Facts Flashcards
DM treatment options with weight negative effect
metformin
GLP-1 (liraglutide, exenatide)
SGLT2 (-flozins)
Which DM medication should be avoided with history of genital mycotic infections
SGLT2 (-glflozin)’s
colon cancer screening in UC
start 8-10 years after UC diagnosis and repeat every 1-2 years
treatment of pulmonary arterial HTN
If + response to vasoactivity test –> CCB FIRST
no symptoms at rest, only activity – then start with oral meds
(PDE-5 inhibitors = sildenafil, viagra) or
(enothelian receptor antag = bosentan, ambristan)
treatment of rising PSA after prostate cancer in past
radiation and leuprolide (androgen deprivation)
pyoderma gangrenosum
non healing ulcer, culture neg
assoc with UC/ IBD
tx: prednisolone, cyclosporine
goal BP for intracerebral hemorrhage?
<140 systolic
ethylene glycol overdose clinical features and tx
CNS depression
inc anion gap metabolic acidosis
inc plasma osmolar gap (>10 difference bw measured and calculated serum osm)
renal failure
tx: fomepazole, HD IV bicarb (if pH <7.3)
DM medications to lower cardiac risk
liraglutide
empagliflozin (dc all cause mortality, death by CVD and HF hospitalizations)
BMI cut off for bariatric surg
> 40 or >35 with obesity related comorbidities
lower incidence of statin induced myopathy with…
pravastatin, rosuvastatin
criteria for lung transplant referral
FEV1 <25%, PaO2 <60, CO2 >50
hidradenitis suppurativa tx
clindamycin-rifampin
infliximab
surgical excision
normal ABI
PAD ABI
nl: 0.9 -1.4
PAD: <0.9
ischemic rest pain < 0.4
if borderline nl and symptomatic–do EXERCISE abi
if > 1.4 it indicates the presence of calcified, noncompressible arteries in the lower extremities and is considered uninterpretable.— do toe brachial index instead
treatment of glioblastoma (IV)
surgical resection
followed by chemo (Temozolomide) + RT
acute Wegners treatment to induce remission
steroids and rituxmab or cyclophosphamide
DEXA score cut offs
osteoporosis < -2.5
osteopenia (-1 to -2.5
normal -0.9 to 1+
Indications for antiresporptive treatment (ex: bisphosphonates, denosumab, raloxifene, teriparatide)
osteoporosis
osteopenia with FRAX > 20% major and >3% hip
fragility fracture
vertebral or hip fracture
moderate or high 10-year risk for a major osteoporotic fracture taking at least 2.5 mg of prednisone daily for 3 months
risk of DKA with which diabetes med
SGLT-2 inhibitors (-flozins)
** DKA with normal glucose
anti-HTN to lower serum urate
losartan
HCTZ and salicylates elevate it and predisposes to gout
acute gout flare tx
NSAIDS (CI in PUD, CKD, HF, old, post op)
colchicine (CI in kidney failure)
glucocorticoids (oral vis intra-articular)
** do not change dose of allopurinol during acute flare
indications for long term urate lowering therapy
2 attacks of gout
1 attack with CKD
uric acid nephrolithiasis
visible tophi
tx options: allopurinol, febuxostat (for non tolerance allopurinol), IV pegloticase (severe refractory)
**give NSAID/Colchine with when initiation and continue flare prophylaxis if active disease or tophi for 3-6 months
tx for refractory gout
IV peglocticase
tx of status epilecpticus
IV lorazepam then phenytoin or fosphyenytonin (not keppra)
meineres triad
senisuronal hearing loss, vertigo, tinnitus
Rhinne vs. Weber (tuning fork to forehead)
normal is air >bone.
conductive loss is bone >air
Sensorinural– Weber louder in good ear (Ipsilateral)
Conductive– Weber louder in affected ear
time cut off for tpa in acute stroke
4.5 hours (asa okay 24 hours after TPA given)
3 hours is <80yo, DM with prior infarct, on anticoagulation
(must get to PCI center in 2 hours for acute MI or get TPA)
door to balloon is 90 mins in STEMI
age for cc screening
50 -75 (if prior screening and up to date)
if no prior screen can start up to age 85
when to FNAB a thyroid nodule
> 1cm with normal TSH and suspicious features
<1cm with high risk features (calcifications, etc)
- after two negative FNAB can just follow clinically
** if suspect thyroid cancer/MEN check calcitonin (elevated in medullary thyroid cancer)
GFR cut off for metformin contraindication
<30
don’t start with GRF <45
Pioglitazone C/I in?
chronic liver disease and HF
drug of choice for coccidiodies
fluconazole
best anti-seizure meds for older people
lamotrigine, levetiracem, gabapentin
low potency steroids for face
1% hydrocortisone validate
can use 0.1% triamcinolone for other body parts
indications for surgery in primary hyperPTH?
age <50 CKD with GFR <60 nephrolithiasis T score < -2.5 Ca greater than 1 above the ULN
treatment of ILD in systemic sclerosis
mycophenolate
criteria for adequate stress testing
85% of age predicted maximum HR
atleast 4 METs
H pylori Tx
triple therapy: PPI, amox, clarithromycin
Quad therapy in clarity resistant areas (asia, australia) or pcn allergy: PPI, bismuth, flagyl + tetracycline!
prior exposure to macrolides: amox, levaquin, PPI
** test for clearance at least 4 weeks after completing therapy
** do not test for H pylori until off PPI for 2 weeks and abx for 28 days
Tx of NON-small cell lung cancer based on mutations
EGFR –>
ALK/ROS1 –>
PD-L1 –>
EGFR –> erlotinib
ALK/ROS1 –> crizotinib
PD-L1 –> pembrolizumab
indications for airborne contact precautions
TB
disseminated varicella zoster
localized zoster in an immunocompromised
measles
** neisseria meningitis only needs droplet
characteristic of AVNRT on EKG
SVT–Narrow QSR tachycardia
RP < PR
P wave buried in QRS
pseudo R in V1
tx:
hemodynamically stable: vagal maneuver/carotid massage, adenosine (C/I in asthma exac bc risk of bronchospasm)
unstable: sync cardioversion
DM med assoc with risk of cholestasis, cholelithiasis, choleycystecomy
GLP-1 (eventide, liraglutide)
- bc rapid weight loss it causes saturation of cholesterol in bile and delayed release of bile
- also inc risk pancreatitis
reversal of dabigatran (direct thrombin inhibitor)
idarucizumab
AAA screening US age group
age 65-75 who smoked more than 100 cig
tx of DM caused by chronic pancreatitis
INSULIN only bc pancreatic beta cell destruction
hemolytic anemia, hypocellular bone marrow/ pancytopenia, and lack of CD55 and CD59.
portal vein thrombosis
Paroxysmal Noctural Hematuria
timeline for radiation pneumonitis vs. radiation fibrosis of lungs
radiation pneumonitits–typically 6-12 weeks
radiation fibrosis—typically 6- 24 months
treatment for essential tremor
primidone or propanolol
interpretation of FeUrea
<35% = pre-renal
pre-renal findings
BUN: Cr >20:1
FENA <1%
U sodium <20 **
hyaline casts
ATN findings
BUN:Cr 10:1
FENA >2%
Urine sodium >40
muddy brown casts, tubular epithelial cells
AIN urine microscopy findings
leukocyte casts, eosinophilliura
mononeuritis multiplex assoc with
polyarteritis nodosum
- medium vessel vasculitis–mesenteric and renal vessels
- assoc with hep B
best seizure med for women on OCP/ reproductive age
Keppra
testing for lyme disease
TWO-tiered:
Enzyme assy (Lyme Ab EIA) - if positive --> Western blot IgM and IgG (after 30 days will be present)
treatment after thyroidectomy for thyroid cancer?
if high risk – > radioactive iodine
high risk:
size of the primary tumor (between 2 and 4 cm), the presence of vascular invasion and extrathyroidal extension and the number of involved lymph nodes (>5).
mitral regurg—indications for mitral valve repair
asymptomatic and LV dysfunction (EF <60%)
symptomatic and EF >30%
Pulm HTN
new onset Afib
dx west nile via
IgM ab
fever, meningitis signs
+ FOCAL neuro deficit
tx of PID in hospitalized patient
cefoxitin (IV cephalosporin) + doxycycline
OD with increased anion gap acidosis, and an elevated osmolal gap.
methanol (wood alcohol)
ethylene glycol (antifreeze)
Tx: fomepizole, HD( if severe)
isopropyl or ethanol OD have elevated osmolar gap but NOT elevation anion gap and no metabolic acidosis
tx of RA
Methotrexate then DMARD/TNF-a inhibitor (if that doesn’t work then rituximab)
prednisone only for acute flares
how to prevent stroke after carotid a. dissection
aspirin
tx of partial seizure
tx of generalized seizure
partial–carbamazepine
generalized epilepsy– valproic acid
safest anti epileptic in preg
levetiracetam (or lamotrigine)
reasons to treat after FIRST unprovoked seizure
age >65 h/o head trauma focal findings on imaging/EEG h/o partial seziure h/o postictal weakness/paralysis
otherwise treat after 2 unprovoked
tx of relapsing-remitting MS
interferon B (C/I in liver disease or depression) or glatiramer vit D supplementation
refractory –> Natalizumab (C/I with pos JC virus Ab)
IV methypred (high dose steroids) for acute exac Interferon C/I in depression/liver disease
Travel
episodes of fever, polyserositis, arthritis, erysipeloid rash around the ankles, and elevated acute phase reactants
dx?
tx?
