Family Med EOR Flashcards
MC org endocarditis
- Native value infection: strep viridian’s (staph aureus and enterococci)
- IVDU: S. aureus (tricuspid valve)
- Prosthetic valve: s. aureus
Endocarditis treatment
- empiric
- native valve: vanc +/- cefazolin
- Ill with HF: gentamicin + cefepime + vanc
- Valve replacement if refractory or abscess
Endocarditis prophylaxis
- before invasive dental work
- If have prosthetic valve or congenital heart defect with prosthetic material or device, hx of previous endocarditis, unprepared cyanotic congenital heart disease, cardiac transplant with valve regurg
- amoxicillin (clarithromycin or azithromycin)
Endocarditis
- criteria for dx name
- criteria
- Duke Criteria
- 2 major, 1 major and 1 minor, 5 minor
Endocarditis
Major criteria
- two + blood cultures with typical org
- echo with new valvular regurgitation
Endocarditis
minor criteria
- predisposing factor
- Fever >100.4 (38)
- vascular phenomena (embolic dz or pulmonary infarct)
- Immunologic phenomena (glomerulonephritis, osler node, roth spot)
- blood culture not meeting major criteria
First line BB therapy for CVD
AM
Atenolol and metoprolol
Nitrates
- special dx instructions
- effect
- must have 8-10 hour treatment free interval to avoid tachyphylaxis
- reduces preload and afterload and myocardial O2 demand via dilation of coronary arteries and increased supply of blood
CCB in CVD
- effect
- coronary vasodilation and after load reduction
- reduces contractility
- 2nd line to BB and NTG
FEV1/FVC
- obstructive
- restrictive
- obstructive: reduced ratio dt reduced FEV1
- restrictive: normal ratio with reduced FEV1 and FVC
how should asthma spirometry respond to albulterol
FEV1 or FVC increase > 12%
What type of med should be avoided in asthmatics
beta blockers
Asthma
- CXR
- ABG
- hyperinflation
- hypocarbia: have increased respiratory rate. If normal or high, may be sign of impending respiratory failure
Intermittent Asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
- ≤ 2 days/week
- ≤ 2 times a month
- no interference
- ≤ 2 times a week
- FEV1 >80% predicted
- 0-1 exacerbations
Mild persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
- > 2 days/week, not daily
- 3-4 times a month
- minor
- many but not all days
- FEV1 >80% predicted
- > 2 times a year
moderate persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
- daily
- > once a week, not nightly
- Some interference
- Daily
- FEV1 60-80% predicted
- multiple
severe persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
- multiple times daily
- daily
- extremely limited
- several times a day
- FEV1 < 60% predicted
- multiple
Asthma therapy steps
Step 1: SABA
*steps 2-6 SABA plus…
Step 2: Low dose ICS
Step 3: medium dose ICS OR low dose ICS + LABA/montelukast/theophylline
Step 4: medium dose ICS + LABA/montelukast/theophylline
Step 5: high dose ICS + LABA +/- omelizumab
Step 6: high dose ICS + LABA + oral steroid =/- omelizumab
COPD
- MC cause of exacerbations
- infection
- noncompliance
- cardiac disease
COPD
- overview of treatment meds
- Beta agonist and anticholinergic
- +/- ICS
- theophylline for refractory disease (less effective and more ADR vs. inhaled bronchodilators)
Ipatroprium bromide
- brand
- type of med
- atrovent
- anti-muscarinic inhaled: antagonists M1 and M3 to prevent bronchoconstriction
SABA example brand and generic
- Albuterol / proventil HFA
- Levalbuterol / Xopenex HFA
How are LABAs used differently in asthma and COPD
- Asthma ALWAYS used with a ICS, never used alone (step 3 and above)
- COPD used with a SABA in all but the most mild cases
LABA example brand and generic
- Salmeterol / Serevent diskus
SAMA example brand and generic
ipatroprium / atrovent
LAMA example brand and generic
tiotroprium / spiriva
ICS two examples brand/generic
- Fluticasone / flovent
- budensonide / pulmicort
2 Combo ICS and LABA that are common
- fluticasone + salmeterol (Advair)
- budensonide + formoterol (Symbicort)
biologic used in asthma
omalizumab (Xolair) vs. IgE
COPD pharm based on GOLD
I: SAMA and/or SABA PRN
II: SABA PRN + LAMA or LABA
III: SABA PRN + LABA/ICS or LAMA
IV: same as III?
Definition of CAP timing vs. HAP timing
- CAP: Outside hospital OR within 48 hours of hospital admission (pt does not live in long term care facility)
- HAP: occurs more than 48 hours after hospital or other health care facility admission
CAP S/Sx
- fever
- cough +/- sputum
- SOB on exertion
- sweats, chills, rigors, chest discomfort, pleurisy, myalgias, HA, abd pain
- tachypnea and tachycardia
- O2 desat
- inspiratory crackles and bronchial breath sounds
- dullness to percussion
CAP
- CXR findings
- patchy airspace opacities to lobar consolidation with air bronchograms
Pneumonia vaccinations
- Prevnar 13 and Pneumovax 23
≥ 65
- Prevnar 13 then pneumovax 23 in one year
- Received pneumovax 23 before 65, wait one year and then give prevnar 13, then wait one year and give pneumovax 23 again
- Received pneumovax 23 at or after 65, wait one year and then give prevnar 13
19-64 with underlying conditions:
- smoker, chronic illness, long-term facility living : pneumovax 23
- immunocompromised: prevnar 13, 8 weeks then pneumovax 23, 5 years then pneumovax 23
MC pathogen
- CAP
- HAP
- VAP
- CAP: s. pneumoniae
- HAP: s. aureus (MSSA and MRSA), pseudomonas
- VAP: acinetobacter, stenotrophomonas maltophilia
What is the most common opportunistic infection in HIV patients?
