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
Tx acute IPF exacerbation
Don’t intubate - poor outcomes with severe IPF
Use NARCOTICS FOR PALLIATION
Goal - reduce unnecessary suffering (remote likelihood of recovery
DOn’t give anti-fungals if no evidence of fungal infxn (neg sputum)
acute exacerbations tx’d empirically with abx without knowlege of causative agent - when several days go by without improvement
If already tx with steroids for several days high dose pulse steroids won’t likely help
Albuterol WILL NOT WORK - IPF not restrictive dz
Acute optic neuritis
unilateral ocular sx
afferent pupillary defect
contrast enhancement of optic nerve on MRI, white matter lesions, PERIVENTRICULAR
Tx: high methypredisolone -> glatiramir acetate reduces risk of development of MS
(also interferon beta)
Acetazolamide - tx for idiopathic IC HTN - b/l visual changes, h/a, +papiledema - no contrast enahncement on MRI
Migraine does not cause afferent pupillary defect or enhancement of optic nerve (can cause white matter lesions)
Only watch and wait and MRI if NO white matter lesions
Dermatofibroma
benign firm brown or violet brown papule - MC lower extrem, size of pencil head with button/dimple when lateral sides pulled together - arise from minor injuriese ie bug bites, shaving, folliculitis - DO NOT REQUIRE TX
Epidermal inclsuion cysts - flesh colored SQ nodules with prominent central punctum filled with keratin
Melanoma - darkly pigmented lesions - ABCDE - review!
BCC - nodulear lesions, pearly, pink, waxy, , telengiectasic vessels
Seborrheic keratosis - brown scaley, waxy papules/plaques stuck on appearance - verruncous/warty features
Locally advanced gastroesophageal junction adenoCA
Stage III - risk factors male, barretts, GERD
Barretts - columnar epithelium (like stomach) replaces squamous epithelium of esophagus
-> inc’d risk of adenoCA
Tx: surgery + periop chemo
Radiation or chemo only is palliative - pt has potentially curable cancer
Dx cause of gynecomastia
abnormal large mammory glands in man could be from imbalance of testosterone to estrogen ratio (low testosterone or high estrogen)
Here if testosterone normal the CHECK ESTRADIOL
Adrenal CT only if elev estradiol - and after testicular US to exclude testicular neoplasm - if neg then abd ct r/o neoplasm in adrenals
Breast US only if unilateral dz, mass or assymetric growth
karyotype only if LH was elevatetd and testoterone dec’d to r/o kleinfelters
Assess cardiac risk in young woman
Reynolds risk score
Sex specific, Fhx, CRP - results in reclassification of a lot of intermediate to either low or high risk women
Framingham - not as good in women - BP, chol, smoking, HDL, age
QRISK2 - CV risk in pts in england and wales only
SCORE for europeans CV risk
Manage UGIB and hemodynamic instabililty
Large GI hemorrhage - h/o ASA use suggets GI source - IVF, blood, IV PPI infusion
If still low bp give more blood and IVF
intensive rescusitation reduces mortality
After adequeate rescuitation - then EGD within 24hrs
-can’t do to inadequetely resucitated pt - also even mod sedation will cause hypotension
Octreotide - known or suspected liver dz - used in variceal hmorrheage - decreases portal venous inflow and intravareceal pressure
Don’t do NG tube lavage (high false neg rate) and false + from NG tube irritation (can help localize bleed but not always) - hematemsis already shows large UGIB
Primary syphilis
Syphilitic chancre - SINGLE lesion, painless, border raised, cartilagenous consistency
MSM
Treponella pallidum
RPR often neg in primary syphilis
Also screen for HIV, gonorreha, chlamydia
Chancroid - single or multiple PAINFUL!! ulcers with ragged border and purulent exudate
HSV - mutiple PAINFUL ulcers - initially vesicles
Human papilloma virus - GENITAL WARTS (not ulcers)
Rapidly progressive glomerular nephritis (RPGN)
Urine findings cw glomerular dz - erythrocytes, acanthocytes (disfigured RBCs), RBC casts
Rapid loss of kidney fxn over days, weeks, months
Etio: antiglom basement membrane Ab dz, immune complex depostion (lupus nephritis), ANCA + vasulitis
Glomerulonephritis: hematuria, oliguria, HTN, kidney insuff caused by glomerular inflamm
U/A - hematuria, cellular/granular casts, proteinuria
Sx: poorly controlled HTN, periorbital edema, LE edema - with RBC casts in urine
Acute interstitial nephritis
mostly pyruia, leukocyte casts
no HTN, edema
aw medication reaction
Acute tubular necrosis
sustained ischemia or nephrotoxic agent
muddy brown casts
Polyarteritis nodosa
vasculitids of med sized vessels
HTN, kidney insuff, kidney infrction bleeding
hematuria/subnephrotic proteinuria
NO RBC casts (no glomerular inflammation)
Evaluate secondary ammenorrhea (3 or more consecuteive months)
Pt with normal FSH, LH, not pregnant, gonadotropin, TSH/free T4, no hirusitism, acne, alopecia, clitoromeagaly, galatorrhea, no hot flushes, night sweats, wt chagnes, prior preg, fhx of thyroid dz or primary ovarian insuff
Also had normal menstrual cycles
Oligomenrrhea more common
Serum FSH>35=primary ovarian failure, 20-35 = low ovarian reserve
FIRST TEST - progesterone withdrawal challenge: determines if making adqueate estrogen - progesterone should make bleed - if not, low estrogen state - likely hypothalamic or pituitary cause given normal FSH
If signs of hyperandrogenism (hirsuitism, virilazation clitoromegaly, voice deeping) - check testosterone and DHEA
No MRI as prolactin and FSH normal
Asherman syndrome - endometrial scaring as cause of 2ndary amenorrhea - h/o D&C or uterine infection - would need pelvic US
Lyme myocarditis
with 2nd or 3rd deg block - tx with IV ceftriaxone (confirmed serological lyme) if sx then hospitlaization for cardiac monitoring
Asx patient with 1st deg AVB - oral doxy or cefuroxime
No PPM as likely is reversible with tx of lyme
Need to treat not just observe
Migraine w/o aura
unilateral, throbbing, photosensitivity, nausea
4-72hrs (ddx from cluster as >3hrs) (DDx from tension as severe and with n/photophobia)
PPX: amytryptiline (TCA), topiramate, divalproex, timolol, propranolol
DO NOT USE BB (timolol, propranolol) with h/o asthma
No evidence for fluoxetine or other SSRI in migraine prev
Verapamil -> prevention of CLUSTER h/a
Mg/Riboflavin (B2) ppx for h/a, NOT Vit D
Salicylate toxicity - DDX of toxicities
AG metabolic acidosis + resp alkalosis
DDX salicylate toxicity, liver dz, sepsis
Can get salicylate poisoning from oil of wintergreen (in homeopathic creams)
MS change, n/v, fever, tinnitis
No osmol gap
Methanol toxcity AG met acidosis with osmolal gap - would have an osmolal gap but NO RESP alkalosis
No sepsis - no signs of fever, normal serum lactate, no hypotension, no WBCs
Metformin toxicity - SEVERE lactic acidosis
in pt with AKI in seting of critical illness or following acute OD - normal lactate would r/o this
Anorexia nervosa
abnormally low body weight with fear of gaiing weigh (t solve problem of anorexia nervosa
Manage acute COPD exacerbation
Pt dyspnic at rest, O2 sat 86% off O2 - ADMIT TO HOSPITAL
Severe dz, advanced age, significant comorbidieis, inc’d intensity of sx, new arrythmias - insuff home support, failure of initial med management
Needs hospital for O2, abx, steroids, inhaled broncodilators
Home O2 would not work - resting hypoxia shows lack of improvement
don’t just broaden abx - needs hospital for agressive management
don’t just use steroids - needs other care in hospital
Patient with Rheum Arthritis taking MTX - pregnancy
D/C MTX 3 months prior to conception attempt
MTX VERY teratogenic (cat x along with leflunomide)
advisable for men to d/c as well
Women in preg usually get spontaneous remission of RA in 2nd trim - if not then ok to use low dose prednisone, hydroxyclorooquin (retinal exam) or sulfasalazine
Avoid NSAIDs in 3rd trim - premature closure of PDA, interference with labor
Resume post partum unless breast feeding as dz flares post partum
Autoimmune pancreatitis
Tx: corticosteroids
Painless jaundice with diffusely enlarged pancrease, narrowed pancreatic duct - mass r/o by CT and EUS, normal CA-19 r/o pancreastic CA
Elev IgG4 = autoimmune pancreatitis
If do not improve in 3 months, consider other dx
If relapse with steroids try immunomodulator (azathroprine)
No Abx (only for ascending colangitis or infected pancreatic necrosis) - pt not febrile
No need for biliary stent as most strictures respond to steroids in AIP
No reason for whipple with AIP (for pancreastic cancer)
Eval need for AVR
Indications for replacement
- Very severe stenosis - mean gradient >60
- LVEF <50%
- Rapid progression of stenosis
- exc related hypotension or sx
- Other cardiac surgery needed (CABG)
If none then repeat TTE in 12 months (interval exam 6 months)
Balloon Aortic Valvulopasty in hemodynamically unstable patients as bridge to AVR (r/o stroke, MI, death)
Dob stress - if low flow, low gradient with severe LV dysfxn - do dob stress - if LVEF improves then possible AVR (or if gradient improves)
**Bevacizumab induced VASCULAR PERFORATION
vasc pereforation -> intestinal perforation -> abd pain, free air on xray targets EGF on vasular tissue HTN poor wound healing bleeding, thrombosis
5FU s/e - diarrhea/mucositis (no perfs)
Oxaplatin - neurotoxicity, distal sensory neuropathy
Typhilitis - neutropenic enterocolits - complication of myelosupp chemo - fever abd pain - NO PERF
Acute SVT
Atrial tachycardia - adenosine slows or blocks AV node but will see rapid p waves on EKG while AV node blocked
Adenosine will terminate AVNRT and AVRT as it interupts circuit - if adenosine fails to terminate SVT then likely not AVNRT or AVRT
Tx for Atach - BB or CCB first
If not then IC or III antiarrythmic
If that doesn’t work then RFA (less succesful as multiple foci)
Early stage carcinoid tumor
small incidentally found carcinoid - well differenctialed within appendix when taken out - curative
No Indium-111 scan - see’s somatostatin expressing tumors but if CT is neg for other abn no need in setting of small appendeceal tumor
Octreotide - somatostatin analog for management of hormonal sx of neuroendocrine tumors when present and can slow metastatic carcinoid
no role in post resection adjuvant tx of localized and resected neuroendocrine tumors
Large carcinoid tumors - with more aggressive histology - right hemicolectomy - clear local LN
Streptozosin + 5FU - antitumor activity in pancreatic neuroendocrine tumors
Evaluate randomized control trial for generalizability
Pt is NYHA I - drug evaluated in NYHA III/IV - pt’s HF too mild to take drug (not geenralizable to NYHA I) and derive benefit
RCT gold standard cuz allows confounding variables that might obscure benefit to be balanced between groups
usually restricted to very homogenous group with rigid inclusion/exclusion criteria - makes conclusions narrow and not very generalizable (ie pt with NYHA III/IV benfit but can’t extrapolate to NYHA I)
Pt’s are balanced in RCT with or without co-existing meds - can’t be sure if taking or not taking BB in addition to exp drug will affect seeing benefit
No arbitray adverse event cutoff - need to consider risk vs benefit
Use caution when generalizing results of RCT to pts outside of inclusion/exclusion of trial
Canniboid hyperemesis syndrome
episodic abd pain, n/v, +marijuana use
aw compulsive washing (ie relieved with baths)
Tx: cessation of marijuana use
Cyclic vomiting syndrome: acute episodes of vomiting for up to a week, 3 or more episodes in 1 year, absence of n/v in between - personal or fhx migraine supportive
-> if cannabis use then Cannoboid hyperemeis syndrome more likely
Gastroparesis usually daily sx in setting of long standing DM
Chornic intestinal pseduoobstruction - abd distention, pain, nausea sometimes vomiting, acute, chronic or recurrent, - dilated small bowel - absense of true obstruction - can be caused by neuropathic d/o such as DM, amyloidosis, paraneoplastic, , myopathic - dx made by gastric and small bowel manometry
Dx PJP PNA in AIDS patient
Pt with known risk factors and HIV + PCP PNA is most common Opp infection subacute dry cough, dypnea diffuse interstiial dz on CXR PO2<50 - fever, night sweats, wt loss - inovlve liver, spleen, LN but NOT PULM DZ
Candida is RARE cause of PNA - pseduohyphae on sputum liekly from candida
Hypopituitarism treatment
when treating central hypothyroid NEED TO TREAT for progressive adrenal insuff with GLUCOCORTICOIDS (hydrocortisone) if cortisol low or low normal
Central hypothyroid - low Free T4 but inappropriately normal or low TSH
If you treat central hypothryoid first then metabolism revs up an uses up little cortisol reserve and goes into adrenergenic shock
Don’t need to treat low testosterone or low GH yet
Don’t need vasopressin if no signs of (central) DI
Erosive hand osteoarthritis
aw episotic hand inflamm attacks one or two joints usually inflammed osteophytes and joint space narrowing on Xray (diff than polyarticular attack in RA) \+bouchard (PIP) + heberdens (DIP) central erosioins or cystic changes mildly elevated ESR/CRP
