries
No progesterone challenge - only when ammenorrhea in normal estrogen state (pt is low estrogen)
Don’t need to measure estadiol as elevated FSH already shows that pt is low estrogen state
Avoid NSAIDS with CV toxicity in pt with OA
1st line is tylenol
2nd line tramadol - low addictive poteintial opiate and does not cuase constipation
don’t use COX-2 - inc’d CV risk (pt already has PAD)
Don’t use indomethacin - HTN/kidney dz induction - r/o CVD
Don’t use oral prendisone (inejctions ok for temporary releif)
No colchisine (potent anti inflamm for gout or fam med fever)
Decompensated cirrhosis
Refer for liver tx if: acute liver failure hepatic decompensation due to chronic liver dz primary liver cA inborn errors of metabolism HCV, cirrhosis from NASH, etoh liver dz
If patient has manifestation of etoh liver cirrohosi (ascietes, encephaloptahy, gastroesophagela variceal hemorrhage )-> refer for liver tx - 50% 2 year mortality
abstain from etoh x 2 years
Nonselective BB (propranol, nadolol) for medium or large varicies - DO NOT NEED IF NO VARICES
Protein restriction only if encephalopathy not managed with lactulose alone
Older patient with cobalamin (vit B12) def
Vit B12/cobalamin def = elevated homocystine AND MMA
oval macrocytes, basophilic stippling, hypersegmented neutrophils (>5 lobes), elev LDH, bili, megaloblastic anemia, loss of vibratory sense, parastheisia, loss of position sense, wk spasiticity, paraplegia, bladder incontinence,
MCC - malabsorbtpion
Best way to supplement = oral (less expensive and easier that shots)
Folate def = elevated HOMOcystine ONLY
same peripheral smear as B12 def
No neurologic findings
If deficient replace ORALLY
Hypopituitarism aw Sheehan syndrome
Adrenal insufficiency
Immediate hydrocortisone replacement
low morning cortisol
Sheehan syndrome - pitutary infarct/hemorrhage in setting of complicated delivery with significant blood loss and hypotension
Will need brain imaging to r/o sellar mass (though no prior sx suggestive of pre-exisiting pitutiary lesion)
Subacute progressive hypopituitarism - inability to lactate 2/2 prolactin def, ammenorrhea
DI rare in sheehan syndrome so argine vasopressin (ADH) replacement not needed
Hyponatremia should correct with replacement of pituitary hormones - don’t neeed hypertonic saline
No need for synthroid unless free thyroxine low (not urgent as no signs of hypothyroid
Reduce risk of lung cancer with smoking cessation
risk down by 1/2 with quitting smoking compleletly
No mortality benefit in CXR surveillence
No decrease in mortality with B carotein suppleemtation
Isotreetioin supp does not decrease mortality in smokers
Treat erythema nodosum aw UC
Intensify therapy for UC to treat erythema nodosum
follicular non-infectious panniculitis of SQ tissue
one or more tender, erythematous nodules on anterior shin easily palpated and visualized
Prodrome of fever, malaise, arthralgia
Lot of cases are idiopathic
others: infectious, drugs, systemic dz (inflamm d/o UC, sarcoid)
Self limited with tx of underlying d/o
Recurrent may require corticosteroids or immunosupp’s
Don’t tx EN with abx unless underlying cuase is infectious
NSAIDs only if idiopathic - don’t use NSAIDS with inflamm bowel dz - can exacerbate and cause flare
No role for TOPICAL steroids - doens’t treat underlying cause
Manage tick borne ricksettial infxn
Start empiric doxycycline now
serologic testing for any tick borne ricksettial infxn often neg in acute phase - high suspeicion with multiple tick bites requires tx - inc’d morbiidity if wait
Human granulocytic Analplasmosis - few get rash
Human monocytic erylichosis - few get rash
Rocky Mtn spotted fever - has rash (blanching erythematous macules start at wrist and ankles, spread centripetally and becaome petechial)
Initiate tx empirically as 2/3 won’t get rash (HME, HGA)
All non-focal febrile illenss with cytopneia and elev LFTs
Tick vector for HGA is same as one for lyme dz - in NE US/great lakes , tick vector for HME in south central US, RMSF througout US (continental)