pneumocystis jirovecii (pneumonia)
- fever, sob, cough
- CXR: perihilar infiltrates, reticular interstitial pneumonia
- sputum: wright-giemsa stain or DFA
- CD4 < 200 if AIDS
- Bactrim
CAP treatment
KNOW charts
when to admit CAP
CURB 65 score:
- confusion
- uremia
- respiratory rate
- blood pressure
- > 65 yo
<1: no hosp
1-2: hosp
3+: ICU
TB
- mc org
- transmission
- s/sx
- CXR
- mycobacterium tuberculosis (acid fast bacilli)
- aerosolized droplets
- fatigue, weight loss, fever, night sweats, productive cough
- CXR: caseating granuloma formation, pulmonary opacities (MC apical)
PPD results
Positive:
- induration >15 mm and no risk factors
- induration >10 mm and high risk (high prevalence area, homeless, immigrant in 5 years, prisoner, health care, nursing home, contact, etoh, DM)
- induration >5 mm and very high risk (HIV, steroid, organ transplant, TB contact, CXR with cavitation)
TB treatment
- latent
(negative CXR, sputum, or both)
9 months INH
TB Treatment
- active
- droplet precautions until sputum negative AFB
- 2 months 4 drug RIFE tx then 4 months INH and rifampin
- if isolate is INH and rifampin sensitive, can use 2 drug regimen
- treat 3 months past negative culture
Small cell lung cancer
- s/sx
- recurrent pneumonia
- anorexia, weight loss
- weakness
- cough
Small cell lung cnacer
- associated sx
- superior vena cava syndrome - obstruction by mediastinal tumor
- phrenic nerve palsy: hemidiaphragmatic paralysis
- recurrent laryngeal nerve palsy: hoarse
- Horner sx: anhidrosis, ptosis, mitosis
- pleural effusion
- Eaton-Lamber sx: similar to myasthenia gravis
- digital clubbing
Small cell lung cancer
- dx
- definitive treatment: tissue bx
- CXR for dx (NOT for screening)
- CT w/ contrast to stage
- sputum cytology to dx central tumors
- PET scan
Small cell lung cancer
- tx
- limited: chemo and radiation
- extensive: chemo only, radiation of responsive to chemo
small cell lung caner
- prognosis
- limited: 10-13% 5y
- extensive: 1-3% 5y
non-small cell lung cancer
- etiology
squamous cell carcinoma MC
non-small cell lung cancer
- s/sx
- Airway: cough, hemoptysis, obstruction, wheezing
- Pancoast syndrome: superior sulcus tumor - shoulder pain, horner syndrome, pain and upper extremity weakness
non-small cell lung cancer
- associated sx
- SIADH
- ectopic ACTH
- PTH-like secretion
- hypertrophic pulmonary osteoarthropathy
non-small cell lung cancer
- dx
same as small cell lung cancer
non-small cell lung cancer
- tx
- surgery (unless metastatic outside of chest)
- radiation adjunct to sx
- chemo- uncertain benefit
Lung cancer screening
- low dose CT
- 55-80 yo
- 30 pack-year smoking hx
- current smoker or quit within past 15 years
- dc screening once 15 years since quit or health issue that substantially limits life expectancy
OSA
- diagnostics
- polysomnography (definitive): 5+ episodes of apnea, hypogea, respiratory related arousals per hour
- CBC: erythrocytosis
- Thyroid: r/o hypothyroid
- ABG: CO2 >45 mmHg
OSA
- treatment
- weight loss
- CPAP (curative)
- BiPAP if O2 < 90%
- tracheostomy is definitive tx
Tobacco dependence
- 4 meds
- bupropion (zyban)
- nicolette gum (nicolette)
- nicotine patch
- verenicline (chantix)
MOA
- bupropion (zyban)
- nicolette gum (nicolette)/nicotine patch
- verenicline (chantix)
- norepinephrine/dopamine reuptake inhibitor
- nicotinic cholinergic receptor agonist
- partial cholinergic receptor agonist
ALT vs. AST specific organs
ALT more specific for the Liver
AST found in several tissues
when is alk phos elevated
obstruction to bile flow in any part of the bile tree (cholestasis)
There is one cause of diarrhea that is associated with a random other disease, what is it?
C. jejuni is associated with guillaine-barre
what marker is used to track colon cancer
CEA
AST and alk phos lab results
- Acute hepatitis
AST >10-20
alk phos <3
AST and alk phos lab results
- chronic hepatitis, cirrosis, tumor
AST < 10
Alk phos <3
AST and alk phos lab results
- extra-hepatic obstruction
AST >4
Alk phos >4 (very high)
Bilirubin in hepatic dz vs. extrahepatic obstruction
- extra-hepatic obstruction will increase serum bilirubin but the kidneys compensate by excreting excess bilirubin (bilirubinemia)
- hepatic failure can’t conjugate bilirubin and secrete via kidneys so get HIGHER bilirubin levels vs. extra-hepatic obstruction
PT - clotting factors
II, VII, IX, X
(extrinsic pathway)
prolonged in advanced liver disease
LFTs in cirrhosis or metastatic liver dz
often nl or low bc there is a reduction in healthy functioning hepatocytes
Anal fissure
- MC site
posterior anal midline
below or distal to dentate line
Anal fissure
- s/sx
- tearing pain with defecation
- perianal pruritus and/or skin irritation
- BRBPR
- chronic: anal spasm, high anal pressure
- external skin tags (sentinel pile) at distal end of fissure
- hypertrophied anal papillae at proximal end
Anal fissure
- dx
- endoscopy: bleeding + 2 mo of tx
- sigmoidoscopy: pts <50 with no fam hx of colon cancer
- colonoscopy if suspicion for crohns
Anal fissure
- tx
Acute
- fiber, water
- sitz bath
- topical anesthetic, vasodilator (nifedipine and NTG)
Chronic
- Botox
- lateral sphincterotomy (Gold standard)
Anal fissure
- prevention
- proper anal hygiene
- high fiber diet, fluids, avoid straining
- avoid anal trauma
- prompt tx of diarrhea
Anorectal fistula
- MC location
interspincteric
Anorectal fistula
- MCC
anorectal abscess
Anorectal fistula
- s/sx
- non healing abscess following drainage or chronic purulent drainage and pustule-like firm mass in perianal or buttock area
- intermittent rectal pain (worse with defecation, activity, sitting)
- malodorous perianal drainage
- pruritus
- excoriation/inflammation perianal skin
- inflamed, tender, draining external opening
Anorectal fistula
- dx
- Anoscopy to look for internal opening
Anorectal fistula
- tx
Simple:
- fustolotomy
- simple ligation of internal fistula tract
- fistulectomy (larger wound, longer healing, more incontinence vs. fistulotomy)