Psoriatric arthrtisi - DIP - absnese of rash does NOT rule out
inflamm of tenosynovial jnc - cuases inflamm beyond joint (sausage digits) - more desrtuctive than hand OA
Tophaceous gout would have tophi depostis
Late onset RA - need to look for MCP invovlement to rule in RA vs OA and change in pattern of arthritis
Alpha 1 antitrypsin deficiency
Sx and spirometry COPD - in young pt
FEV1/FVCd
Reversible cerbro vasoconstriction syndrome
thunderclap h/a recurrent over a few days or weeks in association with transient cerebral vasoconstriction
severe an explosive
Need cerebrovascular imaging
r/o SAH
no abn on neuro exam
Tx: CCB
may present during pregnancy or peripartum
Don’t do MRI brain
Indomethacin for specific variations - aw cough, exertion, sexual activity
Sumatriptan - acute migraine
Tinea versicolor
aka pitriaysis versicolor
superficial fungal infection of skin
yeast - Malassezia furfur
Spores/hyphae from scraping KOH - spagetti and meatballs
tx: Topical ketoconazole, bifonazole, miconazole, clotrimazole
Oral azoles only for recalcitrant tinea versicolor or very extensive making topical agents impractical
drug interactions and abn LFTs
Don’t use topical corticosteroids - relieves pruritis temporarily but makes infection WORSE - allows yeast to flourish
Thyroid nodule
FNA thyroid nodules
benign vs malignant
FNA at least 5mm with worrisome sonographic character (fhx, hypoechoic, cystic, microCA, central vasc, blurred margins)
Don’t just watch pts with suspicious features
Thyroid lobectomy - only if cancerous <1cm
MRI less useful - only for local extension
Fistulizing/complex crohns dz
Surgical tx and infliximab
Fistula - abn conn between bowel and adj organs
fecal matter thru skin
drain abscess - start infliximab
Simple fistula: superficial, single opening, no abscess, no rectovaginal fistula, no anorectal stricture,
tx: Cipro/flagyl
Do not use steroids
High risk early stage bladder CA
resect all resectable dz intravesicular BCG immunotx (Stage I invading mucosa only) reduces local recurrence surveillence - repeat cytology/cystoscopy q3m
Radiation - only if invades muscle
CYstectomy - for CA that invades muscle, bladder CA in situ recurring after resection + BCG or INCOMPLETE resection
DO not just observe
Pulm HTN dx
If inc'd RV pressure on TTE -> RHC neck vein dilated, RAD, prom central pulm veins, clear lungs, dil RV elev RVP, V/Q normal prom pulm compoent S2 r/o OSA Can also test response to vasodilators
Clear lung field with pulm sx out of proportion r/o lung dz - no need for HRCT
No need for pulm arteriogram - VQ scan normal - rules out chronic thromboembolic pulm HTN
No sx of OSA - no need for sleep study
TEE won’t add anythng new
NICM device tx
LVEF 120
already on OMT (BB, ACEi, spironolactone)
decreases mortailty, sx, HF hospitalization
improve LV syncorny by coordinating septal and lateral wall contraction
No single/dual chamber ICD - RV pacing would be harmful
NO bivi pacing only as needs ICD too
Pseduomonal PNA
Critically ill patients
pseduomonal coverage
Cefepime, tobramycin, azithro
antipseudomonal B lactam with pneumococcal coverage (cefepime, impipenum, meropenum, zosyn) + cipro/levo
or antipseduomonal B lactam + aminoglycos+azithro
or antipseduomonal B lactam + aminoglyc+resp quinolone
Aztreonam replaces B lactam
Risk factors for pseudomonas
frequent exac of COPD, long standing corticosteroid use
Evaluate options for kidney replacement therapy in pt with CKD
Plan for pre-tx PD
If healthy, otherwise independent, no abd surgery
can’t wait a year for genetic identical kidney
don’t use cadaveric - less allograft survival than live donor
don’t start pre-empitve dialysis - doesn’t help
Relapsing polychondritis
autoimmune inflamm d/o
cartilage of nose/ears (boxer ear, saddle nose def)
RA like polychondritis
Check Pulm flow volume loops - cartilagenous tracheal rings of larynx, trachea, bronchi - obstructive findings on flow volume loops
Not granulomatosis with polyangiitis as neg ANCA, no sinus dz
No RF
Utox only if suspect cocaine induced nasal septum damage
opthalmic herpes zoster
herpes zoster opthalamacus - urgent acylocvir, valcyclovir or famcyclovir and opthal consult
Can lead to blindness
usually single dermatome and doesn't cross midline Hutchinson sign (eruption on nose) not predictive of eye invovlement
no warm compresses or abx for viral infxn
never use steroids as single agent for herpes zoster if needed in conjunction with antiviral by specialist
Primary Sjogren’s
keratoconjuntivitis sicca, xeroophthalma, xerostoma - difficulty chewing and inc’d peridontal dz
vaginal dryness, parotid enlargement
inflamm polyarthritis, cutaneous vasculitis, mononeuritis multiplex, distal RTA, interstitiial nephritis
Pulm involvement - Interstitial lung dz
Schrimer test - moisture under lower eyelids
ANA+, RF+, Anti La/SSB
xerostomia/xeroopthalimia/Anti ro/SSA/Anti La/SSB + abn schrimer = 94% sensitive for Sjogrens
Meibomianitis - dysfxn of meibomian glands that make lipids for tears
Both RA/SLE would involve systemic sx (arthritis, pleuritis, cerebritis, lung dysfxn, skin changes also
Eval pt with small asx pulm nodules
Soitary pulm nodules = < 3cm surrounded by normal lung no LAD
Lung mass=>3cm
Low risk individual with t detect)
Substituted judgement in pt without decisional capacity
continue to make decision for pt cw previously expressed wisihes and values - “what would they do?” (substituted judgement)
If pt presents to ED without ability to express desires - emergency care is under IMPLIED consent - but once wishes known do not do what they woudl NOT wnat to do
No court appoitned guradian if pt expressed his views and subsequent decsions made by duly appt’d surrogate
Do not try to change decisoin of duly appt surrogate
Manage bacterial meningitis
S. pneumoniae, Listeria monocytogenes -
Empiric abx - vanc, ampicillin, 3rd gen ceph (ceftriaxone, cefotaxime) + dexamethasone (attenuate release of bacterial virulence component from lysis of bacteria)
may limit inflamm s/e from meningitis (cerebral edema, inc’d ICP) - give with 1st dose of abx
Only add rifampin if suseptibility shows sensivitive
Ext ventricular drain only with hydrocephalus
Repeat CSF only if have not impvoed in 36-48hrs
Age related memory loss
Memory loss that does not interfere with social/occupational fxn does NOT indicated dementia - requires no further eval and tx
(short term memeory - recall names, faces, location of placed objects)
MMSE does not indicate dementia
Mild Cognitive impairment - loss of cog ability that exceeds age related memory loss and DOES interfere with - 10-15% ppl with MCI meet dementia criteria w/in 1 year
If evidence of dementia or head trauma - need MRI/CT
apolipoprotein E4 = alzhemiers risk - no sx so no testing
No neuropsych testing if no fxn abn
Donezepil - improves cog fxn in pt with mild, mod or sev alz dementia - no role in age related memory loss or MCI
inflamm vs non-inflamm arthrtis
Rheum arthritis
Morning stiffness >1hr and synovial fluid count >5K = inflammatory arthritis
symm swelling of PIP, elbows, ankles - can also affect most joints
lumbar/thoracic spine and DIP spared
Usually symmetric, small joints of hands/feet
h/o non-inflamm back pain
If pt with inflamm back pain with new periph inflamm artritis - w/u for spondyloarthris or psoriatric arthritis
Fibromyalgia - widesspred chronic MSK pain at least 3 months - women 20-50, PE normal excespt widespead pain/tenderness - no active synovitis
OA - hip, knees, , lubar/cervical spine, PIP/DIP - asymmetric - no typically abrupt and simulantous (no elbow/ankle invovlement unless prior trauma)
Polymyalgia rheumatica - aching shoudlers, neck, hip girldle area - fatigue, malaise - weeks to months
Uric acid stones
urine alkalination with potassium citrate
allopurinol (XO inhibitor)
Pt typically with low urine volue and hyperuricosuria (high protein diet), tumor lysis - gout, DM, metabolic syndrome, chronic diarrhea
Get pH>6
limit protein
Don’t use aceetazolamide - can alkalayze urine but -> metabolic acidosis
CaCarbonate for Ca Ox stones to dec oxalate absorbtpion
Don’t use HCTZ or chloritalidone - increas serum uric acid - inc propensity for gout
Fulminant wilsons dz
Wilson’s dz
Young patient with acute liver failure (high INR, high AST/ALT)
hemolytic anemia, high retic ct, large fraction unconjugated bili
low alk phos
Zinc is cofactor in alk phos production - copper is competitive inhibitor of zinc - reduced alk phos prodxn
Referal for liver tx
Near 100% mortality without tx
Acetaminophen toxicity - pt h/o tylenol use and urine metabolites - no hyperbilirubinemia OR hemolytic anemia
Acute viral hepatitis - hep A or hep B +, (Ab to hep B shows immunity to hep B and IgG to hep A means past infxn and immunity to hep A)
Primary biliary cirrhosis (PBC) - DOES NOT presents as acute liver failure - pressentation progressive clinical decline - has CONJUGATED hyperbili, ELEVATED alk phos from inflamm of bile ducts in PBC
Treat severe COPD
Tx for COPD
Tiotropium, budesondie/fometrol inhaler, albuterol as needed - tapered prednisone after exacerbation
+Roflumilast - oral PDE-4 inhibitor (for pt with severe and very severe COPD with frequent exacerbations)
Strong anti-inflamm but NOT brocodilator (not for acute exacerbation) - shows modest inc in FEV1
S/e - diarrhea, wt loss, n, headache, backache, depression, dec’d apetitie, dizziness, occ neuropsych sx (depression/suidcidaltiy)
No long term oral corticosteroids - limited benefits adn many side effects (osteoprosis, glaucoma, adrenal suppresion)
No O2 unless < 88% PO2t show improved lung fxn or clinical outcomes in pt with stable COPD or acute exacerbation
Dx ostium primum ASD
Dypnea, enlarged right heart, fixed split S2 - inc’d murmur of RVOT (soft systolic murmur 2nd L ICS inc’d with resp), mitral regurg (holosystolic murmur at apex no change with resp), LADev, RVH, parasternla impulse, tall A waves, c/w osteium primum asd with associated mitral cleft adn MR
Aortic coarctation - early systolic murmur, occ diastolic murmur, - HTN, pulse delay upper to lower extrm, figure 3 sign on CXR - collateral flow around ribs
Pulm Valve stenosis - early systolic murmur 2nd left ICS, pulm S2 split (varies with deg of stenosis) - NO MR, EKG RADev, RVH
Small perimembranous VSD - loud holosystolic mumur with thrill, moves into S2 (normal S2 - no pulm HTN), no EKG abn, CXR ab
Asx patient with incident adrenal mass
Repeat testing in 6-12 months
2.5 cm mass no clinical (HTN, elect abn, glucocorticoid excess)/biochemical signs of excess hormone secrtion of glucocorticoid, mineralocorticoids or adrenal androgens, or catecholamines
Size < 4cm, housfeld <20 units not suspecious for malignancy -
Pt with early pheo or cushings may have no clinical manifestations - always screen for both with any indicental mass, (urine metaneph, low dose dexamethasone suppression) hyperaldo screen - serum aldo to renin ratio
no MIBG - hunt for pheo - if not HTN or biochem excess of catecholamines
MRI not needed
No indication for surgery for incidental non fxn mass that is small
Anti-NMDA rct encephalitis
Limbic encephalitis
subacute memory disturbance, personality change, psychosis, enceph, seizrues, oral dyskinesia (invol mouth movmements)
aw ovarian teratomas
Prodrome = flu like illness
FLAIR MRI - temporal lobe enhancement
CSF - mild lymphocytic pleocytosis, normla protein
Anti-NMDA rct ab in serum or CSF
Tx: early oophroectomy, plasmapheresis, IVIG or corticosteroids
Anti Hu paraneoplastic encephalitis
motor or sensory sx
limbic encephalitis in 20%
aw small cell lung CA
Anti-Hu autoAb
Herpes encephalitis
limbic encephalitis memory disturb, seziures, psychossi In immunocompetant - more acute presentsion fuliminant sx over DAYS \+fever no oral dyskinesia CSF lymhocytic pleocytosis with or w/o elev protein (CSF can be normal) \+erythrocytes in CSF MRI flair in temporal lobes PCR CSF for herpes empiric tx with acyclovir
Viral meningitis
inflamm of covering of brain (not parenchyma - encephlaitis)
no memory disturbance, psychosis, seizures - CSF with lymphocytic pleocytosis
MRI enhancement of MENINGES not parenchyma
Post traumatic stress d/o
At least 1 month of sx including intrusive thoughts about event - , nightmares, flashbacks, avoidance of reminders of event, hypervigilence with sleep disturbance (sx in all three areas - re-expeeriencing event, heightened arrousal, avoiding reminders of event)
Co-morbid conditions - depression, anxiety, substance abuse,
Tx: CBT, -cognitiviely reframing thinking patterns and gradually re=exposing pt to truamatic event, stress management, SSRI
Generalized anxiety d/o
excessive anxiety and worry about VARIETY of events or activities fo rat least 6 months - difficulty controlling worrying, h/a, nausea, trembles, - ususally not particular inciting event
Major depressive d/o
5 or more of 9 cardinal depression sx in 2 week period