Amoxicillin doesn’t treat these tick dz’s
Diagnose resistant HTN
blood pressure above goal with 3 classes of anti HTN meds including diuretic
Need to document real resistent HTN with ambulatory BP monitoring
(older age, high BMI, high baseline BP, DM, blacks)
If still high then search for secondary cuases, - salt intake,, use o fNSAIDs, OSA
No TTE needed for HTN w/u
Onlly add another med if resistant HTN confirmed with montioring
Only look for secondary caues (r/o pheo) if resistent HTN confirmed
Chronic paroxysmal hemicrania
trigeminal nerve related pain - ipsilateral automonic features, lacrimation, ptosis, injection, nasla congestion, rhinorrhea
Cluster h/a last 15-80 min, 1-8x/day
Chronic paroxymal hemicrania - 15 min 8-40x/day
tx: INDOMETHACIN
Carbamazepine - Trigeminal neuralgia - severe pain along distribution of Trigeminal nerve
Pain paroxymal, lasting seconds, volley/jabs of sharp pain
trigger zones around mouth/nostrills
2nd and 3rd branches of CN V no autonomic fts
Not prednisone - not giant cell arteritis given pattern and timing of pain and normal ESR
Topiramte for migrain ppx - no use in cluster/Chro Parox Hemicrainia
Verapamil - for cluster h/a not chronic paroxymal hemicrania
Eisenmenger’s syndrome in adult
Eisengener’s - aw Down syndrome
EKG RAD with RAE
RVH with strain
CXR central pulm artery enlargement, reduced pulm vasc
Longstanding cardiac shunt with eventual reversal of shunt - Eisenmenger’s physiology - digital clubbing, cyanosis, RV hypertrophy, dec’d pulm vascularity
Downs - half have congential HDz - AV septal defect - develop pulm HTN, reversal of shunt -> eisenmengers
Aortic Coarctation
HTN in upper extrem, systolic murmur or continuous murmur in left infraclavicular area, LE pulses reduced, radiofemoral pulse delay, LVH on EKG, CXR 3 sign - aortic narrowing with rib notching
Ebstein anomaly
RV enlargement, Tricusupid regurg ASD or PFO - cyanosis Tall peaked p waves (himalyan waves) QRS prolonged, RBBB, pre-excitation CXR - RH enlargement, clear lungs
Tetralogy of Fallot
cyanosis/clubbing
loud systolic murmur - severe RVOT obstruction
Association of Herpses Simplex virus with erythema Multiforme
recurrent mucocutaneous eruption that follows acute infection
HSV infection
erythematous plaques with concentric rings of color - dusky center might become necrotic and can blister or eschar
Few to hundreds of lesions - extensor surfaces of extremiteis (hands/feet) -
Mucosal lesions - lips, gingival sulcus, sides of tongue
painful erosions or bullae
1-2 weeks - can have residual hyperpigmentation
Recurrences common
systemic corticosteroids can provide relief but
Abx only if identified bacterial cuase
If 2/2 new drug - d/c drug
EM not caused by staph but abx used to treat can cuase it
EM not caused by Parvo B19 ,or varicella zoster
Prevent medication errors from occuring
Pt need specific instructions on increase in pre-hospital meds
Need to communicate with PCPs on changes
Need list of medication at d/c with med changes, discontinuation and addition
Diuretic resistance uncommon, highly unlikely as pt inc’d pre admission lasix and added spironolactone
Hosptial f/u for CHF exacerbation - 1 week
Spironolactone won’t cause CHF exacerbation (decreases mortality in patients with Systolic HF)
Warm autoimmune hemolytic anemia
incidious sx of anemia, jaundice, splenomegaly, peripheral blood smear with spherocytes
(erythrocytes losing central pallor)
Strong + coombs for IgG, weak for C3
COLD agglutin dz
Coombs test
IgG neg
+ complement - pathogenic IgM ab
G6PD def
peripheral smear shows BITE CELLS
eccentrically located hemoglobin NO SPHEROCYTES
No + direct coombs
Hereditary spherocytosis
fhx anemia, jaundice, splenomegaly, gallstones
Spherocytes on smear
NEGATIVE direct coombs
would always have abnormal CBC (spherocytes)
TTP
microangiopathic hemolytic anemia
schistocytes on smear
inc’d LDH
thrombocytopenia