Complex
- Seton
Hemorrhoid
- internal vs. external
Internal
- superior rectal plexus (insensate area)
- above dentate line
External
- inferior rectal plexus
- distal to dentate line
Hemorrhoids
- tx
- conservative management first line
- rubber band ligation: protrudes with defecation, enlarged, intermittent bleeding
- closed hemorrhoidectomy: permanently prolapsed
Hemorrhoid grading
I: visualized on anoscopy, may bulge into lumen but no prolapse
II: prolapse from anal canal with defecation/straining, reduce spontaneously
III: same as II but require manual reduction
IV: irreducible, may strangulate
Colon cancer
- MC type
adenocarcinoma
villous > tubular
Colon cancer
- s/sx
- abd pain
- change in bowel habit
- weight loss
- hematochezia
Colon cancer
- tx
- surgery is curative (CEA level prior to sx)
- adjuvant: chemo and radiation
- f/u: stool guaiac, annual CT abd/pelvis, colonoscopy 1 year, then 3 year, CEA q 3-6 mo
Familial adenomatous polyposis (FAP)
- autosomal dominant
- > 100 colorectal adenomas
- iron deficient anemia
- endoscopy 25-30 yo
- prophylactic colectomy recommended
- thyroid screening annually
- CRC risk 100% by 30s-40s
Peutz-Jeghers
- hamartomas in small bowel, colon, stomach
- pigmented spots around lips, oral mucosa, face, genitalia, palmar surface
- complications: GI bleed, intussusception
- increased risk of other ca
colorectal screening
- 50 to 75 yo
- fecal occult blood test annually
- start 10 years younger than age of dx of relative
- Colonoscopy q 10 years or 5 years with fam hx (** colonoscopy is most sensitive and specific test)
- flexible sigmoidoscopy: 1 5 y + FOBT every 3 years
how to use CEA with CRC
NOT for screening
- useful for baseline and recurrence surveillance
PUD
- 3 MCC
- h. pylori
- NSAIDs
- zollinger-ellison syndrome
(smoking, ETOH, coffee, emotional stress, dietary factors)
PUD
- dx
- endoscopy: to dx ulcers, r/o malignancy
- barium swallow
- h. pylori testing
- biopsy (gold standard)
- serum gastrin measurement for zollinger-ellison
PUD
- tx
Supportive - no ASA/NSAIDs, etoh, smoking, dec coffee - reduce stress - avoid eating before bed Acid suppression - **PPI, H2, antacids - H. pylori: 3-4 drug therapy (CAP - clarithromycin, amoxicillin, PPI - MC) Cryoprotection - sucralfate: ulcer healing - Misoprostol: reduce risk ulcers with NSAIDs Surgical intervention - truncal vagotomy and antrectomy
PUD
- duodenal vs. gastric
Duodenal
- increased offensive factors
- RF: NSAIDs
- low malignancy
- younger pts
- releived with eating
- MC nocturnal pain
Gastric
- decreased defensive factors
- RF: smoking
- high malignancy
- older pts >40
- eating makes pain worse
Gastritis
- etiology
- NSAIDS **
- ASA
- h. pylori
- etoh, cigs, caffeine
- physiologic stress
Gastritis
- S/sx
- epigastric pain
- no relationship with eating
- dyspepsia
- abd pain
Gastritis
- dx
- upper GI endoscopy with bx (1st line)
- h. pylori testing
Gastritis
- tx
Acute
- stop NSAIDs
- empiric tx with acid suppression: PPI for 4-8 weeks.
- no response, test for h. pylori
Chronic
- triple therapy (CAP) X 2 weeks or quad therapy (CAP + pep) X 1 week
Acute viral gastroenteritis
- MC norwalk virus (rotavirus, enterovirus)
- fecal-oral
- MC cause of acute diarrhea
- n/v
- supportive
Travelers diarrhea
- ETEC (campylobacter, shigella, salmonella)
- contaminated food/water
- 3+ unformed stools in 24 hours + one of fever, n, v, abd cramp, tenesmus, bloody stool
travelers diarrhea
- tx
- Cipro empiric
- resistent, children, preg: azithromycin
- Bismuth-subsalicylate: 60% effective
Salmonella
- food/water (poultry and eggs), fecal-oral
- inflammatory diarrhea (blood), n/v, fever
- 24-48 hours after food
- Pos fecal leukocytes
- Supportive tx usually, avoid dehydration
- Cipro for immunocompromised and enteric fever (s. typhi)
Shigella
- fecal-oral
- MC in developing countries, children <5 and their caregivers
- abd pain, inflammatory diarrhea small volume, mucous/blood stool, tenesmus*, n/v
- Pos fecal leukocytes
- tx: bactrim in severe cases
Enterohemorrhagic E. coli (EHEC)
- aka
- overview
- e. coli O157:H7, shiga-toxin producing e. coli
- under-cooked ground beef
- water, voluminous non bloody diarrhea with n/v turns to bloody diarrhea
- no fecal leukocytes
- abx not recommended
- HUS complication
HUS
- AKI
- thrombocytopenia
- hemolytic anemia
Enteroinvasive E. coli
- food
- cramping, watery diarrhea
- positive fecal leukocytes
- tx: hydration, peptol-bismol, imodium
Cholera
- profound, rapidly progressive dehydration and death
- enterotoxin by org as colonizes in SI
- consumption of shellfish, contaminated water
- “rice water stool” diarrhea
- tx: Fluoroquinolone**, tetracycline, macrolide, rehydration
Amylase or lipase for pancreatitis?
both but Lipase is much more specific
what are the randon criteria
glucose calcium hematocrit BUN ABG LDH AST WBC
Pancreatitis
- most accurate testing
CT
Pancreatitis
- Tx for mild
- NPO
- IV fluids
- electrolyte balance
- pain control
Pancreatitis
- tx for severe
- ICU
- Enteral nutrition via NJ tube X 72 hr
Chronic pancreatitis
- Etoh
- n/v, weight loss, steatorrhea
- Gold standard dx: ERCP “chain of lakes”
- CT scan (calcifications), KUB
- Amylase and lipase not elevated
- stool elastase for pancreatic insufficiency
Chronic pancreatitis
- tx
- Pain control
- NPO
- Pancreatic enzymes, H2 blockers, insulin,
- frequent, small-volume, low-fat meals
- Pancreaticojejunostomy or whipple
Chronic pancreatitis
- cComplications
- Narcotic addiction
- DM
- Malabsorption
- pseudocyst
- CBD obstruction
- B12 malabsorption
Markers for
- Ulcerative colitis
- Crohns
- UC: ANCA
- Crohns: ASCA
Ulcerative colitis
- LLQ
- Tenesmus, bloody or pus diarrhea
- small but frequent bowel movement
- fever, weight loss, anorexia
- No skip lesions
Ulcerative colitis
- extra intestinal sx
- scleritis and episcleritis
- primary sclerosing cholangitis
- erythema nodosum
- pyoderma gangrosum
- ankylosing spondylitis
What three conditions/diseases are fecal leukocytes positive?