one shoudl be depressed mood or loss of interest/pleasure
change from prior fxn, with sig clinical distress/imppairment fxning
Obsessive compulsive d/o
recurrent obessesion/compuslions at least 1hr per day - marked disterss/impaired social fxn
Obsession - persistent thoughts, impulses, images - intrusive, aw anxiety/distress
Example: fear of leaving doors unlocked, germophobia
Compulsions - repetitive behaviors - ie handwashing, checking, ordering, coutning - repeated to dec anxiety from obsessions
Dx fixed airway obstruction using flow volume loops
Significant dyspnea with stridor and reduced inspiratory and expiratory flows without improvement with inhaled broncodilator
Fixed airway obstruction: flattened inspiratory AND expiratory volume loops (exp top, inspir bottom - alphab order)
Likely 2/2 tracheal stenosis from prolonged intubation
Dx: with CT (ie virtual bronch) or direct inspection from flex bronch
Not c/w asthma exacerbation - low FEV1, NO reduction in inspiratory flow, improvement with broncodilators - no corticosteroids needed
Lung volume measurement not needed - shows dec’d TLC since pt unable to take full breath 2/2 tracheal stenosis, - no evidence of fixed airway obstruction
Voice/speech therapy not needed - only for VCDysfxn
VCD - more inspiratory wheezing, heard over neck
No reduction in FEV1
Flow volume loops - preserved exp loop (top), flattened inspiratory loop (bottom)
Manage acute uncomplicated cystitis
Nitrofurantoin x 5 days if sulfa allergic (normally use bactrim if < 20% local resistance)
DO NOT USE IF PYLEO suspected
Don’t use amoxicillin or ampicilin - high freq of E coli resisance unless shown to be susceptible
Fosfomycin - inferior and not to be used if pyelo suspected
Flouroquinalones (levofloxacin) alternative for pts intollerant to first line agents or live in areas that >20% resistance to bactrim - should only use in more serious infct than acute cytitis
Manage chondrocalcinosis
No treatment for asx chondrocalcinosis - manifestation of calcium pyrophosphate deposition dz (CPDD) - crystals deposit into cartilage - or released into joint - acute PSEUDOGOUT -
Deposits in cartilage of wrist and knee
HypoPhos, hypoMg, hypothryoid, hemochormatosis, hyperPTH, - shoudl be screened and tx’d for udnerluing conditions
Tx with NSAID, corticosteroids, colchicine for reducing inflamm but not needed if asx (elec abn ruled out, thyroid ruled out)
No way to alter deposition process
INtraarticular hylaurine injection no benefit vs NSAIDs even though levels decreased in OA
Allopecia areata
Autoimmune dz with well defined round smooth area of hair loss with preserved follicular openings
Onset abrupt and occurs in younger otherwise healthy pts
No inflamm or scale (unlike other allopecias)
Hair at periphery easily extracted - tapering pencil point fx
Nail pitting
Spontaneous resolution
Personal/fhx autoimmune d/o (ie hashimotos)
Androgenic allopecia
gradually over years
hair thinning in crown and temples
Lupus
allopecia in well defined pathches - with inflammation, scaling and dyspigmentation
telogen effluvium
diffuse hairloss in months after pregnancy or surgery - isolated areas of diffuse allopecia not seen
Tinea capitus
fungal infection of scalp - well demarcated area of allopecia - PROMINENT SCALE +- erythema
Opioid induced constipation manageemnt with methylnaltreoxone
Opiod analgesic constipation
micro opiod rct antagonist - methylnaltreoxone - helps with constipation s/e without reducing anlagesia
Naloxone - tx of opiod OD - counteracts neg effects of respiratory depression and central nervous depression
Diatrizoate sodium enema - could help pt if not respondin gto other measures
Don’t just decrease morphine - inadequate pain control
Mantle cell lymphoma
multiple extranodal sites - bowel/BM
Oveerexpression cyclin D1 and t(11;14) translocation
worse features of both indolent and agressive lymphomas - incurrable - (like disseminated indolent lymphoma) but shorter mean survival -
Diffuse B cell lymphoma can invovle multiple organs but no cycliln D1
Follicular lymphoma NO BOWEL infovlement and no Cycline D1
Sezary syndrome - cutaneous t cell lymophoma - skin invovlement = mycosis fungoides - patchy areas to diffuse erythroderma range - infection of skin lesion - sepsis
NO bowel inovlvment
Focal segmental glomerulosclerosis
MCC nephortic syndrome in Black patient
nephrotic syndrome, microscopic hematuria, HTN, kidney dz, high chol, severe edema, low albumen
Secondary cuases = processes causing glomerular hypertrophy and hyperfiltration (toxin, infection, atheroembolic dz) but seondary with mild edema,
Bx: scarring/sclerosis of some glomeruli
IgA nephropathy - white/asian (rare in blacks)
immediately after URI, normal complement
microscopic or gross hematuria
proteinuria mild - rapid kidney faiulre rare
Deposits of IgA in mesangium on immuno study
Post infectious glomerulonephritis - several weeks afer strep/staph infxn - from immune complex dep on kidney, low complement - nephritic syndrome
Manage pt with recently placed DES for elective non-cardiac surgery
Elective surgeries shoudl be postponed at least 1 year of DAPT after DES
DES - at least 1 year of ASA plavix prior to elective surgery
BMS - 4-6 ASA plavix
Even after 1 year still risk of late stent throbosis likely from hypercoag period post op
Don’t just proceed to surgery on DAPT - may cuase throbmosis 2/2 hypercoag period after surgey = no reason to rush as surgery elective
UFH/ LMWH does not prevent stent thrombosis
Prevent transmission of hospital aquired infections
Hand washing with soap and water for at least 15 to 30 seconds or etoh hand hygene alternatives - also barrier precautions, gloves, protective equipment, transport of contaminated linen
Bleach to clean rooms for c diff but not acinetbacter
PPx antibiotic not as effective as proper hand hygene, +resistance
removing contaminated drain/catheters does not prevent spread to other patients
Stage 2 HTN
combination drug therapy for stage 2 HTN
>160/100
In pt age < 140/90
If >20 mm SBP need multi drug
Lifestyle mod - exc, reducing etoh, will not lower 20mmHg
Monotherapy won’t lower SBP 20mmHg
Need to initiate therapy after 2 subsequent high readings
Restless leg syndrome
movement d/o
ill defined discomfort or dysethesia invovled with legs when trying to fall asleep
coupled with urge to move 20’s to middle age
Familial
Tx: dopamine agonists or opiates (codeine)
Also with periodic limb movement - can be confirmed in sleep study
disturb partner sleep
can be aw iron deficency - check ferritin
both caused by dopamine def
Tx: dopamine agonists ie pramipexole or ropinrole
Akasthesia - restless coupled by urge to move but no dysethesia or or periodic limb movements
- generalized sensation not limited to legs
Nocturnal leg cramps - sustained muscle contx in calves,
Nocturnal myoclonus - limbs jerk suddenly as trying to fall asleep
Spinal fx risk in Ankylosing spondylitis
Xray back
Spine fx happen even with minor truama in AS
ossification of vertebral disk -> rigitidty-> dec’d ability to dissapate energy - >low mineral density -> easy fx
No prednisone for AS - bone loss and fx risk
Change to another TNF alpha in same class if recurrent symptoms -
Epidural steroid inj - radicular pain - no benefit in spinal stensosi or non specific back pain
Pt with bradycardia taking digoxin
CHECK DIG LEVEL
regularized ventricular rate in pt with afib taking dig=dig toxicity
coarse afib with regularized ventricular rate
=complete heart block with ventricular escape (this is why its regular)
(also sinus arrest, atach, jnc tach, av block, PVC, VT)
N/v, fatigue, vision abn, MS change
Dig cleared in kidney so with AKI/CKD tox more probable
DCCV only if afib with sx
Only TVP or dob if bradycardia is cause of sx (with good BP and HR in 40s likely not)
DIG cannot be removed with HD
Need digibind
Also aw hyperK+ as interferes with K+ pump into cells
Evaluate obscure GIB
Nuclear schintography - technictum - if pt has low bleeding rate (1mL/min
If HD stable and requiring blood only q3day likely not bleeding at this rate
MR enterography/CT not good for vasc blleeds only if there is RP hematoma (extraintestinal)
Small bowel barium enema - ID mass or crohns not bleed
Allergic broncopulmonary aspergillosis
Difficult to control asthma and h/o recurrent pulm infiltrates Consider ABPA Elev IgE, +EOS Aspergillus fumigatis Central bronciectasis - chest CT Check allergic skin test for Aspergillis
No use for bronch at this point unless reason to believe has superiposed OI or alt dx
Sputum gram stain can’t make dx of ABPA
Sweat testing if suspect CF - not likely given older age, no extrapulm sx - clubbing/ GI sx
Adrenal incidentaloma
R adrenalectomy
Tumors >6cm -> should be surgically resected
High attenuation should be resected (suggestive of malignancy)
Whether or not fxnal
Don’t just bx - no need
No need for 24 hr urine cortisol or Serum renin aldo ratio
HTN screening
> 18yo screened for HTN q2yr for those with BP < 120/80
Yearly screening for preHTN (120-139/80-89)
Preop eval in pt with sickle cell dz requiring tx
Minimize risk for alloimmunization using PHENOTYPICALLY MATCHED blood
C, E, K antigens and antigens already developed
avoid delayed hemolytic transfusion rxn
Need to get pt to Hg 10 to avoid Acute chest syndrome
HbS neg blood decrases risk for vasoocculisve crisis but not alloimmuniz
Irradiation dec’s risk of graft vs host dz, not alloimmuniz
Washed PRBC dec’s risk of allergic rxn (IgA def) but not alloimmuniz
Manage gout with urate lowering agents
Reduce frequence with both allopurinol AND colchicine
Gout - acute intermittent attacks of severe pain, redness, swelling of joint with intracellular crystals seen in polarized light -
NSAIDs, colchicine, steroids for acute attacks
Use of urate lower agent inc’d short term r/o gouty attack for ppx with cochcine approparitae as well
Reduce fructose adn purine intake, dairy, wt loss, etoh consumption
D/c urate inc’ing meds ie HCTZ, salicylates
Febuxsat MORE EXPENSIVE
colchisine only would not address underlying urate deposition
Gonnococal urethrtis
ceftriaxone and azithromycin
coinfection with gonorrhea and chlaymdia
intracellular diplococci -
Don’t just use high dose azithro
Don’t use cefoxitin - won’t cover chylmdia
Don’t use cipro - gonorrhea resistance
Acute diarrhea
most pt’s with diarrhea have self limited gastroenteritis
No testing or tx needed
work contacts sick with similar sx
Additinal eval if: fever, bloodly stools, elderly/immunocomp, hosptialization, food handler, recent abx use, , volume depletion, significant abd pain
Well hydrated, loperamide
C diff if recendt abx use
Fecal leukocytes rarely helpful
Flex sig only for persistent watgery diarrhea r/o microscopic colitis
Differenctial between type 1 & 2 DM
Check for pancreastic autoab - Islet cell ab or glutamic acid decarbosylase Ab
If + then DM1 - will start insulin right away
If - then DM2 - lifestyle modification/metformin
No need to check c-peptide - pt obese with hyperglycemia and no ketones is making insuliln - c peptides fasting or daytime and insuli will all be high
Treament pt with Parvovirus B19
Ibuprophen erythema infectiosum Schoolteach (elementary) polyarthralgia, flu like sx, slapped cheek rash IgM + parvovirus B19 (IgG past infection) NSAIDs for joint pain and fever
Azithro and PCN for bacterial infections
Strep - Rheum fever - migratory polyarthritis/fever,
erytehma marginatum - evananecent pink macular rash on trunk adn limbs NOT face - expands outward, clears inward, antistreptolysin O +
Hydroxychloroquine - lupus/RA - low ANA and RF can be seen during parvovirus B19 infxn
Acute respiratory failure
contraindication for non inv ventillation:
resp arrest
CV instability
high asp risk
copious secretion
recent facial or gastreoesophageal surgery
craniofacial trauma or nasopharyngeal abn
burns
extreme obesity
NO nitro with hypotension
Pulm catheter placement only in certain patietn to address hemodyamics
Neuromuscular respiratory failure
Bedside vital capacity - assess impending resp failure in pt with NM weakness - along with negative inspiratory pressure
Serial ABG not good enough
CXR doesn’t tell enough
Rapid shallow breathing index - predict if patient can be successfully wheened
Incidental kidney mass
If found on CT - get kidney US to determine cystic vs solid
If US -> simple cyts, no further eval
If US-> not simple cyst - CT with contrast (check for local LAD, invovlement of renal vein)
Do not bx if >3cm
Do not wait for f/u 6 months for masses >3-4cm - highly suspicious
No reason for MRI
Antibiotic stewartship
Zosyn initially
Change to ampicillin - good narrow spectrum agent for sepsis
Nitrofurantoin - not absorbed in bloodstream well
Zosyn, imipenum, cipro too broad - need to descalate
Counsel patient regarding smoking cessation
assess tob use at every visit
advise smoking cessation
assess interest in quiting
assist with medication
FIRST SEE IF INTERESTED in quitting