Familial Mediterranean fever
colchicine
DM medication assoc with medullary thyroid cancer
liraglutide (GLP-1)
permissive HTN goals
- after ischemic stroke
- after/ before TPA
- after ICH
after ischemic stroke <220/120
before TPA <185/110
after TPA <180/105 (for at least 24 hours)
ICH – <140
treatment of poison ivy
high potency topical steroid
Type IV hypersensitivity
Chicungunya distinction from Dengue
fever recurrent + migratory polyarthralgias (small joints of the hands, wrists, and ankles) and much less thrombocytopenia.
Dengue has more myalgia, arthralgia, back pain (bone break fever)
Pneumocystis jirovecii prophylaxis after solid organ transplant
bactrim for 6-12 months
pusles paradoxus
systolic drop by >10 with inspiration
- seen in tamponade, constrictive pericarditis, asthma, COPD
Four statin benefit groups
- Clinical ASCVD (ACS, MI, Angina, CVA, TIA, PAD, aortic aneurysm, Coronary a. calcium score >100) —goal LDL <70 (add ezetimibe, then PCSK9)
- LDL >190 (high int)
- DM (mod inten) unless ascvd>20 then high
- ASCVD >7.5% (mod int), ASCVD >20% (high int)
preferred SSRI in preg
sertraline, fluoxetine
paroxetine is worse for preg
risky meds in preg
isotretitonin (X), warfarin (X), statins (X), bisphosphonates, ACE/ARB, valproic acid, SSRI, quinolone, tetracyclines
tx of alcoholic hepatitis to decrease mortality
indications?
prednisolone
Maddrey > 32, MELD >18
or encephalopathy + ascites
indication for MRI with headaches…red flags?
first/worst headache change in pattern of headaches aura lasting >1hr focal deficit new HA in age <5 or >50
psychiatric symptoms, seizures, autonomic instability, and choreoathetoid movements.
anti-NMDAR encephalitis
** strong assoc with ovarian teratoma
treatment can include tumor removal (if present), intravenous glucocorticoids, intravenous immune globulin, plasmapheresis, and rituximab
Differences between types of RTA
nl anion gap metabolic acidosis w/ positive urine anion gap: (Na+K) - Cl
Type 1– distal
- urine pH»6, low bicarb, hyperK
- ass cat phos stones, SLE, Sjogerns
Type 2— proximal
- urine pH <5.5, glycosuria
- assoc MM
Type 4–
- urine pH < 5.5 low renin, low aldo, Hyper K
- assoc DM, develop severe HyperK with ace/arb
afferent pupillary defect, pain with eye mvmt, central scotoma
Optic neuritis, think MS
Get MRI brain
when to use vit K for supratherapeutic INR
oral vit K for INR >9
5-9 hold warfarin
IV vit K for life threatening bleeding only
Elevated LFTs, hemolytic anemia, unconjugated hyperbili
+neuro dysfunction
Liver biopsy to confirm Wilson’s disease
- unexplained acute liver failure in <40yo.
Indications for ICD
indications for ICD post-MI?
EF <35% and NYHA class 2 or 3 symptoms
Not class 4 unless patient is transplant candidate
inherited long QT
Brugada
high risk HOCM
VT/VFib arrest
sustained VT with syncope or structural heart disease
at least 40 days post MI - EF <30%
- at least 3 months since PCI/CABG
- life expectancy at least 1 year
Murmur of HOCM
Increases with valsalva, change from squatting to standing (dec preload)
decreases with hand grip or squatting
(inc after load)
** murmur improves/decreases with volume in heart.
Increased risk of death with dehydration
timing of pneumococcal vaccine
23 valent age 19-64 with COPD/asthma
repeat 23 valent (polysaccharide) at age 65 if 5 years has lapsed
everyone gets 13 valent (conjugated) at age 65 [ 1 year after 23 valent]
PSV23 and PCV13 are also indicated in patients with functional or anatomic asplenia, cochlear implants, persistent cerebrospinal fluid leak, and significant immunocompromising conditions. Preferably, these patients should receive PCV13 first followed by PPSV23 at least 8 weeks later. This patient will require another dose of PPSV23 at the age of 65 years.
broad vs. narrow anti-epileptics
broad: topiramate, lamotrigine, levetiracetam, valproic acid, and zonisamide
- for both generalized and partial epilepsy or if unknown
narrow: Carbamazepine, gabapentin, and phenytoin
- used to treat partial-onset epilepsies(specific auras (déjà vu or a rising epigastric sensation) and unilateral clonic shaking before onset.)
nephrotic syndrome with risk of thromboemobolism
membranous glomerulopathy
when to administer TDAP during preg
b/w 27-36 weeks with every pregnancy
treatment for cluster headache (acute and prevention)
oxygen
subQ sumatriptan
for prevention: verapamil
when to screen for diabetes
adults age 40-70 who are overweight or obese
surgery vs. medical management of aortic dissections
surgery with Type A (ascending or aortic arch) or complicated Type B
medical mgt with type B–IV BB to decrease HR below 60 then IV nitro
which MELD score to send for transplant
> 15
TIPS c/i for >20
follow up colonoscopy timing for sessile serrated polyp vs. adenomatous
serrated:
<10mm — 5 years**
>10mm — 3 years **
adenomatous:
1-2 that are <10mm — 5-10 years
3-10, >10mm, villous, high grade dysplasia– 3 years
>10 polyps – < 3 years and eval for genetic cause
hyperplastic
if small and distal, regular 10 year interval
tests to screen for cushing’s disease
24 hour urinary cortisol
1mg (low dose) dexamethasone test
evening salivary cortisol
- *NEED TWO ABNORMAL TO DIAGNOSE
- **NOT AM cortisol, bc it fluctuates
how to diagnosis CTEPH
VQ scan
diagnosis of sarcoidosis
bronch biopsy
biliary disease assoc with UC
Primary sclerosisng cholangitis (intra and extra hepatic ducts)
Primary Biliary cirrhosis is assoc with anti-Mitochrondrial ab.
treatment of rosacea
rosacea – topical metronidazole
anterior knee pain that is slow in onset and typically made worse with running, climbing stairs, and prolonged sitting.
patellofemoral pain syndrome
lateral knee pain that is worsened by walking down an incline. On examination, there is frequently tenderness to palpation of the lateral femoral epicondyle,
illiotibial band syndrome
treatment of babesiosis
atovaquone + azithromycin
MEN syndromes
MEN1 – diamond (pituitary (prolactinoma), parathyroid, pancreas(insulinoma) )
MEN2A — square (parathyroid, pheo)
MEN2B — triangle (neuroma, pheo)
2A and 2B assoc with medullary thyroid cancer
treatment of secondary hyperPTH due to CKD
calcitriol
agent for pharmacologic stress ECHO with COPD/Asthma
dobuatmine
- vasodilators, such as dipyridamole, adenosine, and regadenoson, can cause bronchospasm during cardiac stress testing; these agents can be used with caution in a patient with a history of COPD but are contraindicated in a patient who is actively wheezing.
size to warrant aortic aneurysm repair in men/women
5.5 cm in men and 5.0 cm in women
screening with annual low-dose CT in patients with
age 55 to 80 with at least 30 pack years and current smoker or quit within 15 years
treatment of lupus nephritis
class III and IV - prednisone AND mycophenolate or cyclophosphomide
V
- prednisone AND mycophenolate
Treatment of ITP
Platelets > 30,000 and no bleeding
- clinical observation , repeat CBC in 1-2 days
PLT<30K—- prednisone.
