Deck 4 Flashcards
Life threatening candidemia
TX: Caspofungin (echinocandin - micafungin)
Risk factors - exposure to broad spec abx, , paraenteral nutrition,
Alt tx: Amphotericin B (conv or lipid) but either would worken AKI
Fluconazole - for less critically ill - when more stable an step down from Caspofungin
Voriconazozle - little advantage over fluconazole
Manage colorectal screening in pt with positive fecal occult blood test
Only use FOBT if average risk (not with familial CRC syndrome pts)
If any + result -> Colonoscopy now
Immediate retest for FOBT or repeat in 1 year not warranted - need colonoscopy
Don’t do flex sig will miss bleeding source in proximal colon (prox to sigmoid flexture)
Manage meduallary thyroid CA
If medullary thyroid CA detected (staining + for calcitonin) then consider MEN2A/B - both have Pheo
Dx: Check plamsa free metaneph/normetanephrine
Elevated serum Ca - suggestive of medullary thyroid CA also
No radioiodie - iodine not taken up by parafollicular cells ini medullary thyroid CA
Need TOTAL thyroidectomy not lobectomy as medullary thyroid Ca tends to be b/l
After surgery - levothyroxin for hypothyroid
Levothyroxin without surgery not warranted - parafollicular cells NOT resposive to TSH suppression
Treat H Pylori infection after treatment failure with 2nd line regimen (quad tx)
bismuth, flagyl, tetracyclinne, PPI
Test of cure 4 weeks after initial course
Use urea breath test or H pylori stool antigen
(don’t use H pylori serology as will remain positive despite tx - however do use in initial dx in setting of GIB/PPI use)
(initial tx amox, clarithro, PPI)
Failure either 2/2 resistance or non-compliance
Most likely clarithro resistance - so don’t repeat regimen with clarithro (avoid prior abx)
Also esp in pt with h pylori ulcer need tx also with bismuth to help heal ulcer
Aquired hemophilia
Needs recombinent factor VIIa
uncomplicated vaginal delivery 1 day ago
prolonged PTT - doesn’t fully correct on mixing study - >
aquired antibody likely VIII
rVII bypasses need for VIII -> binds directly to plt -> generates Xa -> thrombin -> fibrin
DIC - microangiopathic hemolytic anemia, low plt, prlonged PT, dec firbrogin, elev D-dimer
NOT DIC so no FFP/Cryoprecip
Desmopressin - only if vWD - can cause post partum hemorrhage but would have had h/o menorrhageia, bleeding with tonsilectomy
Manage hypernatremia
Signficant hypernatremia
If no hyovolemia or sodium depletion
Correct with 5% dextrose Water
UT obstruction - tubular injury - concentrating defect
Edema and hypernatremia - excess total body sodium - don’t use saline solution, use D5W
Desmopressin used to tx central DI - but would have low urine osmolality
Urine osm < 200 with DI - no water dep test indicated
Neuroleptic malignant syndrome
Exposure to dopaine rct antagonists (antipsych - haldol, fluphenazine)
Hyperthermia, autonomic dysfxn, tachy, diaphroesis, seizures, labile BP, elev CPK, AMS, extrapyramidal signs, arrythmia, rhabdo
new meds, inc’d dose, or parkinson pt who d/c meds
Tx: d/c drug, ICU, supportive care, cooling, dantrolene, bromocriptine
Acute lithium tox - ataxia, agitation, tremors, fasciulation, myoclonic jerks
malignant hyperthermia - inherited sk muscle d/o precip by inhallational anesthetics (fhx rxn to anesthesia) - holthane, isofloane, sevoflorane, succinycholine,
inc’d IC Ca - sustained muscle contrasction /injury
tachycardia, hyper carbia, hyperthermia, arrheytmia
LIFE Threatening
Rhabdo/AKI
serotinin syndrome - high fever, muscle rigiditdy, cognifivve changes, shivering hyperreflexia, myoclonus, ataxia - need antecedent use of SSRI
Thyroid nodule
bx any nodule >1cm
bx smaller nodules if risk factors (fhx, radiation exp, cervical LAD, bad US characteristics)
Follicular neoplasm - 30% chance of harboring CA
Can’t diff malignant from benign adenoma on FNA
-> need thyroiectomy (partial or full)
If clear that patient has thyroid CA - suppression with levothyroixin ok
If pt has thyroid CA dx after thyroidectomy - then radioactive iodine
Don’t repeat FNA in 6 months - already suspicious needs thryoidectomy now
Eaton lambert syndrome in pt with small cell lung CA
Lambert Eaton - rare NMJ presynaptic d/o Ab vs volatage gated P/Q calcium channels
Sx: proximal muscle weakness
dysautonomia, dry eyes, dry mouth, constipation, ED
Facilitation - DTR and wk improves with brief isometric excercise
EMG and P/Q CC Ab confirmatory
Development of EL does not suggest lung CA activity or recurrence
Not brian mets - should be asx, or focal neuro def, aphasia, unilateral motor or sensory changes, h/a - would not cause generalized wk and dec’d DTR
Radiation tox - CNS - cognitive defects
Spinal cord compression -can be aw SCLC, typically aw back pain - wk aw Spinal cord compression below lesion but aw HYPER reflexia (UMN sign) prox and istal muscle wk, incontnenece, NO dry mouth/eyes
Spinal cord comp, rad tox, brain mets no aw facilitation - very specific for Eaton lambert
Antiphospholipid syndrome
+lupus anticoagulant, anticardiolipan ab, B2 glycoprotein Ab in setting of arterial thrombosis, vasc thrombosis, 1ST TRIMESTER MISCARRIAGES
Si: thrombocytopenia, livdeo reticularis, valvular heart dz, microangiopathic kidney dz -
May be primary or secondary to other Cn Tiss dz (SLE)
Elev Cr, proteinuria, non-inflamm urine sediment (microangiopathic kidney insuff)
Inc’d PTT - suggest lupus ac but needs further testing
aw raynauds/migraines
Not ITP - has low plts and easy bruising but no other signs of ITP
MDS - more common in older ppl - unexplaned cytopenia, usually more than one cell line, JAK2
If pt with neg lupus serology and neg antiphospholipid, would need BM asp/bx
Not SLE - no inlfamm sx ie rash, fever, arthritis, pleuropericarditis
Polymyositis
Subacute onset proximal muscle weakness No rash (heliotrope - dermatomyositis) bx gold standard for dx Bx: lymphocytic muscle infiltration with necrosis and regeneration, CD8 t cell infiltration of endomysium -
Dermatomyositis - similar muscle sx but with heliotrope or photosensitive rash in shoulder/neck/anterior chest, gouttron papules (hyperkeratotic red papuules on bony prominence)
Bx: CD4+ t cells in perivascular and perimysial areas
Hypothyroid myopathathy unlikely in pt with normal TSH
Inclusion body myositis - proximal AND distal muscle wk, Bx: rimmed vacuoles, reddish inclusions
Cause of hypophosphatemia
Proximal RTA type 2
2/2 nephrotoxic ifosphamide (chemo) analog of cyclophosmaide
INduces fanconi like syndrome (glycosuria in setting normal serum glucose, renal phosphate, urate and AA wasting) 2/2 tubular dysfxn from nephrotoxic agent
Minimzie tox by limiting cumulative dose
Hypo Phos = 5% = renal wasting - c/w fanconi/nephrotoxicity
Nausea/anorexia could mean malnutrition - but FE PO4 would be <5%
Oncogenic osteomalacia - hypophoshatemia - aw kidney phosphate wasting - seen in pt with small slow growing mesenchymal tumors, FGF+
Primary hyperPTH - would have hyperCa first then hypophos(inhibits prox reabsorption of phosphate)- no glycosuria in setting of normoglycemia
Anticoag for afib periprocedural situation
CHAD=2 or less with no additional risk factors ie TIA/stroke hx, mechanical valve - no periprocedural bridging needed - d/c warfarin and restart after procedure if no bleeding (12-24hrs after)
Chads 3/4 - or h/o remote TIA/CVA, mech aortic valve - managemnet individualized - bridging may be reasonable
Chads 5/6 - recent TIA or CVA, mechanical MV or rheum valve dz - bridiging with LMWH or UFH needed!!
Contraception options in women who smoke
> 35yo F smoker - no estrogen OCP - inc’d r/o VTE
or person h/o VTE/CVA
Can use progesterone only - mini pill, depot medroxyprogesterone, SQ progesterone implant, prog IUD
Estogen only patch NEVER good for contracetion - only HRT in postmenopausal women WITHOUT uterus
Combined estoge/prog patch/vaginal ring - still contraindicated in women who smoke
Pt with severe asthma exacerbation on mech vent
Needs prolonged exp time - severe airway obstruction can lead to breath stacking - auto peep
avoided by increasing exp time
avoids inc’d end exp pressures, dec venous, return, hypotension and barotrauma
inc inspriatory flow rate
good use of sed and anesthesia
If suspect HD compromise by autopeep - disconect vent and hand ventillate
Do not inc inpriatory time - will make PEEP worse
Don’t dec inspir flow - will make inpr time longer and peep worse
inc’ing minute ventillation will also worsen peep
Progressive supranuclear palsy (PSP)
Impaired VERTICAL eye movement
square wave jerks - inappropriate horizontal saccades)
suprnuclear gaze paresis
facial dystonia, axial rigidity
Inability to read can be from vertical gaze impairment
dementia - cognitifve slowing, passivity, apathay
Parkinsonian plus syndorme - ie Progressive supranuclear palsy - lots of falls
Imaging - marked atrophy of brain
Neurofibrillary tangles - basal ganglia, midbrain, brainstem - progressive
Not alzhemiers - no eyefindings or absense of tremor (would have forgetfullness, word finding and slow gait)
Not lewy body - no hallucination or REM d/o
Not parkinsons - no visual sx, would have tremor
Evaluate for autoimmune dz (connective tissue dz) in pt with nonsp interstitial PNA
NSIP - aw undiff connective tissue dz
If did not meet dx criteria at dx of NSIP and develop new sx then retest for CTDz - can develop later
With bx proven NSIP no need for BAL to r/o infection or malignancy
NO need for repeat lung bx
Don’t just observe with new joint sx
Cholesterol embolization syndrome
red to purple discoloartion of toes, livideo reticularis, elev WBC, ESR, AKI, fever - can progress to toe necrosis and escar - large vessel pulses usually not impaired
In setting of recent cath
Tx: supportive
Acute intersitital nephritis - AKI with EOSuria - hansel stain, 2/2 hypersensitivet to med - B lactam abx, PPI, infections, auto immune
Contast induced nephropathy - not aw systemic rxn (fever, WBC) or pain/discoloration toes
Delayed Hypersensitiveity rx - no localized distal digital rxn
Morton neuroma
burning pain on plantar surface in space between 3rd and 4th toe
inflamm/edema/scarring of small interdigit nerves
from wearing tight shoes or high heels
Tx: conservative, padding, orthotics,
if failes - cortiosteroid local injection
Hammertoe - flexion deformity of PIP toe normal DIP/MTP - pain, difficulty wearing shoes, corn
metatrasal stress fx - tnederness to palpation on fx site - no pain btween toes
Tarsal tunnel syndorme - entraptemnt psoterior tibial nerve at medial maleoulus - pain and burning sensation - mimicks plantar faciitis
Yersenia Pestis (PLAGUE)
- pneumonic plague - inhalation of bacteria - bioterroism - can spread person to person in resp droplets or from animals
(tx streptomycin, gentamycin, tetracyclein) - bubonic plague(MC) - purulent LAD near innoc site
- septicemic plague - septic presetation from eitehr of other syndromes
Endemic SW US (NM) - resevior rodents
bipolar staining gram neg bacillus - CLOSED SAFETY PIN
Legionella - inhallation of infectous aerosol from CONATMINATED WATER SOURCE (A/C, coolers) - usually PNA - gram neg bacillus - but NOT bipolar bacillus
CAP - with pseduomonas UNCOMMON in young ppl
Gastroenteritis - cuased by salmonella enteritis - does not cause PNA
ALL
Young women with fatigue and
Induction chemo - daunorub, vincrisinte, prednisone
Blasts are lymphoid - TdT+, CD10/20 (b cell markers)
+allopurinol and IVF
High risk patients with suitable donor benefit from allogenic stem cell transplant during first remission
Imantimib - BCR-ABL inhibitor for CML - tx for philadelphia chromosome t(9;22) ALL - if cytogenetics normal no need for imantimib
Leukapheresis - only if signs of hyperleukocytosis - resp abn, dypena, diffuse intersititial/alveolar infiltrates on cxr, neuro sx (dizziness, MS change, vision change, tinnitis)
MC in AML than ALL (rare)
Rituximab tx of CD20 + b cells in ALL not proven
BNP in obese pt with acute HF
BNP not elevated much in obese pt with HF
Volume overload - Elevated JVP, pulm crackles ,LE edema, pulm edema on CXR, kerley b lines, prom pulm vasculature,
Tx: IV lasix
BNP can also inc with Acute MI, PE, acute tachycardia
Inhaled iloprolost - tx for pulm HTN - pulm htn can also occur in pt with heart failure
No fever, WBC, URI sx, focal infiltrate or reticular pattern (atypical PNA) so no abx needed
SQ enoxaparin - for acute PE - more likely HF so diuresis not A/C needed
Menstually related migraine
PPX: topiramate
h/o migraine with aura - unilateral pulsatile h/a wiht preceeding visual aura with n/v - responsive to sumatriptan but increasing in freq
Needs ppx
2 or more days/wk - warrants ppx
Topiramate, propranolol, timolol, amitryltyline, divalproex
Butalibital no proven
Not pseduotumor cerebri as pt not obese and no papiledema
Don’t use NSAIDs daily - can have overuse of NSAID induced rebound h/a
OCP avoided as ppx in migraine in pt with atypica/extended aura (>60min) or with fhx stroke or other stroke risk factors)
Hypocalcemia management in malnourish pt with alcoholism
Hypomagnesiemia - in setting of hypocalcemia and proonged QTc - needs to be repleted IV to help correct hypoCa and prevent arrythmia - (low mg inhbits PTH and resistnace to PTH fxn)
No role for measurment of calciftonin
If need to measure vit D then measure 25 OH D3 not 1,25 OH D3
Serum PTH will be inappropriately low with pt with etoh abuse and hypoMg+
Manage shock in hospitalied patient
First volume resuscitation and monitoring in ICU
Si of shock - low arterial/CVP, tachycardia, tachypnea, CV sat < 70%, oliguria, acidosis, delirium, cold extrem, livedo reticularis
Vasopressors only if volume resusitation fails or life treatening hypotension
PRBC only if active bleeding, profound anemia, CAD, hypotension/lactic acidosis, Hg 7-9 ok
Hydrocortisone - not needed if fluids/vasopressors get pressure to SBP>90 - use in refractory shock
Colorectal cancer risk reduction
No specific meds to reduce risk of CRC
Just do routine screening according to risk factors
No evidence for ASA/NSAID/HRT (also bad because of r/o breast and endometrial CA) - blood thinners - more r/o bleeding than reduction in CRC risk (also HTN, kidney impairment, hemorrhagic stroke)
Tx Trigeminal neuralgia
1st line - carbamazipine (or oxcarpabzipien)
2nd line - gabapentin
Sx: older pts -paroxysms of face - pain in face/forhead - 2nd/3rd branches of TG nerve - seconds to mnutes with specific trigger points
Need MRI brain to r/o small but present r/o intracranial lesion
If herpes zoster/shingles cuasing TG nerve pain would also have vesicular rash - no need for acyclovir, valcyclovir, famciclovir
Medically refractory TG neuralgia could be tx’d with microvac decompression via craniotomy
prednisone - cluster h/a, temporal arteritis, would have elevated ESR/CRP - abn MRI?