Cervicitis
Mucopurulent cervicitis
elev pH, leukocytes, neg whiff test
Gonorrhea/chylmydia
Tx: 250mg Ceftriaxone and azithro 1gm x1
(Cefixmime alt for ceftx but also need azithro or doxy for chlaymidia) No flouroquinioones (cipro) for gonorrhea (resistance)
Cefoxtin + doxy - PID tx (+adnexal, CM or uterine tenderness)
Chronic kidney dz eval
Start with kidney US
esp if fhx kidney dz - may be genetic
(r/o obstr, echogenic small kidneys, polycystic)
CT only if can’t US
Kidney bx only if glomerular dz or kidney tx dysfxn
Radionuclide scanning - expensive, limited availablility not needed with accurate GFR equations
ALS
combined UMN, and LMN signs and sx - no pain
UMN - spasticity, inc’d tone, hyperreflexia, patholic reflexes
LMN - fasciculations, atrophy, decreased tone, hyporeflexia
(pt has brisk reflexes of upper arm with muscle atrophy/fasciulations of LOWER arm)
Carpel tunnel - no UMN signs - sensory and neuro sx - wk of thenar muclses
Cervical radiculopathy - no HYPERreflexia (UMN)
Neuralgic amyotrophy - inflamm of brachial plexus - severe pain in distribution of brachila plexus
- winged scapula
Takayasu arteritis
chornic vasculitis of AORTA and major branches
inflammatory
dilation/stenosis of major aortic vessels
h/a vertigo, visual impairment, renovascular HTN
Age 10mm in UE
Aortic dissection would be more acute
Buerger’s dz
small and med vasculitis of hands/feet
SMOKING
MEN
Kawasaki Arteritis
Coronary artery aneurysms, NOT large vessel
Thrombophilic screening
Do not perform during acute thrombotic event OR during warfarin use or on blood from right before initiation of warfarin
Perform 2-4 weeks after cessation of warfarin
(active thrombosis alters levels of protein markers)
Warfarin also dec’s protein C/S activity, inc’ AT3 activity
activated protein C resistance, FV Leiden, prothrombin gene mutation, antiphospohlipid Ab, lupus inhib, protein C/S def
High risk - first VTE <50yo, recurrent, 1st deg relative VTE before 50
Tuberous Sclerosis complex
Fhx kidney dz with b/l kidney cyts
Angiomyolipomas of skin, retina, kidneys, other organs
cognitive impairment, dec’d visuion, cystic lesions kidney
Ash leaf spots (hypomelanotic macules), dental abn (pits on dental enamel)
Need kidney US at dx and q1-3 years
ARPKD massive kidney enlargement at birth
Fabry dz - X linked d/o alphagalactosidase - NOT cystic dz, nephrotic range proteinuria, cutaneous angiokeratomas, painful parathesia hands
Complicated grief
> 6 months - yearning for loved one - other desires incapacitiated
Anticholingeric drug s/e - acute confusion/halluc
Generalized Anxiety d/o - excessive worry and anxiety of a variety of events - anxiety, fatigue, restlessness, sleep disturbance, fxn impairment
Major depression with psychotic fts - pt aware that they are not real (wife is really not there) - true psychosis pts believe they are real
Adult onset Still’s disease
daily spiking fever, salmon colored rash, arthritis, ELEVATED FERRITIN, multisystem invovlement
HSM
Labs: elev ferritin, leukocytosis, RF/ANA neg, anemia, thrombocytosis, abn LFTs
Not lymphomas as BM bx neg
Parvovirus B19 - arthritis and rash - days to weeks, after flu like illness
SLE - not with elev ferritin, spikig fevers, salmon colored rash
Barret’s esophagus
Q1yr EGD
Bx: intestinal metaplasia and goblet cells (no dysplasia)
If low or high grade dysplasia -> esophagectomy
BE-> inc’d r/o adenoCA
COX-2 inhib not proven
Endoscopic ablation on NON-dysplastic BE not recommended -
Surgical fundoplication - pt with reflux sx refractory to medical tx - not shown to decrease cancer risk in BE
Risk factors for Acute MI
Dyslipidemia and Smoking greatest risk of MI
HLD, tob, psychsocial stress, DM, HTN, obsesity, etoh, physical inactiveity, diet low in fruits/veggies
Manage nutrition in critical illness
Always feed enterally if possible
well tolerated, low complication rate
25kcal/kg/day
2g/kg/day protein - combat adverse effects of malnutritio
paraenteral nutrtion s/e infection, not superior to enteral
Immunonutrtion not proven
Lipid supplement not good
Manage unruptured cerebral aneurysm
4mm aneursym too small to cause h/a
low risk = t intervene on small aneursym - risk higher of procedure
Acquired hemophilia
Pt with no fhx or personal hx of bleeding
PT normal
PTT prolonged, corrects ONLY PARTIALLY with mixing study - aquired hemophilia or aquired inhibitor to F VIII
rare, life threatening
Bleeding mucocutaeous and multifocal (echymosses etc) - no hemarthrosis
Liver failure - defect in synthesis of all clotting factors - PT and PTT prolonged - except F VIII (prodxn in endothelial cells) - factor VII worse with shortest half life
Plts also decreased
Mixing study for PTT will correct completely
inc’d fibrinolysis
Factor XI - no prolonged mixing study - ashkanazi jews
lupus inibitor - NOT CORRECTED in mixing study - actually cause VTE and arterial thombosis NOT bleeding
Vaccination in immunosuppressed pt with inflamm bowel dz
Varicella and other live virus vaccines contraindicated
yellow fever, intranasal influenza, MMR, bCG, oral typhoid
IBD patients immunosuppressed if protein def, getting high dose steroids (20mg/day), 6mp, azathr, MTX, TNF alpha, natalizumab - should get before immunosupp
Should get HBV vacc, HPV, pneumococcal, regular flu shot (inactivated)
Familial hyperPTH
Mild hyperCa in young man with fhx of kidney stones and father with anesthesia induced HTN crisis
Neck mass likely medullary thyroid CA
Diarrhea from high serum Calcitonin from medullary thyroid CA
Undx Pheo - explains fathers HTN crisis during anesthesia
Brothers kidney stones from hyper PTH
RET-protooncogene
Benign hypercalciuric hypercalcemia
inactivation of Ca sensing rct - higher Ca levels required to suppress PTH - PTH normal or slightly elevated - no thyroid mass or pheo
Sarcoidosis
hyperCa from prodxn of 1,25 OHD3 from granulomas - would have abn CXR (hilar LAD)
Toxic megacolon in pt with UC
Tx: immediate surgery
1 week of bloody diarrhea unresponsive to medical tx
tachycardia, fever, hypotension, dec’d bowel snds, abd distenstion, transverse colon dilation on xray,
If stable, medical therapy can be tried - IV steroids, abx, fluids, bowel rest
CT scan inappropriate - needs surgery
Infliximab good for flares for UC but not toxic megacolon
IV steroids only for flares or stable toxic megacolon
SLE with pt conisdering pregnancy
Hydroxychlorquine - Preg cat C
reduces lupus flares
protection against organ damage, thombsos, bone loss
continued indefinetly
Pregnancy outcomes with SLE better in absense of active dz
Azathroprine cat D but ok for severe SLE during preg if dependent on steroids
Mycophenolate Moetif NOT DURING PREGNANCY
Prednisone if symptoms worsen
Prevent pre-eclampsia
Low dose ASA
Preeclampsia = BP >140/90, >300mg proteinuria AFTER 20th week
Sx: h/a, visual disturbance, liver dysfxn, fetal growth restriction,
Methydopa - dec’s bp but does not decrease r/o preeclampisa
Ca supp - only reduces risk if low Ca diet to begin with
Mg does not dec r/o eclampsia
Don’t need to keep bp <120/80
Manage secondary prev of CAD in asx women
Statin will reduce risk most!
Post menopausal, asx, overweight woman
pt with DM - LDL goal t reduce risk either in this setting
Suspected TTP
Check peripheral smear r/o TTP - look for schistocytes
microvascular aggregation of plts in brain and other organs (slurred speech, elev Cr, inc’d LDH
Pentad - Microangiopathic hemolyitic anemia, neuro defects, kidney impairment, fever, thrombocytopenia
tx: plasma exchange
Only bmbx if pt thought to have primary marrow failure in setting of throbocytopenia - pancytopenia/abn lymphocytes on smear
E coli O157:h7 - HUS but won’t change need for plasma exchange
No need for brain MRI
Utricarial vasculitis
Tx: Hydroxychloroquine
utricarial plaques fixed in location x 24hr
cutaneous small vessel vasculitis
likely underlying SLE with inc’d ANA and dec’d complement
Use least toxic drug - hydroxychlorquine
Methotrexate only if unresponsive to hydroxych or low dose steroids
Mycophenolate Moetifil - steroid sparing agent for steroid dependent cutanous lesions not responding to MTX, hyroxCh, dapsone
Cyclophosphomaide - severe refractory cutaneous vasculitis not responding to less toxic drugs
Unilateral sensoneural hearing loss
Rhine test - if bone conduction > air conduction - CONDUCTIVE HEARING LOSS
Webber test - pitchfork on forehead - if louder in affected ear then CONDUCTIVE hearing loss
-if louder in unaffected ear - sensoneural hearing loss
MRI to exclude acoustic neuroma/meningioma if not clearly 2/2 to menieres dz
Meniere’s dz - low pitched tinnitis
Behavioral therapy if underlying d/o w/u neg
Sudden hearing loss - immediate tx with corticosteroids -
BPPV - vestibular dizziness - otilith debris in semicircular canals - otolisth repositioning tx for BPPV
Pseduorelapse vs MS flare
Worsening of MS sx can be brought on by UTI or metabolic derangement
Pseudorelapse - tx UTI with 7 days of cipro
(urinary sx, fever, dipstick +) - likely due to urinary retention
Spasticity of legs and urinary sx
Supportive care also - ie antipyretic for URI - should give neuro sx improvement
3 day course of methylpredisolone - distinct MS relapse - don’t give with obvious UTI - could worsen situation
Don’t dec baclofen - could worsen spasiticity and not address urinary retention/UTI sx
Inc’ing oxybutynin - worsens urinary retention and hence UTI
Primary membranous nephropathy
Cl ft - nephrotic syndrome, hematuria, HTN, kidney failure, throboembolic events -
Risk factors for progressive CKD - older age, elev Cr dec’d GFR, male, HTN, secondary glomerulosclerosis, chronic tubulointerstitial changes - persistent proteinuria >4g/24hrs x 6 months, and decline of GFR = progression to advanced CKD
Tx: ACEi & statin
2/3 pts -> remission, 1/3-> progressive CKD
Avoid more toxic meds as 2/3 pts go onto spontaneous remission - initially avoid immunosupp meds (steroids, cyclophosphamdi, mycophenolate moetifil)
HIV tx failure
Tx failure - pt now with detectable VL when had previously undetectable viral load on same meds
Continue current meds and perform viral resistance testing - start new meds once testing completed
Don’t just continue current regiment without resistance testing - could lead to future resistance - don’t discontinue meds - partial suppression better than none (also selective pressure with meds onboard make resistence testing better - more resistant bugs when non-resistent bugs are suppressed)
Don’t just d/c drugs and test CD4 in 4 weeks
Manage r/o MVA in older pts
First step: ask pt and family about driving difficulties
recent near misses, getting lost etc
Risk factors for MVA - Age, visual deficit, dec’d motor fxn, dec’d cognifitve fxn,
Premature to ask to stop drivign - before assessing driving skills - refer to driving rehab, provide pt with info on safe driving
Local driving may be worse as more signs and confusion and congestion
Report to state only if seizures or immediate threats - need to evaluate pt first
Early latent syphillis
single dose IM benzathine PCN G
has neg syphillis result 6 months ago but now +
should screen HIV pt’s regularly
Partners should be evaluated and also be treated (regardless of serologic results)
If any doubt they will f/u serologic testing should just treat before dx established
Late-latent syphillis (>1 year or unknown duration) - 3 doses weekly IM benzathine PCN G
Neurosyphillis - Aqueous crystalline IV PCN G
CSF RPR >1:32, CD4< 350 - need to have CNS sx
Doxycycline to tx syphillis if PCN allergic!!
Mild persistent asthma
Mild persistent asthma - >2 days/week (not daily) wakes up with sx 1 night/week (not nightly)
Tx: add low dose inhaled corticosteroid
(alt: leukotriene rct agonits or theophylline)
Do not add long acting B2 agonist if not already on inhaled corticosteriod
Only add long acting B2 if medium ICS doesn’t work (don’t add B2 and ICS at same time)
Allergic immunotherapy not for asthma - just for allergic rhinitis
Central adrenal insufficiency
Pt with h/o pulm sarcoid now with adrenal insuff, hypothyroid, and hypogonadism - (low TSH and low free t4, low FSH/LH, low ACTH despite low morning cortisol and cortisol increases with cosyntropin stim test so adrenals ok)
Polyuria and hypernatremia - central DI
Needs pituitary MRI
likely involvement of pituitary adn hypothalmic stalk by sarcoid, pituitary adenoma or sellar/parasellar mass
No adrenal CT as likely central adrenal insufficiency
No lung bx -
No thryoid scan as pt has central hypothyroid
Abdominal aortic aneurysm in pt with significant comorbidieis
Pt is too sick for AAA repair no matter what dx testing would find
Elective repair of AAA >5.5cm indicated for patients who are good opeartive candidates
Not candidate for open repair - too many risks associated with endovascular repair post op for this patient
No reason for Abd US, MRI or CT (they are good modality for dx) but findings won’t change fact that this pt is not good candidate for repair.