2nd line = IVIG
3rd =rituximab/splenectomy
Colonoscopy follow up timeline after cancer
Follow up colonoscopy at 1year and 3year and if normal then every 5 years
Hip pain with FABER (flexion, abduction,external rotation) plus tenderness of SI
Sacroillitis
FABER causes–posterior hip pain in the presence of sacroiliac joint dysfunction, groin pain from an intra-articular cause, and lateral hip pain from greater trochanteric pain syndrome.
critera for extubation
RR <35 and O2 sat of at least 90%
indications and treatment of Essential thrombocytopenia
> 60yo, h/o thrombus, PLT >1million
tx: hydroxyurea + asa
low risk patients– asa only
stroke/TIA–platetletpharesis
time to get to PCI center for STEMI
<120 mins otherwise give TPA
(symptom onset within last 12 hours for giving TPA)
c/i if history of brain bleed, known AVM in brain, active bleeding, ischemic cva within 3 months, closed head/facial trauma within 3 month
door to balloon goal 90 minutes
vasculitis assoc with HepC and ear infarctios
cryoglobulinemia
-low C4, normal C3
small R wave and deep S wave in V1 lead
EKG with wide QRS and “W” in V1 and “M” in V6
LBBB
diagnosis of parkinson’s
presence of bradykinesia and at least one of the other cardinal features of resting tremor, rigidity, or postural instability.
c-ANCA
p-ANCA
cANCA (anti-protinease Ab)
- Wegners (granulomatosis w/ polyangitis)
pANCA (anti-myeloperoxidase)
- *MPA– microscopic polangitis**
- Churg Strauss (eosinophillic granulamtosis)
pneumonia vaccine time line
13 (conjugate)
23 (polysaccaride)
*see pic
treatment of myasthenia crisis
plasmapheresis
IVIG
** stop pyridostigmine during acute crisis due to it causing inc in resp secretions
treatment of status migraineous
intravenous infusions of dihydroergotamine
when to screen for HCC in HepB carriers
asian men >40, asian women >50 cirrhosis famHx of HCC persistant LFT elevation african descent age 20 DNA levels > 10K
tx if ALT elevated and HBV DNA > 10,000
ICD vs. CRT placement (biventricular pacemaker)
ICD– EF <35% and class 2-3 HF on GDMT
Cardiac resync therpy– EF < 35% , class 2-4 symptoms on guideline-directed medical therapy, and LBBB with wide QRS*
dif b/w folate and b12 def
folate – elevated homocysteine
B12– elevate homocysteine and MMA
pap smear screening guidelines
21 to 65 q3 years with cytology (Pap smear)
30 to 65yo- pap + HPV q5years
can stop at 65 if two neg HPV+pap in last 10 years
nephrotic syn assoc with HepB
membranous
treatment of sever or symptomatic Mitral stenosis
**rheumatic heart dz = MCC
Percutaneous balloon mitral valvuloplasty is treatment of choice.
MV replacement if mod-severe mitral regur or LA thrombus
complement levels in lupus nephritits
low C3
low C4
biliary disease assoc with UC
Primary sclerosis cholangitis
( beads on screen)
(diagnose with cholangiography)
compressive spinal cord lesion
steroids for anything compressive
imed RT– if plasmacytoma or myeloma, leukemia, lymphoma, myeloma, and germ cell tumors
surgery–all other causes
ADAMSTS13 testing indication
suspicion of TTP (hemolytic anemia + low PLTS)
- treat with plasma exchange
ITP only has low platelets but no hemolytic anemia
positive direct antiglobulin (coombs) test
warm-Ab autoimmune hemolytic anemia
tx= steroids
+flow cytometry for CD55 and CD59
and how to treat?
PNH
no hemolysis—no treatment
tx for severe disease is eculizumab or HSCT
spherocytes
Autoimune hemolytic anemia (+coombs) or hereditary spherocytosis
anthrax tx
mild cutaneous– PO cipro
inhlational–IV cipro + 2 other abx
painless ulcer with black eschar
Gram pos bacilli
widen mediastinum– inhalation anthrax
small-vessel vasculitis affecting the skin, joints, kidneys, and gastrointestinal tract. Deposition of IgA
Henoch schonloin pupura
treat with steroids
Kleinfelter (XXY)
he extra sex chromosome results in malformation of the seminiferous tubules and typically of the Leydig cells. Physical examination is likely to reveal small, firm testes and decreased virilization. Additional manifestations include oligospermia and infertility.
low testosterone
- with high FSH/LH
- with low or normal FSH/LH
high fsh/LH = testicular failure
**Klinefelter (check karyotype), mumps orchitis, prior pelvic RT
low or normal = secondary hypogonadism
- OSA, hyper Prolactin, hypothalamus or pit disorders, use of opiates/anabolic steroids, glucocorticoids
- –> always eval prolactin, iron studies (hemochromatosis), pituitary MRI
what depth of melanoma requires sentinel LN biopsy
> 1mm– get LN biopsy and 2cm surgical margin
<1mm- get 1cm surgical margin
if greater than >4mm deep or LN involvement–immunotherapy with interferon alpha
treatment of melanoma with BRAF mutation
vemurafenib preferred over immunotherapy
treatment of anal cancer
squamous cell assoc with HPV
–radiation with concurrent chemo
diagnosis of preeclampsia
HTN after 20th week gestation
PLUS
proteinuria or END ORGAN DAMAGE
low PLT <100K, Cr elevation, elevated LFTs, pulm edema, cerebral or visual symptoms
cardiac/pulm side effect of limited cutaneous systemic sclerosis
pulmonary HTN (pulmonary arterial pressure > 25)
–eval with ECHO
THEN maybe right heart cath
alternatives to colon cancer screening
age 50-75
- FIT Or high sens FOBT (gFOBT) yearly
- flex sig q5
- CT colonography q5
- flex sig q10 +FIT/gFOBT
- fecal DNA q3yr
how to determine surreptitious thyroid use
low thyroglobulin levels
treatment of hyperthyroidism in 1st trimester pregnancy and with thyroid storm
PTU
other wise treatment is methamizole
when is radioactive iodine c/i for hyperthyroidism treatment?
pregnancy
concurrent graves opthalamopathy
biggest side effect of hyperthyroidism tx
methamizole and PTU can cause agranulocytosis (severe neutropenia)
pre-op treatment of pheochromocytoma
IV phenoxybenazamine
first thing to do when evaluating hyper PROLACTIN
r/o hypothyroidism!!
dix hallpike differentiation b/w peripheral and central disease
peripheral
- latency bw maneuver and symptoms
- lasts <1min
- fatiguability
- horizontal w/ rotational
central (brainstem or cerebellar stroke)–get MRI
- no latency,
- Lasts >1
- not fatiguable
indications to monitor pericarditis as inpatient
high-risk features (fever, leukocytosis, acute trauma, abnormal cardiac biomarkers, immunocompromise, oral anticoagulant use, large pericardial effusions, or evidence of cardiac tamponade)
indications for BRACA testing
- breast cancer before age 45 years
- breast cancer at any age and a family history of breast and/or ovarian cancer
- triple-negative breast cancers diagnosed before age 60 year
treatment of burkett lymphoma
R-CVAD immediately bc it is aggressive
reasons for early surgical intervention in infective endocarditis (before 6 weeks)
heart block veg >10mm HF left sided w/ staph aureus/fungal/resistent persistant bacteremia >7 days annular or aortic abscess
episcleritits vs scleritis
uveitis
episcleritis
- painless
- no vision changes
scleritis
- painful, assoc w/ systemic AI diseases
- risk of vision loss, imed referral to optho
Uveitis
- most dilation at corneal edge
- Unitlateral
- assoc with HLA-b27
b/l painless gradual peripheral vision loss
elevated IOP
open angle glaucoma
Macular degen causes central vision loss
initial evaluation of palpable breast mast
MMG (or US if <35yo)
then FNA or biopsy
c/i to combined OCPs
uncontrolled hypertension breast cancer VTE liver disease migraine with aura.
Estrogen-containing preparations are contraindicated in women >35 years who smoke
treatment of menopause hotflashes + vaginal dryness
if have uterus— combined estrogen + progesterin
- **younger than 60 and within 10 years of menopause
- **max tx is 5 years
no uterus–can use estrogen alone
if just vasomotor hot flashes– SSRI
if just vaginal dryness – topical vaginal estradiol cream
indications for bridging
mechanical Mitral valve
mechanical aortic valve with afib or risk factors
recent VTE <3mos or afib and CVA <3 mos ago
time to wait for surgery after DES?
Bare metal
DES– atleast 6months, maybe 12
Bare metal- 30 days
treatment of ankylosis spondylitis if NSAIDs aren’t working
TNFa inhibitor for axial disease (adalimumab = humara)
MTX, sulfasalazine, HCQ for peripheral joint disease
initial tx of neutropenic fever
MONOTHERAPY: zosyn or cefepime or meropenem/imipenem
**if signs of severe shock can add vanc simultaneously
no impvt in 4-5 days, add anti-fungal
ICD after MI
EF <35%
at least 40 days post MI
or 3 months post PCI
peripheral vertigo after URI
Vestibular neuronitis
- no hearing loss
Labrynthitis
- hearing loss
treatment of polycythemia vera (high Hgb, low EPO, +JAK2)
phlebotomy (goal HCT <45%)
asa 81
high risk– hydroxyurea
- if EPO not low, consider a paraneoplastic syndrome, testosterone, chronic hypoxemia
treatment of ET
low dose asa (low risk)
high risk ( leukocytosis, >60yo, prior thrombi) —hydoxyurea
if need rapid PLT reduct (stroke, MI)—platelet pheresis
fever, hypoxia, pulm infiltrate after ATRA for APML
differentiation syndrom
- tx with dexamethasone
treatment of Afib when patient also has WPW
procainamide
not BB, CCB, dig–> can cause VF
treatment of WPW
asymptomt tachycaridia–procainamide
sympt tachy– ablation
unstable— cardioversion
WPW conduction w/o symptoms–no treatment or investigation
treatment of pericarditits
asa (esp after MI) or NSAIDS
+
colchicine – to prevent reoccurrence
topical vs. oral antifunal
oral terbinafine or itraconazole for onchomycosis, tinea capitus (head), extensive tinea corporis
topical clotrimazole or terbinafine for everything else
topical options:
imidazole, miconazole, clotrimazole, ketoconazole, ciclopirox, or terbinafine
tinea versicolor tx
topical treatment using ketoconazole 2% shampoo or selenium sulfide suspension is effective.
