Deck 3 Flashcards
Hungry bone syndrome
unmineralized bone matrix formed during hyperparathyroid period mineralizes after parathyroidectomy - severe hypoCa+
Peri oral numbness, cramps in hands/feet, +Chvostek/Trosseau signs
Secondary hyperPTH
In CKD
Hyper Phos, HypoCa+, 1,25 OHD3 def all stimulate PTH secretion -> causes mobilization of Ca+ from bone and less Ca+ excretion in urine
Dilutional hypoCa+ from fluids (massive)
Alkaosis - hyperventillation - does not affect total Ca+
Acne tx during pregnancy
DO NOT USE topical Tazarotene (preg X)
Treitonin toical - Preg C -
Do not use oral Treitionin
Topical clinda and azelaic acid Preg B (ok)
Trochanteric bursitis
inflammation of bursa Pain with palpation right over bursa active hip abduction increases pain Pain while lying on affected side Tx: lidocaine inj into bursa Rest NSAIDs, ICE/heat Injection with corticosteroid
Iliotibial Band syndrome
Young athletes - runners/cyclists
lateral hip pain - radiates down outside of leg
Paini along palpation of band down to knee
Adducting knee elicits pain
Lumbar radiculopathy
Pain to lateral hip
Straight leg positive
parasthesia and wk of leg
pain while sitting not while walking
Osteoarthritsi/synovitis of Hip
groin/gluteal pain, pain wiht passive motion
Evaluate for TB in pt with Pulm Silicosis
INhalation of crytalline silicone oxide
Inc’d r/o TB -> PPD
Multiple small nodules upper lobe predominant
Don’t give steroids until TB excluded
Plan do study act
Plan is made - implemented in limited manner, results observed and a refined action taken based on results
Plan-do-study-act
Greater involvement of patient in communication not reliable
SAAG Gradient
SAAG gradient = Serum alb-ascites albumin
>1.1 = portal HTN as cause of ascites
with Ascites protein >2.5 - Check TTE for RV Failure or constrictive pericarditis or Bud Chiari
with Ascites protein < 2.5 - cirrhosis of liver
<1.1
Evaluate for ishemia in pt with new onset HF with high pretest probabily for CAD with CATH
Pt with DM - likely silent ischemia
Q waves in inferior leads
Indication for cath - new onset LV dysfxn in setting of condition predisposing to silent ischemia (ie DM)
or angina
No reason to stress as pt already high pretest probability
CMR for infiltrative CM or inflammatory CM -
No role for cardiopulm exc testing in this case
Guillan Barre
Occurs in setting of recent infection (or surgery, trauma)
Lower back pain from inflammatory demyelination at spinal nerve root level - weakness worst in distal extrem - asciending paralysis
CSF elevated protein but NO CELLS or organisms
(absense of CSF pleocytosis)
Acute transverse myelitis
Follows viral infection - subacute weakness involving bladder - aw SLE
unlikely if low ANA, normal CBC, low ESR, normal U/A
Leptomeningeal sarcoidosis
less likely in pt with no chest xray findings or PE findings c/w sarcoid
Polyarteritis nodosa
fever, abd pain wt loss over months
mononeuritis multiplex
elevated ESR, anemia, leukocytosis
Progressive lupus nephritis
New onset HTN High titers anti DSDNA hypocomplement proteinuria hematuria erythrocyte and granular casts Small joint polyarthritis, oral ulcers, cytopenia, kidney dz
Focal segmental Glomerulosclerosis
Blacks primary nephrosis syndrome microscopic hematuira HTN, kidney insuff No RBC casts
IgA nephropathy
NOT AW SLE (is aw HIV, chronic liver dz, celiac dz, inflamm bowel dz)
Postinfectous Glomerulonephritis
triggered by infection
hypocomplement - complement depostiied in glomeruli
activating cytokine pathways
No polyarthritsi, oral ulcers or cytopenias
Alpha thalasemia trait
Inefficive hematopoesis -/alpha, -/alpha or --, alpha/alpha microcytosis, target cells, hypochromia, mild anemia NORMAL Hg Electrophoresis NO TX NEEDED
B thalesemia minor
Inefficive hematopoesis
Hg Electrophoresis - increase HgA2 (alpha 2, delta 2)
IDA
microcytic, hypochromic, anisopoikilocytosis, iron low, TIBC high, TF sat high, ferritin low
Sickle cell/B+ thal -
sx of sickle cell dz - abn HgElect - Hb S, HbA, HgA2
Spinal cord compression
Corticosteroids-> radiation therapy
medical emergency!