Treat woman with low bone mass and post menopausal sx
Start Alendronate
Female with osteopenia and high FRAX score (fhx mother hip fx and slim body habitus) - bisphonsponates for >20% fx in 10 years or >3% hip fx in 10 years
and added that aromatase inhibitor will further decrease bone mass
Denosumab - monoclonal ab inhibits osteoclast formation - for pts with high risk of fx and multiple risk factors or prev fx’s
No estrogen in pt with dx of breast CA
Teriparatide - recombinent human parathyroid hormone - anabolic agent inc’s bone density and dec’s fracture risk but black box warning for osteosarcoma - contraindicaated if pt had radiadtion therapy which also in’cd osteosarcoma risk
Raloxifene - selective estrogen modulator - osteoporosis prevention - by FDA - vasomotor sx - associated with use so not tolerated in pt with hot flushes arleady
Mycobacterium marinum infection
Freshwater or saltwater mycobacterium
local innoculation boating, handling fish, other marine activities
granulomatous skin lesion
If untreated can locally extend to joint
nodular papules may form and ulcerate
Dx: culture joint fluid for mycobacterial infxn
Naeglleria foweleri - freshwater amoeba - freshwater lakes or underchlorinated pools - nasal exposure contraction - no joint infection but does cause nearly universally FATAL meningioencephalitis
Neiserria gonnorhea - sexual activity - not local presentation in skin break and marine exposure
no local arthrtis
Sporothrix schenckii - soil fungus - enter skin thru breaks -granulomatous papular skin infection - spread lymphatically to joint - should have soil exposure
Dementia with Lewy Body dz
Mild parkinsoniansm with prominent bizarre visual hallucinations (tiger and bears in backyard), dream enactement behavior, atremulous parkinsonianism
Pt recognizes halluncinations as NOT real but is still disturbing
Tx of parkinsonian sx will likely exacerbate hallucinations
Dopamine agonists CONTRAINDICTED
Tx: levodopa when sx treatment needed
Alzheimer’s dz - comorbid with demtia with lewy body - no parkinsonianism or dream enactment beh or bizarre hallucinations
Frontotemporal dementia - apathy, perservation, hoarding, disinhibition, personality changes
Neurosyphillis - no rapid eye movement beh d/o - can cause dementia
Manage pre-HTN
Lifestyle modification + recheck BP in 1 year
high risk to -> HTN
inc’d age and fhx - inc’d r/o -> HTN
given borderline BMI and lipids - lifestyle mods needed
Ambulatory BP - suspect whitecoat HTN, monitor difficult to control HTN, or pt with hypotention on therapy - or autonomic dysfxn
CRP - marker of inflammation - inc’d aw CV events - used to stratify pts with CV risk
No need to tx pre-HTN with meds
Turner syndrome
45XO short stature, shield chest, webbed neck Primary amenorrhea Bicuspid aortic valve (ejection click, early systolic murmur) aortic coarct, ascending aortic dilation inc'd r/o rupture 2.5cm2/m2 or greater
Down syndrome
atrioventricular septal defect (partial or complete)
cognitive impairment, upslanting palebral fissures, epicanthal folds, open mouth protruding tongue, short neck
Holt Oram syndrome
developmental d/o of heart and upper limbs
Autosomal dominant
40% sporadic
minor thumb abn to congiential UE defect
osteoum secundum ASD most common cardiac defect
Marfan syndrome
d/o of connective tissue
tall stature, arm span > height, long fingers, joint hypermobility, sternal deformity,
dilation of proximal ascending aorta, with or w/o MVP
Asymptomatic pancreatic pseduocyst after acute pancreatitis
typically follow acute pancreatitis and resolve on own - no dx testing needed
EUS only for pancreastic cysts - mucinous cyst - check for septation, echogenic mucin or mass
MRCP not needed because CT already showed no connection between pseduosyst and pancreastic duct
percut/surgical drainiage not needed - pt asx - if becomes sx or fever, pain, anorexia then drain
Pneumococcal vaccine
Pt’s younger than 65 with risk factors
chornic CV dz, HTN, chronic pulm dz (asthma), chonric liver dz, , DM, etoh abuse, smokers - ok for pts with mild illness (ok in hopsitalized pts) - core measures for PNA pts
Hep B - high risk pts for aquisition - travelocrs to endemic regions, sexual percutaneous risk (MSM, IVDA, health care workers)
HPV males 11-21, 22-26 ok) - genital warts, anal CA, transmission of HPV to women
Meningiococcal - adolescent living in dorms, miliary barracks or who are asplenic
TB induced Hypercalcemia
TB (granulomatous dz) produces 1,25 OH Vit D3 (also sarcoid, crohns, leprosy) - macrophages in granumomas convert 25->1,25 vit D
Will see low PTH in response (appropriate)
Dehydration won’t cause low PTH, just incd Ca
Parathyroid adenoma would have inc’d PTH
Humoral hypercalcemia - PTHrP - osteoclast activation, resorbtion of Ca in renal tubules, in’cd clearance of phos - usually when inc’d tumor burden
Hepatopulm syndrome
arterial hypoxemia - from pulm vasc dilation in seetting of portal HTN - aw cirrhossi - PO2 < 70mmHg, dyspnea
Dx: saline bubble TTE - see microbubbles in LA within 3-6 cardiac cycles - indicated dilated pulm vasc bed
Tx: Liver tx
Deconditioning does not cause hypoxiemia
Myocardial blood flow not affected by HPS
Portopulm HTN - PAH in pt with portal HTN-not aw arterial hypoxemia -
Asx Pt with stool samples with blastomycotic speiceis
Asx pt with blasto in stool - no need for further tx
no additional stool cultures to document clearance
-protozoal parasites frequently found in human stool - no diff in pts with or w/o diarrhea
Cipro no activitiy against blasto
Bactrim and flagyl ok
Sx tx for 48-72 hrs - immediate studies for pt immunocomp, severe sx, comorbidiies public contact (food preparers/childcare workers)
Topiramate s/e
inc’d r/o kidney stones - in’cd r/o cal phos/caoxalate stones
Dx COPD with spirometry
Dypnea, chronic cough, sputum prodxm, smoking hx
FEV1/FVC check bronchial challenge testing - uses broncoconstriction inducing chemicals
CT only if suspicion of lung CA - won’t dx COPD
DLCO - >80%= normal - presence of parenchymal dz and pulm vasc dz - normla in pts with abn spirometry and lung volume measures
VTE ppx in preg pt with h/o VTE (idiopathic)
Needs antepartum AND post partum ppx 6 weeks
LMWH
NO WARFARIN - embryopathy
LMWH/UF AND ASA only in pt’s with antiphospholipid syndrome and recurrent fetal loss
Can’t do with NO ppx
Mild cognitive impairment
reported memory loss, some impaired fxn, no other cognitive inovlvment
MMSE ~ 26
No problem with executive fxn, language diff, ADL,
Tx: Cognitive rehab - neuropscyh = ext memory aids and organiz/attention skills - some improvement in fxn
Alzhemiers - use anticholinesterase inhib - donezepil, galantimine, rivastigmeine - modest improv ADL, fxn (does not slow MCI -> dementia)
No role for PET
Pt with MCI to -> dementia at rate of 12%/yr
Uncomplicated type B aortic dissection
Medical therapy for HR and BP only
No need for urgent surgical or endovascular repair
Equal flow (equal contrast) in main lumen and dissection flap
Cocaine use aw aortic dissection
Medical tx - 90% 30 day survival
HR<60, SBP 100-120 - reduce aortic shear stress
in setting of cocaine use - use labetolol (both alpha and beta blockade)
If life treatening organ ischemia (ie renal, mesenteric, peripheral ischemia) then emergency fenestration of flap needed
PPX stenting of false lumen not better than medical therapy for type B dissection
Surgery or endovasc stenting for pain despite med tx, threatened aortic rupture, malperfusion syndrome
Identify cause of change in pt BP
Repeat BP measurement when one erroneous reading by staff - errors in position, cuff size, talkign, recent caffeine or nicotine
5 minutes rest, empty bladder, back supported, feet on floor, proper cuff size, cuff bladder 80% arm, on skin (not thru clothes)
Adjust meds only if repeated measurement has inc’d BP
Ambulatory BP monitoring if suspect Whitecoat HTN, masked HTN to see if BP ok outside office or hospital setting
Prevent high altitude sickness
Acute mountain sickenss/periodic breathing - when gradual ascent not possible - use acetazolamide
h/a, nausea, sleep disturbance (high altitude periodic breathing - altitude associated breathing change), fatigue,
Best tx: gradual ascent
Next best : acetazolamide 24-48 hrs prior
Accelerate acclimitazation by stabilizing ventillation, improve oxygenation, counteract fluid retention by mild metabolic acidosis
Also give to pts with cardiopulm dz
Dexamethasone - for established acute mountain sickness or cerebral edema
Effect of acetazolamide in decreasing HAPB not thru diuresis - furosemide won’t work
Zopidem won’t work for HAPB
Invasive aspergillosis after transplant (stem cell or other)
Aspergillis MC fungal infection after tx
(esp lung tx or neutropenic phase after hematopoetic stem cell tx)
Fever, dry cough, hemoptysis
Dissem to brain - h/a focal neuro def, MS change
Risk factor: neutropenia, persistent fever while on broad spec abx, pulm nodules
Tx: Voraconazole
(Fluconazole covers for candida NOT aspirgillis)
CMV PNA - less likely in first few weeks (can occur weeks to months out ie POST ENGRAFTEMENT phase) - also NO pulm nodules
Murcomycosis (zygomycosis) - rapidly progressive fungal infxn in pt with heme malignanies - or other d/o with prolongued neutropenia and immunsupp
(severe burns, trauma, DKA) - inc’d risk with corticosteroids, cytotoxic agents, deferoximine
Rhinocerebral/pulm inovlvment - most common
-less likely to be early fungal infxn following stem cell tx
PCP PNA - less likely in acute setting followign tx - chest xray b/l infiltrates - but can vary from normal to nodules, pleural eff, cysts, consolidations
Large granular lymphocytosis
Cause of Pure Red Cell Aplasia
absense of erythroid precursors in marrow, severe anemia, lack of retics,
Leukocyte and plt prodxn UNAFFECTED
Smear with large granular lymphocyte - abundant cytopalsm with azurophillic granules
CD57+ Tcells and clonality on T cell rct gene rearrangement studies
MDS - ineffective hematopoesis with pancytopenia and hypercellular marrow with dyerythropoesis
Parvovirus B19 = viral syndrome, malaizse, fever, arthraliga, - no splenomegaly - BM shows giant pronormoblasts - no large granular lymphocytes on smear
Thymoma - paraneoplastic effects - Myasthenia gravis, PRCA, hypogammaglobulinemia
Teratomas
Advanced Knee OA
OA dx clinically…no advanced imaging needed
Pain + 3 of following
age>50
stiffness t help
Subclinical hypothyroid in pt with multiple risk factors
+fhx, +thyroid peroxidase Ab, small goiter, desire to become pregnant
Subclinical hypothyroid - elevated TSH with T4 and T3 in reference range
Mild or no sx of hypothyroid
Tx for pt with TSH >10
Tx: lower threshold for pt with goiter, fhx thyroid dz, antiTPO ab or pregnant
Need to avoid hypothyroid during preg because cuases low birth wieght, inc’d r/o miscarriage, premature death, fetal loss, Optimal TSH in preg 0.5-2.5
FNA only for thyroid nodule
NO reason to wait 6 weeks and check TSH again
Thyroid scan only if nodule or painful gland + unecessary radiation risk
Azathroprine drug-drug interaction
Probenecid increases urate excretion - good in pt that is underextreter (low urine urate despite hyperuremia)
does also inc r/o kidney stones so need urine alkalyzation and aggressive hydration - use with caution in pt with r/o stones (ie h/o tophaceous gout or stones)
Azathroprine active metabolite broken down by XO - so DO NOT USE XO inhibitor or get azathroprine tox (ie allopurinol, Febuxistat)
Pegloticase - immunogenic - lowers serum urate by enzymatic digetstion - only approved for tx failure gout
Vaccination strategy in pt with HIV
FIRST check CD4 ct
needs vaccin against Hep B, varicella, MMR, dipthera, pertussis, flu vaccine
No live vaccines in immunosupp pts or HIV pt CD4200
Only inactivated flu shot
Hep B for HC workers, HIV pts and unknown hep B status - first get CD4 ct
Pt born after 1980, HC workers with and those borne before 1980 with high risk for varicella should get varicella vaccine - unles seroligc evidence or physician documented evidence of varicella or varicella vacc - PT SELF REPORT NOT GOOD ENOUGH
Sporadic Creutzfeld jakob dz
CJD (sCJD) - accumulation of prion protein in neural tissue - spongiform brain pathology relenteless sx progression progressive dementia myoclonus bland CSF findings non-dx imaging of brian Dx: need path of brain (spongiform changes EEG: 1-2 Hz periodic sharp waves CSF: 14-3-3 protein
Cryptococcal and mycobacterium inf of CNS - subacute to chronic meningitis
CSF: pleocytosis
h/a, fever, meningeal signs
NO MYOCLONUS
Tertiary neurosyphillis - dementia is possible - months to years - CSF pleocytosis
Chronic mesenteric ischemia
Abd pain after eating (30 min) -> weight loss
ie intestinal angina
fear of eating 2/2 pain
(contrast to acute mesesnteric ischemia - sudden onset)
Progressive - mild pain while eating, food intolerance then pain without eating
Risk: age, HTN, HLD, smokign
Dx: doppler (low sens) - MRI/CT angio
Tx: PTCA - definitive=surgical revascularization
Chronic pancreatitsi
pain, malaborption, new onset DM - chornic constant pain in midepigatrum -> back, exacerbated by food
COlonic ishemic/ ie ischemic colitis
reversible colonopathy, stricure, gangrene, , chronic colitis
acute onset LLQ pain - urgent defication - red or marron rectal bleeding
Gastroparesis
nausea, vomiting, bloating, postprandial fullness, early satiety, abd discomfort, succession splash
Hairy cell leukemia
Cladribine - single cycle curative in 80%
sx: fatigue, abd distention, enlarged spleen, no LAD
Pancytopenia
BM aspirate - “dry” tap
BM bx - diffuse infiltration - small lyphocytes hairlike projections
Don’t observe, treat - no further imaging (PET or CT) needed
Anthrax (bacillus anthracis)
flu like sx prodrome (crop dusters? - handling infected animals, wools, hides)
rapid septic state (hypotension, tachy, skin cool/mottled, diminshed breath sounds b/l)
CXR: widened medistinum (spores lead to tissue destruction and hemorrhage in mediastinal LN and cause diffuse LAD)
Spores lie dormant in soil - can be infected thru cutaneous, ingestion or inhalation
(doesn’t spread person to person)
Tx: Cipro, doxy, PCN
Erysipelothrix rhusiopathiae
gram + bacillus - occupational contaminated meat/fish usually cutaneous infection
LIsteria monoctyogenes
ingestionc ontaminated food/unpaturized milk - severe dz in elderly and immunocomp - usually diarrheal illness
Norcardia
cutaneous, lymphocutaneous, pulmonary, or central nervous system dz - nodular/cavitary lung lesinos
Acalculous Cholecystitis
Gallbladder inflammation in absense of obstructive cholelithiasis
Abd US - demonstrates GB wall thickening/distention
Chronic stasis of bile in GB from underlying dz
10% acute cholecystitis
Sx: upper quad pain, fever, leukocytosis, abn liver enzymes -
Dx: US - gall bladder wall thickenss, sludge, hydrops
Tx: cholecystectomy
EUS with bx would no give explanation for elev liver enzyes, distended gallbladder and fever
If no suspicion of AAC - MRI MRCP would be reaonaable to r/o biliary tract path - choledocolithiasis, biliary stricture, extrinsic
Liver bx if MRI MRCP neg and still abn liver enzymes
Chest pain evaluation in pt with intermediate pretest prob of CAD
Pt with atypical CP but age and sex makes him intermediate risk
Pt has normal EKG and is able to walk so Excercise treadmill stress test is best to start
Pharm nuc - only if pt can’t excercise 2/2 arthritis, deconditioning or advanced lung dz and in setting of abn EKG
Cath - only if pt has limiting angina despite OMT, high risk stress test result or sucessful resucitation from SCD
TTE - does not exclude underlying CAD (normal echo) - can assess LV fxn, valve abn, WMA
Appopriate medical therapy for CAD (pt with DM)
ASA, BB, statin
h/o CAD - ASA, BB
elevated LDL - statin goal < 100 (CAD+DM t go without therapy - needs all 3
Hypoxia altitude stimulation test
Predicts in flight hypoxia in COPD patients
PO2 < 70= indication for HAST
In flight O2 needed if during HAST PO2 < 50
if >55 no O2 needed
50-55 borderline - need stress HAST
EST, 6 min walk test, PFT do not predict in flight hypoxemia
GH deficiency
MC anterior pitutiary problem after Traumatic brain injury is GH deficiency
Change in body composition - inc’d central adiposity, reduction musle mass, dec’d bone density, dec’d libido
Dx: IGF-1
Do no just test GH - pulsatile hormone
Glucose tolerance test is for GH excess and suppressibility when suspecting acromegaly
Gonadotropin releasing hormone - don’t need if pt has high testosterone
Early rehab after stroke
Need early agressive rehab after stroke - pt at risk for DVT Speech/swallow therapists tx post stroke depression No ppx abx even if swallowing issues No role for carotid stenting
Evaluate pt for malignancy prior to kidney tx
Use CT with contrast (ok in pt with minimal kidney fxn on HD)
Only avoid nephortoxic agents in pt with significant kidney fxn residual
Intravenous pylography outllines collecting system - can’t tell malignant from benign masses
Don’t use MRI with GAD - nephrogenic systemic fibrosis (NSF) - edema, thickened skin - affects visceral organs
No PET for kidney masses - kidney has high baseline activity so PET useless
Evaluate pt with 2ndary h/a
Temporal arteritis
Tx: immediate prednsione tx -> temporal artery bx
Sx: elderly global non-descript h/a, progressively worse, maliase, fatigue, tenderness in scalp over temporal areas, elev ESR, CRP
No need for HCT or cerebral angio if doesn’t suggest stroke, aneurysm, CV occlusion
No LP if meningitis not suspected
Tx pt with HELLP and pre-eclampsia
emergent delivery of fetus RUQ pain, elevated liver enzymes, low plts, hemolysis (schisotcytes on smear) High AST/ALT Pre-eclampsia - HTN/proteinuria/edem (3rd trimester) (DDX - TTP, DIC, HUS)
No corticosteroids, IVIG
Plasma exhange only if sx persist after delivery
Asthma during pregnancy
No bronchial challenge testing during pregnancy - methacholine/mannitol cat C - can’t use
Just add long acting B2 agonist if not sufficent control with as needed B2 agonist (short) and ICS
Theophylline not preferrred in preg patients
Anterior uveitis
abrupt onset of eye pain and redness photophobia, tearing, dec'd vision, h/a urgent opthal eval Systemic dz associate - sarcoid, behcets, spondyloarthrtis, granulomatosis with polyangiitis (wegeners) Dx: check CXR r/o sarcoid HLA B27 - r/o spondlyoarthritis ANCA - granulomatosis with polyangiitis RPR - r/o syphillis
Posterior uveitis - sarcoid, TB, histo, syphillis, lyme
Anti DSDNA - SLE (retinal vasculitis)
Anti Ro/SSA - Sjogrens - dry eyes, corneal ulceration
RF - dry eyes, episcleritis, scleritis
Polyarteritis Nodosa
necrotizing vasculitis of medium sized vessels
aw HEP B!!