Treat chronic cervical radiculopathy with neuro defects
Refer for surgical eval - cervical radiculopathy with progressive motor deficit and
defined anatomic ab (herniation with nerve compression) on MRI -> surgical eval to avoid permannet loss of fxn
Without progressive motor deficits - conservative approach ok - rehab/PT, local steroid inj (faster reilef)
continue analgesics and rest - all inapprporitae if progressive motor deficits
Preop COPD exacerbation
Pt with preop COPD exacerbation - delay elective surgery
should tx COPD exacerbation prior to surgery if elective
Broncodilator tx - corticosteroids and abx
prevents post op pulm complciations
(lung infxn, atelectasis, inc’d airflow obstruction)
Risk factors: smoking, poor helath status, COPD severity
Early mobility, incentive spirometry, deep breathing all dec periop pulm complications
Stable COPD does not require repeat PFTs if had recently
Roflumilast - PD4 inhib for chronic tx of pt with SEVERE COPD and h/o recurrent exacerbations
Don’t just go ahead with surgery - needs optiization and tx of COPD/exacerbation
Prevent travelors diarrhea in pt with inflamm bowel dz
PPX rifaximen - reduce r/o traveors diarrhea in pt with inflamm bowel dz
(or immunocomp illness, CAD)
highest risk mexico, south/central america, asia, africa (not south aftrica)
Def: 3 or more unformed stools/day, abd pain, cramps, n/v bloody stools, fever
Usually self limited
Enterogenic E coli - salmella, campylobacter, vibrio, shigella, norovirus
PPX only recommended in pt with risk ie inflamm bowel dz - usually cipro used but resistance occurs
Use rifaximien instead
Avoiding tap water does not confer much benefit but should do so anyway
Bismuth slaicylae is toxic and does not work well
Probiotics efficacy uncertain in travelors diarrhea
Antimotility agent ie looperamide not effective
Hyperkalemia causes
NSAIDS - ie celicoixib - inhibit renin synthesis - hyporenemic hypoaldosteronism - decrease K excretion - hyperkalemia
Transtubular K gradient - ratio of K in collecting duct to peritubular capillaries -
TTKG=(Urine K/(Urine osm/Plasma osm))/Serum K
TTKG normal diet 8 or 9
>10 in hyperkalemic state - reflecting excretion of excess K+
Low TTKG - defect in kidney K excretion in presence of high serum K
-> likely NSAID toxicity
B/l adrenal hemorrhage - adrenal insuff - loss of glucoand mineralocorticoid activity - also with hypotension, flank pain, fever, nausea
High K intake - rarely cuase of hyperK in pt with normla renal fxn - if tha twas case TTKG would be >10
Pseduohyperkalemia - in setting of plt>400, excluded if pt has EKG changes c/w hyperK
Dx Pancreastic CA using EUS
Elderly pt with painless jaundice
focal cutoff sign of bile adn pancreatic duct with upstream dilation
Next: EUS for detecting tumor (more senstiive than CT for small tumors) - and can bx tumor if found
MRI not as sensitive
Don’t use Ca 19-9 for screening or dx tool
Whipple should not be performed until defiintive dx made
Vent associated MRSA in pt with reaction to vanc
Change to linezolid
Good in lung tissue for MRSA/VRE
s/e myelosupp (esp plts) - weekly CBC
Not Dapto - bound by surfactant - can’t tx PNA
-is good for staph bactermia, R endocarditis, skin/soft tissue infxn, good for VISA where requirement for vanc is high
Don’t use rifampin - resistance grows quickly
Don’t use tigacycline - only for CAP - not for Vent assoc PNA or HAP
Drug induced SLE
D/C offending drug - infliximib -
on TNF alpha inhib - develop - ANA, anti DSDNA, Anti Sm,
Phototoxic skin rash - > likely DILE if autoab also +
Can use hydroxchloroquine to tx RA but need to d/c offending agent for DILE first
Don’t combine TNF alphas - marginal benefit and higher risk of infxn
Can increase MTX in absense of DILE if active synovitis occurs with MTX+TNF
HIT therapy
D/C heparin, monitior plt and start argatroban
HIT - dec’d plts 5-7 days after tx with heparin for DVT or other reason
Dx: Plt 4 ab or Serotonin release asssay
need argatroban and warfarin
DTI argatroban (cleared thru liver)
Don’t use lepirudin - cleared thru kidney - in pt with CKD!
No enoxaparin - will exacerbate HIT - also contraindicated with CKD
Don’t use fondaparinum - no evidence of efficacy with HIT and cleared by kidney so can’t use in CKD
Don’t just stop heparin - needs tx
Colonic pseduoobstruction - cause of hypokalemia
Urine pot-Cr ratio = UK+ x 100/U Cr
Ratio >20 - Renal K wasting
hypokalemia
Furosemide - blocks K uptake in thick ascending loop of henle and thru hypovolemia casuing secondary hyperaldo - further K losses in urine - K-Cr ratio should be >20 though
Vomiting/NGT loss - does not do much as most loss in this case 2/2 urinary K loss - K-Cr should be >20
Need very high bicarb and alkameia to shift that much K into cells…
Somatization d/o
constellation 2 GI sx 4 pain sx 1 pseduoneurologi 1 sexual sx Unexplained persistent sx Start before age 30 Need to diff from depression with somatic features
Malingering - concisouly fabricate sx for some secondary gain - somatiform d/o are unaware sx are manifestation of psych d/o - need h/o secondary gain
Celiac dz - wt loss, GI sx - no focal neuro sx
MS - can cause nausea - MRI neg so likely not MS, no somatizataion sx in MS
Treat depression
D/C buproprion and start setraline (SSRI MC rx’d depression med with sexual s/e)
Goal - achieve complete remission 6-12 weeks into tx and continue 4-9 months - check in at 2-4 wks for drug adverse rxn, suicide risk, - 6-8 wks for respones - use PHQ-9 to assess nature of response
Need at least 50% reduction in sx
Complete responder - continue tx for 4-9 months
Partial responder/non-responder - higher dose(already max), add 2nd drug or switch to new drug or psychotherapy(doesnt want)
Don’t use buspirone - anxiolytic - no anxiety sx
Don’t continue current therapy ifnot working at 8 weeks - change to diff drug in same class or diff drug
ECT - suicidal pt or severely depressed - psychotic features - need rapid response - pt not suidcial
Appropriate dx test for pt with abn resting EKG and chest pain
Excercise stress echo - pt with LVH with strain on resting EKG
Pharm stress indication - cant excercise, LBBB (false + anteroseptal rev defects on imaging at increased HR caused by excercise)
Stress with imaging - abnormal resting EKG - LBBB, Vpacing, ventricular pre-excitation, major ST-T abn, LVH with repol
CMR - not for finding ischemia - can show prior infarct/scar - also excercise gives additionial prognostic info.
Giant cell arteritis
Pt with unexplained fever and polymyalgia rheumatica - or for pt with suspected Giant cell arteritis whose temporal arter bx neg - get CT or MR angio of neck and chest -
PMR - hip/shoulder girdle stiffness/pain
GCA - can be confined to great vessels - need imaging of great vessels
No need for BM bx - without leukopenia/thrombocytopenia and normal smear (no exp of cuase of fever/joint pains)
Kidney/mesenteric angio - dx of polyarteritis nodosa - should also have abd pain, HTN kindey dsfxn or mononeuritis multiplex
MRI hips/shoulder limited use in pt with minimal PE findings
Evaluate post-menopausal woman for suspected ovarian CA
Post menopausal woman with ascites and pelvic mass on US
1st step - paracentesis and cytology exam
70% women have met dz beyond pelvis at dx
any palpable ovary druing exam shoudl be suspicious for ovarain CA - nuliparity and tob inc’d r/o ovarian CA
BRCA not useful - only one 2nd degree relative with breast CA likely not syndromal
No need for lap and bx at this poitn - paracentesis better first step - used for definitive staging if first step +
Cervical CA not likely given age and normal cervical exam
CA-125 - can’t be used to dx ovarian ca - not sensitive or specific - can be used to monitor after dx (also elevated in other dz’s PID, peritonitis, endometriosis)
Ankle sprain
Ankle splinting…
ankle radiograph only if can’t bear weight or bony tenderness to palpation at posterior edge of either lateral or medial maleolus
Grade II ankle sprain - partial tear of one or more ankle ligament - mod pain some difficulty bearing weight - NSAIDs, rest, elevation and ankel splint - no surgery
+- rehab
No need for corticosteroid injection
MRI only if simple ankle sprain don’t resolve with conservative measures or complex ankle sprain
Urgent surgical referral - grade III ankle sprain - complete ruputreof one or more ligaments - pw severe swellign, echymosses, instability, inablity to bear weight
Cluster h/a
Cluster h/a - severe unilateral pain
orbitotemporal region
15-180min
aw ipsilateral tearing/rhinorrhea, motor restlessness
male/tob user
cluster in 6-8 weeks, remission 2-6 months
Tx: Oxygen therapy
No amoxicillin for cluster h/a (or for sinusitis) - absnse of fever/purulent nasal d/c argue against sinusitis
No hydrocodone for cluster h/a
Oral sumitriptan doesnt help cluster h/a
(SQ/IN do)
Verapamil/corticosteroids for PREVENTION of cluster h/a not tx of acute episode
Very severe COPD with lung volume reduction surgery
Lung volume reduction surgery - reduces hyperinflation, improves efficiency of resp musclees, improves exp flow - only in highly select patietns as is very extensive surgery
1. b/l emphysema on CT
2. post broncodil TLC >100%, RV >150% predicted
3. Max FEV1 45 room air
5 - upper lobe emphysema better
No reason to inc O2 if O2 sat >=88%
Long term corticosteroids - limited if any effect
Pulm rehab not defiitive therapy
Treat migraine during pregnancy
Tx: tylenol along with antinausea - metochlopromide/ondasetron
non-pharm tx ice, hydration
Tylenol cat B
Migrains can cause adverse preg outcomes
low birth weight, preeclampsia, placental abruption, preterm delivery
No reason for ppx - too few attacks - adn amytripline cat c
Naproxen - can’t use during 3rd trim (PDA closure, materanl bleeding at delievery)
Oxygen for cluster h/a not migraine
Rizatryptan - Cat C - don’t use before tylenol
Manage pt with advance Hodkin lymphoma with neg PET after treatment
Finish remaining cycles of chemo
Tx: 6 cycles of ABVD - stage IV Hodkins poor outcome regardless of initial therapy
Pt with neg PET after 2 or 3 cycles of chemo have high likelihood of complete and durable remission with compeltion of cycles of chemo
In pt with +PET after 2 to 3 cycles - need intensification of chemo with bleo, etopiside, doxorubicin, cyclopho, vincristine, procarbazine, prednisone - also early high dose chemo and autologous stem cell support
No need to bx LN in on residucal LAD not visible on PET because results unlikely to show viable malignant cells
Total LN irradiation NOT needed - particularly with bone inovlvement not effective in achieveing complete remisiion and can limit additionial therpay 2/2 BM suppresion
Screen for HIV infection
all people age 13-64 should be screened for HIV
screening effective even in low prevelance settings - particulary effective given HAART therapy availability
need to confirm Ab test with western blot
(don’t western first - high false +)
Cholesterol screening: screen all pt 20-35 with increased CV risk, age 35 for pt with no CV risk
NCEP guildine - start screening at age 20 then q5yr if normal
DM screening - for all adults with BP 135/80 or greater
Screen all adults 45
Screen all adults BMI>=25 with one or more additional risk factor - gestation DM, HTN, HLD fhx DM2 in 1st deg relative
Hypothyroid - no agreement on screening - USPTF does NOT recommend screening
Manage complicated endocarditis
Needs AVR
complicated infective endocarditis - HF, abscess, fistula, severe Left side valvular regurg, refractory infxn despite abx therapy, recurrent embolic event esp with vegetation >1cm
NO delay in surgical intervention if surgical indications are met - complication likely won’t improve with medical therapy alone - likely worsen and increase operative risk
No reason to add rifampin for viridins strep - needs surgery
Cath not indicated - inc’d r/o emboization - worsending HD status - cath only prior to planned valve replacement if r/o CAD
Heparin does not reduce embolic events with vegetaivie lesion endocarditis
Site of care for CAP - CURB65
C - onfusion U - BUN>19.6 R - RR>=30 B - BP65yo Score 0-1 outpt therapy Score 2 or more hospitalization Score 3 or more consider ICU
ICU? - need for vasopressor or mech vent
minor criteria - confusion, hypothermia, hypotension requiring fluids, multilobar infiltrates, aPO2/FIO2 20
3 or more minor criteria -> ICU
Do not D/C pt need inpt therapy
Nutrition in patient with extensive burns
Most deisrable nutrition approach = enteral via NGT
need to supply hypermetabolic state - prevent mucosal bkdn, prvenet infection, loss of lean mass, assist in wound healing
Feeding thru stomach NGT best as keeps GI tract working and prevents atrophy
Even with burns and airway injury tolerate NGT placement
J-tube placement only if concern of regurg or if upper GI tract not working - J-tube perc also source of infectioin, no benefit in aspiration risk or reflux
Can’t do TPN thru peripheral - limited volume possible
not enough given high metabolic needs from burns
TPN thru central line - high risk of infection - particularly with burns - maintanence of access (needs to be changed), GI tract will atrophy, trace element deficiency, high cost - only use if parenteral options tried and failed or not tolerated
Proximal RTA (2)
d/c tenofovir (drug related damage to mitox - particularly in renal tubules)
Prox RTA (II)
glycosuria in normglycemia
hypophosphatemia (dec’d prox tubule absorption of Phos 2/2 damage from tenofovir)
proteinuria
Urine pHd tubular sec of Cr (reversible - not kidney damdage), no change in true GFR)
No role in check lactic acidosis - if elevated would cause AG met acidosis (this pt with normal gap)
Laxative abuse - NORMAL gap met acidosis - laxative induced bicarb lossses exceed ammoniagenesis so get metabolic acidosis with normal AG
Dengue fever
Flavivirus - MC mosquito borne viral illness in world
Carribean/Latin america/southern US
fever chills, frontal h/a, retroorbital pain, msk pain/arthraliga lower spine - nonsp maculopapular rash sparing palm/soles
Incubation 4-7 days
“breakbone fever”
leukopneia, neurtropenia, thrombocytopenia, mildly elev LFTs
prolongued fatigue
Full recovery usually
tx: symptomatic (no vaccine)
Leptospirosis - urine or tissues of infected animals - (rodents, small mammas) - self limited - fevers, myalgia, abd pain, conjunctival suffusion - RARE rash
Malaria does not cause rash
Yellow fever - subsaharan africa, SA NOT carribean
Essential thrombocytopenia
myeloprolif d/o - elevated plt count - in absnse of other conditions causing thombocytosis(secondary) >1 million plt
strongly suggestive
HSM possible
r/o reactive thrombocytosis - IDA, underlying inflamm d/o, cancer
Dx: plt >600 on two sep occasions >1 month apart
BM: hypercell marrow with megakaryocyte hyperplasia (morp abn), mega in clusters
50% JAK2
CML - WBC>100, diff all stages of cells
IDA - unlikely with normal Hg and normal MCV
P Vera - unlikely with normal Hg
Acute cholangitis
bacterial infection of biliary tract (CBD)
choledocolithiasis usual cause
Charcot triad - RUQ pain, fever, jaundice - septic shock and confusion -> reyanaud pentad
elder pt may not have fever, leukocytosis or abd pain
Empiric abx
imaging may not show ductal dilation or choledocolithiasis
ERCP=dx/tx - if high clinicial suspcion - also can tx while in there - bililary decompression
Broad spec abx
No chole in acute choangitis scenario - only after resolution of acute cholangitis
HIDA - looks for acute CHOLECYSTITIS
MRI with MRCP - clincial evidence of cholangitis and need for possible intervention - not possible with MRCP
Tx symptomatic hyponatremia
3% saline txment
hypotonic hyponatremia - SIADH (low serum Na and high urine osmol, high urine Na)
Uosm>200, UNa>40, low plasma Osm, no evidence of hypovolemia
correct 4-6meq in 24 hrs
if too fast - osmotic demyelination (cells shrink as water goes out of them) if >10meq then reverses with D5W +-desmopressin (ADH analog)
Do not use NS - will cause more Na out than H20 and make hyponatremia worse
Lasix only with asx chronic hyponatremia 2/2 SIADH - causes more dilute urine to be excreted
Tolvaptan - oral V2 vasopressin rct antagonist - asx euv/hypervolemic hyponatremia - causes free water diuresis
ADH - keeps free water in and causes hyponatremia (inappropriately in SIADH)
Tolvaptan blocks ADH receptor and fixes hyponatremia
Manage knee OA
Wt loss an excercise needed
Obesity most important modifiable risk factor for knee OA
Tibiofemoral knee OA - pain worse with weight bearing
tibiofemoral joint space narrowing and osteophytes
Risk factors: obesity, age, Female, joint injury (overuse, trauma, occupation), genetic factors
Wt loss/excercise better than NSAIDs
No celecoxib - inc’d myocardial risk in pt with CAD - can also cause dyspepsia
No effect of glucosamine sulfate in reducing pain
MRI knee - eval for meniscal or ligamentous injury - not needed if no locking of knee or neg exam for ligament or meniscal tear (ant drawer, post drawer, varus/valgus)
Manage fibromyaligia without depression
Pregabalin or SNRI (duloxetine, milnacipran) for fibromayalgia with or without depression
Fibromyalgia - widespread pain/tenderness for at least 3 months - fatigue, sleep disturnabce - mood d/o, cognitive impairment
Non pharm tx: aeorobic excercise - CBT
Fibromyalgia NOT inflamm conditioln - won’t respond to steroids or NSAIDs (NSAIDs may help in conjunction with SNRI)
No good evidence for SSRI in fibromyalgia
Manage post CRC surveilence
Colonscopy in 1 year after hemicolectomy