MRI confirmed spinal cord compression with LE hyperreflexia/weakness
Abn BM bx, hyperCA, anemia, (plasma cell myeloma)
Do not delay tx to bx mass
Plasma cell myeloma - suppression of hematopoesis, anemia, thormbocytopenia - tx wit immunomodulary chemo agent - lenalidomide -
NOT JUST RAD TX
Prerenal azotemia
History of decreased fluid intake or insensible losses, inc’d sun - exam findings c/w volume depletion
Pt taking NSAIDs vulnurable
FENA can be >1% slightly if takes diuretic
FE urea < 35% = pre-renal (less affected by diuretics)
Urinalysis concentrated, high specific gravity
Acute interstitial nephritis
hypersensitivity rxn to med
leukocyte casts, EOS in U/A
recent med new
ATN
physiolgic insult to kidney - hypoxia, toxin, prolongued kidney hypoperfusion -
Rapid kidney failure
Muddy brown casts
Lupus nephritis
no dysmorphic RBC or erythrocyte casts
Dx HCC
Pt with Hep B/cirrhosis
HCC screening with US q6-12m
Nodule in liver found on US (Screening)
Contrast CT/ Gad MRI next - no need for bx - characteristic blood supply from hepatic artery (neovascularization)
Don’t just repeat in 6 months
Anemia in pt with systemic sclerosis
diffuse cutaneous systemic sclerosis
aw gastric antral venous ectasia (GAVE) - causes GIB - pt p/w fatigue, dypnea, IDA
Tx: EGD - photo/laser coag
No Epo unless causes of IDA excluded
No need for BM bx
Colonoscopy only if altered BM, or if EGD neg
No hydrogen breath test - no sx of bacterial overgrowth (bloating, steatorhea, abd pain
Neuropathic ulcer
develop in skin with decreased or absent sensation
areas of trauma/friction (metatarsal heads)
painless
thick macerated rim hyperkeratosis
Debridement - off loading of pressure, watch for OM
Arterial ulcer
setting of severe PAD
Painful, well demarkated ulcers
any part of limb but usually over bony prominance
Absent periph pulses, cool skin, pallor
Palpable purpura/Vasculitic ulcer
small vessel vasculitis
painful, irregular shaped, punched out
erythema, purpura
Venous stasis ulcers
varicose veins, medical legs around medial maleous, hyperpig and sclerotic (lipodermatosclerosis)
Evaluate lung CA in pt with abnormal PET
Pt has +PET shows likely areas of LN spread of CA but not confirmed - need mediastinal LN bx
EBUS or medistinoscopy FOR STAGING
CT guided bx of primary lesion not needed first - need Medistinal LN for staging
Need to stage before surgery or chemo decided
Hemorrhagic colitis
Shiga toxin prodcuing E. Coli E O157:H7 produces shiga toxin - not preformed - gross blood in stool contaminated food - undercooked burger abd tenderness, leukocytosis
Bacillius Cereus/Staphylococcus
foodborn GI illness - PREFORMED TOXIN - sx < 24 hrs
n/v not gross blood/diarrhea
Campylobacter jejuni/Yersenia histolytica
foodborne Gastroenteritis - no gross blood
Manage ED in pt with CAD
PDE inhibitor (not a nitrate drug) if fewer than 3 CV risk factors CV risk factors: Age, HTN, DM, Smoking, HLD, sedentary lifestyle, fhx premature CAD
Testosterone replacement only if low
Don’t stop metoprolol in pt with metoprolol
Localize PAD
Buttock and hip caludication, diminsihed femoral pulses and erectile dysfxn (Lerich syndrome) -> aortoilliac dz
Common femoral - thigh pain with effort, NO ED
Tx: surgery or POBA NOT stent
Popliteal artery - pain in lower calf - tx with excercise program and med tx - if no benefit then bypass
SFA - pain in upper calf - tx with med therapy first then angioplasty
Pt with HLAB 1502 allele
elevated r/o SJS from carbamazine, phenytoin, oxacarbazzpine, lamotrigine
but NOT levetiracem (keppra)
findings of Todd paralysis
Partial focal lesion-> generalized
Asian patient
need genetic testing
Acute CVA tx with tPA
tPA guidelines
w/in 3-4.5 hrs
<220/120
Hypertropic CM
Dynamic LVOT obstruction Systolic murmur inc'd with dec'd preload (valsava) Dec'd by increasing afterload (handgrip) Asymmetric septal hypertropy \+- mid cavitary obstruction Small LV cavity, LAE, diastolic dysfxn Sx: Asx, dizziness, CP, dyspnea
Concentric LV hypertrophy (athletes heart)
Weight lifter
LV cavity ENLARGED
no LAE
NO diastolic dysfxn
LVH
impaired diastolic filling (HTN CM)
Restrictive CM
accentuated early diastolic filling
Subacute thyroiditis
dx: Radioactive Iodide uptake test destructive thyroiditis h/o viral infection fever, elev ESR High T3, T4, low TSH RAIU t work in destructive thyroitis Tx: BB tx
Serum thyroglobulin - differentiate between destructive thyroitidits vs exogenous levothryoxine use
Subungal melanoma
acral lentigous melanoma
originates under nail
pigment extends to adjacent skin (hutchinson’s sign)
wider area of pigemnted area on prox end - indicates expanding of lesion
Longitudinal melanochya
pigment lines lighter and constant diameter - multiple nails
Subungal hematoma
2/2 trauma
Dark brown or black
violet/red hue
Onychomycosis
nail fungus - variety of colors - multiple nails - dx with nail clipping KOH
Testicular tortion
testicle twists on spermatic cord men < 30 severe sudden pain high riding testicle abscent cremater reflex (99% sensitive) Rapid surgical decompression
Epididymitis
subacute onset scrotal pain, dyuria, freq/fever
Posterior adn superior testicle
Scrotom edematous/erythematous
- not from malpositioned testicle
Inguinal hernia
asx bulge, feeling groin/abd presure - painful mass in scrotum with signs of bowel obstruction
Orchtis
inflammation of testicle viral (mumps) ext of bacterial infxn from epididymitis or UTI Mump - parotidits 5 days prior Testicle DIFFUSELY tender/swollen postion testicle normal \+cremaster reflex