angiogram - aneurysm/stenosis of med vessels (renals)
ANCA NEG
fever, abd pain, arthralgia, , mononeuritis multiplex, ulcers, purpura, livido reticularis
Dx: skin/sural nerve or angiogram
Giant cell arteritis - large/med vessels of head/neck - temporal, opthalmic, ciilary - no kidney inovlvmenet
Granulomatosis with polyangiitis - necrotizing vasculitis - kidney and resp tract - p/w upper airway sx - sinusitis - kidney bx - pauci immune crescentic glomerulonephritis - no aneursyms
Takayasu arteritis- chornic vasculitis of AORTA and major branches
inflammatory
dilation/stenosis of major aortic vessels
h/a vertigo, visual impairment, renovascular HTN
Age 10mm in UE
Encounter with impaired colleague
Contact hospital admin and report right away for patient saftey sake (do not wait till monday, could harm patients until then)
Immune thrombocytopenic purpura (ITP)
No splenomegaly, normal peripheral smear Sx: none or mild to severe bleeding in setting of normal CBC - Can be drug induced If Plt>30-40 -> low risk Repeat CBC in 1 week
If < 30-40 or with bleeding
-steroids/eltrombopag
No need for BM bx if peripheral smear normal except for thrombocytopenia
Do not check anti-plt Ab - lots of false +/ false -
Carotid artery dissection
abrupt cervical pain + horners syndrome \+h/a (ipsilateral neck, face, orbit) horners, amaroxix fugax, retinal infarction, pulsatile tinitis, diplopia, stroke sx Etio - traumatic - chiropractic Dx: Imaging (angio/CT/MRA)
Not migraine if secondary h/a suspected
isolated horners unliekly in stroke
Cervical herniation not likely to produce horners
Tx pt with DM, HLD, Non etoh fatty liver dz with statin
Statin now
type 2 DM - poorly controlled
LFTs mod elevated but no other evidence of liver dz so ok to start statin even with mildly elev LFTs (3x ULN)
Fibrates don’t reduce LDL much
Don’t wait to start statin until glycemic control or LFTs normalize
Don’t use nicotinic acid first - can raise glucose/LFTs, can cause liver damage - adverse s/e
Treat older woman with cerebral infarct in stroke unit
Stroke unit admission - reduces mortality
beneficial 2/2 interdisciplinary care, emphasis on early rehab
No rehab yet - needs hemodynamic stability, etio of stroke determined (CV/vasc imaging)
No reason for ICU - BP does not need acute lowering
Treat aortic stenosis with LV systolic dysfxn
Surgical AVR
decompensated HF 2/2 severe AS
despite LV dysfxn has good gradients across stenostic valve - needs AVR
No BAV - only for pt with severe AS and hemodynamic compromise - as bridge to eventual AVR - if HD stable with diuresis then no need - high rate of restensosi w/in 6 months
No TAVI - only in pt with high predicted surgical mortality
No nitroprusside - only with severe AS c/b decompensated HF and low CO - not if responds to diuresis
Manage carbon monoxide poisoning
with CO poisoning and high carboxyHg levels
tx: 100% O2 and HYPERBARIC oxygen tx to prevent delayed neurocognitive impairment
(hyperbaric does clear faster but 100% O2 clears very well too if hyperbaric not available)
Mechanical vent not needed if resp failure not immienet, (or if evidence of airway thermal injury or low solubility toxin)
Pulse ox UNRELIABLE with CO poisoning/carboxyhG falsely reassuring o2 sat- need to follow ABGs or CO-OXIMETRY - monitor oxyhemoglobin levels
Cyanide poisoning
lactate level >90 specific for cyanide poisoning
tx: sodium thiosulfate
Dx malignancy in pt with SLE
Two newly enlarged supraclavicular LN - pt with SLE on immunosupressives with inc’d r/o Malignancy
(NHL, HL, lung Ca, hepatobiliary CA, cervical dysplasia)
Bx LN
Increasing immunsupp won’t tx or dx new LAD
Don’t need to test for TB in setting of new LN - need to bx r/o malignancy - TB skin test likely neg in setting of immunosupp anyway - LN bx will show TB if present
Small pulm nodule in pt at risk for lung CA
Pulm nodule < 4mm in smoker/former smoker - f/u CT 12 months - if nodule unchanged - no further imaging needed
Non-smoker - <4mm nodule (with no 1st deg relative lung Ca, or radon/asbesetos exp) NO F/U imaging needed
4mm or larger - follow guidelines
New nodule 8mm or larger with no old imaging - prompt calc and prob for malignnacy - consideration of additional imaging or bx
Solid nodule - stable on cxr or CT x 2 years is considered benign - growth is strong indicator of malignancy
Evaluate pt with probable kidney stones
Helical non-contrast CT (gold standard)
Stone hunt CT
New onset gradual abd/flank pain - urinalysis with hematuria and low grade pyuria - aw kidney stones
KUB can detect most radioopaque stones - false neg with small stones, uric acid stones, indinavir related stones, interfernce of overlying bowel (use to follow burden)
MRI can’t visualize stones
Intravenous pyelography very spec and sens but requires use of contast (contraindicated with aki)
Kidney US no radiation but lower sens/spec - may require confirmatory CT anyway
Treat asx patient for elevated risk for CVDz
Measurement of CRP can reclassify intermediate risk (framingham 10-20%) pt to either low or high risk
+ ASA and crestor to meds
CRP >0.2 with LDL < 130 - benefit from crestor + ASA
No benefit from B carotein, vitamin E, folic acid, vitamin C
Dx Herpes simplex infection
Perform HSV PCR
pt with HSV-2 genital - may have prodrome of prurutis but no gential lesions
Presense of fissure can be atypical HSV-2 presentation
(can also do viral culture - less sensitive)
Lymphogranulum vernerum - genital ulcer dz - L1,2,3 serovars of chlymdia
Painless papule or ulcer at site of innoculation, resolves without tx - > followed by PAINFUL unilateral inguinal LAD - with fever/malaise
Tzanck smear for HSV LOW SENSITIVITY - don’t use
Candidal vulvovaginitis - have vaginal pruritis/burning/fissures - but ALSO HAVE VAGINAL D/C - so if no vaginal d/c then no KOH mount needed
Post strep glomerulonephritis tx
Supportive care and diuretics/antiHTN for fluid retention and HTN
Immunologic dz triggered by infection - > release of immunoglobulins and activation of complement proteins (low complement) - depostited in glomeruli - activating cytokine pathways
Acute nephritic syndrome - rapid onset of edema, HTN, oliguria with low urine Na+, erythrocyte casts in urine
Do not require kidney bx for dx
Bx only if course or findings are atypical for PSGN or if no clear antecedent streptococcal infection
Early tx of infection can lessen severity of PSGN
Managment of PSGN is supportive only (extreme - HD if needed - otherwise diruesis and anti HTN agents)
Less common - PSGN can manifest as Rapidly progressive glomerulonephritis - advanced kidney dz
Tx: intravneous pulse methyprednisolone, prednisone, cyclophosphamide, cyclosporin or plasmapheresis - if early in course - condition could likely resolve on own with supportive care needed only
Manage esophageal adenoCA
After bx confirmed dx of esophageal adenoCA need STAGING with CT/PET and endoscopic US
SCC in upper esophagus
AdenoCA in lower esophagus
Sx: dysphagia for solid foods
Odynophagia is less common (aw ulceration of lesion)
other sx - CP, anorexia, wt loss, GIB, regurgitation
Endsoscopic bx - dx tumor
CT/PET - detect distant mets
EUS - tumor and LN staging
May also need VATS
In pt with mediastinal regional LAD - neoadjuvant chemoradiotx followed by surgery better surviival
No need for feeding tube if no wt loss or inability to sustain caloric intake
Loss of >10% body weight, evidence of malnutrtiion on exam or labs, inability to maintain caloric intake -> indication for feeding tube or perc gastostomy tube
Radiation tx - pt with localized CA and not good surgical candidate - or pt with clearly unresectable CA - or palliative care for pt with severe pain due to mets not controled with pain meds
Manage elevated liver enzymes in pt on statin tx
LFTs < 3x ULN ok or total bili >2x ULN
Measure LFTs prior to therapy and clinically after if evidence of liver dysfxn (clinically)
LFTs usually rise in first 12 weeks after starting statin therapy, are asx and resolve without d/c’ing statin (thought to be 2/2 leak of liver enzymes 2/2 inc’d hepatocytes permeability) - no associated hispatholic changes - most common with higher doses of statins
Statin only to be d/c’d if clinical evidence of hepatoxcity - usually only occurs in setting of underlying liver conditions or drug interaction (ie taking tylenol as well)
In setting of hepatoxiticty - persistent elev after d/c’ing statin - warrants further w/u with liver US
Common causes of liver dz should be r/o HEP C, Non etoh fatty liver dz, autoimmune hepatitis (ANA, SMA, Mitox)
Check serum Ab and liver US - withold statins till investigation complete
Low risk primary myelofibrosis (PMF)
Tx: close observation, palliative care as needed
chronic myeloprolif d/o characterized by overprodxn of megakaryocytes and bm stromal cell mediated collagen depostion - JAK2
Peripheral smear : leukoerythroblastic findings - tear drop shaped cells and megathrobmocytes
Bone marrow aspirate “dry” - unsuccessful aspirate
BM bx - marked fibrosis
Low risk: absence of: 10, leukocytes< 25, circulating blasts less than 1%
Allogenic hematopoetic stem cell tx - potentially curative for PMF but significant mrobidity/mortality - only consider if progressive dz -
Transplant preferred tx for younger pt with 2 or more adverse prognostic factors
Danazol - tx PMF related anemia if Hg<10 or tranfusion dependent
Hydroxyurea - if constitiution sx like fever, wt loss, night sweats, sx splenomegaly, problematic throbocytosis
Imantimib - appropriate therapy in pt with with CML (not PMF) - pt neg for t(9,22) translocation
**Manage MTX toxicity - DO NOT USE WITH ETOH or with liver dz
D/C etoh use prior to MTX inititiaion - can cause MTX induced hepatitis
Also caution of MTX use in pt with pre-existing liver dz
Want to continue folic acid - reduces MTX induced liver toxicity
Continue hydroxychloroquine - synergistic and lowers r/o liver issues
Steroids have good short term control so should be tapered to lowest effective dose NOT d/c’d with initiation of DMARD (MTX)
No absolute indication to quit smoking with starting MTX but good for overall health
Stage III thyroid Ca (Papillary)
> 4cm with LN involvement - tx with thyroidectomy/levothyroxin then radioactive iodine tx - decreses r/o recurrence and death
- relapse in 12% of pts with no evidence of dz after primary resection
Tumors not tx’able with surgery, levothyroxine and radio iodide therapy - are treated with ext beam radiotherapy or chemotherapy (cytotoxic drugs ie doxorubicin) - response is poor
Observation not good - need radioiodide tx
Evaluate patient with recurrent syncope
Patient with normal EKG, echo, holter/event recorder and still with syncope needs TILT TABLE TESTING
discriminates neurogenic vs orthostatic syncope and evaluate freuqent syncope in pt with psych dz (ie pt with no orthostasis)
EEG - in pt where syncope thoguht to be cuased by seizure - if pt no risk factors or prodrome, seizure activity or post ictal state - not likely
Excercise cardiac stress test - low yield for syncope pts at low risk for ischemic heart dz (normal echo, EKG)
Signal average ECG - detect altered depolarization through myocardium that leads to re-entrant arrythmias - that may not be evident on regular ekg - ususally for pts after MI to assess for r/o VT - not used for evaluation of syncope
Manage flare of UC with C diff testing
Pt with UC/Crohns with dz flare and inc’d diarrhea
Check stool studies, O&P, c diff
CAN HAVE CDIFF IN YOUNGER PT with NO PRIOR ABX USE in setting of inflammatory bowel dz
Especially suspicious is high WBC (>20K)
Tx: usually oral flagyl - however with inflamm bowel dz - can use oral vancomycin
If no oral intake - IV flagyl or vanco enema -
CT only if inc’ing abd pain, distention, rebound/tenderness, hypoactive bowel r/o toxic megacolon/perforation
RUQ US only if si/sx of cholelithiasis
Colonoscopy second linie if pt does not respond to c diff therapy, UC therapy or another infection therapy
Consider superimposed CMV infection in pt on long standing steroids for inflamm bowel dz - obtain bx specimen from colonoscopy
Pt with blood infection of vanc intermediate MRSA
D/C vanc and start DAPTOMYCIN
(vancomycin intermediate Staph aureus - VISA)
MIC >4mg/mL
Dapto is alt to vanc for VISA -
Don’t use linezold for blood infection of VISA/MRSA
Bactrim only for skin/soft tissue MRSA, not for blood infection
Don’t just increase dose of vancomycin when MIC high, won’t work and will cause vanc toxicity
Dx early severe atherosclerosis in pt with SLE
Long standing SLE - high risk for premature atherosclerosis and MI - need EKG stat for rapid dx and tx
SLE death pattern
Early: active dz and infection (immunosupp)
Late: CV dz - develop sx at younger age - women 35-44 - 50x more likely to develop CAD