- ulcerative colitis
- ischemic colitis
- infectious diarrhea
When you avoid colonoscopy in UC
severe disease - to avoid risk of perforation or toxic megacolon
UC
- treatment
- Sulfasalazine
- steroids
- immunosuppressants
- proctocolectomy (curative)
Crohns
- Mouth to anus
- terminal ileum
- flares and remissions
- transmural inflammation
- fistulas and bowel lumen narrowing
- RLQ pain
Crohns
- extra intestinal manifestations
- uveitis
- arthritis
- erythema nodosum
- aphthous oral ulcers
- cholelithiasis
- nephrolithiasis
Crohns
- dx
- Endoscopy/colonoscopy: cobblestone appearance, psuedopolyps, skip lesions, rectal sparing
- Abd CT
- Upper GI with small bowel follow through for ileum or fistulas
Crohns
- Tx
- mesalamine/sulfasalazine
- prednisone for acute exacerbations
- Metronidazole
- Immunosupression
- bile acid sequestrates
- sx: SBO
Ischemic colitis
- s/sx
- acute onset
- mild, crampy abd pain
- blood in stool, minimal blood loss
- urge to defecate
- anorexia, n/v
- tenderness over affected area
Ischemic colitis
- dx
- Definitive: Colonoscopy: petechial hemorrhage (early), segmental erythema w or w/o ulcerations (late)
- leukocytosis, metabolic acidosis, elevated lactate
- Abd radiograph: bowel distention and air-filled bowel loops
- Barium enema - thumbprint, longitudinal ulcers
- CT w/contrast
Ischemic colitis
- tx
- IV fluids
- hemodynamic stabilization
- bowel rest
- no vasoconstrictive drugs
- empiric abx
- 20% require surgery (peritonitis) - bowel resection with colostomy
Appendicitis
- etiology
- lumen obstructed by hyperplasia of lymphoid tissue MC
- obstruction > stasis > bacterial growth and inflammation
Appendicitis
- s/sx
- epigastric > umbilicus > RLQ pain
- anorexia (ALWAYS)
- n/v
- McBurney point tenderness
- rebound tenderness, guarding, diminished bowel sounds
- low-grade fever
- Rovsing, Psoas, obturator sign
GI bleed
- upper vs. lower
Ligament of Treitz defines
- upper: peptic ulceration, esophageal varices, gastritis, AVM, tumor, Mallory-Weiss tear
- Lower: diverticulitis (MC), colitis, colon cancer, anorectal disorders, proctitis
Cholelithiasis/biliary colic
- overview
- epigastric, RUQ pain
- steady
- often after eating
- radiates to scapula
(in the gallbladder)
Acute cholecystitis
- overview
- severe epigastric, RUQ pain
- radiates to scapula
- Fever, nausea, vomiting
- Murphy sign
(gall bladder)
- Murphy sign
Ascending cholangitis
- overview
- abd pain, jaundice, fever (Charcot triad)
- Triad + confusion and hypotension (Reynolds pentad)
- hepatomegaly
- icterus
Gallstone pancreatitis
- overview
- severe epigastric pain
- pain radiates to back
- n/v
- elevated lipase
- elevated ALT
Progression of gallbladder disease
- biliary colic
- acute cholecystitis
- choledocholithiasis
- ascending cholangitis
Cause of acute (ascending) cholangitis
stasis and infection of biliary tract
Treatment of cholangitis
broad spectrum abx (piperacillin-tazobacam)
- biliary drainage (ERCP)
Spontaneous peritonitis
- past history of what
- presenting sx
- chronic liver disease, cirrhosis
- fever, chills, abd pain
Spontaneous peritonitis
- PE
- labs
- diagnosis made via what
- ascites, shifting dullness
- PMNs >250, WBC >1,000, pH <7.34
- analysis of ascites fluid
Spontaneous peritonitis
- MCC org
- tx
- e. coli, strep spp
- IV abx (3rd gen cephalosporin), ? albumin
Vitamin A
- source
- functions
- risk groups
- liver, fish oil, fortified milk, eggs
- vision, epithelial cell maturity, resistance to infection, antioxidant
- elderly, etoh, liver dz
Vitamin A
- deficiency sx
- toxicity
- night blindness, dry skin, dry eyes, impaired wound healing, squamous metaplasia, Bitot’s spots (white spots on conjunctiva)
- skin disorder, hair loss, teratogenicity, ataxia
Vitamine C
- source
- function
- risk group
- citrus, strawberry, broccoli, greens
- collagen synthesis, hormone function, neurotransmitter synthesis
- etoh, elderly men
Vitamin C
- deficiency sx
- toxicity
- scurvy (poor wound healing, petechiae, bleeding gums)
- diarrhea
Vitamin D
- source
- functions
- at risk groups
- fortified milk
- calcium regulation, cell differentiation
- elderly, shut-in, low sun exposure
Vitamin D
- deficiency
- toxicity
- rickets, osteomalacia
- hypercalcemia (tetany), kidney stones, soft-tissue deposits
Vitamin D
- tx
- ergocalciferol
Vitamin Bs
- list
- B1 thiamin
- B2 riboflavin
- B3 niacin/nicotinic acid