Metabolic acidosis in CKD
Progressive CKD with metabolic acidosis
bicarb < blank - > add oral sodium bicarb - slows CKD progression
causes chronic bone dz - as bone buffers pH in met acidosis
affects, Thyr, CAD, GH, muscle strength
No need for allopurinol unless gout/gallstones
No phophate binder if Phos norma
No kayexalate if K normal
IPF
Best test is HRCT
restrictive PFT, dec DLCO
DDX: IPF, nonsp interstitial PNA, cryptogneic organizing PNA, hypersensitivity pneumonitis
CT x 1 = solar radiation x 1 year
MRI not preferred for lung
PET not good enough
VQ not correct test
Asx bactiuria
except in pregnancy and prior to invasive uro procedure
DO NOT TX asymptomatic bactiuria
(do not tx non-preg F, ppl with chornic foley)
Cipro and bactrim ok for UTI
No US needed, no repeat u/a uctx
Dx Testicular CA
Non-seminoma - elevated AFP (always AFP with non-seminotoma - embryonic or yolk sac tumor)
Seminoma - NO AFP - could have elev BHCG
Epidiyditmis - tender testicular mass - fever, abn u/a, WBC
Hematoma - testicular trauma - not with elev AFP/BHCG
Testicular torsion - severe pain - n/v - ABSENCE of cremasteric reflex - high riding testicle
no tender nodule, no high AFP
Polyarteritis nodosa with active hep B
small/med artery vasculitis
myalgia, abd pain, wt loss
h/o IVDA
active hep B - HB Sag, Hep B e Ag
Elev ESR
aneurysm of mesenteric and renal arteries
Prednisone for polyarteritis nodosa
TREAT HEP B - entecavir
Polyarteritis nodosa - painful cut nodules, skin ulcers, palp purpura, livido retuclaris,
More severe dz - steroids with cyclophosphamide
Rituximab or TNF alpha - contraindicated with active hep B (exacerbates viral replication)
Mycophenilate Mofetil - steroid sparing tx - prevent relapse in other forms of systemic vasculitides - after initial response to cyclophophamide - no role in primary/initial tx of Polyarteritis nodosa
Reduce duration of mech ventillation
Pt with weight gain, pleural effsuions, peripheral edema, relaively elevatd CVP -> should diuresis patient
Early use of paralytics has been shown to improve moratlity and decrease duration of mecahnical ventillation - not widely adopted
Prone positioning only in severe ARDS patients
inhaled NO on ards patients improved oxygenation but not mortaily
Evaluate hyperprolactinemia
Pt with modestly elevated prolactin
FIRST - pregnancy test even if h/o prolactinoma
Acromegaly - prognathism, enlargement nose, lips, tongue, frontal bossing, dental malocclusion, increased space between teeth, sleep apnea, enlargement hands/teeth, arthritsi, carpel tunnel, skin tags, oily skin, Prolactin co-produced 40% time - amenorrhea, galactorrhea
Measure IGF-1 not GH
No evidence of cushings - don’t measure serum cortisol
(muscle wk, echymosses, hypokalemia, osteoporosis, new onset HTN, DM, amenrrhea
Vision test if temporal field vision loss
Lactose malabsorbtion after Gi illness
Stool osm gap =290-2(stool K + Stool Na+)
If = >100 then osmotic diarrhea ie lactose malabsorbtion
reduce lactose intake
Stool gap < 100=secretory diarrhea (
Cholecytecomtom would not expalin stool osmol gap so not bile salt diarrhea
Microscopic colits - secretory diarrhea
eosinsophilic gastroenertis - either secortory or osmotic diarrhea very uncommon
Osmotic gap not with irritable bowel syndorme
Manage early rheumatoid arthritis
Methotrexate within 3 months of onset of any duration or degree
+RF, +Anti CCP, elev ESR
Distal PIP
morning stiffness >1 hr
Etanercept if high dz activity with poor prognostic factors
Hydorxychloroquin with MILD cases only wihtout poor prognostic factors
Do not wait and reeval unless +Parvo B19 or hep B (mimik early arthrtis)
Atrial septal defect
Ostium secundum defect RV parasternal impulse/heave fixed split S2 RVH, RAH RAD inc RBBB systolic murmur inc'd flow thru pulm artery Diastolic murmur - inc'd flow thru tricuspid 2/2 L-> R shunt
Eisenemnger syndrome
severe pulm HTN 2/2 congential cardiac dz
Cyanosis/clubbing
Pulm HTN -> pressure RVH
P2 inc’d - no fixed split S2
enlargement central pulm arteries - reduced peripheral pulm vasculature
RAD, RVH with strain
Idiopathic pulm HTN
Young men
parasternal lift, inc’d pulm component S2
RAD, RVH with strain
Rheum mitral stenosis
prominent apical impulse loud S2 S2 inc'd with pulm HTN opening snap diastolic murmur LA enlargment post displacement heart
Stage II small cell lung CA
Surgical resection followed by chemo (stage II (I))
NSCLC - no nodes +
No radiation
Rad/chemo if non-resectable (Stage III)
Chemo only (Stage IV metatastic) + selective rad (bronch compression, SVC syndrome, bony mets)
Pes Anserine bursitis
anteromedial aspect of proximal tibia distal to joint line of knee
worsens with step climbing UP and at night
Overuse (runners)
Iliotibial band syndrome
knife like LATERAL knee pain
flex/ext activities of knee ie running
consevative tx with rest/streching
worse walking UP and DOWN steps
Patellofemoral sydrome
men
peripatellar
from running, descending stairs, prolonged sitting
pain on compression of patella (+aprehensiveness)
Prepatellar bursitis
Pain anterior knee
swelling/tenderness to palpation lower pole patella
Typhoid fever
salmonella enterica - typhi - ingestion in endemic area
1-4 week incubation
Escalating fever 104deg
bradycardia, sig abd pain, constipation/diarrhea
salmon colored maculopapules on trunk
distended tender abd with splenomegaly
anemia, leukopenia, thrombocytopenia
elevated bili and aminotransferases