Risk factors: DM, HTN, HLD - all worse with chronic steroids
longer course=more risk
n/v not typical sx of CAD - but not uncommon esp in F’s
CT angio of abd - for pt with abd symptoms - and postiive antiphospholipid Ab with unexplained abd sx - r/o mesenteric thrombosis and ishemia
CT pulm angio - next step if EKG normal - r/o PE - may p/w CP, dypnea, tachycardia - pain pleuritic
RUQ sono if suspect acute cholecystitsi - but unlikely without fever, RUQ tenderness
Dx Asymptomatic PDA
Continuous machine like murmur
Below left clavicle
envelops S2
No parasternal impulse, no pulm HTN, no pulse delays
Aortic coarctation
continuous murmur - obstruction from coarct and collateral flow
left infraclavicular region
+systemic HTN
+radial femoral pulse delay
ASD
fixed split S2
systolic murmur 2nd L ICS - inc’d flow thru pulm valve
diastolic rumble if shunt large (not audible in left infraclavicular space)
Pulm valve stenosis
systolic murmur 2nd L ICS INcreases with INspiration pulm ejection sound - dec's with inspriation no diastolic murmur unless PR as well
VSD
systolic murmur that envoelops S2
No diastolic murmur unless concominent AR
Aplastic anemia dx
Bone marrow fails to produce blood cells hypocellular BM and PANCYTOPENIA Bleeding(thrombocytopenia), fatigue(anemia), fever(neutropenia) Prodrome viral syndorme (EBV, CMV) Low retic ct, hypocellular marrow
AML
malignancy of myeloid progenitor cells
Age ~ 67yo
presentation similar to aplastic anemia
BM bx - abundance of myeloid cells (not hypocellular)
(can tx from MDS - philadelopha chrom t(9,22)
CLL
MC form of lymphoid malignancy Dx age 70s - unusual in young patients Symptoms vary - may be asx at dx Leukocyte count ELEVATED at dx BM bx: prevalance of lymphocytes
MDS
clonal hematopoetic stem cell d/o ineffective hematopoesis Tx to AML Incidence INCREASES with age NOT usually acute or in young patients BM: hypercellular (not devoid of cellular elements)
Type I gastric carcinoid tumor
Gastric carcinoid tumors noted on EGD for non-specific gastric sx as incidental findings
Type I gastric carcinoid tumor: single or multifocal -
95%
Tx: endoscopic removal of tumors + EGD surveillance q6-12 months for 3 years
Octreotide tx - symptom control for flushing and diarrhea in pt with CARCINOID syndrome (particularyly type II tumors in zollinger ellison syndrome or MEN type 1)
Octreotide inhibits hormone secretion from many tumors ie carcinoid, insulomas, gastrinomas - binds to somatostatin rct’s
Antrectomy - reduces G cell mass - lowers serum gastrin levels - thought to stimulate type I gastric carcinoid tumors - only for numerous tumors >5 or large tumors
Total gastrectomy - Type III - sporadic gastric carcinoid tumors - aw normal gastrin levels - unfavorable prognosis - justifies aggressive surgical intervention
West nile myelitis
Acute onset flaccid paralysis
Check West nile IgM ab assay
Transmission from bird-> mosquito-> human
Poliomyelitis like syndrome
NM sx - mild unilateral wk to quadriplegia with resp failure
Can overlap with encephalitis or meningitis
Ab better as viremia is brief in duration so PCR is neg in 40%
Ehrilicosis - febrile illnes with polyradiculopathy, occ meningioencephalitis but no focal paralysis
Borriella burgdorfi (lyme) - neuro sx occur >1month after infection Early dissemninated lyme - aseptic meningitis - cranial neuropathy, or radiculopathy - encephalopathy or encephalomyelitis also possible
CMV - polyradiculoapthy - but only in pt with advanced HIV - sensory loss and urinary retention
Treat infected cysts in pt with ADPKD
Cipro=good Cyst penetration
Flank pain with fever in pt with ADPKD
Can be infected cysts
no abn findings on u/a or u culture (don’t communicate with rest of urinary tract)
Tx: abx with good abx coverage for urinary tract bugs and good cyst penetration (cipro) - 2-4wks
nitrofunatoin, cephalopsportin, PCN (amoxicillin) DO NOT PENETRATE CYSTS WELL
Pt with ADPKD can also have cystic hemorrhage rupture - with flnak pain and low grade fever - however not likely if fever with elev WBC
Infectous arthritis with concurrent gout
Needs empiric abx - vanc + zosyn
Has gout attack - presence of tophi + intra/extracell neg birefringent crystals (urate)
Also with high WBC in synovial fluid >50K so ALSO SEPTIC JOINT
NEG GRAM STAIN INSUFFICIENT TO R/O infection!!!
Pt with chroic joint damage from frequent gout attacks and DM at higher risk for joint infection
Surgical drainage/debridement only after infection confirmed on ctx - tx with abx first (surgery first only if definite infection and inadequately perc drained joint)
Intraarticular steroids - for acute gout attack - whilte minimizing systemic steroid effects - but never inject into potentially infected joint
Also prednisone ok for polyartiuclar gout but never until infection definetly ruled out
Dx Masked HTN
Normal office BP with high ambulatory BP Need ambulatory BP monitoring Likely explanation for unexplained LVH inc'd r/o CV events suspicious if office bp normal and home BP high or discovery of unexplained findings like LVH
Cardiac MR - if hypertrophic CM suspected with nondx TTE - MRI can detect focal areas of scarrign and ventricular hypertrophy -
TTE findings of HOCM - asym hypertrophy of ventricle - preserved systolic fxn but has diastolic dysfxn
Treat with BP meds if ambulatory BP monitoring shows high BP at home
CAC - correlates with r/o CAD but not direct measure of severity of luminal CAD - not indicated for routine screening - can be considered for asx pt with intermedicate risk score for CAD - 10-20% - because CAC>400 indication for more aggressive preventative medical tx - won’t explain LVH
Dx Tuberculous pleural effusion
Adenosine deaminase >70u/L -> tuberculous pleural effusion (0.6, fluid protein/serum protein>0.5)
If ADA elevated - start TB therapy and get pleural bx
If left untreated can resolve spontaneously but may return as active TB
Negative pleural stain for acid fast bacilli DOES NOT R/O TB, pleural fluid cultures are also often negative even with active infection
Gram stain likely won’t establish dx
Bacterial PNA with parapneumonic effusion likely not case in subacute presentation - usually have more cells in bacterial pna with parapneumonic effusion
Evaluate woman with atypical CP
Excercise EKG stress
Despite higher false positive rate in women - use Excercise EKG stress first
Needs stress - has risk factors - Fhx premature CAD, HTN, HLD
Atypical - sharp, not exertional, localized, resting EKG normal - pretest probability intermediate
Excercise EKG stress ok in pt with RBBB, less than 1mm ST dep at rest, provides prognostic indication based on excercise duration, presense or absense of angina, magnitude of ST changes (DUKE TREADMILL SCORE)
No cath as pt pretest prob is intermediate (not high)
Pharm stress not indicated - pt able to excercise - dob (inc’s HR and contractility) or vasodilators (causes increases in relative bloodflow to myocardial regions not supplied by stenotic vessels) - exc provides additional dx info and prognostic info and is therefore preferred if possible)
Do not use imaging (echo or perfusion) in absense of baseline ECG abn - even though increases sensitivity of EKG stress - does not reduce cardiovascular events
Manage adrenal insufficiency
Glucocorticoid insufficiency 2 weeks after d/c’ing megastrol (has strong glucocorticoid activity) - suppresses hypothalamic pituitary adrenal axis - sudden discontinuation causes adrenal insufficency
Megastrol - used in patietns wth anorexia as appetitie stimulant -
Physical exam - plethoric rounded face, cervical fat pads, central obesity - cw exogenous glucoorticoid - also low ACTH despite low cortisol also
TX: oral hydrocortisone
No need for CT - is central adrenal insuff (inactivated axis)
Dexamethaosone supp test - used to investigate hypercortisolism -
Low dose DMS test - suppresses cortisol in pt with no pathology in cortisol production
High dose DMS - suppresses overactive ACTH cells in pitutiary but not in ectopic ACTH producing cells or adrenal adenoma
If ACTH low or undectable and cortisol not supperessed by high or low DMS then primary hypercortisolism likely
If ACTH normal to elevated, cortisol not suppressed by high or low DMS then ectopic ACTH likely - if no adrenal tumor then need CT to r/o other tumor producing ACTH
Dx Acromegaly
Sx: h/a, recent DM, HTN, glove/shoe size increase, painful knee/hip - sleep apnea, carpel tunnel syndrome, coarse facial features, frontal bossing, acc nasolabial folds, large tongue
Dx: check serum IGF-1 (high GH cuases liver to produce IGF-1) - DO NOT MEASURE GH - is pulsatile
If unclear can use glucose tolerance test - GH levels not suppressable by hyperglycemia in acromegaly
Prolactin not useful in dx acromegaly
MRI can show pituiary adenoma but not dx of acromegaly - after dx can do MRI to determine etio of acromegaly and size/location of adenoma
Interaction of OCP and anti-convulant drugs
Estrogen OCP can reduce levels of lamotrigene and other AEDs - need to increase dosage if starting OCPs or will lead to more seizures
(reduces levels 40-60%)
Check baseline drug level before OCP then check again 10 days after increasing AED and starting OCP
Don’t use low dose combined OCPs
Don’t use combined OCPs in pt taking carbamazepine, phenytoin, barbituates, pirmadone, topriamate, oxycarbazepine - inc meatabolims of OCP making useless
would inc r/o unplanned pregnancy
carbamazepine and phenytoin bad for pt with idiopathic generalized seizrues - may exacerbate
Don’t just keep AED at same level
Evaluate possible mechanical obstruction in pt with symptoms of achalasia
EGD
Pt with birds beak on barium swallow and
and esophageal manometry showing aperistalsis
Next step = EGD to eval esophagastric jnc
Failure of lower esophageal junction to relax
dysphagia, CP, regurg of food, wt loss (Deg of myenteric plexus) - leaves LES tonically contracted
EGD to r/o malignant mass (direct malignant infiltration or paraneoplastic syndorme)
Myotomy - 1st linie therapy after EGD confirms no mass at EGJ -
CT abd/chest - if mass discovered on EGD at GE Jnc - maligancies aw pseudoachalasia are usually adneoCA - need CT for staging - if metastatic spread - no surgery
Swallowed aerosolized steroids - eosinophillic esophagitis - young man with h/o asthma - food impaction, heartburn, dysphagia
Secondary spontaneous PTX
Need to admit to hopsital even for small (2cm
Needle decompression less effective than tube throacostomy
If air leak >3-5 days - consider difineitve tx with pleuredesis - chemical or thorascopic
Manage patient with Meningioencephalitis
Pt pw meningioencephalitis - AMS >24hrs aw fever, seizures, pleocytosis (CSF), abn neuroimaging
HSV MCC of meningioencephalitis (sporadic)
threfore empiric therapy should be started
If HSV PCR neg may d/c acyclovir tx for HSV
Oral acyclovir/valcyclovir don’t penetrate CSF well so do not use anyway
Usually pt with HSV encephalitis have abn MRI - if abn then continue acyclovir until 2nd CSF sample 2-4 days later -
If + HSV PCR then tx with IV acyclovir x 14-21 days
Influenza vaccine in healthy woman
All adults need vaccination against influenza yearly regardless of risk factors
Between Sept and March
Healthy adults either inactivated IM or live attenuated intranasal vaccine
HBV vaccine - all children and adults thru age 18, ppl with HIV or other recent sexually transmitted dz’s, sexually active but not monagamous, workers with occup exposure to blood, clients or staff of institutions for dev disabled, correctioinal facility inmates, illicit drug users, DM65 - also post partum women HC workers, adults in close contact with infants < 12months old - one time Tdap booster if not already given
Cyclic Mastalgia
40% premenopausal women
Tx: supportive bra
b/l throbbing discomfort during luteal phase
Education, reassurance, well fitted bra
Inc’d activity without use of supportive bra may exacerbate discomfort
20% resolve without intervention
If supportive bra dosen’t work - and severe persistent pain - try danazol
Can try tamoxifen if supportive bra doesn’t work - off label use for cyclic mastaliga - rarely a/w hot flushes/mentrual irregularity
Cyclic mastalgia dx’d if PNA, pleuritis, Myocardial ischemia, infection, costochondritis ruled out
If no palpable mass or skin/nipple changes - no need for dx mammo
Idiopathic intracranial HTN/Pseduotumor cerebri
DX: lumbar pct showing inc’d ICP with otherwise normal findings
Cl features: young obese woman, visual disturbances, tinnitis, progressive h/a, papilledema, normal brain MRI
CN VI palsy false localizing sign aw elevated ICP
No carotid US - carotid lesion won’t cause elev ICP or isolated CN VI palsy
No CT sinus - CN VI palsy and papiledema localizes to Intracranial cavity not sinuses - if 2ndary h/a invovling paranasal sinus cuased this they would extend into cranial vault which would show up on brain MRI and MRV