erythema multiforme
target with violaceous dark cente (multiple)
- strong assoc with recurrent HSV or mycoplasma
- also can be drug rxn
- -> supportive care
NOT to be confused with erythema migranes of lyme which looks like bullseye
abrupt onset severe psoriasis assoc w/
HIV
HIV post exposure ppx
3 drug regimen: tenofivir, emtricitabine, dolutegavir
4 weeks of tx
within 72 hours of exposure
testing at 0,1,3 months
indications for coronary a. calcium score test
10–year ASCVD is borderline (5-7.5%) or intermediate (>7.5%) to determine need for statin for PRIMARY prevention
pneumonia assoc with livestock
Coxiella Burnetti
aka- Q fever
tx: doxycycline
formula for serum Osm
Serum Osmolality (mOsm/kg H2O) = (2 × Serum Sodium [mEq/L]) + Plasma Glucose (mg/dL)/18 + Blood Urea Nitrogen (mg/dL)/2.8
TB skin test cut offs
>15mm = normal population >10mm = IVDU, LTAC, healthcare, DM, homeless, recent arrival from prevalent country >5mm = HIV, contact with active TB, CXR with old TB, organ transplant
SBP antibiotic prophylaxis reasons
- ascites with GIB or variceal bleed– 7 day course
- chronic abx if hx of SBP
- hospitalized with ascites protein <1.5 with (Na <130, Cr >1.3, or bill > 3)
tx: fluoroquinoles
indication for carotid endartectomy
greater than 80% stenosis
asymptomatic infarcts on brain imaging
an abnormal transcranial Doppler ultrasound study
rapid progression.
oral lesions in bullous pemphigoid or pemphigus vulgaris
oral lesions in pemphigus vulgaris (easily ruptured)
bullous pemphigoid–subepidermal vesicles and blisters that are tense and do not rupture easily, chronic, autoimmune
LVH on EKG
large S in V1
large R in V5/6
(S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm).
treatment of Bechets ulcers
topical steroids
colchicine for preventing recurrent ulcers
examples of PSK9 inhibitors
alirocumab or evolocumab
** add if LDL still >70 with statin + exzetimibe
treating dermatitis herptiformis
gluten free diet
dapsone (make sure not g6pd deficient first)
HTN on fundoscopy image looks like?
AV ratio <1 arterioles are very narrow compare to veins
flame-shaped hemorrhages; s
mall, white, superficial foci of retinal ischemia (cotton-wool spots);
yellow hard exudates
optic disk edema
acid base findings of asa overdose
HAGMA + Resp alkalosis
tx: alkalize urine with sodium bicarb
thin white vaginal discharge, fishy odor, no pain
+ wiff test
clue cells
pH >4.5
BV ( gardnerella)
tx: flagyl (clinda if preg)
candidas– painfull/itchy, pH <4.5
what to give for lyme prophylaxis after tick bite and when?
doxycycline if tick has been attached 36 hours or longer and given within 72 hours of bite
otherwise just watchful waiting
asthma treatment directed at IgE?
directed at high eosinophils?
IgE 30-700 – Omalizumab
Eospinophil count >150 — Mepolizumab/reslizumab
hold long to hold NOAC pre-operatively
3 days
indications for closure of ASD
- symptoms (dyspnea/embolism)
- L to R shunt
- RA or RV enlargement
acute onset nephrotic syndrome (without hematuria, just proteinuria) most likely?
minimal change disease
when to test for thrombophilla after unprovoked DVT?
NOT in acute setting
NOT while on AC— at least 2 weeks after discontinuation of anticoagulant therapy to minimize diagnostic error.
anticoagulant treatment of valvular afib
warfarin (IF mod/severe rheumatic MS or mechanical valve)
otherwise– calc CHADS VASC and treat 2 or greater in men 3 or greater in women with NOAC
stool osm gap
secretory vs. osmotic
290 - [ 2(stoolNa + stoolK)
gap >100 osmotic diarrhea ( low vol, improves with fasting)
*lactase def
<50 secretory diarrheal (large vol, no improvement with fasting)
* celiac, infectious, collagenous colitis, VIPoma
old man with diarrhea, confusion (neurologic symptomatic), joint pains
Whipple disease
Dx: small bowel biopsy (foamy macrophages) and PCR from tropheryma whippelli
tx: 1 year abx (ceftriaxone then bactrim)
classification of chronic diarrhea
> 4 weeks (1 month)
**first step is colonoscopy with biopsies
when to do EGD with GERD
alarm symptoms ( anemia, dysphagia, vomiting, wt loss)
refractory to PPI (once daily then BID for 4-8 weeks)
male >50yo with symptoms for more than 5 years and inc risk factors (nocturnal symptoms, hernia, inc BMI, smoker)
mgt of Barrett’s
no dysplasia – repeat EGD in 3-5 years
low grade– ablation OR repeat in 6-12 most if not choosing ablation
high grade– ablation
treatment of eosinophilic esophagitis
young adult with acute food impaction
EGD– trachealization of esophagus (stacked rings)
tx: 8 week trial of PPI, if persistent diagnosis is confirmed and treat with swallowed fluticasone or budesonide
Zollinger- Elison syndrome
chronic diarrhea, PUD, esop ulcers
dx: fasting serum gastrin after stopping PPI for 7 days
first test to do with acute pancreatitis
RUQ US to rule out gallstones
CT only if severe, >48hours or complications suspected ( DO NOT routinely order)
who to treat with Hep B
- compensated cirrhosis or acute liver failure
- immunosupressed
- polyarteris nodosum, membranous nephropathy, membranoprolifeerative
- HbeAg +, LFTS > 2x ULN, DNA > 20,000 U/mL
IgG to core - HgeAg neg but ALT >2 ULN and HBV DNA > 2000
tx: entecavir or tenofovir
if also HIV– emtricitabine-tenofivir
hemochromatosis
dx:
tx:
iron overload in multiple organs bc increased intestinal absorption (liver, heart, pit, pancreases)
- arthritis (destructive), ED, fatigue, DM, bronze skin
- hooked osteophytes
dx: fasting transferrin/ iron saturation
tx: phlebotomy (if elevated ferritin) otherwise monitor
- screen for HCC q6mos US
- liver biopsy if elevated LFTs or ferritin >1000
first thing to r/o with RLS symptoms
** check ferritan/iron def
DAPT after stroke
asa + plavix for 21 days, then asa only
** only if initiated in first 24 hours (otherwise plavix only is more efficacious than asa only)
UMN + LMN signs and NO SENSORY deficit
ALS
- usually begins distally and asymmetrically
tx: Riluzole
UMN (hyperreflexia, spasticity, and an extensor plantar response
LMN (atrophy and fasciculation)
triad: long standing RA splenomegaly neutropenia --> ** risk of infections/LE ulcers/lymphoma/vasculitis
Felty syndrome
tx: agressive tx of RA
which carbapenem does NOT cover pseuduomonas
ertapenem
treatment of cyanide poisioning (house fire)
hydroxocobalamin
- house fire, lactic acidosis
- inappropriate high O2
- late– hypoTN, heart block, arrythmia
A-a gradiant
normal <20
elevated– causes?
normal (<20) – hypoventilation
elevated- VQ mismatch, shunt, diffusion problem (fibrosis/vasculitis), empysema
Calculating A-a gradient = PAO2-Pa02
PAO2 = 150- (PaCO2/0.8)
vent strategy in ARDS
low TV (<6mL/kg ideal body wt)
high PEEP
allow for permissive hyperCapnia
cryptogenic organizing pneumonia
cough, fever, and malaise for 6 to 8 weeks that does not respond to antibiotics
patchy opacities on chest radiograph; and ground-glass opacities on CT scan that are peripherally distributed
tx: glucocorticoids
lung malignant assoc with hyponatremia
Small cell CA (bc SIADH)
treatment of CO poisioning
supplemental O2
Hyperbaric O2 (if LOC, ischemic ACS, neuro deficits, carboxyHgb level >25%
treatment of IPF
nintedanib or pirfenidone
management of a parapneumonic pleural effusion
empiric abx (anaerobe coverage)
If complicated (pH <7.2, glucose <60) or empyema (frank pus----> CT drainage and TPA into pleural space if not completely drained
what therapies can decrease freq of COPD exac
roflumilast
long term macrolide (azithro) therapy
lung + liver disease
empyema with bullous changes in lung bases
alpha1-antitrypsin
causes of eosinophiluria
AIN (NSAIDS, PPI, Sjorgrens, Sarcoidosis) post infectious GN atheroembolic ideas septic emboli small vessel vasculitis
when to start 2 antiHTN at same time
BP >20/10 over goal
(>150/90) if goal is 130/80
D- lactic acidosis
increased anion gap metabolic acidosis in patients with short-bowel syndrome or other forms of malabsorptio
what kidney stone size cutoff is unlikely to pass spontaneously with supportive care/tamsulosin/nifedipine
urologic intervention for:
>10mm any sign of infection AKI obstruction of solitary kidney b/l obstruction
acute onset of severe hypertension, kidney failure, and microangiopathic hemolytic anemia.