HYPONATREMIA
isolation of salmonella typhi blood, stool, BM or skin
Vaccines not ENTIRELY effective
Brucellosis
Zoonotic infxn
chronic fever, bone/joint sx, neuro/neuropsych sx
weakness/malaise
No rash
Leismaniasis
protozoal dz sandfly wt loss, fever, HSM pancytopenia, hypergammaglobinemia incubation - several months after exposure in endemic area
Malaria
cyclic pattern of fever, no GI sx, NO RASH
Asx extracranial carotid stenosis
Start Statin (pravastatin) - not zocor as had statin myopathy previously with zocor - check CK prior to starting (r/o progression to rhabdo, AKI, myoglobinuria)
Low risk of ischemic stroke but high risk of operative procedure
No carotid revasc for asx 80%, rapidly progressive stenosis, asx infarcts on imaging,
Tx with OMT for PAD - has CV equivalent - LDL goal 80) and comorbidies bad candidate for revascularization
Over the counter meds as cause of elevated BP
OTC decongestants contain pseduoephedrine or phenylephrine or NSAID - all raise BP in prev well controlled BP
combination ACEi/ARB not good - decreases proteinuria BUT significant side effects and no clear benefit for CKD
May increase ACEi or ARB but first need to make sure extra meds not increasing BP given BP was previously ok
Dx ARDS
Septic shock -> triggers ARDS (one reason)\ Acute hypoxemic respiratory failure Onset 48-72hrs after risk factor don't have to r/o CHF b/l alveolar opacities Chest CT Mild, mod or severe
Ecoli pneumonia not common
Not CHF - normal CVP, no cardiomegaly
Idiopathic acute eosinophilic PNA
infiltration of lung parenchyma by eos
fever, cough, dyspnea, b/l infiltrates
EOS in bronch lavage
unlikely with G neg sepsis
Post excercise hyperglycemia
During excercise - hypoinsulemia state (no insulni before excercise) stiulated hepatic glucose release
(If pt had DKA means completetly insulin deficient)
without insulin - muscles can’t uptake glucose - and further demand by excercise inc’d more hepatic gluconeogenesis
Need adequate insulin BEFORE run
Excess carbs would inc glucose but not specifically after excercise
gastroparesis does not explain hypergylemia after run 12hrs after last eaten
Treat with life threatening bleeding in pt taking coumadin
IV Vit K and prothrombin complex concentrate (PCC)
PCC can be reconstictuted in minutes (lyophilized)
FFP would take several hours to prepare - too slow
Oral vit K too slow
Intracranial atherosclerosis
Need to keep BP t reduce CVA/CAD HLD associated risks
Intracranial stenting not proven yet
Warfarin only superior in pt with afib
Reduce risk of contrast induced nephropathy
Pt with CKD particulary vulnurable
Avoidance of contrast best
if needed - low osmolar contrast agents and hydration promotes urine and avoid volume contraction decrease risk
Isotonic saline IV best (with bicarb no better)
diuresis with mannitol or loop diuretic doesn’t help
Oral hydration not as effective
PPX HD - NO BENFIT (even harm)
Eosinophilic fasciitis
woody induration of extremities sparing hands and face in ABSENCE of raynauds
Scleroderma spectrum d/o
Bx: lymphocytes, plasma cells and EOS infiltration
+- peripheral EOS
Diabetic Scleroderma
skin of upper torso and girdle - long standing IDDM
Diffuse cutaneous systemic sclerosis
skin invovlement prox to distal forearms and knees
subcut calcinosis
Raynauds in 95%
Nephrogenic systemic fibrosis
Only in pt with MRI with Gad and ESRD on HD
Unlikely with no GAD and no ESRD
Acute myopericarditis
Inflammatory condition of pericardium and myocardium
Etio - can be viral
Pleuritic CP, regional/diffuse concave down ST elev, regional or global WMA with +CE -> NON OBSTRUCTIVE CORONARIES ON CATH
Aortic Dissection
CP “Ripping” in quality
Discrepancy in BP of arm,
diastolic murmur of AI
can occulde coronary with retrograde dissection of LCC or RCC
Acute MI
coronary vasosapm can also cause MI - however no vasosapsm on cath makes less likely
Absense of coronary throbus/occlusion makes AMI unlikely
Acute pleuritis
not aw EKG or WMA
Not eccentuated by recumbanet positon (lying on back) better leaning forward
PE won’t cause WMA, or +CE
Microscopic colitis
Women >40
Collagenous colitis - bx - subepithelial collagen band in lamina propria
Lymphocytic colitis - bx - inc’d intraepithelial lymphocytes
Colonscopy bowel looks normal in both
chronic relapsing rmiting watery diarrhea aw wt loss, abd pain, fatigue, nausea
comorbid dz - celiac, DM, thyroid dz, RA
Etio - abn mucosal response to luminal exposures (infxn/drugs - lansaprozole, NSAIDS, sertraline, ranitidiine, ticlodipine, acarbose)
Supportive Tx: loperamide
2nd line mesalamine, budesonide
Refractory - prednisone
If do not respond test for co-existing celiac dz - gluten free diet (check TTG)
Temporomandibular joint d/o
Initial Tx: Jaw heat, relaxation, therapeutic excercise
Clikcing on jaw movement - unilateral jaw discomfort esp on chewing
Cog beh or biofeedback tx - reduce pain, depression, jaw applicance (no proof this works)
Fluoxetine/NSAIDs no good evidence
Only if jaw locking or structural jaw issue get jaw MRI
Dx of TMJ clinical - radiography only good if suspect co exiting dental dz
Epidural abscess with neuro deficits
Likely epidural abscess with acute presentation, mild fever, signs of OSTEOMYELITIS on MRI, DISKITIS, h/o IVDA
EMERGENY SURGICAL DECOMPRESSION within 24-36hrs
Afther ctx - empiric abx can be started
Med tx only if localized pain/radicular sx
Radiation Tx (emergent) not for epidural abcess - only if was malignancy
Manage etoh withdrawal