If possible endo/CT imaging studies to ID and remove synchronous malignancies
Colonoscopy in 2-6 months ONLY if preop colonoscopy can’t go through whole colon - need to go back and inspect whole colon early - removal of synchronous polyps - still need surveillence colonoscopy 1 year after surgery
Vasovagal syncope
uncomplicated faint - no further testing required if physical exam and EKG normal
3 P’s
P=posture - occured uring prolonged standing - similar prev episode aborted by lying down
P=provoking factors - pain/medical procedure
P=prodromal sx - sweating, feeling of warmth right before faint
Pts with situataion faint, orthostatic hypotension - shoudl undergo EKG but no further testing if physical exam and EKG ok
Hospital telemetry - undx syncope with known structural heart dz, high risk for arrythmia
Neuroimaging HCT - limited use - highest yield in >65 with neuro symptoms - h/a, neuro exam abn, head trauma, on A/C
Echo - if str heart dz suspected - ie murmur
Tilt table - suspected neuro not confirmed by history and physical exam - , recurrent episodes - and with suspected cardiac cause
Constrictive pericarditis
Sx: dyspnea, pedal edema, clear lungs, JVein engorgement
Elevated RH pressure - JVP, hepatojug reflux, pedal edema, Kusmall sighn (jugular vein engorment with INSPIRATION) -
ECHO - restrictive filling, ventricular interdependence (diastolic filling of one chamber impeding other - normally free walls would bulge out to accomidate but in constrictive pericarditis thickened pericardium doesn’t allow that) to and fro motion of IV septum
Cardiac CT with pericardial thickening
Complciation from CABG (risk factor - violated pericardium at some point)
Restrictive CM - cardiac amyloid - dypnea, right sided failure, restrictive ventricular filling - increased wall thickness -
NO LVH
NO ventricular interdependence
Cardiac tamponade - dypnea and JVD - need pulsus paradoxus >10mm Hg (abn decrease in SBP with inspriation >10mmHg)
Severe TR - dypnea/pedal edema, elevatged RH pressure
Holosystolic murmur - would see TR on echo
Treat heavy menstrual bleeding
Progesterone stabilizes endometrium stops uterine flow
Medroxyprogesterone acetate
for menorrhagia of known etiology (fibroid)
Estrogen/prog OCP - doses too low in combo pills to affect heavy bleeding
If pt orthostatic or dizzy then IV estrogen ok
r/o PE/VTE
Don’t just observe as pt has heavy bleeding
Factor IX deficiency (hemophilia B)
congential X-linked d/o
normal PT, prlonged PTT - corrects with mixing study fully
Post op and traumatic bleeding is severe
compartemnt syndrome is manifestation of bleeding diathesis (epistaxis, hemarthrosis)
Replacement of deificient factor is treatment of choice
recurrent hemarthrosis results in cripplling degenerative joint dz unless treated with factor replacement
CNS hemorrage also occurs
ASA/NSAIDs contraindicated
Aquired F VIII inhibitor - normal PT, prlonged PTT - INCOMPLETELY corrects with mixing study
Factor V def - prolonged PT AND PTT
Factor XII def - normal PT, prolonged PTT but NO BLEEDING associated
Psychogenic gait
Excessive elaborate gait that varies in appearance from moment to moment (inconsistent) - non-neurologic
inconsistent with lesion in CNS
unconvincing displays of weakness, extremem lurching without falling
Dx gait with chorea, dystonia, tremor, myoclonus hard to dx but with prolonged observation are consistent in pattern
Peripheral injury dystonia, PSTD with dystonia, Reflex sympathetic dystrophy - fixed dystonic posture coupled with pain, sensory chagnes and autonomic instability of limb
MS related spasticity tx
Tx: Tizandine, baclofen, cyclobenzaprine
UMN spasticity 2/2 MS and hyperreflexia
impaired gait 2/2 stiffness
PTx and anti spasticity drugs
No need for EMG - pt has normal CPK (so no inflamm myositis) or NM d/o (ALS)
MRI lumbosacral spine - only images lower spine - PE findings c/w upper spinal cord or brain lesions
Oxybutynin treats bladder spasiticty/overactivity - not a sx in this patient
Diverticular bleeding
Pt with painless rectal bleed - likely from colon - MCC is diverticulosis
PE unremarkable
unless large bloodloss -> tachycarida, orthosatsis, hypotension
Coloosocpy can ID diverticulosis and also r/o AVMs - tx both with epinephrine/electrocautery
Colon CA - rarely causes brisk arterial bleed - usually chronic occult blood loss
Melena - suggests UGIB - 150-200cc blood - hematochezia from UGIB suggests at least 1L blood - pt would be hemodynamically unstable
Ischemic colitis - sudden temporary reduction in mesenteric blood flow - hypoperfusion affects “watershed areas” (splenic flexure/rectosigmoid jnc) - can have dizziness
pw sudden onset crampy abd pain - bloody stool/bloody diarrhea
Limited cutaneous systemic sclerosis
Needs PFTs and echo
Skin involvement only in face and extrem distal to elbow
Dx lcSS - tightness/thickening skin swelling digits extending proximal to MCP
Without skin changes need 2 of following
Sclerodactyly
terminal digital pitting/ulceration
basilar interstitital fiborsis on CXR
ANA+
antecedent h/o raynauds
r/o PAH in ABSENSE of other pulm manifestations
need PFT/TTE for early detection of PAH
Esophageal dysmotililty common with LcSS but no need for barium esophogram if no sx of dyphagia
HRCT - needed only with sx of dypena or impairment of oxygenation with restrictive pattern on PFTs - not indicated without pulm sx or abn PFTs
RHC indicated with dyspnea or PAH noted or PAH noted on echo
Treat patient with stage III colon CA
Adjuvant chemo used to improve disease free survival after hemicoloectomy removed all visible cancer
Improving “disease free survival” increases period without recurrance - ie disease relapse delayed or even prevented
Clinical Benefit rate - outcome of cancer therapy given palliatively instead of for curative intent - with metasatic dz tx may only stabilize and not shrink tumor, sum of measurable complete and incoplete responsders as well as disease stability is clincial benefit rate
Disease specific survivial - percentage of patients alive without have recurrance of dz - excludes death from tx or other cuases wheether related or not - goal of adjuvant therapy is survival not just prevention of cancer recurrance and death
Aduvant chemo does not decrease risk of second GI cancer or other GI malignancies
Evaluate low intensity murmur
asyx benign murmur < 3/6 early and brief systolic lack of radiation absnese of additional heart snds emotional few extra beats NO ADDITIONAL TESTING NEEDED for asx benign murmur with no associated findings of valvular or cardiac dysfxn
Ambulatory EKG - 24-48hrs - continuouis or event activated - not indicated for brief palpiations without hemodynamic abn
Only for repetive frequent palpitations
TEE - pt with poor imaging via TTE, or to evaluate surgical repair feasiblity of valves
TTE - systolic murmur 3/6 or greater, any diastolic murmur, continuous murmur, holosystolic murmur, late systolic murmur, ejection clicks, murmur radidating to neck or back
Dx hypoxemia in pt with falsely elevated pulseox O2 sat
Need to get ABG
In pt with dyspnea and somnolence -
high chance of arterial hypoxemia from alveolar hypoventillation - with CO2 retention
Normal O2 sat on pulse ox does not exclude hypoxemia in setting of HEAVY smoking - carboxyHg high - false high O2 sat on pulse ox
No need for chest CT
CBC might show inc’d Hg in setting of long standing hypoxemia -not useful acutely
Echo not needed - might show elevated RH pressures 2/2 COPD/ corpulmonarle
Tx severe CHF with spironolactone
Add spironolactone
Pt already on standard med tx (BB, ACEi)
NYHA III-IV EFt inc BB with low HR and borderline BP
Eosinophillic esophagitis
Sx: Young man with with solid food dysphagia - foods stick in mid esophagus - occ heartburn, no issue with liquids - no wt loss - recent disimpaction of food
EGD - rings in esophagus - bx >15 EOS/field
Need to first exclude GERD which can also cuase EOS infiltration of esophagus - either PPI trial or ambulatory PH monitoring
If neg for GERD
Tx: swallowed aerosolized fluticasone
EGD dilation on if refractory to medical therapy (dont do early - inflamm makes mucosa fryable - r/o rupture)
No role for food allergy testing
Granulomatosis with polyangiitis
systemic necrotizing vasculitis - affect upper/lower resp tract and kidneys
can have upper airway - sinusitis, orbital/nasal, laryngeotracheal inflammation
Pulm sx - cough, hemoptysis, pleursy
CXR: MF infiltrates/nodules- may CAVITATE
Pauci immune glomerulonephritis (erythrocyte casts)
Initial clinical feature may be inflamm of salivary glands -
if untreated saddle nose deformity, nasal septal perf,
Sarcoidosis - inflamm lesions of orbits, trachea, nodular lung infiltrate - necrotizing sarcoid granulomatosis - intersitital nephortis not aw glomerular dz (no erythrocyte casts)
Sjogrens - salivary gland enlargement with lung infiltrates - trach inflamm/nodular/cavitary lung lesions absent
may cuase interesitial nephritis but NOT glomerular dz
TB - can invovle cervical LN but rarely in adults - can also be in Submandibular glands but does not explain glomerulopathy
Dx benign prostatic hyperplasia
need to r/o underlying UTI - check U/A first
nocturia, urinary frequency, hestiancy, retention, incmplete bladder emptying, incontinence
Post void residula - not needed for BPH - used for overflow incontinecne or neurogenic bladder
Elevated glucose - can cause freq/nocturia from osmotic diuresis but not weak stream or hesitancy
No reason to check PSA
TRUS - evaluatiion of prosatte CA - rarely causes lower urinary tract sx
Manage metabolic alkalsosis
Add acetazolamide
Metabolism of citrate from excess blood products -> prdocution of excess bicarb-> metabolic alkalsosis
Pt with cirrhsois - less renal blood flow - impairs kidney bicarb excretion (increased prox tubular reabsorbtion of bicarb) - increased bicarb load and met alk
Acetazolamide - promotes bicarb excretion
also dumps sodium
Lasix dumps NaCl but not bicarb - will actually worsen situation because pateint will become hypovolemic and experience contraction alkasosis then even less renal perfusion -
Isotonic saline - will not increase bicarb excretin - sodium cl will be retained from inc’d prox reabsorbtion of Na in setting of low renal perfusion - worsening ascietes/fluid ol
Octretoide - splancnic vasoconstrictor - used as adjuvant after endoscopic therapy for variceal bleed - - does not do anything about met alk - no need to dc
Avoid adverse outcomes aw opiod tx for pain
Pt has had definitive surgery for back pain 2/2 spinal stenosis and still has pain out of proportion for post op - not participating in PT 2/2 pain - not tapering pain meds - has risk factors for drug dep - fhx etoh abuse, age < 45, smoking,
Needs pain managment contract
Amitrylpline good adj tx but need to address opiod use first -
If have to use opiods - change to long acting tough not appropropiate for long term pain
No focal neuro so no imaging needed
Suspected CA MRSA PNA
Pt with cavitation and no known risk factor for HAP - tx for CAP (Strep pneumo, H flu)+CA MRSA PNA
ceftriaxone, azithro, vancomycin
Scenario - viral URI seems to be improving then suddenly worse - CA-MRSA superinfection
AKI in pt with HIV
Tenofovir induced nephrotoxicity mitochondrial damage to renal tubular cells (prox RTA II) Fanconi like syndrome Glycosuria despite normoglycemia Phophaturia causing hypophos AAuria mild proteinuria normal AG with LOW bicarb in serum low urine pH (distal tubule still fxn in acidifying urine)
Hep C assoiated glomerulonephritis - significant hematuria/proteinuria/RBC casts
immune complex d/o
HIV associated focal segmental glomerular sclerosis (collapsing form)
high VL, nephortic syndorme with high level proteinuria
Atazanavir - nephrolithiasis
Mild sx hereditary spherocytosis
Supportive care only
close f/u, immunizations, folic acid
Cl ft - splenomeg, fhx, leg ulcer/pigmented gallstones 2/2 chornic hemolysis - spherocytes on smear
Pt still able to goto college and run so fatigue no limiting - mild anemia stable
PPX Cholestyecotmy controversial - if knwn choledocolithiasis then ok
No benefit for pednisone for hered spherocytossi - treatment for AUTOIMMUNE hemolytic anemia
More severe dz with sx anemia, splenomeg, sk changes, extramedullary tumors - respond well to splenectomy
Manage pt with erythema migrans
Empiric doxy regardless of cause for EM
Either lyme or southern tick associated rash illness
both ticks endemic to Virginia
Erythema Migrans - expansive, target like lesion
Don’t need boriella burgdofi PCR skni testing with EM present - just treat
IV ceftriaxone with cardiac or neuro lyme manifestation
No need for B. Burgdori serology - false neg with early lyme or southern tick associated rash illness - just treat
Neuropscyh impairment common complication after critical illness
Post ICU neuropsych impairment - up to 75%
aw pt age, duration of vent, glycemic control
eps with severe sepsis or ARDS
Aquired dementia
correlated with hypoxemia
Not chornic DIC = would have issues with low plts and thrombosis
Critical illness polyneuropathy - risk factors - steroid use, NM blocking agents, DOES NOT AFFECT COGNITION
not likely if regained muscle strength
Prolonged NM blockade - aw paralytics in pt wtih liver dz - does not cause cognitive impairment
Assess risk of pregnancy outcome in pt with reduced kidney fxn
Check serum Cr to assess degree of kidney fxn - the worse the Cr/GFR - worse outcomes - r/o eclampsia, pre eclampsia + possible irrev decline in kidney fxn
Women normal shoudl be t predict preg outcomes
HTN aw CKD - not predictive of preg outcome - no need for amb BP monitoring
If dx known no need for repeat kidney bx - preg outcomes depend on level of kidney fxn not etiology kidney dysfxn
Diabetic amyotrophy
Lumbar polyradiculopathy Primarily muscles of thigh L2-4 Severe pain at onset followed by weakness/numbness over coming weeks aw DM - period of wt loss
DM Polyneuropathy - axonopathy - distal to prox sensory loss, parasthesias, pain, distal LE wk
Absnet/dec achilles reflex, stockig distrib sensory loss
Guille barre - no thigh pain - numbness and weakness symmetric start distally and radiate PROXIMALLY, tendon reflexes hypoactive in both legs
Meralgia parathetica - lateral femoral cutaneous nerve of thigh, sensory loss only over lat thigh, NO motor/wk sx
Manage excessive daytime sleepiness
First step in sleep eval - sleep diary
Insufficient sleep syndrome
ID number of hours sleeping/night
No need for EEG if no sz suspected
Polysomnography - if OSA suggested - less likely in young thin man without obvious upper airway ab - reasonable if sleep diary etc neg
Multiple sleep latency testing - establishes dx of narcolespy - done after insufficent sleep excluded and PSG r/o OSA
Noncompressive myelopathy from copper def
Gastric bypass hx
Deficiencies: B12, iron, Ca, folate, 25 hyroxy vit D,
Also copper, Mg, zinc, Vit A, B complex, Vit C
Pt with Myelopathy (hyperreflexia/upgoing toes)
-> localizing to posterior columns/b/l corticospinal tracts
B12, copper, neurosyphillis
Copper def also aw macrocytic anemia
(zinc def, malaborbtion, nutritiondef)
Folate def not aw myelopathy
Vit D def not aw myelopathy
Thiamine def - wernike korsekoff - NOT myelopathy
Vit A def - blindness, benign idiopathic IC HTN (pseudotumor cerebri) - not aw myelopathy
Early stage Hodkins lymphoma
Stage I/II - chemotherapy and radiation
doxorubicin, bleomycin, vinblastin, dacarbazine (ABVD)
Sx: palpable LAD or mediastinal mass
Hodkins highly curable in any stage
Never radiation along - some cases can do chemo only
Single agent rituximab - only role in lymphocyte predom CD20 + hodkins lymphoma
Don’t just watchful wait - always treat hodkins as highly curable at any stage
Immune thrombocytopenic purpura
Corticosteroid and IVIG - need rapid rise in plts 2/2 bleeding
Dx of exclusin - bleeding in setting of otherwise normal CBC (except low plts) - or organ dysfxn -
Need tx if plts t use rituximab
Splenectomy is only for refractory ITP (to med tx - last resort)
Aseptic meningitis HSV-2
recurrent episodes of fever h/a, vomiting, photosensitivity
meningeal inflamm w/o known bacterial or fungal cause
Usually virus
HSV-2 - meningitis (HSV-1 encephalitis)
genital lesions of HSV-2 preceed meningitis
CSF low leukocytes, higher/normal gluc, gram stain neg
Bacterial meningitis
CSF - leukocyte 1-5K, neutrophils, glucose <100 cells
Acute retroviral syndrome - fatigue, fever, pharyngitis, LAD
rarely CNS sx
Rash - diffuse maculopapular extrem, back, - not pruritic
b/l LE edema 2/2 LE edema due to venous stasis
dependent symmetric b/l le edema
compression stockigns, sodium restriction, leg elevation, weight reduction
venous insuff
Lower abd/pelvic imaging not needed (only if suspect lesions obstructing venous/lymph return) - not likely in otherwise healthy woman
No need for diruesis - may lead to orthostatic hypotension
don’t reliably move fluid from interstituim to vasc space in setting of venous insuff
LE venous duplex - r/o DVT - if no concerning sx or risk factors then no need for scan
Infectious esophagitis CMV
IV Gancyclovir
DDX odynophagia - infect esophagitis (HSV, CMV), pill induced esophagitis -tetracycline, iron, bisphosphonates, KCL, nSAID, quinidine
CMV - isolated deep ulcers with CMV inclusion bodies
Acyclovir - HSV infection only - not CMV - multiple superficial ulcers (not deep), GG nuclei, mutinuc giant cells on histo - +PCR for HSV
Fluconazole - for candida infxn - dysphagia not odynophagia - curdy white dep that adhrere to mucosa
Swallowed aerosoized fluticasone - tx for eosinophillic esophagitis