- B6 pyridoxine
- B12 cobalamin
B1 Thiamin
- source
- fn
- at risk group
- pork, grain, beans
- carb metabolism, nerve function
- etoh**, poverty
B1 thiamin
- deficiency sx (3)
- Beriberi
- Wernicke’s encephalopathy
- Korsakoff’s dementia
Beriberi
- what vitamin
- sx
- B1 (thiamin)
- nervous tingling, poor coordination, edema, weakness, cardiac dysfunction
Breakdown: - dry: nervous system changes
- wet: high output heart failure, dilated cardiomyopathy
Wernicke’s encephalopathy
- Ataxia
- global confusion
- ophthalmoplegia (paralysis or abnl of ocular muscles)
Korsakoff’s dementia
- memory loss (esp short term)
- confabulation
- irreversible…
B2 riboflavin deficiency
- source
- function
- at risk group
- milk, spinach, liver, grain
- energy
- No risk group
B2 riboflavin deficiency
- deficiency sx
- oral inflammation
- eye disorders
- oral-ocular-genital syndrome
1. oral lesions, magenta colored tongue, angular cheilitis
2. ocular: photophobia, corneal lesions
3. genital: scrotal dermatitis
B3 niacin
- sources
- functions
- at risk group
- bran, fish, meat
- energy, fat metabolism
- poverty, etoh
B3 niacin
- deficiency
Pellagra (3 Ds)
- dermatitis (photosensitive)
- Diarrhea
- dementia
B6 pyridoxine
- source
- function
- at risk
- animal protein, spinach, salmon
- protein metab, hemoglobin, nt synthesis
- adolescent, etoh
- INH use
B 6 pyridoxine
- deficiency
- HA, sideroblastic anemia, seizure, flaky skin, stomatitis and glossitis
- peripheral neuropathy*
B12 cobalamin
- source
- physiology
- function
- at risk
- animals
- stomach releases B12 from food, binds to intrinsic factor, absorbed in terminal ileum
- folate metab, nerve function
- elderly, *vegans
B12 cobalamin
- deficiency
- Neuro: paresthesias, gait abnl, memory loss, dementia
- GI: anorexia, diarrhea, **glossitis
- Macrocytic (megaloblastic) anemia: inc MCV + hypersegmented neutrophils
B12 cobalamin
- 4 etiologites
- pernicious anemia
- strict vegans
- malabsorption
- reduced intrinsic factor production
Pernicious anemia and B12 deficiency
- autoimmune destruction or loss of gastric intrinsic cells
- reduced/no intrinsic factor
- dx: ab testing, Schilling test
Malabsorption and B12 deficiency
- alcoholism
- disease affecting ileum (Crohn’s, celiac dz)
What can reduce the production of intrinsic factor?
- drugs: PPIs and H2RA
- gastric bypass sx
- atrophic gastritis
Folate
- source
- fun
- at risk group
- green leafy veg, OJ, grain, organ meat
- DNA synthesis
- etoh, pregnancy
Folate
- deficiency sx
- megaloblastic anemia
- sore tongue
- diarrhea
- mental disorders
How to diagnose metabolic syndrome
3 of the 5:
- Abd obesity (waist >102 men, >88 women)
- Triglycerides >150 or on drug tx for triglycerides
- HDL <40 men <50 women
- BP >130/85 or drug tx for HTN
- glucose >100 or drug tx for hyperglycemia
Necrotizing (malignant) otitis externa
- invasive infection on EAC and skull base
- MC elderly pts with DM
- pseudomonas aer.
Clinical: - otalgia and otorrhea
- not responsive to topical tx
- pain worse at night
- radiation to TMJ (pain with chewing)
PE difference in three types of conjunctivitis
- Bacterial: mucopurulent discharge, red, not pruritic
- Viral: watery discharge, red, pruritic
- Allergic: rare discharge, cobblestoning, red, pruritic
nystagmus with water in ear
COWS
- Cold Opposite
- Warm Same
Bilateral discharge on day 3 of life in neonate
- Gonococcal ophthalmia neonatorum
- topical 0.5% erythromycin applied after birth to prevent
Three types of neonatal conjunctivitis and time of presentation
- Chemical: first 24 hours, secondary to use of topical agents to prevent gonococcal conjunctivitis
- Gonococcal: 3-5 days after birth
- Chlamydia: 5-10 days after birth
Croup
- peak age
- clinical presentation
- MCC
- Xray
- Toxic appearance?
- Vaccine?
- Management
- 6 mo to 3 years
- URI, barking seal cough, inspiratory stridor, low-grade fever
- parainfluenza virus
- steep sign PA view
- NON-toxic
- No vaccine
- Steroids, aerosolized epi
Epiglottiis
- peak age
- clinical presentation
- MCC
- Xray
- Toxic appearance?
- Vaccine?
- Management
- 3 to 7 yo
- rapid progression high fever, drooling, stridor
- H. influenza, strep spp, S. aureus
- Thumbprint on lateral view
- toxic appearing
- Vaccine for h. flu
- Airway management and Abx
Bacterial tracheitis
- peak age
- clinical presentation
- MCC
- Xray
- Toxic appearance?
- Vaccine?