Delirium tremons
fluctuating conciousness
reduced attention, global amnesia, impaired cognition and speech, hallucinations/delusions
48-96 hrs after last drink - seizures can occur
tx: benzodiazpines (lorazepam)
CT of head if any neuro dificits
Do not use HALDOL - lowers seizure threshold, masks sx of withdrawal
Lactulose enema for hepatic encephalopathy - but doesn not cause agitiation, hallucinations, diaphoresis, tremulousness
Secondary stroke prevention in pt with prior ischemic stroke
If was on ASA - substitute plavix
Don’t use both unless CAD with PCI - risk of hemorrhage
Dont use ticlodipine - s/e agranulocytosis and TTP
Only use warfarin or NOAC if evidence of afib or LV thrombi
Venous stasis dermatitis
venous HTN, chronic inflamm, microangiopathy etio
Location - medial maleous
Skin is red, warm, eczematous, hyperpig, hemosiderin deposition, visible varicose veins, skin/SQ tissue thicken with stasis dermatitis -> lipoderatosclerosis
Asteatoic eczema - winter itch, anterior shins of old people with dry skin - red dry cracked, small fissues more common in winter and dry conditions
Cellulitis - usually UNILATERAL, +fever/WBC, pain, acute course
DVT - pain/swelling in calf -
Asx adult with repaired aortic coarctation
MRI/CT to assess recurrent coarct or aneursym - late complications after repair
Bicuspid aortic valve common aw aortic coarct
also have HTN
Do not replace valve if asx - wait for higher gradient or symptoms or high risk features
(will likely be required in future)
No need for invasive cath (MRI/CT and Echo sufficient for anatomy and hemodynamics)
No aortic stent if no signs of recurrence of coarct
Manage plt tx in pt with intracranial hemorrhage
NeuroSx proc/ issues, IC hemorrhorage - keep plt >100K (first few days)
Nonneurosx proc, non-central nervous system bleeding - keep plts>50K
Acute mesenteric ischemia
CT showing small bowel wall thickening with pneumatosis
Metabolic acidosis
elevated lactate
Pain out of proprotion to exam
Etio - likely ischemic embolus -> SMA (from LV/Atrial thrombus) or cardiogenic shock
Dx: CT angio
Crohns could cause small bowel thickening but not acute presenataion, shock, met acidosis
INtesuccuptio - bowel obstruction
Acute pancreatitsi - unlikley to lead to quick shock - CT woul have pancreatic edema
Pneumococcal vaccine in pt prev vaccinated
Protects against Strep Pneumococcus 23 antigens 60%
Adults age 65 and older need one shot of pneumococcus
Special populations: alaskan natives, American indians, long term care residents, radiation tx, immunsuppresives, smokers, chornic pulm d/o (including asthma), CVD, DM, CKD, cocklear implants, asplenia, immune d/o, malignancies
High level ab x 5 years
If vaccine 65 or older no booster
immunocompetants vaccinated b4 65 get one AT 65 or 5 years after vaccine if vaccinated between 60 and 64
Immunocompromised or aplenia get booster 5 years after initial vaccine
Never give MORE THAN 1 booster
All pts with vaccine before 65 need booster after (5 years after or 65 whichever later (unless original vaccine 65 or older)
Contraception for woman with SLE, antiphospholipid syndrome and osteoporosis
Can’t use estrogen based contraception
NOT candidate for ESTROGEN containing contraception
(oral, vaginal, transdermal) - inc’d r/o thrombosis with antiphopholipid Ab
aw 2nd /3rd trimester preg losses
USE progesterone ONLY contraception ie prog intraunterine device or progesterone only pill (less effective, higher rate of breatkhru bleeding and other s/e)
No combination contraception pills (contain estrogen) in pts with antiphospholipid Ab’s, h/o thrombosis or other contraindications
- ok for antiphopholipid ab neg SLE pts
Don’t use IM Medroxyprogesterone - ihibits ovulation and not recommended for long term use - aw risk of osteoporois (rel contraindication in pt with osteoporosis)
Purulent cellulitis
Celluits aw purulent drainage or exudate but without drainable abscess -
Outpt Tx: bactrim (CA-MRSA), linezolid, tetracylcine (doxy), clindamycin
Pop: chilren, MSM, student and pro athletes, prisoners
Don’t use amoxicililn, cephalexin, dicloxacin - active vs B hemolytic strep but NOT CA-MRSA (only for NON-purulent cellulits)
Diagnose aldosterone excess in pt with resistent HTN
Obtain plasma aldo-renin ratio (ARR)
Resistent HTN - BP above goal despite 3 anti-HTN including one diuretic
(renovasc HTN, primary hyperaldo)
Primary hyperaldo - not nec low K+
Also check for urine - aldo excretion (>12mg aldo in urine after 3 days of of high sodium diet and correction of hypo K+) - can use saline infusion
Don’t just sub loop for thiazide - ONLY FOR PTS with resistant HTN AND CKD or hypervolemic states
DOn’t just switch to other alt agent to lisinopril
Pt has no risk factors for renovasc HTN, check ARR first (usually aw widespread atherosclerosis, vasc, CVD, ischemic end organ damage)
Sweet syndrome
Neutrophilic dermatosis
aw underlying malignancy (AML)
Pt with MDS -> sweet syndrome inidcated -> AML
“juicy” bright red demarcated plaques with sharp cut off between normal and inflammed skin - neck upper trunk extrem’s
Bx: neutrophillic inflamm infiltrate/papillary dermal edema
bullae
neutrophillic/fevers
HSV
immunocompromised host
cutaneous vesicles - rupture-> erosions
Leukemia cutis
red to violacious dermal papules and nodules
bx: atypical leukemic cells infiltrating dermis and dissecting thru collagen bundles
MRSA abscesses
large red, indurated tender warm papules - crusted papule/head at center of furuncle