Familial Mediterrainian Fever
recurrent 12-72hr episodes of fever with serositis (abd or pleural), synovitis(monoarticular, LE), erysipeloid rash
sx begin in childhood
few times/year
kidney amyloidsos can occur in untreated ppl
Tx: colchicine reduces likelihood of acute attacks and amyloidosis
Adult onset Still’s dz
fever, rash, joint pain, serositis (pleural or pericardial)
Fever < 4hrs (not upto 72)
Rash - salmon colored - not painful trunk/prox extrem
VERY ELEVATED FERRITIN
Crohns
progressive fatigue, diarrhea with abd pain, wt loss, fever, estra abd manifestation - arthritis, skin rash, (erythema nodosum or pyoderma gangrenosum) - usually chornic not brief episodes
Reactive arthritis
monarticular arthrits but no fever or abd pain
+uveitis, urethrtis, arthritis
Cardiogenic shock
Mechanical hemodyn support for pt in CV shock with no improvment with iontropic agents
IABP placement - reduces afterload
Evidence low CO - cool extrem, AKI, confusion, elev LFTs, vol o/l (elev RAP, PCWP)
Conivaptan - vasopressin rct antag used to tx SIADH (hypervolemic hyponatremia)
PAC shows low CO even with ionotropes - can’t use diuresis while SBP still unstable - first IABP then possible diuresis
Nesiritide - pure vasodialtor - natriuretic/diuretic effect - NO IONOTROPE OR VASOPRSSOR effect - don’t use in setting of hypotension
Panic d/o
Tx: SSRI, CBT
Sudden panic attacks - acute onset somatic sx ie chest pain, palpitationis, sweating, nausea, dyspnea, numbness
“feeling of doom” 5-60min
aw agoraphobia
r/o cardiac, thyroid or pheo
not typical GI sx so no PPI, no cardiac risk factors so no reason for cardiac testing
Morphea
Cuteanous sclerosis that involves ONLY skin - no systemic manifestations
Hx similar to systemic sclerosis but no systemic sx
Limited - one or more discrete plaques of skin
Diffuse - can invovle limbs/trunk
No extracut sx ie GI, GERD, raynaud
Diffuse cutaneous systemic scloersis - skin thickening involving areas prox to elows/knees
Limited cutaneous sytemic sclerosis - skin disease that doesn’t progress prox to elbows/knees
linear scloerderma - skin thickening followed by dermatomal distribution on one side of body
Dx insulinoma with EUS
Pt with fasting hypoglycemia (5-6) likely has insuloma - if not seen on CT then should get EUS
MRI no better than CT
Penteotide scan not eff for insulioma - not enough somatostatin rct to be effetive
When preop localization not psosible then operative exploration needed
Pneumococcal Meningitis
Vancomycin + 3rd gen cephalosporin
gram+ dipolococci -> S pneumoniea
CSF with low gluc, high WBC, high protein
Can’t just treat with ceftx, no levoflox
Pt with HOCM and risk factors for SCD
ICD placement
Risk factors: Fhx premature death 1st deg relative
Ventricular wall thickenss >30mm
->ICD indicated
Pt with LVOT obstr, HF sx refractory to medical tx - septal myotomy or etoh septal ablation indicated (not if asx)
No EPS - pt with HOCM not reliable to risk stratify for SCD
No need for checking for blunted BP resposne during exc if already has 2 major risk factors
Amiod can be considered to prevent SCD in pt with HOCM with one or more risk factors - if ICD implant not feasible
Physical activities - only low intensity - golf/bowling, not basketball/bodybuilding etc
Plasma exch associated hypocalcemia
Calcium gluconate needed
perioral numbness, anxiety, vomiting, neuro instability during plamsa exh = calcium def
Citrate used chelates calcium
NS won’t correct hypoCa
diphenylhydramine only if rash/hives/utricaria
Epi only if anaphylaxis
Heparin - only if PE
Nonasthmatic Eosinophilic broncitis
non-prod chornic cough without apparent cause
check sputum for EOS
No airway responsiveness on challenge testing - differnetiaes from asthma
Tx: trial inhaled corticosteroids - need bronchial muc bx for def dx
No need for sinus imaging try antihistamine/decong first
Diet/lifestyle mod and PPI trial prior to 24hr manometry to r/o GERD
Hypoventillation 2/2 NM wk
bilevel Pos pres airway
decreases nocturnal pCO2, daytime pCO2 and sleepiness
inadequate alveolar vent
Dont NEED sleep study but helpful
CPAP only for OSA - and hypoventillation during sleep - this pt with NM wk has daytime hypercapnia also
CPAP only maintains airway patency (ok for OSA) but does not augment ventillation
DOn’t use just supp O2 can depress ventillation and worsen hypercapnia (if used only with BIPAP)
Trach - only if can’t tolerate non inv vent or has trouble handling secretions -
Screen for CKD
Fhx of CKD - should check Cr eGFR, u/a (blood, protein, casts)
also if h/o DM, HTN
Kidney US - only if h/o polycystic kidney dz in family or abnormal CKD screen
24hr urine cr precise estimate of kidney fxn only in case o fliving donor tx candidates
Radiouclide scanning - gold standard but expensive - only used occasionally
Evaluate pt with essential thromboctopenia
Pt with budd-chiari -> aw myeloprolif d/o like essential thrombocytopenia or p vera
Hepatic vein thrombosis
UQ pain, hepatomega, rapid jaundice/ascities, elev LFTs
+ finding -> need for cytoreductive therapy
CHeck for JAK2 V617F mut
Essential thrombocytopneia - >600K plts
Antiphospholipid syndrome - aw first trim preg losses, SLE - usual sites of thrombosis (art/venous) - calves
No associated thrombocytosis
Paroxysmal nocturnal hemoglobinuria - CD55/59 on flow cytometry
not aw thrombocytosis
complememnt med hem anemia
unusual area for thrombosis (splenic vein)
AT3 def - protein C def - autosomal inherited (dom/rec) - inc’d r/o VTE esp in calf but NO THROMBOCYTOSIS
Dx CF in pt with dz mimicking asthma
Check sweat chloride \+clubbing, upper lobe bronchiectasis Sweat Cl>60 then gene testing Milder cases can be misdx as asthma - then find to be hard to control
No need for dx bronch now
Echo - clubbing and suspected of congential heart dz - no other stigmata ie loud murmur, asym pulses, HF, cyanosis - no TTE for now
Diary of asthma sx and peak exp flow good to assess asthma control - but does not explain bronchiectasis and clubbing.
Risk factors for torasades
EKG with prolonged QT - likely 2/2 haldol which does inc QT
should d/c haldol
keep K>4, Mg>2
Risk factors: age, femaile, use of multiple QT agents - diuretics, impaired hepatic drug met, bradycardia freq PVC, h/o long QT syndrome
Should avoid QT proonging drugs in future
Dig, dilt, enox, bactrim don’t affect QT
Exc dig can cause acc jnc rhtym, reg afib, atach, HB, PVC, VT, VF
Dilt - AVB or sinus brady
Treat recurrent mild to mod c diff
Severe cdiff = WBC>15 and Cr >1.5x baseline
Tx: Flagyl 10-14 days even for 1st recurrence
NO long runs of flagyl - neurotox
Oral vanc only for severe c diff
Oral vanc + IV flagyl only for pt who drugs won’t reach distal colon (illeus/toxic megacolon)
2nd recurrance - prolonged vanc taper 4-8wks
elevated LDL in pt taking multiple meds
Use pravastatin - renally metabolized instead of hepatic
Goal t use rosuvlstatin with warfarin - will inc INR
Hep C associated Glomerulonephritis
Glomerulopnephritis Nephritic hematuria \+cryoglobins low complement (C4) \+RF Palpable purpura, arthralagia, periph neuropathy, Bx: capillary microthombi, diffuse IgM/cryoglobulin dpeosition in capillary loops
Polyarteritis Nodosa - systemic necrotizing vasculitis aw Hep B - bx vasculitis WITHOUT immune complex depsoition in glomeruli
Hep B - immune complex glomernephritis - would have labs showing active infxn
Thrombotic microangiopathy -microangiopathic anemia+thormbocytopenia - no depositoin of immunoglob/complement
Dx anemia in CKD
Need to check serum iron stores - iron, TIBC, ferritin
anemia in CKD 2/2 low EPO, EPO resistance
normocytic/chromic, low mcv, low retic
IDA - iron/TIBC = transferrin sat = low
ferritin >100 excludes IDA
ferritin 100, TF sat >20%
Assess driving skills in pt with cognitive impairment and Parkinsons
Need formal driving assessment - pt has visuospatiail task difficulty so could hinder driving - pt insistin gtha the is ok not reliable
Shouldn’t just relinquish licence or insisit on supervised only driving if unfounded
use clinical jusdgment based on hx - accidents, aggressive impulses/control issues, reduction in ability to manage own affairs, impaired spatial processing and executive fxn -
Daytime only driving won’t help - issue of visual processing not vision impairment
Evaluate for cholangio CA
Pt with primary sclerosing cholangitis
-continued intrahepatic duct inflammation/destruction
r/o cholangioCA - presentation is biliary obstruction/biliary stricture
Dx: ERCP - get cytoloic brushings/bx
Abd US not needed - show abn ducts as seen on MRCP - can’t do bx with US alone
CA19-9 NOT SPECIFIC do not use
No need for AST/ALT monitoring at this point - need bx from ERCP
Prosthetic joint infection
Pt with MSSA prosthetic joint infxn Not resonsive to nafcillin still sx Now joint loosined Needs surgical removal of joint high WBC, very high ESR/CRP \+synovial ctx after complete resolution new joint can be placed
Refampin only with early joint debridment with MSSA
IV Vanc only for MRSA joint infxn
Catheter associated UTI
Dx: 10^3 CFU in Uctx
Sigh/sx - new onset fever, rigors, chills, AMS, malaise, lethargy, CVA tenderness, flank pain, acute hematuria
In pt with SC injury - inc’d spasiticity, autonomic dysreflexia, sense of unease
no other source of infxn
Cloudiness or +gram stain not dx of UTI
LE in urine not dx of UTI but if neg good NPV
Treat HLD
Despite good lifestyle/excercise
Pt with fhx early MI and LDL 196 - needs statin therapy
Goal s CV risk
Tocluzimab for RA can alter LIPID profile
Check lipid profile after starting Tocluzimab
only start after TNF fails for RA
Can inc serum transamiases, leukopenia, thrombocytopenia and inc chol
Pt had normal other labs (LFT, CBC prior to last tx 2 wks ago)
Just need to check chol/LDL esp in pt with risk factors for CV dz
No cardiac tox - no need for EKG/TTE
No effect on Ig - so no need to check serum Ig
ARDS pt optimize PEEP
ARDS - inc PEEP - inc’s Oxygenation by recruiting atelecatatic (collasped) alveoli
6mL/kg ideal body weight
Persistent hypoxemia
-how to fix
1. Inc PEEP (inc to level of FIO26mL/kg under ARDS NET
Nitrix oxide not shown to improve sruvival - vasodil improves V/Q mismatch
Oligometastatic liver CA
3 lesions in right liver lobe - likely mets from colon CA - no reason to bx as will not change fact that she needs curative resection - R hepatic lobectomy
No hepatic artery embolization as this is not cruative an only for palliation of HCC/neuroendocrine tumors
Radiation tx - rarely used in tx of mets, not curative
Don’t use pall chemo if there is possibility of cure
TIA
ABCD2 Score Age: one point for Age>60 BP: one point for BP >140/90 Clinical hemiparesis : one point Duration: 2 points if >=60min
3 or more points - hospital inpt eval - stroke eval and monitor for recurrence
Don’t use both ASA and plavix unless CAD - no risk red in stroke but in’cd r/o hemorrhage (cerebral)
No outpt ECG monitoring - pt needs admission
Type 2 DM post op
Even if pt is on diet/oral meds at home - stress of surgery may require insulin during perioop period - shoudl use both long and short acting
Don’t use oral agents - variable ability to eat and absorb - hard to titrate as longer acting
ISS - inferior to basal + bolus
Goal of post op keep Gluc < 180 not overly tight control
Gestational thrombocytopenia
Repeat CBC in 1-2 weeks
Asx, plt >50 in last trimester=gestational throbocytopenia
If < 50 in 1st trim - then ITP
No intervention if plt>50 , no IVIG, plastma exch, steroids, emergent delivery
Excercise ABI to eval b/l leg pain
Risk factor for PAD - age, smoking (prior), HTN, HLD
diminshed peripheral pulse and hair loss in legs
Resting ABI normal (>0.9)
-> still high clinical suspicion check EXCERXISE ABI
dec of ABI >20% dx of PAD
Only get contrast imaging if PAD dx made, fails med therapy and evaluating for intervention
MRI lumbar spine - lumbar spine stenosis - shuld also have dec’d DTR at ankles
Segmental Plethysmoography - pt with established PAD - to localize lesion - drop in BP 20mm or more = zone of decreased persion/sig dz
Anastomatic leak from bariatric surgery
Sustained sinus tach - indictiative of suture leak
Need upper GI series with contrast (water soluble) to dx leak at anastamosis site
Fever, abd pain, sinus tach
CT angio to r/o PE - less likely without hypoxia, tachpnea
EGD contraidicated if anastomatic leak found
No emergent surgical exp as pt is hemodynamically stable - even if not found on contrast UGIS (or CT abd) and index suspicion still high - might need ex lap
Cancer of unknown primary
Women - should be treated like stage III ovarian CA -
Surgery-> chemo
Monitor CA 125 for response
No radiation for abdomen too much small bowel s/e
Too early for palliative care - need to treat
Adverse effect of MS tx
IFN-B - flu like sx
ELEV LFTs
lymphopenia
worsening underlying spasticity, depression, migrains
Persissent elev LFT may need reduction or cessation of IFN
MRI, retinal exam, BUN/Cr don’t directly montor s/e of IFN
Prevent catheter related UTI
Maintain urine collecting bag below level of bladder so flow always outward
Foley
For stage 3/4 ulcers on buttocks
hand washing, sterile placement, securing, closed sterile drianage, prevent back flow
No benefit to cleaning meatus
No benefit to abx coated catheters
No benefit to tx asx bacturiia in NON pregnant pts
No benefit in routine change of catheters
Secondary erythrocytosis
Sleep study to dx OSA
With P Vera - EPO level is suppressed by autonomous inc in Hg from myelprolif d/o
If EPO inc’d - dx is 2ndary erythocytosis 2/2 likely sleep apnea (snoring, obesity, wife witness apnic episodes)
Tx: CPAP
PV - non sp sx ie tinnitisu, blurred vision, h/a - prupritis after taking bath**, erythromelagia (burning sensation palms/soles - plt activ), splenomeg -
Tx: therapeutic phlebotomy and low dose ASA can try hydroxyureas if doesnt work
No need for BM bx - hypercell marrow can be in both p vera and secondary erythrocytosis
Cardiac stress testing in pt unable to excercise
Pretest prob of elderly pt with atypical angina is intermediate - needs stress test
Baseline EKG changes so needs imaging
Unable to excercise 2/2 advanced OA needing upcoming surgery
Pt with severe reactive airway dz - cant use vasodilator pharm stress (adenosine/regadenosine)-> use dobutamine
Dobutamine stress echo
Don’t go directly to angio - needs stress first (atypical angina)
Central retinal vein occlusion
Acute onset painless blurry vision/optic disc swelling
Blood and thunder (cotton wool spots)
dilated/tortuous veins, flame shaped retinal hemorrhages
Afferent pupillary defect (light shined in affected eye no effect - shined in opposite eye causes affected eye to constrict)
Older pt with HTN and atherosclerotic dz
aw cartoid diss, inc’d visc (p vera)
Tx: no particular tx - investigate etiology
Acute angle closure glaucoma
narrowing of anterio rchamber angle
impedes trabecular drainage
Painful - dec vision, halo, red eye, dilated pupil, firm globe, exam either normal or optic dis cupping
Tx: meds
Central retinal artery occlusion
50-70yo painless abrupt blurring or loss of vision morning hours affernt pupillary defect PALE retina cherry red spot (fovea) box caring in blood vessels
Retinal detachment
diminished vision, photopsia (flashes of light) multiple floaters, abrupt onset, wavy vision
Trauma or spontaneous
Distorted folding/tearing retina allowing fluid to pass underneath
Manage pt with metastatic carcinoid tumor
Asx patient with indolent, well circumscribed small carcinoids
Observation and repeat imaging in 3-4 months
low grade on bx
normal blood serotonin
no evidence of carcinoid syndrome (flushing, diarrhea, wheezing)
Hepatic artery emboliz if growing or sx liver mets of carcinoid
RFA - ok for limited number of mets
No reason for chemo as pt asx, low grade
Manage warfarin in high risk pt periop
CHADS2 =5 (>2) then need stop warfarin and provide bridging A/C LMWH or UFH and withold morning before surgery
-can’t just stop warfarin - high risk of thomboembolic event
Dont continue warfarin till surgery or 1/2 dose - INR too unpredictable
CHADS 2 or less - ok to stop warfarin without bridging
Drug induced lupus
TNF alpha Drug induced lupus
fever, myalgia, non blanching purpuric rash, arthritis, hem, pancytopenia, proteinuria, active sediment abn
+ANA, +anti-DSDNA
DILE with OTHER MEDS -
anti histone Ab+
+ANA
+Anti single stranded DNA
If DILE and infxn r/o - then r/o underlying LAD/lymphoma with CT
Don’t use RF/Anti CCP to follow RA flare - doesn’t change, will be positive
Evaluate patient for intracardiac shunt
TTE with agitated saline contrast
detect R-> L shunt
TTE already showed mile RVE, mild pulm HTN
Fixed split S2 -> ASD
(in normal study with no shunt - bubble only seen in RA then dissipate in pulm circulation - don’t opacify LA)
DOnt need cath for detection of cardiac shunt (intracardiac)
Don’t use microbubble - will opacify both sides of heart in normal heart (doesnt dissipate) - caution with severe HF/sev pulm HTN
SPECT CT tagged RBC not useful for dx of shunt (intracardiac)
Treat inadequately controlled asthma
Moderate persistent asthma (>1 night/wk wake uP) + daily daytime sx
No signs of infection
Already on short B2 and med dose ICS
ADD LONG ACTING B2
DO not double ICS - at high dose get systemic s/e - adrenal supp, cataracts, glaucoma, osteopenia, skin thinning,
check for good inhaler technique
Ipratropium enhances B2 agonist effect in acute exacerbation but not good for long term
Abx not used for routine asthma control
Manage severe ANCA vasculities