- Management
- 3 to 8 years
- URI prodrome like croup, intensifies to high fever, both inspiratory and expiratory stridor
- s. aureus
- subglottic narrowing, ragged edge of tracheal air column,
- Toxic appearing
- No vaccine
- Airway and abx
Epidural vs. subdural hematoma
Epidural
- artery (middle meningeal): rapid expansion
- skull fracture
- dura pushed inward (convex)
Subdural
- bridging veins: slow expansion
- does not cross falx, tentorium bc dura attached to the skull
Hodgkin Lymphoma
- incidence
- Assoc with what
- Bimodal: 20s and >50s, MC males
- Epstein-Barre virus
Hodgkin Lymphoma
- Clinical
- Painless lymphadenopathy
- alcohol may induce lymph node pain
- Advanced: night sweats, weight loss, cyclical fever
Hodgkin lymphoma
- Dx
- Reed Sternberg cells (owl eyes) large cells with bilobed or multi lobar nucleus
- mediastinal lymphadenopathy (PET/CT)
** highly curable compared to Non-hodgkins
Non-Hodgkin lymphoma
- Overview
- Risk factors
- lymphocyte neoplasm
- MC >50 yo
- ** peripheral lymph nodes
- RF: age, immunosuppression (HIV)
Non-Hodgkin lymphoma
- clinical manifestations
- subtype name and sx
- Local painless lymphadenopathy (Gi, skin, CNS MC)
- Burkitt lymphoma: abd pain, jaw involvement, starry sky histology
Non-Hodgkin lymphoma
- managment
- unpredictable course
- rituximab
Multiple Myeloma
- pathophys
- proliferation of a single clone of a plasma cell
- monoclonal ab (IgG and IgA MC)
- ab accumulate in bone marrow, interrupt nl cell production
Multiple Myeloma
- Risk Factors
- > 65 yo
- AA
- Men
Multiple Myeloma
- Clinical manifestations
BREAK
- Bone pain (MC spine and ribs): osteolytic, destructive lesions
- Recurrent infection dt leukopenia
- Elevated calcium
- Anemia
- Kidney failure
Multiple Myeloma
- Dx
- Serum protein electrophoresis: monoclonal protein spike**
- Urine protein electrophoresis: Bence-Jones proteins**
- CBC: Rouleaux formation, increased ESR
- Skull xray: punched out lesions
- Bone marrow bx: plasmacytosis
Multiple Myeloma
- Tx
- autologous stem cell transplant
Acute Lymphocytic Leukemia (ALL)
- pathophys
- distribution
- RF
- malignancy of lymphoid stem cells
- MC childhood (3-7 yo)
- RF down syndrome
Acute Lymphocytic Leukemia (ALL)
- clinical
- Pancytopenia –> Fever (MC)
- CNS: HA, stiff neck, vision
Acute Lymphocytic Leukemia (ALL)
- PE
- DX
- hepatosplenomegaly, lymphadenopathy
- Bone marrow: hyper cellular >20% blasts
Acute Lymphocytic Leukemia (ALL)
- Tx
- chemo
Chronic Lymphocytic Leukemia (CLL)
- pathophys
- Clinical
- B cell clonal malignancy
- Most asx, incidental finding on CBC, fatigue MC
Chronic Lymphocytic Leukemia (CLL)
- Dx
- well differentiated lymphocytes with “smudge cells”
- Pancytopenia
Acute Myeloid leukemia (AML)
- common population
- MC acute leukemia in adults (>50)
Acute Myeloid leukemia (AML)
- Clinical
- pancytopenia: anemia, splenomegaly, gingival hyperplasia
- Leukostasis: WBC>100,000
Acute Myeloid leukemia (AML)
- Dx
Bone marrow bx:
- Auer Rods
- > 20% blasts
Chronic Myelogenous Leukemia (CML)
- pathophys
- age
- clinical
- granulocyte proliferation
- Usu >50 yo
- most asx until blastic crisis, splenomegaly
Chronic Myelogenous Leukemia (CML)
- Dx
- Philadelphia chromosome (tx with imatinib)
- Very high WBC counts
Abx vs. MRSA
- Bactrim
- Rifampin (rapid resistance when used alone)
- Clindamycin (GI)
- Tetracyclines
Causes of erythema multiform
- target-like lesions
- herpes simplex (MC viral cause)
- Mycoplasma
- Sulfonamides
- PCN
- barbituates
- Phenytoin
- etc
Erythema Multiform vs. SJS, vs. TEN
EM <10% TSBA - Hands/forearms - Target lesion - 50% have oral lesions
SJS
- <10% TSBA
- MC in children
- URI like prodrome
- Drug rx MCC
- > = 2 mucosal sites
- Burn center
TEN
- > 30% TBSA
- Elderly MC
- HIV increased risk
- Abrupt onset
- Nikolsky sign
- burn center
Rocky Mountain spotted fever
- Org
- clinical presentation
- Tx
- rickettsie rickettsii
- Tick bite (dog or wood ticks)
- abrupt onset sx
- Fever, HA, myalgias, Rash (palms and soles to trunk)
- Petechiae formation after blood pressure cuff inflation
- Doxy
Type 1 hypersensitivity
- time frame
- what antibodies
- examples
- explanation
- Immediate
- IgE mediated, degranulation of mast cells and release of mediators
- Anaphylaxis, urticaria, angioedema
- requires 2 separate exposures to antigen. First causes sensitization
- Foods, Abx, hymenoptera stings
Type II hypersensitivity
- antibodies
- examples
- explanation
(cytotoxic)
- IgG or IgM react with cell antigens with resultant complement activation
- Autoimmune hemolytic anemia, Goodpasture syndrome, Erythroblastalis fetalis
- requires 2 separate exposures to antigen. First causes sensitization
Type III hypersensitivity
- antibodies
- examples
(immune complex)
- IgG or IgM deposition and subsequent complement activation
- serum sickness, SLE, RA
Type IV hypersensitivity
- Antibodies
- examples
(cell mediated- delayed)
- T cells activated vs. surface bound antigens
- Contact dermatitis
- TB skin test
- Transplant rejection
Burn classification
- list types
- Superficial
- Superficial partial
- Deep partial
- Full
Superfiical burn
- epidermis only
- pain, red, mild swelling
Superficial partial burn
- dermis: papillary region
- Pain, blisters, splotchy skin, severe swelling
Deep partial burn
- Dermis: reticular region
- white, leathery, relatively painless
Full burn
- Hypodermis (subcut tissue)
- charred, insensate, eschar formation
Amide vs. Ester anesthetics
Amides (have two Is)
- lidocaine, mepivicaine, bupivicbine, prilocaine, ropivacaine)
Esters (have one I)
- Procaine, chloroprocaine
Bullous Pemphigoid
- overview
- elderly (>65 MC)
- drug, injury, skin infection triggers
- autoantibodies target *basement membrane. Separation of epidermis from dermis forms a sub epidermal blister
Bullous Pemphigoid
- Clinical
- prodrome: red, itchy, urticarial or papular eruption
- *Tense bullae, rupture to form erosions
- rare mucous membrane involvement (oral mainly)
- negative Nikolsky
Bullous Pemphigoid
- Dx
- Immunoflourescence: ab fluorescente along BM
- H&E of skin: subepidural blister, eosinophils in superficial dermis, C3 deposition epidermal BM zone
Pemphigus Vulgaris
- epidemiology
- etiology
- 5th/6th decade (younger than bullous pemphigoid)
- MC Jewish, mediterranean, middle eastern
- IgG autoantibodies vs. desmosomes in epidermis which causes epidermal separation
Pemphigus Vulgaris
- clinical
- flaccid bullae
- mucosal erosions (usu oral)
- Nikolsky sign
Pemphigus Vulgaris
- Dx
- Immunoflourescence: chickenwire pattern (vs. basement membrane in BP)
- Histology: intraepidermal blister formation
Bullous Pemphigoid and pemphigus vulgarisms tx
steroids: topical and systemic
Urge incontinence
- Common causes
- Sx
- Tx
- stroke, alzheimers, parkinsons, BPH
- urgency, frequency, day or night
- Anticholinergic drugs (WHAT)
Stress incontinence
- Common causes
- Sx
- Tx
- urologic procedure, multiple childbirths
- small volume urine loss coughing or laughing
- topical estrogen
Overflow incontinence
- Common causes
- Sx
- Tx
- BPH, fecal impaction
- Poor stream, incomplete emptying
- alpha-adrenergic blockers (WHAT)
Atonic bladder
- Common causes
- Sx
- Tx
- DM neuropathy, stroke
- loss of bladder control
- Intermittent cath
Acute Lymphocytic leukemia
- brief overview
- MC childhood leukemia
- 75% affects b-cell precursors, 20% T-cell
- good prognosis
Chronic lymphocytic leukemia
- brief overview
- MC adult leukemia
- smudge cells
- worst prognosis
Acute myelogenous leukemia
- brief overview
- more common adults vs. children
- Auer rods
- Fair prognosis, worse than ALL
Chronic myelogenous leukemia
- brief overview
- Mostly adults
- Philadelphia chromosome
- Basophilia on smear
- Good prognosis
Flexor Tenosynoviits
- dx
- Kanavel’s criteria:
- flexor tendon tenderness
- fusiform or symmetrical swelling of the finger (sausage finger)
- pain with passive extension
- finger held in flexion
Deep tendon reflexes test what nerves?