Pyogenic granuloma
small benign vascular papules with collarette of scale - occur anywhere, tend to be on extrem around nails and face - ppl on HAART and acne meds tend to get
Juvenile Myoclonic epilepsy
infrequent convulsive seizures
provoked by etoh or sleep deprivation
absense seizures and myoclonic seizures worse in AM
Fhx convulsive sz or myoclonic jerks
Childhood absence seizures
may have convusions - usually have remission by puberty
etoh related seizure
NO morning jerks or absnese seizures
Convulsive seizure
with or without aura
can be initial presentation of temporal lobe epilepsy
No morning myoclonus
Evaluation for arrythmia
24 hr continuous ecg monitor - if daily sx
PVCs - made worse with caffein, nicotine, etoh
Usually benign unless fhx struc heart dz, sudden cardiac death, syncope
Tx: reassurance
EPS - for ppl who have sx such as syncope which could be VT (int or greater risk)
can get mechanism and location of arrythmia
Event recorders - sx that do NOT occur daily
Implantable Looping recorder - records events prior to event device being triggered in response to arrythmia
(very infrequent)
Post sx recorder - good for arrthmias that pt can activate device (not if syncope)
Dx Polycythemia vera
inc’d H/H>18.5/16.5 (M/W), and O2 sat >92%
JAK2 V617F analysis
erythromelagia (burning sensation in palms and soles - from plt activation
plethora
warm water induced prurutiis
thombotic and bleeding sx
Leukocytosis / basophllia, thrombocytosis
BCL-ABL - philadeophia chormoosome - CML
leukoerythroblastics smear - inc’d granulocytes, left shift - , hypercell BM with myelooid prolif
BMBx - pt with MDS but JAK2 neg
hypercell marrow, abnormal megakaryocytes, in’c retuiculin fiborosis
Sleep study in pt with Hg>18 and OSA-> secondary erythrocytosis
Acute rhinosinusitis
NO ABX chorpheniramine - antihistamines Sx relief is goal conjuntival injection, boggy nasal mucosa with clear drainage oropharynx edematous decongestant
Albuterol does not help
Caused by viruses - no abx Bacterial only if >10 days, with persisent sx (fever, h/a URI) onset with sev sx new fever, h/a, URI TX: augmentin (if bacterial)
NO role for codeine in tx
Nasal ipratropium, cromyln, nasal decongestnats
Vit c, echnasia, zinc,
Tacrolimus toxicity
Tacrolimus/cyclosporin/sirolimus cw
macrolide abx (clarithro) and azole antifungals interfere iwth cytochrome 450, inc levels of anti=reg meds
inc’d levels of tacrolimus
inc’d Cr
tubular d/o, HTN, neurotox, metabolic abn, hyperglyc, hyperK, hypoMg
Use AZITHRO if macrolide needed
Mycophenilate -> GI/ BM suppresion sx, BM suppresion NO AKI - macrolide abx do not affect this drug
Acute interstitial nephritsi - hypersensit rxn to med
fever, rash, eos
U/A leukocyte casts, EOS, protein 2.5
Organ rejection - no likely at 7 months
High risk peptic ulcer after endoscopic tx
High risk = III
peptic ulcers with pulsatile bleeding, non-bleedin vessel, adherent clot
Benign familial hypocalciuric hyper calemia
Fhx of elevated Ca
Check Urine calcium to Cr ratio
Ratio < 0.1= suggest benign familial hyppcalciuria, hyperCa+
High serum Ca
Genes -
Measure prolactin level - MENI
25OH3D - high serum Ca high PTH -
Calcium pyrophoshate arthropathy
OA like arthrtis
atypical joints (MCP)+chondroCA (dep of Ca in soft tissue - see on xray)
radiology - subhcondral sclerosis, osteophytes)
Hemochromatosis/CPP arthropathy - overalp
no evidence of Iron overloa on labs
Peudogout - hass CPP crytals in joint (wk b
Rheum arthrits - +RF, +anti ccp, morning stiffness>2hrs
Manage HTN in elderly pt >80yo
BP controlled to SBP<150 - BV stiffer so erronious high BP and put on many meds that cause serious s/e in elderly
No need to add diuretic or change meds
HLD with HIV pt
Use atorvastatin (or pravastatin) not as much interaction with PI (ritinovir) (cytochrome p450)
DO NOT USE Zocor
statin better than fenofibrate
Hypoglyemia in pt taking sufonyurea
glyburide - renally cleared
Hg A1c 6.2 way too low for elderly pt - confusion, forgetfullness from hypoglycemia
don’t start any hypoglyc agent until pt cleared current drug (even insulin)
Neuroleptic Malignant syndrome
Rx to neuroleptic antipsychotic agents ie haldol
muscle rigidity, hyperthermia, autonomic dysreg
TX: d/c offending agents, IVF, GIVE BENZO (lorezepam) - cooling agents, BP agent ie nitroprusside
D/C lithium
If pt still needs anti psych - start low potency one AFTER 2 WEEKS then titirate up slowly
ASA/tylenol not good with hyperthermia in NMS
Succynly choline avoided druing NMS - r/o malignant hyperthermia - no good evid for NM blocking agents
Only treat BP if still high after tx for NMS
Menopausal vasomotor sx
61yo F pt with CV risk factors and h/o DVT
NON-hormonal tx for hot flushes
SNRI (venlafaxine, paroxetine) NOTfluoxetine or citalopram
Never use hormonal tx on pt with DVT in past and not in women >60
Vaginal topical / vag tablets don’t help vasomotor sx
CMV infection in pt with kidney tx
pt was neg for CMV and got a CMV + kidney and now off acyclovir -> CMV diarrhea
fevers/leukopenia in post tx period
Dx: PCR or antigen
other issues - diarrhea, PNA, encephalitis, hepatitis, GI ulceration, elevated LFTs
CMV inclusion bodies on bx
NOT cdiff - no leukopenia or elev LFTs
Mycophenolate Mofetil - no fevers or elev LFTs
can cause diarrhea/leukopenia
Tacrolimus - can cause dairrhae but no fever, leukopenia or abn LFTs
Oropharyngeal dysphagia
aspiration, chockign coughing while swallowing - episode of PNA (presumed asp),