Induction: Plasmapheresis, cyclophosphamide, corticosteroids
maintenance: azathroprine, corticosteroids
Sevre small vessel vasculitis -> rapidly progressive glomerulonephritis and pulm hemorrhage
Things that can cause RPGN - ANCA+ small vessel vasculitis,
Exclude infection prior to immunosupp
Induction therapy WITHOUT plasmapheresis - only for moderatly active vasculitis (Cr < 5.8, no need for HD) and without pulm hemorrhage
No efficacy trial for myocopheilate mofetil/corticsteroid induction+maintanance
Don’t just use plasmpheresis for ab cleanup - wihtout immunosupp agents will just happen again
Manage resolving transient constrictive pericarditis
NYHA class improving - sx improving (fxn capacity)
resolution of constrictive findings on TTE
No pericardial fibrosis, Ca, refractory HF
COntinue conservative tx with anti-inflamm drugs
Transient form from CTD, infection (TB), chemo, trauma, pericardotomy, malignancy
No need for endomyocardial bx and R/LHC - used to diff constrictive vs restrictive CM but with restrictive filling and ventricular interdependence - very likely CONSTRICTIVE pericarditis
Percardectomy only for progressive constrictive pericarditis in pt with NYHA II/III not with transient cases
Liddle syndrome
rare autosomal dominant
Early onset HTN with met alkalosis, hypoK, suppressed renin/aldo
24hr cortisol normal so NOT CAH, cushing, 5 alpha red def
Tx: Amiloride(also reduced lithium uptake so given in case where have nephorgenic DI in setting of lithium tox but can’t stop lithium) or Triamterine - inhibits sodium uptake
No pheo - no h/a sweating, palpitations
No primary hyperaldo - serum aldo supporessed - (primary kidney sodium retiention and expanded ec vol
Not renovasc HTN - renin/aldo would be inc’d
Dx pre-HTN
Normotension - 140/90 in office with 2 sep measurements <140/90 outside office - absnese of end organ damage (ie LVH)
Use ambulatory BP monitoring to dx
Severe COPD that is otherwise good candidate for lung transplant besides current smoking
All subsance addition (etoh, tob, drugs) in last 6 months contraindic for lung tx
Need to quit smoking first
Tx candidate if deterioration continues despite maximal medical therapy -
BODE - BMI, obstruction, Dypnea, Excercise index
BODE>5 - lung transplant eval
BODE 7-10 - tx indicated if - h/o hopsit for exacerbation of hypercarbia OR pulm HTN OR cor pulmonale OR FEV1 transplant
Pulm rehab effective but not substitute for lung tx
Androgen deficiency
D/C hydrocodone Drugs that can lower testosterone: Opiods high dose corticosteroids hormonal tx Low testosterone can dec libido, energy Check MORNING testosterone (secretion is cyclical)
Metoprolol/BB can cause ED and fatigue but NOT lower testosterone
No need to recheck morning testosterone before d/c hydrocodone
Only start testoserone replacmeent if still low after all testorone lowering meds are d/c’d if possible
Lynch syndrome colnoscopy surveillence
Hereditary nonpolyposis CRC syndrome (LYnch)
(HNPCC)
“3-2-1” rule - (3 affected members, 2 generations, 1 under 50)
HNPCC associated CA = uternine, ovarian
Surveillance at age 20-25 or 10 years prior to youngest affected family WHICHEVER EARLIER
then q2yr until age 40, then q1yr
also need GYN, GU cancer screenings
Colonoscopy at 40 - non-syndromic fmaily hx of CRC
- One first deg relative Colon CA after 60 or 2 2nd deg relatives - colonsocpy at 40 then q10yr
- 2 first deg relatives or 1 first deg relative before age 60 - colonscopy at 40 then q5yr
Colonscopy age 50 - average risk patient
Stool DNA or CT colonography are not substitute for colonoscopy
Hospitalized patient with bacteremic pneumococcal PNA
D/c on 7 days oral amoxicillin
hospital day 3 afebrile, RR 90, pulse <100, , normal MS, oral intake fine
BCTx showed sensitivty to PCN - so d/c on narrow spec ampiclliln - no need for levofloxacin
No need for 14 days tx - quick clinical response to abx - so ok for 7 days
No need to observe on oral abx
Manage lack of response to appropriate COPD therapy by checking inhaler technique
Check and demonstrate inhaler technique
(age, eyesight, dexterity, cognitive fxn, degree of lung fxn, btreathing pattern)
mod COPD
long acting cholinergic, long acting B agonist, adherent
Don’t add ICS until confirm inhaler technique ok
O2 therapy only if O2 sat t restart corticosteroids - not havening exacerbation - no benefit, many s/e
Eval pt with vascular complication after PCI
Duplex US - diff between pseduoaneurysm and AV fistula
Bruit (continuous) heard
Vasc complications: pseduoaneursm, AVF, hematoma, chol emboli, RP bleed
Determine if endovasc or surgical intervention needed
Don’t need ABI - normal would not exclude pseduoany or AVF
No need for CT - would be ok for suspected RP bleed but would also have back/flank pain - with hypotension - but pt likely to unstable to take to CT (from proximal pct of cFa in setting of A/C)
No need for LE angio - only if diminished LE pulses - or concern for dissection of femoral artery - if distal pulses ok no need - if has dissection may need angioplasy/stent
Left atrial myxoma in asx patient
TTE for diastolic murmur shows LA mass - high risk of embolization and stroke
Needs surgical removal EVEN IF ASX
No need for catheter bx of mass - only do this if RA mass and if likley to be malignant - allows for dx
No F V leiden test - is a mass not thrombus
Warfarin not needed for stroke prevention with LA myxoma - efficiacny not proven - not appropriate if pt can have mass resected instead
COnsider carney syndorme in young pt with myxoma - look for spotty skin pigmentation, endocrine tumore (ACTH independent), schwanommas
Evaluate ground glass pulm nodule
Ground glass nodules need MORE than 2 years of yearly CT f/u with no growth to be conisdered benign - may be slow growing adenoCA in situ (bronchioalveolar cell CA)
GG=focal or diffuse opacification of lung parenchyma
Can be adneoCA insitu, focal atelectasis, fibrosis, inflmmation atypical alveolar hyperplasia
GG adeno can have doublding time of 400 days - f/u at least 5 years
GG may not change in size but character - ie becoming part solid - strong indicator of malignancy
Don’t use PET - GGO have low uptake on PET so lots of false neg’s until lesion becomes solid
Don’t resect - just continue yearly CT unless change seen
Don’t needle bx - hard to interpret on path
Treatment of CA of unknown primary
Cancer of unknown primary presenting as axillary LAD in women should be considered breast CA (stage II)
Tx: Mastectomy with LN dissection
Occult primary found in mastectomy even if mammo and MRI normal
DOn’t just excise LN - need to assume breast CA and do mastecomty
Potentilaly curable so don’t just give chemo or radiation
Dx pleural effusion 2/2 HF
Lights criteria pleural protein:serum protein>0.5 = exud pleural LDH:serum LDH>0.6=exud Pleural LDH >0.6 ULN serum LDH If borderline in setting of diuresis then likley transudative
SAAG >1.2 = transudative
Serum protein to pleural protein >3.1 = transudateive
Not due to malignancy - if due to malignancy then would be unilateral, lymphoctic pred,
PNA - exudative effsuion but also with fever
PE pleural eff - usally small and b/l - exudateive
Treat extensively drug resistant pseduomonas
IV Colistin
Pseduomonas with pan resistance in ICUs
Patietns with burns particularly sensitive to pseduoonas
colistin infequently used as has nephortox
but now reliable vs resistant gram neg
Minocycline,rifampin don’t have good pseduomonas activity
Tigecyline - no pseudomonas activity
Wheening from mech vent to NPPV
NPPV after extub reduces need for reintubation - bridge to normal breathing in pt with chronic lung dz and hypercapnia after wheening trial
Incentive spirometry reduces pulm complications post op but no role in non surgical patients post extub
No evidence that heliox helps dec reintub in pts post extub (easier breathing with lower density air, lower resistance in obstructive COPD pts)
N-acetyl cystein - used to thin secretions - no role if already thin - also can trigger broncospasm
Shigellosis
Shigella - mild self lim gastroenteritis - to bloody diarrhea with fever
Treat pt empirically if very symptomatic or if elderly or imunocompr
Patient works in daycare center or NH or food serivce
Shigella very infectious even in low concentration
Under normal circumstances no need to treat but with
DAYCARE WORKER or NH worker or food service- treat with cipro
Treatment shortens shedding of virus/diarreha/fever by 48 hrs
If confirmed microbiolgically - ok to treat anyway to prevent spread to other people
Azithro - empiric tx for campylobacter - high rate of cipro resistance
Flagyl - no activity against aerobic bacteria like shigella
Newly dx CLL
Need B2 microglobulin/genetic testing/cytogenetic for prognostic information and time for observ vs treatment
Most pt are asx and present with early stage dz discovered incidentally in bloodwork Risk stratification LAD? HSM? Thrombocytopenia?
BM bx/asp not needed - prognositic info can be obtained via peripheral blood testing
CT scans not needed - won’t provide additional info in asx patients
PET only if suspect transformation to aggressive lymphoma - will see foci on PET
Prevent tumor lysis syndrome (TLS)
Recent chemo for AML - risk factor for TLS
increase NS to promote faster UOP rate
Manifestations of TLS
AKI, arrythmia from K, phos, urate
Need 6L UOP /day
Even with 200cc/hr still high phos and K - need to increase more
Can also use loop diuretic to incrase urine flow
Don’t add sodium bicarb (inc’s uric acid clearance by solubiliing but also inc’s r/o CaPO4 precip - not good with pt with high PO4
Kayexal will dec K+ but not inc urine flow rate
Rasbucaricase - preferred to allopurinol for ppx of TLS - it breaks down urate and minimizes xanthine accumulation- allopurinol does not - if uric acid level ok no need to substitute.
Treat younger pt with CLL and poor prognostic factors
alemtuzumab based chemo
and allogenic HSCTx
Newly dx advanced stage (IV) - LAD, SM, anemia, thrombocytopenia, elevated B2 microglobulin, unmutated heavy gene 70, 17p deletion
Criteria to inititate tx - B cell sx (fever, wt loss, night sweats), sx from LN enlargement, HSM, worsening cytopenia
HSCT not used in CLL often becuase median age 70 - can’t use in that age
cyclophosp, vincristine, prednisone, fludarabine, rituximab not optimal for adv dz with poor progn factors
Drug induced myositis in cardiac tx patient
Rhabdo 2/2 FLUCONAZOLE potentitaion of cyclosporin and statin
Still need statin because they dec r/o transplant vasculopathy and improve survivial - need good communic between transplant and general
Acute rejection - usually asx - incidentally discovered on endomyocardial bx - manifeestation new atrial tachyarryhmia, new onset HF, no inc in CK
CMV - flu like, GI sx (colits), leukopenia, hepatitis (elev LFTs)
Transplant vasculopathy - coronary dz of transplant - diffuse intimal thickening - MI, high deg AVB, HF, arrest - not likely with normal EKG and neg trop
azoles, CCB, antisz meds,
Pt with von willenbrand dz
Check vWF assay/activity
Pt with personal and fhx mucocutaneous bleeding - autosomal dominant -
MC inhertied bleeding d/o
low levels of vWF - but fluctuate with sttrss, exc, estrogen, inflamm, bleeding
Prolonged PTT not dx of vWF
humoral clotting factors usually produce hemarthrosis (except XI)
PT prolong - warfarin, vit K def, chronic liver dz
inherited factor VII dz (rare) - presents with mucosal, joint, muscle bleeding
manage fall in elderly pt
Vit D decreases r/o fall - no need to check vit D level
Inc’d r/o fall - gen wk, slow gait, recent fall
Don’t d/c ACEi unless orthostasis
Don’t give zolpidem - inc’d r/o falls in elderly
Don’t rx bifocals - inc’d r/o fall
Propofol related infusion syndrome
Type B lactic acidosis lactic acidosis rhabdo hyperTGA myocardial abn on EKG (j point elev/brugada like) unexplained AG met acidosis Tx: d/c propofol, supportive care
No met abn or AG with fosphenytoin
Propylene glycol - solvent used in benzo prep -
does cause met acidosis but not rhabdo, hyperTGA, myocardial abn on EKG
Pyroglutamate acidosis - in pt getting acetaminophen during critical illness - depleteion of glutathione stores 2/2 increased oxid stress - accumulation of pyrogutamic acid
Manage obesity with bariatric surgery
BMI>40, or BMI>35 with obesity related complications ie DM, OSA, HTN, HLD
If diet/excercise and meds like orlistat don’t work
must be well motivated (pt already tried and did not lose weight)
eval by med, surg, nutrition, psych
gastric bypass, lap band
more dramatic and sustained wt loss
No phenteramine - only short term use - ppl usually regain weight when stop med
Very low caloried diet does not work
Excercise alone will not work for massive weight loss
Manage HTN, hyperK in pt with CKD
Need to control BP, pt also with hyperK
control BP to prevent CKD progression and dec r/o CVD
ACEi ideal for BP control in CKD since it slows progression but in setting of hyperkalemia contraindicated
INcrease loop diuretic in this case to control BP and lower K+
Pt with CKD need higher doses of diuretic to be effective
also will dec IV volume which increase BP in CKD patients
Kayexalate may dec K but won’t change BP
Don’t use spironolactoen to control BP, will inc K+
Don’t d/c ACEi - will lower K but will worsen BP
Dx central vertigo
Central vertigo - vertigo with VERTICAL nystagmus - immediate, prolonged, non fatiguable >1min on Dix halpike
medical emergency
Can be ischemia or infarct in brain
inability to stand without dysarthria or diplopia - likeley cerebellar
MRI brain with angiography - superior sensitivity
CT doesn’t see posterior circulation
Epley maneuver/otolith repostioning - resolves sx of BPPV - peripheral vertigo - minutes, multiple episodes - No tinnitius, ear pain, hearing loss
Sx tx for vertigo only for peripheral - URI can cause vestribular labrinthitis however exam incionsistent with peripheral vertigo - on dix halpike should last <1min and fatigues with time and only HORIZONTAL nytagmus
Dx Strep Pneumo after tx (stem cell)
fever, chills, cough, CP,
Late post tx timeframe (6 months) high risk for infxn with encapsulated bug (S pneumo) - reason for Pneuomoccal vaccine for tx patients
Candida rare cause of PNA
CMV - infection usually 1 month after tx - diffuse infiltrates on CXR
PJP - not likely while taking bactrim - also not likely lobar
pre-engraftemment=100 days - high risk of infxn from encapsulated bugs
Treatment of bipolar d/o
In pt with depressive sx need to elicit if hypomanic or manic episodes also -> bipolar d/o
Tx with mood stabilizer
Lamotrigine
Lithium is mainstay but has teratogen, nephrotox, hypothyr
alt mood stabiizer - lamotrigeine, VPA, carbamazepine
Antipsychotics for frank manic episodes - ariprazole, quietipine
If you just give anti-dep will breed frank mania in bipolars
Duloxetine - SNRI - depression tx
Benzo - lorezepam - infeff for dep or mania - adjunct only for mania
SSRI - setraline - may trigger manic episodes in pt with bipolar - if any pt being consdiered for SSRI then make sure no manic sx
Treat pt with tumor lysis syndrome
Aggressive hydration, HD, Rasburicase
malignancies with rapid cell turnover (Burkitts, leukemia)
or in pt with bulky dz, high leukoocyte counts aw rapid adn sig senstiivty to chemo (large cell lymphoma, CLL)
HyperK, HyperUr, hypophos, hypoCal, AKI, DIC
Can’t start chemo in this state - need ppx tx for TLS first
Once stable can start
No radiation for burkitts
Treat recurrent HSV in HIV pt
Severe HSV in HIV pt with very low CD4 -
Suppressive tx-> ACYCLOVIR
>6/yr or severe -> ppx
also restart HAART
Cidofovir, foscarnet - for acyclovir resistant HSV
Cidofovir in ointment can hasten healing of HSV lesions
can cause ulcers
IV Cidofovir - rash neutropenia, AKI
Foscarnet - AKI, nasuesa, sz, paraethesia
Valganciclovir - tx/supp of CMV not HSV
myelsuppresion s/e
Body dysmorphic d/o
Cog Behv therapy
somatoform d/o - focused on single real or imagined symptom
Needs to be medically unexplained - hense many imaging studies/consults
impairment to fxn
NO benzo - tolerance/dependence
No reason for more imaging already confirmed neg
No olanzapine - pt not psychotic
Schizophrenia - psychosis is definiing feature - 6 months of sx - 1 month or more of at least 2 active phase sx - halluc, delusions, d/o speech, catatonic beh
also neg sx - flattened affect
Chronic HTN in pregnant patient
BP Goal <150/100
Proteinuria known to inc during pregnancy
Goal to avoid end organ damage in preg period
No reason to add methydopa (sedating effect and BP under control at this point)
No ACEi or ARB - teratogenic
No reason to inc labetolol - at goal
Manage medication perioop
Don’t d/c plavix before cataract surgery for at least 1 year
Don’t d/c BB if already on BB
Dont d/c benzos, narcotics, antisz drugs - all can cause withdrawal
Evaluate elderly pt with recent fall
Timed up and go (TUG)
aris from chair walk 10 feet turn around and sit back down
>14s = inc’d r/o future falls
Get details of fall, home risks, list of meds
Don’t need to d/c ACEi as BP was not low
Exc program if suspect weakness or poor balance
Need to assess gait and mobility before giving cane/walker
Primary genital HSV
Acyclovir, valcyclovir, famicyclovir
Several vesicular lesions with erythematous base, fever, malaise, dyuria
dx: viral culture/PCR
Chronic tx with valcyclovir prev transmission to sexual partner
Benzathrine PCN G - primary syphllis
chancres - single painless lession with clean base
Ceftx+azithro - mucopurulent cervicitis
Single dose fluconazole - candida vaginitis - fissures/excortiations - no ulcers..