No MRI cervical spine - tension h/a would not cause CN VI palsy and papiliedema
Manage pt with H pylori gastric lymphoma (MALTOMA)
Mucosa associated lymhpoid tissue (MALT)
Gastric associated lymphoid tissue lymphoma
tx: flagyl, amoxicillin, omeprazole 14 day course
MALT lines digestive tract providing immunosurveilence
Malignant transformation of MALT B cells is consequence of chronic antigen stimulation (from H.pylori infxn in context of gastric ulcers)
removal of antigenic stimulus -> complete and durable remission
Involved field radiation tx - large cell gastric lymphoma or MALT lymphomas unresponsive to antimicrobial tx -
Chemo (rituximab or cyclophospamide, vincrisitine, prednisone) only if unresponsive to antimicrobial tx
Don’t just observe - maltoma will eventually progress and disseminate requiring more toxic therapy than abx+ppi
Vibrio vulnificus associated necrotizing fasciitis
Pt with liver dz (hemochromatosis) - at increased risk of necrotizing fasciitis 2/2 vibrio vulnificus infection after eating raw or undercooked shelfish(oysters) or following expoure of traumatized skin to contaminated sea water (warm brakish water ie gulf coast - esp summer months)
Hemochromatosis - with evdience of portal HTN (ascietes)
Pt with liver dz p/w sepsis and cutaneous manifestation of hemorrhagic bullae after possible exposure to waterborne, gram neg rod (Vibrio) - inc’d iron availability inc’s virulence and growth of vibrio (in addition to decreased opsonization and serum bactericidal activity found in pts with liver dz) -
Tx: cephalosporin/tetracycline
Babesia microti
babesiosis - tick associated infection - occurs in NE/upper midwest - flu like sx 1 week after infection from tick -
Peripheral smear shows intraerythrocyte parasites (maltese cross or ring form)
NO RASH - worse in pt with decrased splenic fxn
Tx: atovaquone/azithro
Capnocytophaga Canimorsus
G neg rod from dog or cat bite
cellulitis -> overwheling sepsis (pt with dec’d splenic fxn)
Tx: Augmentin
Ricksettia Ricksetti
RMSF Rash - palms soles wrists/ankles -> moves to center (trunk) maculopapular->petecial No hemorrhagic bullae Tx: Doxycycline
Manage Rheum arthritis with TNF alpha inhib
Use MTX WITH TNF alpha inhib
further reduction in Dz activity and radiographic regression
ongoing mod dz with eleve CRP and synovitis despite MTX
+adalimumab to MTX/folic acid/prednisone
Need aggressive tx to minizize sequellae
(etanerecept, infliximab, adalimub, golimumab, certolizumab all same)
ALways screen for TB first (can reactivate latent TB)
if + then treat before starting TNF
Do not d/c folic acid with MTX - decreases GI/hep toxicity of MTX -
Don’t d/c MTX - use with TNF
Don’t use sulfasaszine instead of MTX - less effective
would not improve and bad with RA with poor prognostic factors
Don’t just continue MTX - need to escalate tx
Use additional testing to risk stratify pt with intermediate risk of CV events
INtermediate risk - framingham 10-20%
CRP can reclassify intermediate risk to either low or high
pt may benefit from initiation or intensification of pharmacologic therapies such as statins
JUPITER Trial - hypothesis that middle aged healthy pt with elevated CRP and LDL < 130 - would benefit from statin therapy - showed ARR of 1.2%
Pt with no cardiac sx does not need stress echo or CT angio
BNP elevated and releaed from cardiac myocytes with inc’d preload, afterload or increased cardiac wall stress NOT inflammatory marker
- not used to guide intensity of tx for primary or secondardy prevention
Pt with high BP should be rechecked, lifestyle mod discussion,
Dx Pheochromocytoma
Pheo can cause paroxysmal HTN, diaphoresis, h/a, anxiety
Surge in BP can be 2/2 catechol release from tumor such as pheo
chromaffin cells derived from neural crest
secrete norepi - sustained or episodic HTN
Diaphoresis, palpitations, h/a (classic triad)
wt loss, dyspnea
arrythmias (atrial/ventricular)
catechol induced myopathy
measure 24 hr categholamine/metaneph in urine or plasma metanephrine(easier)
Therapy: first alpha blockade (terazosin) then surgical removal
Only after pheo biochemically confirmed get CT (MIBG scan)
No catheter angio of kidney - dangerous to stim pheo again and likely not RAS
No reason for echo
Hep B infection in immune tolerant state
Monitor LFTs q3-6 months in pt with immune tolerant hep B infection
High circulating VL but no signs of inflammation (usually pts from endemeic area where acquired perinatally)
As long as LFTs normal - low likelihood of liver dz
If at some point AST/ALT elevate then should be treated
No role for vaccine - pt already with viral load and is immunotolerate not making Ab
Liver bx only if AST/ALT elevated - if has inflamm or fibrosis - start therapy
Don’t start therapy now - pt immunotoleartnt and not likely to progress to liver dz as long as liver fxn tests normal -
Risk of gestational DM
Offspring of mothers with prepreg obesity and then gestation DM at risk for childhood obesity
Gestation DM - usually ID’d 2nd trim
Woman’s B cells can’t compensate for degree of insulin resistance due to placental derived factors
Dx based on OGTT
Could be due to genetic factors and maternal imprinting of genes during intraunterine life
Women with gestation DM likely to develop GDM in future preg and DM2 themselves
Maturity onset DM of young - aw genetic defects on enzymes or trascrition factosr but not getational DM
Type 1 DM - autoimmune -
1A - autoab vs beta cells or their products - anti-glutamic acid decarboxylase, anti islet cell, anti-insulin
1B - idiopathic - no autoimmune markers - asian/african
Neither aw gestational DM
Treat cancer related pain
Long acting morphine indicated in cancer pt with persistent pain throughout day or beyone 24hrs of tx with short acting opiods
Also give short acting for breakthru pain (should uptitrate long acting till good sustained pain control achieved (initial dose 30-50% pts current 24 hrs need)
Fentanyl patch takes 24 hrs to start working - should not be started on DAY OF DISCHARGE
Methadone - unpreicatable halflife - QT prlongs/arrythmogenic - if used need tomonitoring QTC - not ideal fo rlong term pain control
Don’t use difffernt short acting opiods - would interupt sleep with need to take more pain meds
Eaton lambert paraneoplastic sydrome
Eaton Lambert aw Small Cell lung CA
50% EL pt have SCLC - 3% with EL syndrome
Eaton Lambert - rare NMJ transmission d/o from ab againsst P/Q voltage gated (presynaptic) Ca Channels
Sx: prox limb wk, absent DTR, dysautonomia - dry eyes, mouth, constipation, ED
Improveemnt of DTR/muscle strength with brief isometric excercise (facilitation)
Dx: EMG testing/assay for P/Q CC Ab
Myasthenic syndrome not aw thymoma, carcinoid, fibrosing medisatinitis
Pulm Carcinoid - centrally located ENDOBRONCIAL tumor or solitary pulm nodule no mediastinal mass
Fibrosing mediastinis - infiltrative process obliterating fat planes - no focal mass
Thymoma - aw Myasthenia gravis - anterior mediastinal mass
Medication related adverse effect in elderly
Polypharmacy frequent morbidity in elderly
Overmedication in elderly pt taking many meds
Inc’d diuretic can cause overdiuresis/vol depletion - leads to dec’d kidney ability to clear kidney cleared drugs
Pt older than 65yo take many meds - Need routine review of meds
AKI not clearly cause of AMS
Always consider infection as cause of AMS or FTT in elderly
Neurologic exam should be focal to consider stroke…
Chronic kidney dz - bone mineral d/o
Do not start bisophophonates in GFR < 30
Bone scans can’t diff osteoporosis from other bone mineral dz NOT resposnive to bisphosphonates
Only if bone bx confirm osteoporoiss use it in GFRt tolerate vit D analogs because of tendency to develop HYPER CAlcemia -
FDA approved for ESRD and hyper PTH
For pt with stage 4 CKD - target for PTH is normal range
Sevelemir for pt with kidney dz and hyperphophatemia
Ca supp shold be 2gm /day or less between diet, suplement and calcium containing phos binders
Post polypectomy surveillance
Pt with high risk adenomas (>3-10 adenomas, >1cm, villous morphology, high grade dysplasia - size doesn’t matter)
NEED surveillence colonoscopy 3 years later (assuming complete colonscopy was performed to look for other cancer
Repeat colonscopy 2-6 months for sesille adenomas removed piecemeal to ensure complete removal
Colonoscopy 1 year - fhx of hereditary colorectal CA syndromes - or risk factors like inflamm bowel dz (UC/Crohns)
Coloscopy 5-10 yr for one or two small (<1cm) TUBUALR adenoma with LOW grade dysplasia
Dx suspected brain abscess
Traid sx - fever, h/a, focal neuro defects (only 50%)
1/3 are cryptogenic
if >2.5cm - shoudl do CT guided aspiration for definitive dx
microbioligic and histopath testing
Do not LP - has midline shift - could cause brain herniation
Whole body PET or CT shoudl not be performed prior to confirming mass is abscess vs tumor
Predict results of laser photocoagulation tx for diabeetic retinopathy
Panretinal laser photocoagulation - results in PRESERVED central vision with DECREASED peripheral vision (where burns applied) - noticable at night
More bloodflow to central retina as burns to periphery stop neovascularization
Visual acuity should stay same, not improve or deteriorate
Binocular and depth vision fxn of central vision so unaffected by laser photocoagulation
Secondary OA 2/2 hemochromatosis
Secondary OA inovlves joints not typically affected by primary OA
Check transferrin saturation to dx secondary OA 2/2 hemochormatosis
OA of MCP/PIP/wrist in absense of trauma unusual - should investigate for hemochormatosis
Shoulder/hip/knee/ankle
Check Xray - for osteophytes(hook shaped), joint space narrowing
Secondary chondrocalcinosis
Serum transferrin and iron sat
ANA - not needed = SLE can cuase inflamm arthrtis in RA distribution but non-erosive
No other sx of SLE (rash, serositis)
RF - dx of RA - not if asym joints with osteophytes/joint space narrowing
Not gout - so dont check urate - no tophi - distribution diff
Dx Antiphospholipid syndrome
Pt with h/o multiple first trimester miscarriages
Dx’d PE
+lab results - dRVVT 2 weeks apart, anticadriolipan, B2glycoprotein
Need mixing study for protonged PTT
ATIII def - inc’d r/o VTE - early in life and pregnancy morbidity - usually genetic - should have fhx VTE
Factor V Leiden - 5x r/o VTE - is aw preg mrobidity But NOT 1st treim miscarriages
MTHF redcuatase mut - mild to mod hyperhomcysteinemia modest inc’d r/o VTE - not aw preg loss
Natalizumab s/e
Progressive MF leukoencephalopathy
Natalizumab for MS
look out for new or worsening neurologic sx
If any suspicion on brain MRI - CSF tap for JC Virus PCR
IF + stop natalizumab and plasmapehreis to remove circulating Ab
Mitoxantrone - dose dep cardiotoxicity
IFN - flu like sx
Glatamir acetate - skin lipoatrophy at injection site
IFN beta - worsening underlying depression
Advanced stage head and neck cancer
Locoregionally advanced - Stage III, IVa/b without distant mets
Radiation, chemo +- surgery
Need multiple moadalities to attempt optimal therapy
Chemo only if distant mets (cisplatin) - too diffuse for radiation
Early stage (I & II) - surgery or radiation with curative intent
Manage asx thoracic aortic aneurys in pt with marfans
If aortic root >5cm - urgent surgical repair
Marfans - tall and thin, armspan > height, pectus deformity, long thin fingers, scoliosis, ectopia lentis (or just myopia)
Murmur = AR
No symptoms so no need for urgent hospitalization, IV bp meds or emergency surgery needed
Oral lsoartan and metoprolol - reduce rate of aortic root dilation in marfans if caught early - won’t help if already >5cm
No f/u TTE - already large aoritc root needing surgery
Epidermal spinal cord met causing spinal cord compression
Decompressive surgery best chance for future ambulation
Spinal cord compression from met to vertebra which then extends and compresses spinal cord
Need to dx and treat before motor symptoms
Corticosteroids should also be administered right away
then decompressive surgery
then radiation
Androgen dep therapy - gnrh agonist or sugical castration - adjuvant in high risk prsate dz - or first line in pt with incrasing PSA after initial therapy or with mets
Chemo not effective for met cancer causing spinal cord compression unless highly sensitive (ie lymphoma)
Radiation therapy - better after surigcal decompression (head to head surgery better)
Treat severe asthma
Omalizumab (anti IgE) - severe asthma with evidence of allergies and high IgE levels - refractory to high dose ICS and long acting B2 agonist therapy -
Reduces frequency of attacks/exacerbations
r/o anaphylasxi
Very expensive
d/c if no improvement in 6 months
No role for MTX, azathroprien for severe asthma
TNF alpha doesn’t help asthma