scleroderma renal crisis
tx: ACEI
assoc with diffuse cutaneous system sclerosis
GFR when referral to kidney transplant center should be made
<20
**C/I if active malignancy, coronary ischemia, or active infections, no social support
eval of hematuria (not dysmorphic erythrocytes suggestive of GN)
- exclude infection
- CT (non contrast helical to exclude stones, and contrast to exclude renal cell ca)
- IF >35, male, risk factors for malignant –> cystoscopy
IF age <35, female, no risk factors –> urine cytology then stop eval if normal.
mgt of renal a. stenosis
medical mgt (FIRST)-- add ACE-I optimize HLD, cardiac risk factors, (if Cr rises >25% after addition of ACE it must be stopped)
Stenting –those who present with a short hypertension duration; fail medical therapy; or have severe hypertension or recurrent flash pulmonary edema, refractory heart failure, acute kidney injury following treatment with an ACE inhibitor or ARB, or progressive impaired kidney function
HyperCa
hyperCalciuria—> nephrocalcinosis/nephrolithiasis
+ b/l hilar adenopathy or granulomas
sarcoidosis affect on kidney
Hypercalcemia occurs due to peripheral conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by activated macrophages
tx: steroids
which bicarb level to start oral bicarb supplement in CKD?
<22
when to give EPO in CKD?
If iron def r/o to maintain Hgb >10 (avoid Hgb >11.5)
goals with iron therapy in CKD:
maintaining transferrin saturation levels of >30% and serum ferritin levels of >500 ng/mL (500 µg/L).
GFR cut off for thiazide (chlorthalidone/HCTZ)
don’t use with GFR <30
type of IVF treamtment of alcoholic ketoacidosis
** thiamine before glucose
5% dextrose in 0.9% saline
treatment of IgA nephropathy?
ACE-I (esp if have proteinuria)
asymptomatic hematuria 1-2 days after URI
nl complement levels
skin findings in various forms of lupus
acute cutaneous – malaria rash –> develop SLE
subacute cutaneous – papulosquamous, annular or polygonal photosensitive rash that usually spares the face
chronic cutaneous lupus erythematosus—discoid lupus erythematosus, usually presenting as scaly infiltrative papules and plaques or atrophic red plaques on sun-exposed skin surfaces
syndrome assoc with:
interstitial lung disease, myositis, Raynaud phenomenon, nonerosive inflammatory arthritis, constitutional findings such as low-grade fever, and mechanic’s hands
anti-synthatese syndrome
anti-aminoacyl-tRNA synthetases antibodies, such as anti–Jo-1
tx of systemic sclerosis (scleroderma)
tx organ specific problems
** avoid steroids as them may precipitate a renal crisis
ILD– mycophenolate
PAH – treat similar to idiopathic PAH
renal crisis – ACE-I
Raynaud– avoid cold, CCB/ sildenafil/nitrogliycerin
localized pain inferomedial to the knee join
medial knee pain worsened with climbing or descending stairs or rising from a seated position.
pes anserine bursitis.
erythema nodosum +hilar adenopathy + inflam arthritis (usually ankles)
Lofgren syndrome (form of sarcoidosis) - does not require any lymph node biopsy
spherocytes cause by
Autoimmune hemolytic anemia (pos Coombs/DAT with IgG) Herediatry spherocytosis (neg Coombs/DAT
positive test– shows agglutination
DAT = direct antiglobulin test
best screening test for hemochromatosis
transferrin saturation
treatment of MDS
low risk?
high risk?
-deletion of 5q?
low risk–no tx, infrequent transfustions
high risk– allogenic HSCT (young pts), azacytidine/decitabine
5q deletion– lenalidomide **
- favors good prognosis
lymphadenopathy +protein spike + organomegaly + lymphocytes in bone marrow
Waldenstrom macroglobulinemia
*asso with hyper viscosity syndrome— needs emergently treated with plasmapheresis
hook like osteophytes on MCP
hemochromatosis
transfusing sickle cell patients
pre-op (surgery): simple transfusion to goal Hgb 10
if multi organ failure, ACS, CVA, retinal a. occlusion, fat embolism– exchange transfusion to HbS <30%
otherwise avoid blood transfusions with simple vasoclusion or otherwise
reversal of dabigatran
idarucizumab (praxabind)
PLT cut off for treating ITP
PLT <30K
- steroids are 1st line
- if resistant–> IVIG or anti-D-immune globulin (if RhD pos)
- if still unresponsive to drugs or relapse after tapering steroids– splenectomy or rituximab
mgt of Lobular carcinoma in situ (LCIS) on breast biopsy
no immediate mgt, consider high risk
** can consider anti-estrogen therapy like tamoxifen (risk of VTE, endometrial Ca), raloxifine (post menopausal only) or aromatase inhibitor (POST-menoupausal only, need DEXA q2 due to risk of osteoporosis)
examples of aromatase inhibitors
anastrozole
letrozole
exemestane*
– only POST menopausal
risk of osteoporosis so need q2 year DEXA
prophylactic cranial radiation with which lung cancer
small cell
limited stage– chemo & RT together
extensive stage– chemo
for both– prophylactic cranial irradiation
mgt of SVC syndome
get tissue diagnosis (mediastinoscopy) and then treat.
Do not need urgent stent unless patient crashing
can use steroids and diuretic for symptomatic tx while awaiting
tx of non- small cell lung ca (adeno, squamous, large)
I & II– surgical resection plus cisplatin based chemo if >4cm and RT if positive margins
III– (mediastinum or c/l mediastinal LN) – chemo + RT
IV– chemo, +/- immunotherapy
rule for surgical resection of liver mets?
“three lesions or less”
unless they have one of three conditions: tumor involvement of the common artery or portal vein or common bile duct; more than 70% liver involvement, more than six involved segments, or involvement of all three hepatic veins;
treatment of hairy cell leukemia
cladaribine
pancytopenia, splenomegaly, no LAD, “dry tap” bone marrow biopsy
thread-like projections off cells
smudge cells
indications for tx?
CLL
dx confirmed by flow cytometry with CD5 and CD23
asymptomatic– observe
indications for tx: anemia, low PLT, symptoms, rapid doubling of WBC
tx: rituximab + chemo
older pts with late disease— ibrutinib, chlorambucil
tx of renal cell cancer
early stage/localized– nephrectomy
metastaticc— debunking nephrectomy, immunotherapy with VEGF ( bevacizumab) or mTOR inhibitors (pemrolizumab, nivolumab)
** NO CHEMO is effective
tx of bladder cancer
transurethral resection of the bladder tumor followed by intravesical chemotherapy (BCG) and periodic cystoscopy
first thing to do for suspected testicular cancer
measures serum AFP and bHCG
CT A/P
inguinal orchiectomy – NOT NEEDLE BIOPSY
seminoma vs. non seminoma testicular cancer
Seminoma (only HCG, never produce AFP) non seminoma (produces HCG & AFP)
stage 1 (confined to scrotom)– observe
stage 2,3– cisplatin based chemo BEP
target cells assoc with?
thalassemia
EKG changes that make and exercise EKG stress test non reliable
LBBB, ST depressions, LVH, paced, WPW, digoxin use, prior CABG or PCI
cannon a waves
3rd AV block, VT
elevated RA pressure, PCWP and PA pressure with systemic hypotension
cardiogenic shock
nl PCWP <12
nl RA pressure <7
nl PA pressure 13-28/3-13
tx of PAD
1st line– exercise training
med mgt– cilostazol (C/I in HF**)
still not responding– revascularlization
screening for AAA?
tx cut offf>
MEN age 65-75 who have every smoked one time US
surgery if >5.5cm or >0.5cm/year
when to take abx prophylaxis for infective endocarditits?
which surgery?
usually amoxicillin, cephalexin, clinda
prosthetic valve
h/o IE in past
congenital heart defect (unrepaired cyanotic or repaired with prosthesis)
procedures: dental procedures incidiosn/biopsy of respiratory mucosa procedure with GU or GI infection at same time procedure on infected skin placing prosthetic valves/heart surgery
paradoxical split of S2?
fixed?
persistent?
paradoxical– delayed closure of aortic valve (LBBB, severe AS, HOCM)
fixed splitting– ASD
persistant splitting– PS, RBBB
treatment of afib development during with WPW
urgent cardioversion! can be life threatening
procainamide while awaiting
which coronary after assoc with STEMI in
2,3,avF?
V1-V3?
1, avL, V4-V6?