ABO/Rh compatibility
A neg will have ab vs B and Rh O neg is universal donor - give this in urgent situation AB+ is universal receipient O does not have A or B antigens Rh neg does not have Rh antigens
Use of A+ would lead to acute or delayed hemolytic rxn only in emergency if Aneg and Oneg not availble
ABneg would not be compatible - acute hemolytic rxn
(anti B ab)
B+ no good both ABO and Rh incompatible
Screen for cervical CA
Women older than 30, no risk factors for cervical CA and no abn PAPs - change to q3 years with cytology or q5yr with cytology and HPV DNA testing
ACOG - q2yr 21-29 if all normal then q3yr after 30 if 3 normal consecutive pap and no h/o in utero diehtystibestol exp, no immunocomp, HIV, cervical intraepith neoplasia,
Never use HPV alone - poor specificity
Don’t d/c PAP until 70’s at least
Acute limb ischemia
Prompt amputation
Dense anethesia, lack of pulsees and doppler signal, no active motion
If delayed progressive limb necrosis
No role for ABI - no PT or DP so can’t get reading
In less severe limb ischemia (viable or marginally viable) can consider intra arterial thrombolytics
MRA not needed - need immediate surgery
If limb salvageable then reasonable to proceed to emergency angio/endovascular repair
Prevent DM nephropathy in pt wtih DM2 and HTN
Pt currently not microalbuinruic - adding ACEi can prevent progression to microalbuminuria
interupt renin angiotensin system reducing glomerular filtration
Other HTN agents (BB, CCB, diuretics) can lower BP but dont affect glomerular filtration) - so not first line in pt with DM and HTN
Dx Disseminated Gonoccoal infection
Dx: Urine nuleic acid amplicfication for Neisseria gonnococus
Also Blood, synovial, mucosal (throat, anus, urethra, cervix - higher dx yiedl than blood/synovial fluid ctx)
Likely not inflamm arthritis - can be SLE or RA(usually symmetric) but usually not migratory asymmetric polyarticular like in DGI and no erythema nodosum
necrotic vesicopustules on erythematous base
HLA27 only + on 50% reactive arthritis - not reactive arthritis
should also have conjunctivitis, urethrtis, oral ulcers
Cardiac allograft vasculopathy
Pt with heart transplant and new LV dysfxn / HF sx
Syncope, heart block
TTE with segmental dysfxn
MCC of late ventricular dysfxn in cardiac transplant patients -
Chest pain uncommon with CAV as denervation during cardiac tx
Diffuse intimal hyperplasia rather than focal stenosis so hard to treat
Late rejection after long period of graft stablity rare most rejection in 6mo to 1 year
PJP woul dnot explain cardiomegaly, S3, JVD reduced LV fxn
Not recurrent myocarditis - should have some effusion
Orthostatic proteinuria
benign
proteinuria inc’s during the day while standing up
other transient/benign proteinuria - febrile illness/rigorous exc
Not aw long term kidney dz
No further eval needed
Kidney bx only in pt with suspected glomerular dz (RBC casts) nephortic syndrome, acute glomerulnephritis or kidney tx dysfxn
No reason to repeat 24hr urine collection
Spot urine not better than 24 hr no need to do both
Normal protein < 200mg/24hrs - don’ tjust reassure if not orthosatic proteinuria then could be indicator of early kidney dz
Tx hypoxemic resp failure with CPAP
Hypoxemia 2/2 post op atelectasis - pt is extremely obese, now post op in upper abd surgery (bariatric) or lung surgery - inc’d r/o atelectasis and hypoxemia
CPAP reduces risk by opening up alveoli
Bronch only for complete atelectasis suspect mucous plugging - usually try chest physiothearpy first
ALbuterol inhaler only if asthma - no wheezes so likely not asthma
Naloxone only if hypoxemia 2/2 hypoventillation from residual anesthesia effects
Anemia of kidney dz in older patient
EPO underproduction anemia in CKD normocromic, normocytic, low retic normal iron, TIBC, ferritin Smear - burr cells Still need to exclude GIB
Inflammatory anemia - low serum iron, low TIBC, high ferrtin
IDA - low iron, low ferritin, HIGH TIBC
Manage pt with high risk for breast CA
29yo F with h/o hodkins with mantle radiation
yearly breast MRI and b/l mammo
also nulliparus
Also BRCA1/2 carriers need yearly mammo b/l and breast MRI
Breast US not sensitive enough to detect breast CA
No blood tests (CA15-3, CEA, CA 27.29) are for routine surveillance
Pt needs screening as is high risk
Very severe COPD with O2 therapy
Long term O2 therapy >15hrs/day
PO2 < 88%
improves survival, exc capacity, alertness, motor speed
No need for abx or predisone if no acute exacerbation or broncospasm
First need O2 therapy then consider repeat pulm rehab (has shown culumualtive benefits)
Manage ARDS - appropriate plateau pressure
Managing TV
start at 6mL/Kg ideal body weight
then DECREASE until platau pressure <30
permissive hypercapnia ok
Dec RR or inc FIO2 would not affect plateau pressure
Inc PEEP would INCREASE plateau pressure
Treat descenting aortic intramural hematoma/dissection (type B)
Control BP with IV BB then sodium nitroprusside
Type B dissection - med management
No dissection flap seen if hematoma
Neg D-dimer 95% NPV against aortic diss (<0.5)
Chest pain - r/o ACS, PE, aortic syndrome
trop I should be elevated 2 hrs after pain starts
malperfusion syndromes with aortic dissection - will need endovasc fenesttation or stentting - not needed if no signs of malperfusion
Emergency surgery only for type A dissection (ascending) (only B if malperfusion ro significant aneursysmal dilation)
No reason for ppx stenting if no signs of aneursymal dilation
No A/C as hematoma contained within aortic media - no r/o distal embolization
Pt with ACS and DM
Benefit from OMT + epleronone (blockade of renin angiotensin system)
If pt had ACS, LVEF t inc BB if HR low
Only warfarin if afib or LV thrombus
Acute pericarditis
sharp, pleurtic, retrosternal CP - worse with recumbancy (lying down) and deep inspiration
pericardial friction rub
EKG diffuse ST elev/PR dep (wide, concave up)
Antecedent URI (or autoimmune dz, uremia, neoplasm, trauma)
No risk factors and atypical story for ACS
No EKG changes with pleurtiis
No EKG diffuse ST elev/PR dep with acute PE
Eval pt with HIGH pretest prob endocarditis
TEE FIRST if high prob of endocarditis
(pt with staph bacteremia, prosthetic valve or fungemia or intracardiac device)
Concern for AR (wideneded Pulse pres), aortic root abscess (prlonged PR),
Also if aortic diss, LA thrombus,
CT not superior to TEE and not good with elev Cr
No MRI with GAD in CKD - systemic nephrogenic fibrosis
Mange pt with ICD preop
Need to turn off Shock therapy
Need to also change to asynchornous mode (VOO)
ICD thinks cautery is Vfib and will shock and inhibit pacing
Pt has CHB - pacing dep - so needs VOO
No TVP needed - ICD will pace
Magnet ONLY disable shock in ICD (will change PPM to asynchronos)
If pt has ICD but NOT PPM dep then ok to just place magnet to disable shock therapy
Not good if PPM dep as electrocautery would also inhibit pacing
Familial mediterrainian fever
Periodic fever syndrome
serosal inflammation in chest, abd, joints
erysipelas like rash on lower extremity (raised, erythematous warm rash)
neutrophilic leukocytosis
Elevated ESR, CRP
Tx: Colchicine
Sweet syndrome - acute febrile neutrophilic dermatitis - middle aged women with recent URI
fever arthralgia myalgia cutaneous lesion
rash : tender, nonpruritic, well demarked plaques neck upper trunk upper extrem
No abd pain
Tx: steroids
Eythromelagia - parox b/l erythema of extrem with warmth and pain - precip in warmer temp, dependent position
Staph cellulitis - purulence, asymmetric districution - LAD - no episodic occurences
Treat Erectile dysfxn
1st line therapy is PDE5 inhibitor for ED
sildenafil, vardenafil, tadalafil
DO NOT use if on nitrates
2nd line=alprostadil - IU, Intracav(better) - penile pump, prostesis
Don’t give testoterone rep unless sign/sx of androg def and testosterone <200
Manage pt with early stage cervical CA
Small primary tumor (I or II)
Radical hysterectomy or radiation without chemo
No chemo for early stage - for adv stage chemo+rad best
Stage IA1 - microscopic = LEEP/conization and close observation if want to preserve childbearing inhstead of hysterectomy
Pelv radiation + chemo - high risk dz, bulky primary tumor or adv dz (large primary, deep stromal inv, lymphovasc inv, postive LN or surgical margins)
Benign recurrent lymphocytic meningitis (Mollaret meningitis)
HSV-2
Dx: CSF PCR for HSV-2
Many episodes of meningitis - h/a, fever, stiff neck that resolve spontaneously
Transietn neuro episodes - sz, hallucination, diplopia, CN palsy, AMS
Occurs without signs of gential or cut infection
No need for cytologic studies as likely not malignant with recurrent episodes -
WNV - not recurrent
MRI brain only if presented with ENCEPHALITIS (fever/hemicranial h/a, language/beh, memory imp, , CN def, - susually HSV-1 not 2
Treat sepsis
Sepsis: Known infection: SIRS - temp >38, 12 20, P>90 4-6L vol in first 6 hrs Early agrrsive fluids improves mortality
Only hydrocortisone if shock refractory to fluids AND pressors or h/o adrenal insuff
BP ok so no pressors
PRBC only if active bleed or Hct<70 after adequate fluid challenge
polyoma BK virus associated nephropathy in kidney tx pt
BK virus infects epithelial cells
Screen for BK if see decline in kidney fxn after tx
U/A looks like interstitial nephritis (erythro, leukocytes, leukocyte casts)
Kidney bx confirms with viral inclusions in tubular epith cells
Tx: DECREASE immunosupp as much as poss to avoid graft rejection
If doesn’t work - flouroquinolones - leflunomide, cidovovir
**gancclovir, acyclovir don’t work
Muromonab CD3 increases immunsupp by suppresting lymphocytes - makes BK infection worse
Eval pt with benign LAD
Young man, 4 week history of fatigue, inermitt fever, sore throat, LUQ abd discomfort
No night sweats, wt loss, cough, dysuria, diarrhea
soft movable b/l LAD, palpaable spleen
Smear: large atypical lymphocytes
No rash
Dx: Check for EBV (anti EBV ab assay)
No need for BM bx or PET - r/o mono first
LN bx not needed until mono r/o
Peripheral blood flow cytometry - likely polyclonal - doesn’t add to dx
Only useful in malignancy to check for monoclonal population
Anchoring heuristic
Clinician hold onto initial impression (ie dx of referring physician) and doesn’t consider other dx’s
Availability heuristic
basing dx on what is on physicians mind (ie saw similar thing last week)
No fault error
presentation misleading - little opportunity for physician to pick up clues
Representative heurisitic
pattern recog error - appears to fit a typical case but fails to think about other dz that could also fit…
Mycoses fungoides/Sezary syndrome
Mycoses fungoids (skin) Sezary Syndrome (skin and blood) Cutaneous non-hodkin's lymphoma Skin: dry, pruritic, nonerythematous patches (can be observed or tx with topical steroids) Progression: T cells infiltrate organs/blood/LN -> organomegalzy and dysfxn - Sezary cells: CD4+, cerebriform nuclei Immunodef, recurrent infxns Tx: Sezary syndrome - Alemtuzumab
No total body irradiation unless planning stem cell tx
Not just observation - organ involvment and immunodef
Abdominal compartment syndrome
Intraabd pressure>20mm Hg New organ dysfxn (ie AKI) Preceeded by LOTS of fluids (ie 15L post op) or massive ascities or RP bleed Measure pressure thru bladder foley Tx: surgical decompression of abd
Tobramycin - can cause nephrotox but not usually 1 dose
and does not account for increase’d abd pressure
Not from pre-renal - FENA>1% - and unresponsive to fluid resusucitation
Not obstruction - no response to foley and no hydro on US
Viral conjunctivitis
Acute onset of unilateral redness - watery d/c, itching, crusting, diffuse foreign body sensation, mild photophobia
Preceeding URI
Tx: Cold compressess, don’t share towels and hygene things with close contacts, wash hand frequently, may spread to other eye
Allergic conjunctivtis - recurrent, seasonal - cobblstoning on upper lid -
Tx: topical anti histamines/NSAIDS - no oral antihist
Abx (topical) if bacterial conjunctivitis - MUCOPURULENT d/c -
Topical steroids - DO NOT USE - if pt has HSV or fungal conjuntivitis can lead to cornela scarring, melting , perforation
Locally advanced Anal CA
Anal CA - SCC
Radiation/Chemo - NO SURGERY - results in permannet colostomy
Tumor with no mets
5FU/mitomycin
Surgery only if cancer recurs or progresses locally after treatment with chemo and radiation
RECTAL CA adenoCA
Needs surgical tumor resection
Pt with h/o infective endocarditis prior to dental procedure with PCN allergy
Indication for ppx
- Prosthetic Cardiac valve
- HISTORY of endocarditis
- Unrepaired cyanotic heart dz
- 6 months after congential heart dz repaired with syntheetic material
- Palliative shunts/conduits
- Cardiac valvulopathy in pt with cardiac transplant
Amox or cephalosporin
PCN all: Clindamycin, azithro, clarithromycin
Vanco not needed - despite prior MRSA - does not choose coruse of abx for present
Can’t do nothing - pt has indication for abx ppx…
Septic shock
liver failure and sepsis can be distributive shock
+SIRS
AMS
Organ dysfxn (ele cr)
Need to ID source of infxn - with ascietes need dx paracentesis r/o SBP
No abd imaging until SBP r/o by tap
Vasopressors not needed until Map<65 refractory to fluids
No role for corticosteroids unless h/o adrenal insuff or pressor/fluids not working
Cryptogenic organizing PNA
cough and sx suggesting CAP
BUT not improved after one or more abx courses
B/l diffuse alveolar opacities despite normal lung vol
Non-infectious
Tx: steroids
Chronic PE - progressive dypnea/hypoxia over weeks to months but no systemic sx (fever/chills) - pt without clear risk factors
COPD - rare in young pt (if does then Alpha triptan def)
CXR show airway dz, not lung parencymal dz
Lymphangioleiomyomatosis - rare cystic lung dz, aw PTX, predom young women, chylous pleural eff
Tx: anti estrogen, sirolimus, lung tx
Treat systolic HF in pt intolerant to ACEi
Hydralazine -isosorbide dinitrate alt for pt intolerant of ACEi 2/2 hyperkalmeia or kidney dz
No norvasc - neurtral effect on outcome - only use for anginal/bp control if +meds (ACE/BB) maximized or failed,
If intoleratnt of ACEi with hyperK or inc’d Cr don’t use ARB instead - likely to do same thing
Spironolactone only for NYHA III/IV HF inaddition to ACEi/BB - not usd when pt DOES NOT Have sev HF
ALso has s/e of hyperK and kidney dysfxn
Evaluate patient for VTE risk
INR 2-3 warfarin x 3 months Triggered episode (long flight, ortho surgery, factor V ledien hetero) Factor V leiden doesn't inc risk of recurrent VTE - so no need to prolong therapy
No need for lifetime stardard warfarin - risks outweigh benefits
Pseudothombocytopenia
Peripheral smear shows clumping with CBC showing thrombocytopenia
EDTA tube causes plt clumping
Need heparin or citrate coated tube
ITP - dx of exclusion - high dose steroids, if needs rapid rise temp - IVIG
No need for plt tx
Victim of intimate partner violence
Assess pt immediate safety and develop safety plan
provide validation, support emapathy
Don’t need to have pt leave abuser unless IMMINENT danger
Don’t confront abuser directly - may put victim in greater danger
Don’t need pscyh unless risk to harm self or others….