Triceps: C7 Biceps: C5/C6 Brachioradialis: C6 Patellar: L4 Achilles: S1
What is the Galeazzi test?
ID for hip dysplasia (along with Barlow and Ortolani)
- person on back with feet on floor, inspect knee height: if not level, positive test
Ortolani vs. Barlow
Barlow: dislocate hip
Ortolani: reduce hip
Both clunk :)
Sign of colchicine toxicity
severe gastroenteritis
What drug is commonly used to treat RA and lupus?
Hydroxychloroquine (also malaria)
Hydroxychloroquine
- common ADR to screen for
- Corneal and macular toxicity
- Annual ophthalmologic exam
Polymyalgia rheumatica
- associated with what
- clinical
- treatment
- giant cell arteritis
- Symmetrical aching and stiffness of shoulders, hip girdle, neck, torso
- Worse in am
- > 50 yo
- Steroids
Autoantibodies
- Lupus
- ANA
- Anti-dsDNA
- Anti-Smith
(also Anti-SSA/Ro)
Autoantibodies
- Sjogren
- ANA
- Anti-La/SS-B
(also Anti- SSA/Ro
Autoantibody
- CREST
*ANA
Anti-centromere
Autoantibody
- Inflammatory myopathy
*ANA
Anti-Jo1
Autoantibody
- RA
Rheumatoid factor
Autoantibody
- Primary biliary cholangitis
Anti-mitochondrial antibody
Migraine
- Acute exacerbation
- Triptans
- Ergots
- NSAIDs
- Acetaminophen
- Antiemetics
Migraine
- prophylaxis
- Propranolol
- verapamil
- Amytriptyline
- Valproic acid, topiramate
- Botox
Tick paralysis
- rocky int wood tick and american dog tick
- Female tick feeds, sx 4-7 days later
- Salivary toxin = pathologic effects
- Ascending paralysis, ataxia
- Remove tick, sx resolve in hours
Cluster HA
- Always unilateral (can switch sides)
- Excruciating periorbital and temporal pain
- Ptosis, mitosis, lacrimation, conjunctival injection, rhinorrhea, nasal congestions
- 15-180 minutes, attacks in clusters
- 100% O2 and sumatriptan
5 types of dementia and risk factors
- Alzheimers (MC, 2/3): age, fam hx
- Vascular (1/4): HTN, dyslipidemia, DM, smoking, age
- Lewy Body: cognitive fluctuations, visual hallucinations, Parkinsonism
- Neurodegenerative: Huntingtons, metabolic abnl
Croup
- Overview
- laryngotraceobronchitis
- URI-like sx, seal barking cough, stridor, worse at night
- hypoxia is UNcommon
- Tx: cool humidified air, racemic epinephrine, dexamethasone
RSV
- fever, tachypnea, wheezing, nasal flaring, retractions
- CXR: diffuse infiltrates
- bronchiolitis: mucus and inflamed bronchiole wall
Pneumonia
5 common bacteria
- Strep pneumonia: MC CAP, often follows URI or influenza, acute onset
- H. influenza: often after URI, COPD
- Staph aureus: may follow influenza, cavitary, MRSA
- Klebsiella: etoh, DM, immunocompromised, LTAC, aspiration
- Pseudomonas: chronic lung dz, mechanical ventilation
Legionella Pneumonia
- epidemics possible
- Water source and air travel
- Pleuritic chest pain, bradycardia, GI sx, neuro sx, hyponatremia
- CXR: alveolar infiltrates
Postinfluenza pneumonia
- MC staph aureus
- necrotizing pneumonia
- CXR: multiple cavitary lesions
Pneumonia
- Atypical orgs (5)
- mycoplasma pneumonia: young adults
- Legionella: humidifier, hot tube, air conditioning, pleural effusion, GI/neuro, hyponatremia
- Chlamydia
- Coxiella burnetii
- Chlamydia psittaci
Miliary TB
- hematogenous dissemination of mycobacterium tuberculosis
- Clinical: failure to thrive, fever unknown origin, multi organ dysfunction, night sweats, rigors
- Extrapulmonary: lymph, bones/joints, liver, CNS, adrenal glands
- CXR: millet seed pattern
Pertussis
- 3 stages
- Catarrhal (7-10D): mild fever, cough, coryza, conjunctivitis *most contagious
- Paroxysmal (7-28D): spasmodic cough -> inspiratory whoop
- Convalescent (months): decreasing cough
Pertussis
- tx
Macrolides (Azith, erythema)
*Bordetella pertussis
Lung absecess
- cough, fever, pleuritic chest pain, weight loss, night sweats
- CXR: area of dense consolidation and air-fluid level inside thick-walled cavitary lesion
- Usu dt aspiration pneumonia
- Tx: ampicillin-sulbactam, carbapenems, clindamycin
Fine crackles
- characteristics
- Clinical
Characteristics
- discontinuous
- fine, high pitched
- end of inspiration
- not cleared by cough
Clinical
- pneumonia
- HF
- Chronic bronchitis
- asthma
- COPD
Coarse Crackles
- characteristics
- Clinical
Characteristics
- Discontinous
- low pitched, bubbling/gurgling
- Start in early inspiration, extend into expiration
Clinical
- same as fine but usu more advanced dz
- pulmonary edema
- Pulmonary fibrosis
Wheeze
- characteristics
- Clinical
Characteristics
- continuous
- high pitched, musical
- MC in expiration
- small airways
Clinical
- asthma
- COPD
- HF
Rhonchi
- characteristics
- Clinical
Characteristics
- continuous
- low-pitched and coarse, loud, snoring/moan
- MC in expiration
- coughing may clear
Clinical
- Obstructed trachea
- bronchitis
- pneumonia
Pleural friction rub
- characteristics
- Clinical
Characteristics
- superficial, low-pitched, rubbing/grating
- inspiration and expiration
- loudest lower anterolateral surface
- not cleared by cough
Clinical
- pleurisy
- pericarditis
- pericardial effusion
TB test results