2,3,avF? —- RCA (inferior MI)
V1-V3? — LAD ( anteroseptal MI)
1, avL, V4-V6? — left circumflex a. (Lateral MI)
3 conditions with holosystolic murmur
VSD
Mitral regurg
TR
DM meds to use with with cardiac disease
GLP-1 (liraglutide, extend)
SGLT2 (-flozins)— reduce risk of CHF exac
indication for ASD closure
right heart enlargment or
large left to right shunt or
symptoms
percutaneous closure for ostium secundum (MC)
surgical closer for ostium primum
hypocalcium effect on QT
hypocalcium – prolonged QT (>440 in men, > 460 women)
hypercalcium– shortened QT
Anticoagulation of Afib with underlying HOCM?
Warfarin in everyone
(even with CHADSVASC not qualifying for anticoagulant
TTE vs. TEE for endocarditits
TTE
- 1st line
- can rule out IE with low probability
TEE
- for neg TTE in high probability patient
- for perivalvular abscess concern (prolonged PR)
- fungal or staph left sided IE
- HF
- congenital heart disease
- papillary muscle rupture
- AV block
when to treat THORACIC aortic aneurysm
surgery once >5 (or >4.5 with other heart surgery), or rate of growth >0.5/yr.
**marfans – surgery >4.5
if >4.5 or rate of enlargement >0.5 per year then repeat US every 6 months other annual US
anticoagulant with mechanical prosthetic valve
warfarin AND ASPIRIN!!
goal INR 2.5 - 3.5 for aortic
goal 3 for mechanical mitral valve or aortic with risk factors (afib, dec EF, prior VTE)
GDMT for HF
ACE I
BB (metoprolol SUCCINATE, coreg, bisoprolol)
diuretics for vol OL
EF <40 + class 3-4 symptoms
- aldactone/eplerenone
- hydralazine + nitrates
ICD-- EF <35%, class 2-3 symptoms after minimum 3 pos GDMT CRT- EF < 35%, class 2-4 symptoms, LBBB with QRS >105)
cardiac rehab
critical limb ischemia
ABI < 0.5
ischemic rest pain and ulceration
tx: immediate invasive angiography
congenital syndrom assoc with pulmonic stenosis
noonan syndrome
pulmonary stenosis, particularly those with short stature, variable intellectual impairment, unique facial features, neck webbing, hypertelorism, and other cardiac abnormalities, including hypertrophic cardiomyopathy, atrial septal defect, and ventricular septal defect.
indications for migraine prophylaxis?
drug options for prophylaxis?
> 10 days/month
use of acute meds >8 days per month
disabling HA >4 days per month
not responding to therapy
tx?
propranolol, metoprolol, timolol, topiramate, valproic acid, effexor, amitriptyline,
myoclonus, rapid progressive dementia at young age, periodic sharp waves on EEG, MRI with increased signal in cortex and basal ganglia
Creutzfeldt-Jakob
who to treat for influenza
all inpatients
outpatient with high risk (immunocompromised, chronic lung disease, age >64, preg, DM, signifying comorbidities, BMI >40.
treatment of PCP in HIV pts
indications for steroids?
oral bactrim if mild
IV bactrim is more severe
(pentamidine or clinda+primaquine if sulfa allergy)
+steroids IF paO2 <70, or A-a gradient >35
PAO2 = 150- (PaCO2/0.8)
conjunctival suffusion
seen in Leptospirosis
exposure to animal urine or contaminated water/soil
dx: IgM serology
tx: doxycycline
treatment of toxo with ring inenhanocing brain lesions
sulfadiazine, pyrimethamine, folic acid
banana shaped gametocyte on peripheral smear
malaria (p. falciparum)
treatmetn of cat scratch disease
azithromycin for GN coverage of fastidious gram-negative bacterium Bartonella henselae
Other agents that can be used include doxycycline, rifampin, clarithromycin, trimethoprim-sulfamethoxazole, and ciprofloxacin.
tx Yersina plague?
streptomycin/gentamycin
- safety pin
bipolar gram neg coccobacilli
bioterrorism
white painless plaques on side of tongue that cannot be scratched off in HIV patinet
oral hairy leukoplakia
** assoc with EBV in HIV/immunocompromissed
treatment of ESBL organisms?
carbapenems
brain lesion in AIDs patient
toxo or CNS lymphoma (EBV)
** need brain biopsy to differentiate
treatment of cryptococcal meningitis
liposomal amphotericin B and flucytosine
nonpurulent cellulitis tx
dicloxacillin, clindamycin, penicillin, cephalexin,
when can you stop bactrim for PCP prophylaxis
CD4 cell counts greater than 200/µL for more than 3 months
post transplant infection cause
first month— same as general population
> 1mos— infection often CMV or EBV, JC virus causing PML, or polyomavirus BK causing nephropathy/hemorrhagic cystitis
> 6 mos post transplant— back to normal community acquired things
gram stain of neisseria
gram neg (pink) cocci
what to do for exposure to small pox?
Vaccinia immunization within 7 days of exposure
treatment of TB meningitis
RIPE + dexamethasone!
ecthyma vs. pyoderma gangrenous
ecthyma
- necrotic ulcers with tender erythematous border
- typically pseudomonas
pyoderma gangrenosum
- painful pustules or nodules become ulcers that progressively grow.
- not infectious
- assoc IBD, RA
lyme disease rash
erythema migrans
bullseye— dark center with ring around it
recurrent gonnochial/meningiococcal infection
testing?
tx?
terminal complement deficiency def of c5-c9 screen with CH50 assay
tx: standard antibiotics as needed, maintain currency of vaccinations (esp meningococcal)
erythema migrans lyme disease rash with neuro symptoms (facial n. palsy, headache, nuchal rigidity)
**must do LP prior to tx to determine no Neuroborreliosis, which necessitates parenteral therapy with ceftriaxone, cefotaxime, or penicillin.
in acute disease with just erythema migrans, fever, ha, arthralgia, myalgia, etc– can just treat with empiric doxy without serologic confirmation first
treatment of histoplasmosis
pulmonary?
disseminated?
asymptomatic– usually self resolves
subacute, chronic, pulmonary histo– itraconazle
disseminated (hypotensive, diaphoretic, hepatosplenomegaly)— liposomal amphotericin B
diarrheal illness assoc with IgA deficiency
Giardia
tx: flagyl
treatment of cyclospora water diarrhea
bactrim
stool with modified acid fast stain
high risk HIV patients
travel
parasite is endemic, such as Peru, Guatemala, Haiti, and Nepal.
bloody diarrhea after solid organ transplant
CMV
CAP tx:
- outpatinet
- inpatinet
- ICU
outpatient
- macrolide OR doxy alone
inpatient
- beta lactam + macrolide
- fluroquinolne alone (levaquin/moxiflox)
ICU
-IV beta lactam + azithromycin/respir fluoroquinolone
if risk of pseudomonas– double coverage
if risk of MRSA– add Vanc or linezolid
strep gallolyticus
new name for strep bovis
**check colonoscopy
abx with biggest interaction on warfarin
Bactrim (also avoid with MTX therapy!)
also raise INR: amio erythomycin metronidazole -zoles tylenol**
treat of UTI while on warfarin
nitrofuratonin
pcn
cephalosporin
**caution with fluoroqunolones and AVOID bactrim!
drugs that cause peripheral edema
nifedipine, amlodipine, fedolapine pioglitazone -- can trigger a HF exac pramipexole NSAIDS estrogen gabapentin/pregabalin
side effects of tramadol
seizures
suicidal ideation
hyponatremia
hypoglycemia
seizure med that causes non anion gap acidosis
topiramate
**can also cause calcium phosphate renal stones
Side effects of SSRI
hyponatremia
increased GI bleeding risk
sexual dysfunction
what percentage within 1 SD of mean?
2 SD?
68% within 1 SD
95% within two standard deviations
** see bell curve drawing
if 95% CI crosses ___ for a treatment it is NOT significant
if 95% CI crosses ___ for a relative risk or odds ratio it is NOT significant
0
1
NNT formula
ARR formula
NNT= 1/ARR
ARR= % risk in control group - % risk in treatment group
positive LLR
negative LLR
+ LLR = sens (1-spec)
- LLR = (1-sens)/ spec
what are the high intensity statins?
atorva 40-80
rosuva 20-40
age to start cholesterol screening?