Pt with ALS - painless wk atrophy and fasciculations beginning in ARM/leg - UMN signs hyperreflex, ext plantar responses,
Bulbar onset ALS - dyphagia, slurred speech,
NEED VIDEO FLOROSCOPY to assess swallowing foods of diff consistencies
Not esophageal dysphagia (solids>liquids)
Not esoph motility d/o (solids & liquids)
No need for UGI series, EGD or manometry
UGI series/EGD if suspected luminal issue (stricture/ring)
Manometry if suspected motility d/o ie achalasia (dilated esoph on UGI series or EGD)
Evaluate patient with baseline EKG abn (ST elev 1mm diffuse, LVH) with chest pain
Excercise perfusion nuclear stress
Age, sex, atypical chest pain -> stress test
Need perfusion if baseline ST seg changes, greater than 1 mm ST dep, LBBB, pre excitation (WPW)
Coronary artery Calcium score - surrogate for atherosclerosis, evaluates risk for cardiac event rather than prob of CAD
utility in low risk patients 10-20% - CAC higher >400 need more intense risk stratification
If unable to excercise pharm perfusion stress
Adneosine/dipyrmadole - contraindicated in pt with broncospastic dz
Dermatomyositis
Initial tx in pt without severe myositis or extramuscular manifestations (systemic sx, fever, wt loss, pulm, cardiac, GI sx) - high dose prednsione
Gottron papules - pathomneumonic for Dermatomyositis
erythematous violacious clumped papules over extensor surfaces of elbows, metacarpal joints PIP
Fatigue, arthraliga, raynauds, nailfold capillary abn, cuticular hypertrophy, prox muscle wk, photosensitive rash,
continue steroids x 4 weeks until CK comes down
baseline bone density testing, ppx Ca/Vit D, bisphosphonates
Also need phys/occ tx
IVIG only if need more therapy other than steroid and contraindic to other immunosuppressives
Use steroid + steroid sparing immunosupp (azathroprine/MTX) in pt with poor prog or extramusc manifestations)
Dx AL amyloid
Clinical features: macroglossia, hepatomegaly, nephortic syndrome, peripheral neuopathy, IgG lamda M protein
evidence of clonal light chains in amyloid deposits
Plasma cells in BM bx
Need abdominal fat pad bx - if neg then affected organs (kidney, liver) need bx first check BM
NOT ANCA vasculitsi - doesn’t cause neuropathy or macroglossia
Not Cryoglobinemia - nephrotic range protein and neuropathy but no macroglossia - lower extrem purpura
Sebhorreic keratosis
brown scaley, waxy - stuck on appearance - verruncus/warty features
Horn cells (epidermal cysts filled with keratin)
Atypical lesions can be bx r/o melanoma
No tx needed - can remove for cosmetic reasons
Actinic keratosis
red scaley macules in sun exposed areas
PRECANCEROUS -> SCC
easier to feel than see
Melanoma
Asymm, ireg borders, color variation, diameter>6mm, evolution
Basal cell CA - have telangiectasias and look pearly
Solar lentigenes
uniform brown scaley regularly shaped macules and patches - sun exposed areas - are themselves benign but denote extensive sun exposure so at risk for development of cancers and precancers in future
Toxic epidermal lysis
TEN - potentially lethal
prodrome fever, sore throat, burning sensation in eyes 1-3 days before skin lesions
Flat atypical purpuritic targetoid lesions-> coelesce into dusky poorly demarcated confulent patches - TEN with spots or confluent tender erythema without identifieable individual lesions (TEN without spots)
BListers slough and leave denuded skin
Skin pain
two or more mucosal surfaces (eyes, genitals, nasopharynx)
+nikolsky, >30% body epidermal detachment
Etio - meds (antiepileptics, NSAIDs, abx, pantaprozole, sertraline,tramadol, allopurinol bactrim or infx - HIV, kidney dz, acitve autoimmune dz, human leukocyte antigen
Within 8 weeks of starting drug
Vessicles, bullae, erosions
Bx won’t distinguish SJS, erythema multiforme, and TEN
survival improved when causative med stopped
Erythema Multiforme
acute recurrent mucocutaneous eruption, follows acute infection (HSV) can be drug related or idiopathic
several MM to CM - erythematous plaques with concentric rings of color
low grade fever
NO LAD, EOS or inc LFS
Pemphigous foliaceous
Autoimmune blistering dz
scaling and crusted lesions upper face, trunk erythroderma, +nikolsky - no mucosal inovlvement no epidermal detachement (aw TEN)
SSSS
MC in children - adults with underlying immunosuppression or AKI affected too
perioral crusting, and fissuring, - no skin detachment or muscosal invovlement
Volume overload in patient with CKD
Acute decompensated HF and volume overload - give diuresis even if Cr high - AoCKD cause by renal congestion from volume overload - Cr will get better (not worse) with diuresis
IV bumetinide
Glomerular filtration rate inversely related to CVP (cvp up, GFR down) - poor prognosis with HF
If extremely poor kidney fxn may not tolerate diuresis - will need HD
Transfuse only if Hg really low (slight low value can be 2/2 fluid overload)
Also additional blood will worsen volume overload
If pt in low output state then milronone/ionotrope would be appropriagte
Low dose dopamine in pt with AKI and HF doesn’t have benfit
Gene testing strategies
Inquire about dz that run in family
more common ones (breast, prostate, colon, early CVD)
Genetic counseling only if history c/w genetic suseptiblity, if will aid in medical or surgical management
Send to genetics professional i fneed detail pedigre
Don’t screen for common genetic mutations unless clinical concern (high false positives, may be clincially unneccary - harm may outweigh benefit.
