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