M – 35-65
F – 45 - 65
** if any risk factors can start at age 20
low dose lung CT screening
AAA US screening
lung CT– YEARLY in age 55-80 with 30 pack years, current or quit within last 15 years
Abdominal US– ONE TIME ages 65-75 (MEN ONLY) who ever smoked
drug interactions with lithium causing lithium tox
ACE-I ***
diuretics
NSAIDS
tx:
drug overdose causing teeth grinding (bruxity) and hypoNa after a young kid going to a party
ecstasy/NMDA
glaucoma on fundoxscopy
cup taking up most of the disc >2:1
treatment of bulimia
CBT and SSRI (fluoxetine or imipramine)
anorexia– tx with CBT
1st line therapy for insomnia
CBT
when to give low dose asa
Low-dose aspirin for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and colorectal cancer is recommended for adults aged 50 to 59 years with a 10-year ASCVD risk of 10%
labrynthitis vs. vestibular neuronitits
both are peripheral vertigos that are preceded by URI
hearing loss in labrynthitis due to inflammation of CN8
treating combined ED and BPH
tadalafil**
vertigo + vertical nystagmus with no fatiguability
consider brainstem/verterbrobasilar infarct
Pre-operative measurement of serum electrolyte and creatinine levels necessary in?
patients with kidney disease and those who are taking medications that may affect kidney function or predispose them to electrolyte abnormalities.
evaluation of palpable breast lump
age <30 – observere 1-2 menstural cycles, if persistant– US
age > 30 – Mammogram
treatment of prostatitis
GN coverage (cipro, levaquim, or bactrim) for 4-6 weeks
** know how to treat epididymitits based on age
< 35– ceftriazone + doxy
>35 – ceftriaxone + fluroquinoloen
preventing pressure sores
advanced static mattress or mattress overlay
bridging with afib
ONLY IF:
mechanical valve or
high risk: ischemic stroke, TIA, or VTE within the past 3 months.
low dose asa for primary prevention
primary prevention of ASCVD and colorectal cancer in adults aged 50 to 59 years with a 10-year ASCVD risk of 10% or higher
drugs causing peripheral edema
gabapentin
vasodilators (minoxidil, hydralazine, calcium channel blockers, α-blockers)
amlodipine, etc.
pioglitazone and rosiglitazone,
how to treat nephrogenic DI
- if lithium induced: DC lithium, start amiloride
- - if not drug induced: thiazide diuretics and salt restriction
PTH effect of Vit D def
Vit D deficiency causes SECONDARY hyperparathyroidism (high PTH, nl Ca, low phos, high alk phos due to bone turnover)
diagnosis of DM
need TWO abnl:
fasting >126
random glucose >200 with symptoms
a1c > 6.5%
OGGT test– 2 hour post prandial >200
if disconcordance– repeat the abnl test
PRE-DIM fasting 100-126 random 140 - 199 OGTT 140- 199 A1c 5.7 - 6.4%
treatment of hyperthyroidism– 3 options
- methamizole (agranulocytosis/hepatoxic)
PTU (preg 1st trimester and thyroid storm) - radioactive iodine – for multi nodular goiter of hyperfunctioining nodule
C/I in preg/ graves opthalmopathy - thyroidectomy – if have opthalopathy
treatment of subacute painful thyroiditis
NSAIDS and glucocorticoids
BB for symptoms
synthroid is symptomatic hypothyroid
thyroid studies will normalize by themselves
treatment of myxedema coma (ams, hypoVent, hypothermic, hypoNa)
IV synthroid AND hydrocortisone
indications for thyroid nodule biopsy
> 1cm and euthyroid (nl TSH)
<1 cm with suspicious features = calcifications, increased vascularity, ireg boarders)
what to screen for incidentally adrenal adenoma discovery
Cushings– *1mg overnight dex suppression test (cortisol should be < 3 after)
Pheo– 24hr urine metanephrines
if HTN– aldo to renin ratio
C/I for bisphosphonates (alendronate/risedronate)?
alternate therapy?
oral CI with esophogeal disorder
**can use IV zoledronic instead (C/I with GFR <35)
can instead use:
denosumab (safe in CKD), twice yearly
teriparatide– max tx is 2 years
best test for serum vit d levels?
25- hydroxyvitamin D
treatment of adrenal insuf
primary– hydrocortisone + fludrocortisone
secondary– hydrocortisone only
rapidly progressive, or severe hyperandrogenism (hirsutism, frontal hair loss, etc)
consider androgen secreting ovarian tumor– check pelvic US
MC cause of primary adrenal insufficiency (low cortisol, high ACTH)?
21-hydroxylase deficiency causing autoimmune adrenalitis
drug causing sudden peripheral neuropathy
Quinolones
**also assoc with aortic dissection, tendon rupture
drugs causing hypoNa
HCTZ SSRI carbamazepine NSAIDS NMDA (excstasy)
drug induced syncope in elderly
cholinesterase inhibitors
** donepizil
opioid induced constipation treatment
1st line-- stimulant +/- docusate (senna, biscodyl) 2nd line-- osmotic (miralax, lactulose 3rd line-- oral naldemedine subcutaneous methylnaltrexone naloxegol
Does IBD patient in hospital with acute flare and hematochezia need pharmacological dvt ppx?
YES!
regardless of bleeding status need subQ heparin because increased risk of VTE with UC/Chron’s
indications for choley if gallbladder polyp found
> 1cm
any size assoc with gallstones
billiary collic
PSC
confusion, ataxia, nystagmus, discongugate gaze post gastic bypass
thiamine def– wernikes
** give thiamine prior to glucose
mgt of liver lesion
usually biopsy unnecessary
if no decomp cirrhosis and single small lesion– surgically resect
if cirrhosis and
up to 3 tumors <3cm or 1 tumor <5 cm – liver transplant
IBS-C tx
fiber diet
hyoscyamine/dicyclomien short term
SSRI (for C predominant)
lupiprostone/linaclotide for IBS-C
IBS-D: loperamide TCA eluxadoline rifaximin
HELLP vs. AFLP
HELLP- hemolysis, inc ALT, low put
AFLP – has encephalopathy and prolonged INR and hemolysis, low plt, elevated LFTs
tx of both is emergent deliver
development of fever, diffuse capillary leak (pleural effusions, pericardial effusion, pulmonary edema) after starting ATRA for acute promyelocytic leukemia
differentiation syndrome
tx: prednisone
determining readiness for extubation
RSBI < 105 = RR/ TV in Liters
few secretions
awake following commands
strong cough
non-motor symptoms of early parkinsons
loss of smell/taste
REM sleep disorder
constipation
depression
anti-UN-1RP (ribosomal Ab) assoc with?
MCTD
- synovitis, Raynaud, hand edema, myositis
- **pulmonary HTN
Stress test for someone with LBBB or pacemaker?
must be adenosine/vasodilator nuclear perfusion
** cannot do exercise or dobutamine
best test of unhealthy alcohol use?
single item screening test or
AUDIT-C
hyperthyroid mgt in pregnancy
PTU 1st trimester
methamizole 2nd and 3rd
maintain mild hyperthyroid state
monitor thyroid studios every 4 weeks
Fever
polyarthralgia
transient macular faint salmon colored rash
pericarditits/pleuritits
Adult onset Still’s
elevated WBC and ferritin
- know difference between this and Felty syndrome
drugs that can cause drug induced lupus
HCTZ procainamide isoniazid TNF-a inhibitors minocycline
+anti-histone Ab
abx with highest risk of cdiff
fluoroquinoles cipro, levaqin clindamycin 3rd/4th gen cephalosprins augmentin
adverse effect of tamoxifen
VTE
increased risk endometrial Ca
valvular abnormality assoc with GI bleeding due to AVM
aortic stenosis
metabolic disorders assoc with pseudogout
recent parathryroidectomy
hyperPTH
hemochormotosis
hypothyroidism
difference between myasthenia graves and lambert eaton
Lambert eaton– muscle weakness IMPROVES with repetitive stimulation and have hypo reflexes
anti–voltage-gated calcium channel antibodies
assoc with small cell lung ca
Myasthenia
fatiguabiliy
assoc with mediastinal mass (thymoma)– all need CT chest to screen for this
tx: pyridostigmine (if severe– steroids, IVIG)
mgt of pituitary apoplexy (hemorrhage)
high dose IV steroids empirically until adrenal insufficiency rulled out
THEN surgical decompression
sudden HA, CN3 palsy, AMS, vision change
erlichiosis vs. anaplasmosis
fever, elev AST/ALT, **leukopenia, ** thrombocytopenia
ehrlichiosis–
lymphopenia, clumps in monocyte
anaplasmosis–
neutropenia, clumps in granulocyte
tx: doxy
acute onset HTN with flash pulmonary edema
renal a. stenosis
thyroid storm
high fever, tachy, agitation, hyperTN, N/V, tremor, lid lag, goiter
trigger = infection, surgery, trauma, recent iodine load
tx: BB, PTU, steroids
exudative pleural effusion with eosinophilic predom
asbestos
sensorineural hearing loss causes
meniere’s
acoustic neuroma
presbycusis
ototoxic drugs (ahminoglycosides)
lymphadenopathy with leukocytosis
CLL if lmphocytosis
check peripheral smear and flow cytometry
(DONT BE TEMPTED TO BIOPSY LN)
pH level with bacterial vaginosis
> 4.5
clue cell
thing grey discharge
+ wiff test
allergic conjunctivitis
vs.
viral conjunctiivits
allergic– b/l, itchy, nasal congestion & sneezing
tx: topical antihistamine
viral – u/l then b/l
tx: supportive
SAAG and protein eval of asities
SAAG < 1.1 – nephrotic syn
SAAG >1.1 – cirrhosis (protein <2.5) or HF (protein >2.5)
Nephrotic syndrome + HF
restrictive cardiomyopathy + nephrotic syn = amyloidosis
supine hypoxia
diaphragmatic paralysis
dx: sniff test using fluoroscopy
daptomycin does not work for which infection
pneumonia! inactivated by pulmonary surfactant
alopecia aerata
round non scaring hairloss
exclamation point! hairs on margins
tx: intra-lesional IV corticosteroids
indication for CT or pleurodesis for pleural effusion
CT placement if > 2cm
pleurodesis if its the 2nd primary pneumo or any secondary pneumo
primary– tall, thin, marfan, normal lung or blebs/bullae
secondary– assoc COPD, CF, LAM, HIV and PCP pneumonia
difference between GBS and transverse myelitits
TM has a sensory deficit line and affects bowel/bladder function
tx: iV steroids (2nd line = plasma exchange)
GBS is mostly motor (may have some mild paresthesias)
tx: plasmapheresis, IVIG
C/I to NSAIDS for osteoarthritis
CAD, HF, CKD, Ulcer, h/o GIB, HTN, caution in >65
– use topical NSAIDS instead
tx of myasthenic crisis
plasma exchange or IVIG
stop acetylcholinesterase inhibitors (pyridostigmine)
obstructive vs. restrictive lung disease
Obstructive – Fev1/FVC <70%
restrictive– TLC < 80%
what causes overdose with HAGMA + osmolar gap >10
tx?