IDA in menstrating female
simple IDA - oral iron replacement
just menstrating - IDA without GI or uterine dz
fatigue, lack of sense of well being, dec’d exc tolerance, dec’d ET, h/a
microcytic hypochromic erythrocytes
anisopoikilocytosis (varied size/shape)
high RDW
mild thormbocytosis
IV iron only with HD or pt not tolerating or absorbing oral
Transfusion only if sx anemia where rapid correction needed for cardiac causes
Treat DM1
If post prandial FSG too high increase rapid coverage pre-meal
No need to add additional med - can oprimize current meds
DOn’t restrict carbs - pt underweight and tyring to concieve
Don’t change baseline insulin as premeals ok
Refractory GERD managment
If already on high dose PPI then next step is fundoplication
First check for appropriate administration (30 min premeal) and compliance
->EGD to check for other caues (eos esoph, heart dz, acalasia)
If EGD neg - 24 hr pH monitoring to determine if really GERD
Inc’d PPI and sucralafate won’t work
Endoscopic antireflux surgery not needed (RF ablation)
Treat PID outpt
Single dose IV ceftriaxone, 14 days doxy \+-flagyl cervicitis and uterine tenderness=PID abd or pelvic pain with CMT, adnexal tenderness, uterine tnederness Cover Neiserria gonnoarhea, Chylamydia, aerobic gneg rods, anaeroboes Early f/u 72hrs Hospitalization if can't take oral Male partners tx'd
IV could be clinda + gent
No cipro (gorrhea resist)
Single dose ceftxx+azithro ok for cervicicits NOT PID
Type B lactic acidosis
2/2 medication exposure, toxin exp, G6PD, mlaignancy, liver dz (linezold, tylenol, metformin, HIV meds)
AG + inc’d serum lactate
Lactic acid 2/2 tissue hypoperfusion
No shock or hypoxia
DKA - p/w +ketones - AG met acidosis, hyperglycemia, glucose >300,
Pyroglutamate acidosis - critically ill getting tylenol - unexplained AG met acidosis
Sepsis - not without wbc, fever, tachycardia
Dx COPD
FEV1/FVC40, h/o tobacco or other exposure with dypnea, chronic cough or sputum
FEV1>80% mild
FEV1 50-79= mod
FEV1 30-49=severe
<30=very severe
Asthma unlikely with lack of atopy, h/o resp sx as child
GERD - not without some heartburn sx
ACEi aw cough, not ARB
Marfan’s syndrome
ectopic lens, aortic root dilation, lumbsacral dural ecasia
fhx
Long arms, long digits pectus evactium
Classical Erlos danlos
ligamentous laxity, dramatic - velvety hyperext skin, atrophic scarring, no arterial aneurysms
Vascular Erhler danlos
aneurysmal diation of many bv’s, ligamentous laxity, thin traslucent skin
NO ectopic lens, skeletal abn
Osteogensis imperfecta
scholiosis, h/o fx, short, BLUE SCLERAE, dentinogenesis imperfecta (poorly developed teeth)
Allergic contact dermatitis tx
Face/Neck/under breasts/pannus - use weaker steroid - hydrocortisone valerate - less thinnig/atrophy
Clobetasone=ULTRAPOTENT - don’t use on face
bethamethasone, desoximetazone - potent - don’t use on face
Acute otitis externa
uncomplicated otitis externa - 2/2 moist conditions
otalgia, feeling fullness, +-hearing loss, pain with jaw motion, tendernesss with tragal or pinna tugging
diffuse ear canal edema, purulent debris erythema
GOOD TYMPANIC MEMBRANE MOBILITY
tx: clear canal of debris
ototopical agent (polymyxin B, neomycin, hydrocrotisone
(mild - dilute acetic acid)
Allergic rxn to ear plugs - should not have purulent d/c Delayed hypersensitiety (IV) - erythema/edema with vesicles/bullae
Malignant otitiis externa - infection in ear speads to bone cartilage nearby - fever pain otorreha - appear much more ill
Otitis media - no pain wth tragal/pinn atugging, middl ear effusion - eartyema of tympanic membrane
Screen for IC cerebral aneurysm in pt with autosomal dom polycitic kidney dz
prevalence 8%
Screen with cerebral artery MRA
fhx known intracranial aneurysm (1st deg realtive)
No need for 24hr protein if urine protein cr ratio already done
No need for ADPKD genotyping
No need for abd CT if ADPKD already dx’d
Biliary cyst
Dialtion of Common bile duct WITHOUT STONES on ERCP
Not chollithiasis without stones visualized
IBS - does not cause asc colitis
dx’d clinically - no tests
Primary biliary cirrhsois - dz of microscopic bile ducts = jaundice, fever, inflammation, liver inflammation, liver failure
Post coital UTI
Post coital abx ppx
use cipro
often aw spermacide use, liberal fluid intake, post coital voiding - if doesn’t work the cipro
chornic suppressive abx not as good
cranberry juice doesn’t work in studies
Spermacide INCREASES RISK
Treat PE in pt with CKD
Acute PE in pt with CKD and HD stable and oxygenating well
-> UF Heparin + warfarin
Thrombolytic therapy only if persistent hypotension
LMWH + warfarin or fontaparinex + warfarin CONTRAINDICATED with CKD
Argatroban + warfarin - used mainly for HIT (raises INR so hard to manage warfarin)
Hydroxychloroquin toxcity
Retinal toxicity - baseline retinal exam and f/u needed
used for SLE/RA
depostion directly on retina
Add TNF only if needs improvememnt
Don’t d/c MTX if working - unless LFTs inc
Liver bx unnecessary
Pheochromocytoma
Sx: HTN, palpitations, sweating, h/a
elevated plasma metanephrines/normetanephrien, elev urine catecholamines
Tx: first with terazosin/ short acting Alpha blockers
then surgery
BB only after alpha blocker onboard
ACE + arb no good effect
Need to treat can’t just observe
Sickle cell anemia and pregnant pt
Pain crisis tx with MORPHINE (for all pts not just preg ones) +
hydration, supp o2, opiates (not teratogenic)
No hydroxyurea - teratogenic
No ketorlac preg C
No Meperideine - induces seizures
Manage elevated BP after TPA
NO ASA - contraindicated 24hrs after TPA
After TPA keep BP confirm with CT -> cryoprecipitate
No benzo (diazepam) - benzos may impair recovery
Don’t give nitropursside - can inc ICP
Manage difficult clinical encounter - chronic pain
Pt with sx of pain not attributable to cause and is angry
emphatic support at frequent intervals
ongoing discussion to discuss and understand potential causes and significance of pain
Difficult encounters with pts depression/anxiety, poorer fxn status, unmet expectations, reduced satisfaction, greater use of healthcare services
Time consuming, unrealistic demands, anger, don’t follow recs,
somatizaqtion d/o , chornic pain, substance abuse, undx medical problem
Personality d/o (borderline, dependent, histrionic, obsessive, antisocial
Dont just give pt pain meds without understanding etiology
does not identify complex causes of sx or ID more appropriate therapy
Dont just refer to specialist - they undergo unnecessary testing -
Don’t transfer care to another MD, need to recognize potential psych/emotional factors - MD also needs to understand own neg emtions about pt - helps to work collaboratively with patient