Irregular wide complex tachycardia
pre-excited afib NO p-waves, irregular rhythm Delta waves - WPW - with afib **DO not give AVN blocker - degenerate into VF with all conduction down non-decremental bypass tract Tx: procainamide or amiodarone or DCCV if hemodynamically unstable eventual EPS and RFA of pathway
Aflutter - atrial rate about 300, usually 2:1 block ventricular rate 150
MF Atach - usualy vrate 100 - 3 diff p wave morphologies
Polymorphic VT - usually twisting of points -
Prevent CNS mets in pt with limited stage SCLC
limited (one hemithorax, hilar/media LAD within 1 radiation window)
Need ppx rad of whole brain - if respond to initial tx
Chemo+rad for SCLC
No reason to bx residual mass
No reason for chemo beyond 4-6 cycles
Need ppx brain rad - don’t just observe
Cobalamin (vit B12) def
B12 def - elev homocystein AND MMA
+neuro deficits
Folate def - elev HOMOcystein only
NO neuro deficits
exclude B12 def before supp folate - folate can correct anemia of B12 def but not neuro deficits
Manage fall risk in elderly patient
Ask about night lights rugs or thresholds between rooms clutter uneven lighting absent hand rails
Timed up and go test - if <14s = normal
No reason for exc program if normal gait/motor exam
No need for walker if TUG normal
No need for opthal exam if vision 20/20
Asymptomatic severe MR with pulm HTN
Indication for MV Repair
- LVEF 40mm
- Severe pulm HTN >50mm rest >60 exc
- New onset afib
Don’t tx with bosentan- not primary pulm HTN is 2/2 MR
No role for ACE in asx pt for afterload reduction - only if acute decompensation then IV acei
Don’t replace MV if possible - do repair - no long term A/C
All trans retinoic acid induced differentiation syndrome
Sx: dypnea, peripheral edema, wt gain, fever, hypotension, AKI, pleural/pericardial eff, 1-3 wks into therapy
Mech - release of cytokines from differentiating promyelocytes -> capillary leak
Tx: dexamethasone therapy
NOt Transf rel lung injury - fever, dyspnea, pulm infiltrates seen
but NO wt gain, peripheral edema, AKI - should be in last 48 hrs
Not CHF - doesn’t explain fever, AKI, does not have JVD, and S3 gallop
Not PNA - hard to know - may need to treat both…
Stage III Colon CA
Stage III - invading pericolic fat \+3 LN FOLFOX - 5FU, leukovoran, oxiplatin Surgery then folfox better with oxiplatin
No radiation as hard to localize therapy witout bowel s/e (small bowel rad tox)
Radition+chemo for RECTAL CA as can be isolated from small bowel pre-op
Anal ca - chemo+rad only…
Low risk prostate CA in elderly
Observation
Low risk stage I prosate Ca with Gleason 10 years
Evaluate breast mass in post menopausal woman
suspicious finding on PE for breast CA
Core needle biopsy mass
No need for breast MRI - need tissue dx - can feel mass
No Breast US - need tissue dx
Need dx - don’t just reassure
Bacterial vaginosis
Dx: pt with malodorous vag d/c - burning and itchign
1. homogenuous thin d/c
2. clue cells on saline microscopy
3. pH vag fluid >4.5
4. whiff +/fishy odor - no hyphae or pseduohypahe
tx: flagyl x 7 days, vaginal flagyl gel, vaginal clinda cream
if flgayl avoid etoh (disulfuram like rxn)
Vulvovaginal candidiasis - yeah and hyphae on KOH,
- oral fluconazole single dose or topical clotrimazole
Trichomoniasis - multiple sexual parters - malodoorous d/c with vulvar itching, burning, postcoital bleeding - elev vaginal pH - whiff + but NO CLUE CELLS
tx: Single 2g dose flagyl
Manage secondary insomnia
obesity, large neck cirucm, daytime fatigue - r/o OSA
Sleep study
snoring, gasping, breathing problems
ddx - OSA, restless leg syndrome, periodic limb movement d/o)
Sleep latency - t give sleeping pills until 2ndary causes ruled out
Iron studies - if suspicion of restelss leg syndroem - unpleasant sensatio nin legs better with moving - kicks partner in bed, can have associated IDA, ESRD
Acute lower back pain
Uncomplicated back pain
Tx: analgesics and mobilization as tolerated
non-opiod
No CBC/ESR (inflamm spondylitis, infxn, malig) as no signs of systemic infection
No episudral steroids - only with chronic pain
Lumbar imaging only if acutely progressing sx - evidence of cord comperession (saddle anesthesia, dec’d rectal tone) or susptected infxn/malignnacy
Lumbar spine xray - r/o malig or fx - no need if no malig suspsected
MRI not needed even if showed herniation and root compression management would be same
CPAP related rhinitis
Add in line humidfied heated air to relieve rhinitis
NO need for modafinil waking agent yet - need to optimize CPAP
Dont use oxymetazoline spray - will have rebound nasal congestion after d/c use
Nasal surgery only for mild OSA with siginficant nasal obstruction ie nasal polyps, septal dev, tonsillar enlargement
Optimal target for risk reduction CHF and HTN
Decrease BP <70 (CAD+DM)
Tx of TGA only if non-HDL elevated LDL Goal + 30
Appropriate testing for late complication (CV) of cancer tx
h/o hodkins with radiation tx many years ago
worsening DOE
(could be CAD or diastolic dysfxn, radiation valve dz, restrictive CM - pericardial constrictive pericarditis)
For CAD r/o - EKG excercise stress - usually pLAD given anterior location
No reason for cardiac CT - no kusmall’s sign no sign of costrictive pericradits (inc in JVP with inspiration), no RHF, normal CVP, normal IVC with insp collapse
NO reason for RHC - can dx pericardial constriction - equalization of diastolic pressures - dip and plateu, steep y descent
No TEE - if no pathologic regurg on TTE no need
Sx severe mitral stenosis
Baloon mitral valvuloplasty Progressive SOB - symptomatic Severe MS - gradietn >10 LAE minimal leaflet Ca and thickening Min MR, minimal subvalvular thickening
Can’t use BB with low HR (used to inc diastolic filling time)
MV replacement in pt with MS and mod to sev MR, or undergoing other cardiac surgery anyway or unsuccessful percutantous result
Open commisurtomy - r/o surgery only if anatomy not favorable for BAV
Evaluate patient with pleurtic chest pain
r/o PTX with chest xray
Sudden onset pleuritic CP, dyspnea
COPD, sudden SOB with hyperresonance, dec’d Breath sounds, dec’d chest wall movmeent
CHest CT only if xray equivocal
No need for echo or EKG first - r/o PTX first
Manage pt with superficial venous thrombophelbitis
therapeutic dose LMWH -> coumadin
need A/C to avoid involvment of deep venous system
Recurrent risk factors (catheters, thrombophilia, CA)
Potential to -> DVT-> PE
Serious conisderation of A/C with extensive thormbophelbits
(traditionally low risk just compression stockings/NSAIDs)
Don’t just continue ibuprophen - unlikely to provent progressive thormbosis
IVC filter not needed if no A/C contraindication
No vein ligation if close to inovling deep veins (only for inovlvment of a specific target vessel)
Dx depression in older adult
Elderly pt depression pw somatic and vegetative sx not dysphoria -> screen for depression
PHQ-9
10 or greater is cutoff
Risk factors - livining in institution, chornic illness, recent death of spouse,
Assesses anhedonia, deperssed mood, sleeping difficulty, changes in appetitie, feling of guilt, worthlessness, dec’d energy, suicidal ideation, concnetration issues
Dix Halpike maneuver - dx BPPV - check for vertigo or nystagmus
MMSE - cognition testing - only test if some reason to suspect dementia or MCI
TUG - risk for falls >14 s
Transfusion related acute lung injury (TRALI)
hypoxia, dypnea, fever, hypotension within hours of getting blood products - resembles non-cardiac pulm edema - pulm infiltrates on CXR
Etio - antileukocyte Ab in donor blood -> sequester in lung
Tx: supportive
Acute hemolytic transfusion reaction - clerical error in ABO compatilibity - very early rxn - hypotension, DIC, NOT PRIMARILY HYPOXIA
Febrile nonhemolytic transfusion rxn - during tx - > Fevers - NOT hypoxia or pulm infiltreates
Tranfusion associated circulatory overload - usually with multiple units of blood products - more likley with underlying cardiac dz
Manage patient with low risk ovarian CA
Stage IA - observation after surgery with neg margins - no need for adjuvant chemo
TAH+ salphooophorectomy b/l, omenectomy, pelvic washings for cytology
Adjuvant chemo for high stage - IC or greater = paclitaxel/carboplatin
No role for “second look surgery”
IP/IV chemo - stage II/III ovarian CA - not for early stage
Rhinitis medicamentosa
Ongoing use of topical nasal vasoconstrictors - continued use with diminishign returns - withdrwawal cuases SEVERE congestion
Tx: withdraw use - use nasal corticosteroid or nasal saline spray to mitigate withdrawal sx
Chronic rhinosinusitis - mucopurulent drainage, facial pain/pressure typical of sinusitis
Chronic nonallergic (vasomotor) rhinitis - one typical sx of rhinitis (sneezing, rhinorrhea, nasal conj, postnasal drainage), in absense of specific etiology - can’t dx this until rhnitis medicamentosa r/o
Granulomatosis with polyangiitis - necrotizing vasculitis - affects upper resp tract and kidneys - 70% with sinusitis - pulm manifestations including cough, hemoptysis, pleurisy
Patellofemoral pain syndrome
W>M
young pts
Anterior knee pain worse with sitting and going UP AND DOWN stairs
Patellofem compression test- knee extension, push patella both med and lat with pain
tx: conservative tx
OA Knee - Age>50, stiffness <30 min, crepitius, bone tendernes/enlargement, no warmth
Pes Anserine bursitis - pain anteromedial aspecto of prox tibia, swelling at insertion of hamstring medial -
Pre patellar bursitis - caused by recurrent trauma - kneelinig, infection or gout, pain located anteriorly - tnederness/swelling in lower pole of patella to palpation with erythema
Dx: hereditary spherocytosis
Hereditary spherocytosis - splenomegaly, fhx anemia/leg ulcers/gallstones
Smear: spheroctyes
sx: asx to severe hemolysis/fatigue
Episodes of severe anemia from parvovirus B19 infection - transient aplastic crisis
Dx: elev bili, LDH, high retic (5-20%), +osmotic fragility test
Alpha thal (a/-, a/- or a/a, -/-) mild anemia microcytosis, hypochromia, target cells (HALT) NORMAL Hg ELECTROPHRESIS (B thal is abn)
G6PD - AA men - smear normal between crisises - but bite cells during acute hemolytic episode - NO SPHEROCYTES
Warm autoimmune hemolytic anemia - does have spherocytes but would have +direct coombs and no fhx of anemia/gallstones
Sickle cell anemia (Hb SS) - mod to sev anemia with pain crisies - normocytic, sickle cells
Sudden sensonerual hearing loss
Not conductive - better air conduction than bone
DDX: infection, neoplasm, truma, autoimmune, vascular events, ototoxic drugs
Needs urgent ENT eval - oral or intratypmanic corticosteroid tx
Otic herpes zoster (ramsey hunt syndrome) - herpetic lesionis in ear canal - and ipsilateral facial palsy -
tx: acyclovir
Acute otitis externa - neomycin, polymxyin hydrocortisone drops - otalgia, otorrhea tenderness with tragal or pinna tugging
Triethanolamine ear drops - cerumen removal - cuases conductive hearing loss not sensoneural - no tinnitis
Manage pt with advanced kidney CA
L nephrectomy
Pain, mass, hematuria, - chest imaging c/w mets
Survival improved with resection of primary tumor
(ONLY IN KIDNEY CA does it improve outcomes and not just reduce local sx) - only pt eligible for immuotx
then tx with IFN alpha
CT lung bx only after primary tumor resected
Bx not recommended - doesn’t change need for resection - neg bx would be viewed as false neg
Systemic tx - sunutieb, sorafenib, - may be helpful in RCC but NOT cytotoxic chemo…
Lenolidamide associated PE in pt with MM and kidney dz
V/Q scan to dx PE given inc’d Cr
Lenoliamide and dexamethoasone -> high risk of VTE
(also high risk with anthracycline, cytotoxic agents)
Other risk factors - h/o VTE, CV catheter, recent surgery, immobilizattion, hypervisc from paraproteins from MM,
DOn’t use CTA chest with CKD
CT without contrast wouldn’t see PE
without fever, crackles on exam PNA less likely
Manage rectal bleeding
Pt older than 40 with hematochezia should undergo colonoscopy or sigmoidoscopy
r/o colonic neoplasm as source of bleeding
In 50 then colonoscopy (not sigmoidoscopy)
If colon CA excluded - then tx hemorrhoids conservatively - only do banding if conservative tx fails
Fiber supp only is inappropriate need to w/u bleed in >40yo pt
Home FOBT would likely be + with bleeding hemorrhoids - either way will need scope
AAA screening
Pt needs AAA Abd US screening - 65-75yo MAN with smoking history (100 cigarettes or greater)
No CAC - not recommended for asx patients
No CXR or Chest CT (low dose) - despite being former smoker
Lipid profile women Men >35yo or women >20yo who are at inc’d risk for CVD then q5years if low risk
Dx Mild Cogntive Impairment (MCI)
Single or few areas of cognitive trouble
MMSE 24 or 25
Dementia clues - language, memory, apraxia (problems with dressing unrelated to motor fxn), impaired executive fxn,
Alzheimers - less likely if only one or two domains of problems(no issue with ADL, language) - MMSE 19-24=mild dementia - 10-19=moderate
Pseduodementia - cognitive impairment 2/2 depression - tx will improve cognition
Vascular dementia - unlikely with MMSE 25 - vascular dementia would not just have memory defect in isolation - would affect other cognitive and neurologic fxning
Osteonecrosis of hip
Dull aching groin pain - indolent
Risk factors etoh abuse, chronic steroids
Severe pain in early stages with bone death
Limited ROM of hip on exam
Early stage radiolography normal
Patchy areas of lucency/sclerosis may be seen - MRI most senstive and postive earliest
OA of hip - h/o pain in groin and medial thigh - worse with activity better with rest, no period of SEVERE PAIN
Radiographs with joint space narrowing and osteophytes
subchondral sclerosis
NEvere have normal radiograph
Septic arthritsi - acute onset with fevers, limited ROM
L1 radiculopathy - pain, paresthesia, sensory loss in groin
Chronic dizziness in elderly
PT/gait evaluation effective intervention to reduce fall risk in elderly
w/u of dizziness usually unfruitful -
Could be 2/2 meds, sensory impairment, weakenss, neuropathy, anxiety, deconditioning, deperession, postural hypotension
Also needs eval for visioin/hearing aids
Don’t change lantaprolst to a BB(timolol) inc r/o falls/dizziness
Don’t change ACE-> arb won’t do anything
Vestibular rehab only if BPPV
Prostate CA f/u
Patient with average risk prostate CA - DRE+PSA check q6-12 months
Clincial stage IIa with good response to radiation
Androgen deprivation tx - high risk localized dz - or loaclly advanced dz - usually start before radiation then continue after
Chemotx - docetaxel - for hormone refractice met prostate CA - - no benefit in pt without mets
No benefit with serial CT/bone scans
Stage IV NSCLC
Malignant pleural eff = stage4 = uncurable
Tx: palliative systemic chemotherapy
goals syptom palliation/prolongation of survival
Combo chem/rad - unresectable stage III - where tumor and LN can be encompassed in radiation field
No radiation as first line tx (only for palliation with SVC syndrome, obstructive pneumonitis, brain mets, SC compression, bone mets)
No surgery as pt already is stage IV - would not improve survival and would inc morbidity
Evaluate pt for Head & Neck CA
Fiberoptic endoscopy of oropharynx with bx - dx
SCC of head and neck can occur in pt without risk factors - (EBV or HPV?)