Methanol
ethylene glycol
tx of both: fomepizole, dialysis if severe
what pathogen causes bubonic plague (swollen lymph nodes, high fever, lethal)?
how to tx?
Yersinia pestis
(GN cocobacillus, transmitted by fleas on rodents)
** rats
tx: tetracycline or streptomycin
when to give empiric antibiotics for a skin abscess after I&D
>2cm extensive surrounding cellulitis systemic fever neutropenia extremes of age
treatment of chronic urticaria (>6wks)
2nd gen H1 blocker – loratadine, certirizine, fexofendine
what type of hypersensitivity is contact dermatitis
type IV
what exacerbates psoriasis
systemic steroids anti-malarial lithium BB NSAIDS ACE-I tetracyclines
tx of rosacea
topical metronidazole if inflammatory pustules and papules
drugs causing SJS (<10%) or TEN (>30%)
1-3 weeks after exposure
sulfa
allopurinol
anticonvulsants
NSAIDS
type of ezxcema rash in flexure skin folds
atopic dermatitis
extensive refractory seborrhagic dermatitis assoc with?
HIV
sebo keratosis assoc with GI malignancy
Pityriasis rosea reactivation of?
HHV 6 or 7
mimics Syphillus except spares palms and soles so rule out by checking RPR
effect of sarcoidosis on 1,25-vit D
elevated 1,25-vit d
congenital adrenal hyperplasia
virilization, frontal balding
deficient of 21-hydroxylase
** diagnosis with elevated 17- hydroxprogesterone
only lab required prior to giving TPA?
blood glucose level
treatment of osteoporosis or bone mets with CKD?
denosumab
can’t use bisphosphonates if CrCl <35%
difference between neuroleptic malignant syndrome and serotonin syndrome
both have fever, AMS, autonomic instability
NMS– muscle rigidity, no clonus, dec reflexes
precipitated by anti-psychotics, promethazine, reglan, infection, surgery or stopping dopamine agonists
tx: dantrolene
serotonin syn– agitation, rigidity, hyper-reflexia, myoclonus
tx: stop drugs, benzos
malignancy assoc with Klinefelters?
breast CA
Sjogern syndrome increase risk which malignancy?
B cell lymphoma
(large B cell, MALT)
** increased risk heart block in neonates
dx of gastroparesis
EGD 1st if acute symptoms then emptying study
if chronic symptoms–gastric emptying study
avoid bupropion if…
seizure DO
eating disorder
avoid chantix if active psychosis or suicidal ideation
treatment of toxoplasmossi
sulfadiazine + pyrimethamine + folic acid (or leucovorin)
renal angiomyolipomas, renal cell carcinoma, and cysts
hypo pigmented macules
pulmonary LAM (cystic lung disease)
tuberous sclerosis
1st line treatment of mitral stenosis?
C/I?
percutaneous mitral balloon valvotomy (to cut open valve)
C/I– concurrent MR or LA thrombus
- would require surgical MV repair
first choice abx for non-purulent cellulitis
clindamycin
dicloxacillin
cephalexin
persistently elevated lipase and abdominal fullness after episode of acute pancreatitis?
pancreatic pseudocyst
– most can just observe and spontaneously resolve
which nephrotic syndrome assoc with thrombosis?
membranous (MCC of nephrotic syn too)
DCM with left ventricular apical aneurysm– which infection?
T. cruzi– chagas disease
recurrent acute abdominal pain
dark urine
hyponatremia
acute intermittent porphyria
COPD tx based on FEV1
1st step— SABA only
FEV < 60% or symptoms – add LABA or LAMA
once having freq exacerbations– add LABA + ICS (budesonide/formetrol)
gram positive rods meningitis
listeria
tx: ampicillin
how long to continue anti-depressant once patient in remission
1st– 6 months
2nd episode – 1-2x the inter-episode interval
3rd– lifetime
flushing secretory diarrhea telangiectasisa bronchospasm Rt sided valvular disease-- TR
carcinoid syn
secondary causes of ITP
drugs– heparin, antibiotics
diseases– HIV, HepC, hyperthyroid, SLE, CLL
- need to rule these out
C/I for triptans
CAD
cerebrovascular disease
hemiplegic migraine
brainstem aura (vertigo, aphasia, confusion, diplopia, tinnitus)
brain aneurysm size cut offs for surgical intervention
> 12 mm anterior circulation
> 7 mm posterior circulation
Bells Palsy tx?
prednisone if within 72 hours of onset
GBS tx?
IVIG and plasma exchange
c/i for donepizil for dementia
sick sinus syndrome, left bundle branch block, uncontrolled asthma, angle-closure glaucoma, and ulcer disease.
alternative is memantine
parkinsons symptoms + orthostatic hypotension
multiple system atrophy
screening test for hypogonadism?
am serum TOTAL testosterone
relapse of Wegners treated with cyclophosphamide the first time?
tx relapse with Rituxmab
treatment of aplastic anemia
cyclosporine + ATG (antithymocyte globulin)
<50yo allogenic HSCT
BCR:ABL (9:22)
CML
acute leukemia assoc with DIC
APML
t(15:17)
tx: ATRA
indications for long term hydroxyurea in sickle cell patients
> 2 pain crises per year
Acute chest syn
c3 on Direct antigobulin (coombs) test?
cold agglutination dz
tx: avoid cold and rituximab
shistosytes hemolytic anemia low pLT fever AMS renal dysfunction
tx?
TTP or TTP-HUS overlap
tx: plasma exchange once peripheral smear done (don’t wait for ADAMSTS13 deficiency confirmation)
When to check D-dimer
wells DVT < 1
wells PE < 4
which GN diseases have low complements?
- post infection GN (1-6 weeks post infection)
- membranoproliferative (assoc SLE, hepC/hepB)
- cryoglobulinemia
- lupus nephritis
diagnosis of celiac disease
elevated anti-tTG IgA ab
AND
small bowel biopsy required for definitive diagnosis
PFTs with pulmonary HTN
everything normal except decreased DLCO
prophylaxis for travelers diarrhea
fluoroquinole (cipro, norfloxacin) or azithromycin
indications to treat pagets disease (focal bone remodeling + elevated alk phos)
bone pain
radiculopathy
involvement of weight bearing bone/joint (ex: hip)
– need bone scan to determine extent of activity
tx: bisphosphonates
diagnosis of CTEPH
pulmonary HTN without left sided heart disease
** diagnosis with V/Q scan with evidence of chronic thromboembolism
center criteria for strep testing
- fever
- tender anterior cervical LAD
- tonsillar exudate
- no cough
3 or more should be tested with rapid strep test
all 4– empirically treat
bicuspid aortic valve
aortic coarctation
and aortic aneurysm
Turners syn
*short, webbed neck, broad chest with wide spaced nipple
diagnosis on esophageal rupture
water soluble contrast esophagogram (gastrografin)
continuous murmur
femoral pulse delay
coarctation of aorta
** inc risk aortic dissection, intracranial aneurysm
tx of rectovaginal fistula in Crohn;s
mild symptoms– abx
moder to severe– anti-TNF, (infliimab)
protein cut off for nephrotic syn
> 3.5 g / day
>3500mg/24 hours
uric acid stones
tx with potassium citrate
lights criteria with active diuresis
** not reliable
Transudative if:
serum alb - pleural albumin > 1
or protein diff > 3
young patient with chronic pancreatitis should be tested for?
sweat chloride testing for CF
in older adults check IgG4 to exclude type 1 autoimmune pancreatitis (tx: steroids)
length of small bowel resection to empirically try cholestyramine
< 100
curb65
confusion uremia RR elevated low BP age > 65
2– inpatient
3– ICU
coxiella assoc with
livestock
treatment of latent TB
6 months izoniazid
or 4 months rifampin
9 mos isoniazid with HIV
patient with vitiligo should be screened for
TSH
type 1 DM
treatment cut offs of sub clinic thyroid disorders
subclinical hypothyroidism– treat TSH >10
subclinical hyperthyroidism– treat TSH < 0.1 or atrial arrhythmia
warfarin mgt in preg
change to LMWH
unless mechanical valve- then keep on warfarin