Painless mass, mucosal ulcer, localized pain of mouth, teeth, throat, ear, odynophagia, diplopia, loss of vision, hearing loss, sinusitis
Don’t do excisional bx - would compromise tissue planes for surgical approach for cancer later - use FNA instead
MRI after fiberoptic endoscopy for staging
Also PET/CT after endscopy for staging
Evaluate older patient with suspected bladder CA
h/o smoking, elderly pt - painless gross hematuria
Dx: Cystoscopy
Need to r/o bladder CA
can use cytology in conjunction but not instead of cystoscopy (to detect upper GU tract malignancies no seen by cystoscopy)
No PSA - pt with prostate CA can have hestiancy, decreased stream, nocturia but not bleeding usually
No UCtx as pt not with elevated leukocytes in u/a or urinary sx
Buliemia nervosa - purging subtype
Recurrent episodes of binge eating with copenstaory purging to prevent weight gain
vomiting, exercise, laxatives
Purging subtype - metabolic abn (hypokalemia, hypoMg, met alkalosis)
At least 2/wk x 3 months
Self perception influenced by body weight and shape
NORMAL WEIGHT
Dental caries, enlaarged salivary glands
scaring on dorsum of hands
Regular menses
Anorexia nervosa - LOW BODY WEIGHT buliemia nervosa
Binge eating d/o - no assoicated compensatory behavior
Night eating syndrome - excessive eating at night, difficulty sleeping, morning anorexia - prevalaent in obese pts
Genetic counseling
Refer for genetic counseling
only referred for genetic testing with counseling
potential harms of genetic testing
1. pt has personal or fhx of genetic condition
2. genetic test that can be adequately interpreted
3. test results will aid in med/surgical management
Brain MRI not useful in asx patient with huntingtons
Don’t just reassure pt - no idea when symptoms might manifest
Manage pt with VTE after hospital d/c
In first month after hospital dc following VTE - pt should be bridged with LMWH if subtherapeutic and warfarin increased
check INR in 3-5 days
Recurrence risk is 40% so bridging is needed
Chronic warfarin users with <0.5 off therapeutic level do not need bridging
Chronic bacterial prostatitis (category II)
6 month h/o pelvic pain, urinary freq, painful ejaculation, and on multiple UTI abx courses without resolution
Need 1 month prolonged course of abx (cipro)
Acute bacterial prostatitis (cat I) - 1 week bactrim
Category III prostatitis - chronic abacterial prostatis/chornic pelvic pain syndrome - non-infectous - no abx needed
Need CBT + empathetic supportive care
Finasteroide 5 alpha red inhib - used in BPH - reduces prostate volume - not used for bacterial prostatitis
Cobalamin deficincy
macrovalocytes and hyperseg neutrophils on smear
ineffective hematopoesis -> hemolysis -> elev LDH/bili, icterus, fatigue, low retic count
glossitis, wt loss, jaundice, yellow skin
neurologic sx - loss of position sense, vibratory sense - spastic ataxia
Warm autoimmune hemolytic anemia
insidious
anemia, jaundice
smear: spherocytes (erythrocytes lost central palor)
Direct coombs - postiive for IgG, neg for complememnt
tx: steroids -> splenectomy
Paroxysmal cold hemoglobinuria
Rare hemolysis in adults
IgG Ab bind to erythrocytes in cold -> COMPLEMENT FIXATION - smear microspherocytes
Tx: self limited
Hereditary spherocytosis - inherited RBC membrane defect - spheroctes on smear, inc’d gallstones - splenomegaly
B - thal trait dx
Microcytic anemia, target cells, mild anemia, hypochromia
abn or slightly inc’d erythrocyte count
MCV/erythrocyte count 13 (MCV/erythrocyte count)
Sideroblastic anemia - decreased erythrocyte count -
ineffective hematopoesis
basophillic stippling - stain + for iron
hypo or normochromic, macrocytic
Chronic pain syndrome
pt with fibromyalgia previously well controlled now worsened recently
Evaluate psychosocial stressors ie intimate partner violence
No reason for further dx testing or imaging first in absense of physical findings
No NSAIDS for fibromyalgia/neuropathic pain (ok for MSK pain, inflamm arthrits, RA)
GI and cardiac tox
Opiod therapy - don’t give for chronic pain sydorem -> dependence, lack of effect
URI with ear pain
Don’t prescribe abx for adults with otitis media
Viral URI
dull typanic memb with small middle ear effusion
otitis media vs viral uri without otitis media
Just observe, no tx
IF do give abx -> amoxiciinllin (erythromycin if PCN allergic)
No ENT referral - pt just has URI
Post menopausal woman with newly dx breast CA
Hormone + (estrog/prog)
Tx with aromatase inhib if POST menopausal -> Anastrozole x 5 years
20% risk of recurrence without therapy
s/e arthralgia, hot flushes, osteopenia/porosis
Tamoxifen inc’s r/o endometrial CA
Trastuzumab - for HER2neu+ cancers
Early stage melanoma
1mm deep, 2cm margin for resection +LN need LN dissection
No radiation therapy indicated
No adj interferon in <0.75mm deep
Chest pain due to ACS
Admit to CCU
Pt with anterolat ST dep with substernal CP, age, HTN, HLD -> intermediate risk
Don’t stress pt with active ACS (could worsen ischemia and induce arrythmia) - needs tx with ASA, plavix, heparin gtt, statin, BB +- ACEi
CTPA - only if high prob of PE
NSAIDS - acute pericarditis or MSK pain - not pleurtic in nature or reproducible, no EKG changes c/w pericarditis (diffuse ST elev/PR dep) - no EKG change with MSK pain
High risk locally advanced prostate CA
Gleason 8 to 10
cancer beyond prostate
PSA >20
NO SURGERY
Androgen deprivation therapy (GnRH agonist) and radiation
ADT also used for metastatic dz or those with rising PSA after initial definitive tx
Brachytherapy (seeds) - low or avg risk CA Gleason <20
Radiation tx - Low or avg risk
Manage request for physician assisted suicide
respond with empathy, cmpassion
Assess adequacy of current therapy
Don’t seek counsel
don’t just refuse request - talk to pt
Don’t just write a sedative rx
Pt with transfusion associated anaphylaxis
Washed cells - minizes r/o anaphylaxis in pt with IgA deficiency (and therefore likely IgA Ab)
-also prone to GI infections (partuclary giardia), inc’d r/o autoimmune d/o RA, SLE, (or blood products from IgA def donor)
Gamma radiated cells - eliminates leukocytes and reduces r/o graft vs host dz
Leukoreduced blood - reduced febrile non-hemolytic transfusion reactions, CMV transmission, alloimmunization
Phenotypically matched blood - high risk for alloimmuniz (ABO, Rh, Kell (c, e, k) Ags) - no change in anaphylaxis risk)
Aplastic crisis
Pt with chronic hemolytic anemia (ie sickle cell dz)
Already have low erythrocyte survival
Parvo B19 decreases retic/prodxn suppresion
Recent illess - fever arthralgia
Dx: IgM or PCR Parvovirus B19
Hyperhemolytic crisis - sudden worsening of sickle cell anemia with reticulocytosis
Megaloblastic crisis - inc’d demand during grwoth for folate, preg pts, chronic hemolysis - unlikley to be acute
and unlikley if pt takes folate
Splenic sequestration crisis - splenic pooling of rbcs, drop in Hg, reticulocytosis, splenomegaly, LUQ pain
Manage advanced cancer pain
NSAIDs, tylenol, ASA for mild pain (1-3/10)
Mod pain - opiods/non-opiods
Severe pain - opiods
Adjunctive therapy - antidep, steroids, muscle relaxants, anticonvulsants (neurontin) - better for neuropathic pain
Don’t use meperidine - lowers sz thereshold, varable oral availabliity
Don’t give morphine IM - unreliable absorbptio nand don’t give opiod b4 NSAID with mild pain
Contraception for young woman
Pt doesn’t want to take pill -but has high risk behavior
Need condoms + dept form of birth control
Don’t use methyprog depot injection or vag ring along as does not protect vs STIs
Don’t use condoms + the pill as she isn’t reliable taking pill
Primary dysmenorrhea
Trial of NSAIDs
inhibits inflammation, vasoconsriction, uterine ischemia
Next step combo OCP
Depot methprog - don’t use for younger pt - dec’s bone density - 2/2 long term estrog def
No need for hormonal testing or pelvic imaging if no pelvic pain, sig bleeding abn
Early stage NSCLC (curable)
Surgery with adjuvant chemo
Solid tumor without mediastinal or local LN involvment - stage IB (tumor >3cm)
Chemo+rad - locally advanced tumors - Stage III - mediastinal LN involvment
Radiation tx - never used as sole therapy in lung CA
Early stage too much morbidity, late stage not enough, need chemo
Systemic chemo - palliative care in pt with advanced dz only NOT in early stage dz
Hyperviscosity syndrome with Waldenstrom macroglobulinemia
Prompt plasmapheresis
prodxn monoclonal IgM Ab
hypervisc syndroem - LAD, SM, dizziness, blurry vision, dilatd tortuous retinal vessesls - epistaxis from qualitatative plt dysfxn from IgM excess
No UTI so no cipro
No PRBC or diuresis - may exacerbate hypervisc syndrome
Not HTN encep - changes in level of concousness, focal neuro def, visual field def - retinal hemm, exud, papilledema
Manage pt who interupted Hep B vaccine series
Interval on multidose vaccines are MINIMUM not maximum
Just need to complete series if was prev lost to f/u after first shot in multishot hep B series
Only need to measure vacc response with Hep B Ab content in high risk ppl ie HC workers, HD patients, pt exposed to Hep B
Pt with Hep C is at increased risk if exposed to Hep B so needs vaccines - shouldnt just do nothing
Dx Costochondritis
insidious onset lasts hours to weeks
sharp, localized worse with turning, deep breathing, arm movement
CV exam normal
Acute pericarditis CP - pleuritic, worse with breathing, recumbant position, friction rub, h/o recent viral infxn, MI, trauma, malignancy meds, CTD, uremia
Aortic dissection - tearing/ripping pain, rad to back , h/o HTN, asym pulses,
U/A - rad to arms, exertional, better with rest, diaphoresis, n/v, pressure
Counsel pt with motivational interview
Pt chooses agenda
assess which lifestyle changes are important to pt
Don’t tetll to lose weight or quit smoking
Most effective to figure out what pt considers most imporant to change then give advice on that pt likely to be most motivated to do that…
Ulnar nerve entrapment (cubital tunnel syndrome)
at level of elbow
Pain occurs with flexion of elbow
NO PAIN at medial epicondyl
parasthesia palmar and dorsal surfaces of arm
cubital tunnel - near surface of medial elbow
sustained pressure or minor trauma on nerve
maneuvers that strech or compress nerve elicit sx
If entraped at wrist - palmar only parasthesia
Lateral epicondylitis - tennis elbow - pain in lateral elbow radiating down prox forearm to DORSAL hand, tenderness to palpation at lateral epicondyl
Pain with forced EXTENSION of wrist
Medial epicondylitis - golfers elbow - medial elbow pain-> prox forearm, pain repordced by forced FLEXION of wrist tenderness to palp of med elbow
Olecranon bursitis - pain in POSTERIOR elbow - swelling of bursar sac - ROM NOT LIMITED…
Suspected rotator cuff tear
MRI shoulder
Difficulty aBducting left arm
+Drop arm test
Don’t just give NSAIDs or PT - need accurate dx first to r/o need for surgery
Steroid injction for rotator cuff tendonitis or impingement syndrome but not for tear
Chronic primary insomnia
COunsel sleep hygene
behav or environmental factors
coudl be temp
noise level, bed comfort
Etoh can cause insomnia but not likely in small quanitites
only on weekends
Only goto pharm therapy if nonpharm fails
1st line non benzo zolpidem - don’t affect sleep archieture
2nd line benzo - short term only
Age related macular degeneration
painless progressive vision loss distortion of vision central vision loss most prominent Drusen - amorphous depsoits behind retina like yellow spots all round eye Smoking= etio usually
Catarct - opacification of lens - vision loss progressive, worse in BRIGHT LIGHT or at night
Primary open angle glaucoma - inc’d IOP - -> progressive optic neuropathy -
Painless gradual loss of PERIPHERAL vision
later stages central loss
inc’d cup to disc ratio
Retinal detachment - seperation of neurosensory layer from choroid beneath -
Trauma or spontaneous
Sx: diminshed vision, floaters, photopsia
wavy vision, LOSS OF CENTRAL VISION
Fundoscopy: folds of retinal tear
Acromioclavicular joint degeneration
Likley OA given age
Pain to palpation of acromioclavicular joint
Pain occurs with shoulder ADduction and ABduction above 120 deg
Trauma (yonger pt), OA (older pt)
Absense of pain on palpation good NPV
Palpable osteophytes
cross arm test +
Adhesive capsulitis - thickening of capusule around glenohumoral joint
Pain slow onset, near insertion of deltoid
Pain on lying on affect side
Loss of both active and passive ROM in ALL PLANES
Rotator cuff tear - suprspinatous wk, weakness ext rotation, evidence impingment,
+drop arm test
Rotator cuff TENDONITIS - pain 60-120 deg aBduction
can’t int/ext rotate arm
Neer+ - arm extended 180deg (near ear)
Hawkins + like hawk trainer starting postioin - inter/ext rotate arm - pain = psoitive - shows possible impingment of tendons between muscles
Stress urinary incontinence
Pelvic floor muscle training
loss of urine while cough, sneeze, activity, -> sphincter incontience
PE - weakened anterior/posterior vaginal wall (cystoceole, rectocoele)
(Kegels)
Prompted voiding - significant cognitive or mobility issues (can’t make it to bathroom when need to go)
Sling procedure - (pubovaginal) - mod to severe stress incontincne - refractor to kegels, pharm thereapy
Tolterodine - antimuscularinc anticholinergic
For urge incontinence - would have sense of urgency prior to incontinece (detrusor overactivity) - also timed voiding helps
Low risk surgery
Endoscopic sinus surgery - low risk (or catarct, breast, superificial, ambulatory surgery)
No need for preop cardiac testing unless high risk conditions ie unstable angina, decomp HF, significant arrythmia, , severe valvular dz
If currently on BB keep on BB
Revised Cardiac Risk index - only if high risk will need preop testing -
Pt with low or unknown ET and undergoing int or high risk surgery - need preop cardiac testing
No need for cath - try for non-inv testing
TESTING ONLY DONE IF WILL AFFECT MANAGEMENT IE WILL SEND PT FOR CATH TO GET A URGNETLY NEEDED STENT (won’t just benefit from med therapy)
Preop testing in pt without comorbidies
Childbearing age - check preg test
result WILL CHANGE management (or if will impact periop care)
No sign/sx pulm dz so no CXR needed
No h/o, fhx bleeding, liver dz, etoh sig use, A/C use, - so no coags needed
No need for EKG - no sig/sx cardiac dz, no risk factors - only get in pt where silent or prev unrecognized MI possible…
Periop patient with cirrhossis
Elective hip surgery - go with non-operative managemnt pt too high risk
Child Class C - avoid surgery
r/o hep failure, bleeding, infection, adverse drug rxn, poor wound healing,
CTP based on ascites, encep, bili, alb, INR
No role for corticosteroids - only for acute etoh hep (leuko, RUQ pain, jaundice, Hepmegaly)
Cirrhotics - predisp to bleeding from quant and qual plt issues and def of liver produced clotting factosr
Vit K does’t improve cirrhotic bleeding risks - INR elevation not usually 2/2 vit K def in cirrhotics
Assess cardiac risk in pt scheduled for INTERMED risk surgery
No further testing
Only if low ET or multiple risk factors
Need Mets >=4
RCRI - h/o IHDz, copensated or prior chornic HF, DM needing insulin, CKD, h/o CVA
No RCRI factosr so no need for testing even though poor ET
No need for cath
CT coronary not studied for preop risk assessment (coronary)
No need for preop stress in pt with RCRI 0 or 1 (ie low risk patient despite comorbidieies)
Lemierre syndrome
septic thrombosis of jugular vein
CT neck with contrast for dx
fever, inc WBC, pharyngitis, sore throat, unilateral neck tenderness, multiple densities on chest radiograph - septic emboli**
Tx: IV abx (zosyn, ampiciliin-sulbactam)
No need for CT chest
Soft tissue xray of neck won’t see jugular thrombosis
Echo could r/o R endocarditis as source but unlikely in current clinical scenario
Treat plantar fasciitis
Initial therapy NSAIDS or tylenol
Next: Arch support (pt with pes planus - flat foot) - flat foot redistructes forces and cuases pain - may take months for recovery
Don’t inject steroids until arch support fails (only short term solution - steroids)
NO role for extracorporea shock therapy
Surgery only for refractive plantar fasciitis
Vulvovaginal candidiasis in PREGNANT WOMAN
TOPICAL clomitrazole
(not fluconazole)
VVC - itching, discomfort, thick white d/c cottage cheese, vulvar edema/erythema
KOH - hypae/pseudohyhae
Complicated - severe sx (extensive vulvar erutyma, edema, excoration, fissues), DM, immunosupp, PREGNANCY, multiple recurrences
recurrent=>4 / yr
boric acid, voriconazole (non-imidazole)
Treat chronic cough 2/2 GERD
empiric PPI therapy 8-12 wks for GERD related cough
(first lifestyle mod)
No abx if no evidence of infxn
(upper airway cough syndrome - cobblstoning, post nasal d/c - NO NEED for antihist/decong until PPI deemed ineffective
Cough variant asthma - no need for inhaler if pt has reasonable suspicion for GERD as of now
Acute retinal detachment
Predominantly myopic patients Floaters squiggly lines sudden peripheral visual defect black curtain across visual field flashes of light Tx: Surgery - emergent opthal referral
Central retinal artery occlusion - painless loss of vision, elderly, cherry red fovea (accentualted by pale background from dec’d bloodlflwo) - pale fundus - usually elderly
Central retinal vein occlusion - monocular vision loss, cloudiness of vision, cotton wool spot (blood and thunder), congested tortuous veins - retinal hemorrhages
Ocular migraine - with or w/o h/a - foaters/squiggl lilnes - NO VISUAL field defect or tear in retina/folding
Temporal arteritis - h/a, no preceeding floater/squiggly lines
Obsessive compulsive d/o
CBT + SSRI (fluoxetine)
Recurrent obs/comp occupy at least 1 hr daily or interferenign with social fxn/work fxn
Obsession - persistetn ideas, thoughts, imopulses images that felt to be intrusive or cause stress/axiety (fear of germs)
Compulsions - reeptive behaviors that dec anxiety related to obsessions (Hand washing)
Haldol - combi with SSRI if alone not ok
No benzos
Quietapien - 2nd line if SSRI tx fails
Dx cause of syncope
elderly woman
brief prodrome with palpitations
LIKELY CARDIAC arrythmia
Aortic stensosi can cause synope but usually with exertion…
Not myoc ischem - usually have ischemic sx,
Not TIA - usually shoudl have focal neuro sx/findings
Evaluate breast mass in young woman
Palpable breast mass should be evaluated till dx or resolution Needs US likley fibroadenoma or benign cyst (soft, discrete round mobile mass - ) US will give cystic vs solid If cystic - need needle aspiration and analysis If solid - FNA bx needed Still needs to be followed if beningn
Imaging should proceed bx (core needle)
Don’t get mammo in young woman with dense breasts
Don’t wait 6 months and observe need to evaluate now…