> 5 mm
- HIV
- contact with TB pt
- Nodular/fibrotic change on CXR
- organ transplant
> 10
- recent arrival from high-prevalence country
- IVDU
- resident/employee high risk setting
- comorbid conditions
- < 4 yo
- young person exposed to high risk categories
> 15
- no risk factors
Two main types of lung cancer
Small cell and non-small cell
Small cell lung cancer high points
- Central (“S” central)
- Small cell
- Squamous cell
Non-small cell lung cancer 3 types
- Adenocarcinoma (MC), peripherally located
- Squamous cell: starts centrally, hypercalcemia
- large cell carcinoma
S3 vs. S4
S3
- early diastole
- during passive LV filling
- may be normal (children, pregnant)
- Requires compliant LV
- systolic HF
S4
- late diastole
- active LV filling
- Always abnl
- requires non-compliant LV
- diastolic HF
Preseptal Cellulitis
- eyelid swelling
- eye pain
- pain with eye movement
- proptosis
- ophthalmoplegia +/-diplopia
- vision impairment
- chemosis
- leukocytosis
- yes
- may have pain
- no
- no
- no
- no
- rare chemosis
- maybe leukocytosis
Preseptal Cellulitis
- eyelid swelling
- eye pain
- pain with eye movement
- proptosis
- ophthalmoplegia +/-diplopia
- vision impairment
- chemosis
- leukocytosis
- yes
- deep eye pain
- yes
- usually proptosis, may be subtle
- yes
- may have vision impairment
- possible
- possible
Dry age-related macular degeneration
MC
- drusen
- gradual loss of vision
- macular thinning
- not total blindness
Wet age-related macular degeneration
- neovascularization
- less common
- sudden loss of vision
- bleeding, leakage of fluid
- more severe central vision loss vs. dry
Duke criteria
- major criteria
- two separate blood cultures pos for typical orgs
- positive echo
Duke criteria
- minor criteria
- heart condition
- IVDU
- temp >38
- vascular phenomena
- Immunological phenom
- one positive culture but doesn’t meet major criteria
What Duke criteria needed to dx endocarditis
2 major
1 major + 3 minor
5 minor
what orgs are typical for endocarditis
- strep viridan
- strep bovis
- HACEK
- staph aureus
- enterococci
Vascular signs of endocarditis
- major arterial emboli
- septic pulmonary infarct
- mycotic aneurysm
- intracranial hemorrhage
- conjunctival hemorrhage
- Janeway lesion
Immunological signs of endocarditis
- glomerulonephritis
- Osler nodes
- Roth spots
- rheumatoid factor
USPSTF Lung cancer screening recommendations
- age 55 to 80
- low-dose CT
- 30 pack-year hx currently or quit less than 15 years ago
- discontinue once no smoking 15 years, not going to treat anyways
Radial nerve palsy
- Loss of extension of fingers, thumb, wrist
- wrist drop
- numbness over 1st dorsal interosseus muscles
- saturday night palsy (etoh)
- dt radial nerve compression in axilla
Treatment for olecranon bursitis
Compression and NSAIDs
can also aspirate but second line
Medication for acute low back pain
1st line: NSAIDs, acetaminophen
2nd Line: cyclobenzaprine, diazepam
3rd line: opioids, tramadol
Also:
antidepressants, steroids, anti-epileptics
Straight leg raise test
Test for L5 or S1 radiculopathy, sciatica
- passively raise sx leg with knee straight
- Positive: pain in back radiating past knee when elevated 30 to 70 degrees
What is Dupuytren’s contracture associated with?
DM
Dupuytren’s contracture
- fibrous fascia of palmar surface shorten and thickens
- pitted nodules on palm -> contracture of fingers
- Difficult to do tasks (wash face, comb hair, etc)
- steroid injections, sx
- RF: Dm, etoh, smoking
Ankylosing spondylitis overview
- low back/hip pain
- limited ROM spine and tender SI joint
- morning stiffness
- bamboo spine
- men > females
- HLA-B27
- NSAIDs and Infliximab
Cauda Equina
- imagining
- injury of what
- MRI lumbar spine
- lumbosacral nerve roots
Low back pain red flags (4)
- night pain, weight loss (tumor)
- fevers, chills, sweats (bone/disk infection)
- acute bony tenderness (fracture)
- morning stiffness in young adult (ankylosing spondylitis)
Mallet finger
- forced flexion of DIP -> rupture of extensor tendon
- splint in full extension or hyperextension
- can lead to swan neck deformity
Swan neck deformity
- hyperextension of PIP
- flexion of DIP
Boutonniere deformity
- hyperextension of the DIP
- flexion of the PIP
When to perform trephination of subungal hematoma?
- > 50% nail bed surface or smaller if painful
- electrocautery preferred method (heated paperclip, 18 gauge needle/syringe)
- Keep dry and clean for two days
Scoliosis
- Cobb angle >= 10 degrees
- RF: <12, onset prior to menarche, curves >20, female, double/thoracic curves
- confirm dx via XR to obtain cobb angle
- Treatment based on Cobb angle:
- <10 reassurance
- 10-19 observe with f/u q 6-9 months
- 20-40 bracing
- > 40 surgery
MC shoulder and hip dislocation
- Shoulder: anterior
- Hip: posterior
How to image suspected spinal stenosis?
MRI of lumbar spine
Ganglion cyst
- location
- tx
- dorsum of wrist at scapholunate joint
- observation, needle aspiration of cyst, sx
CHA2DS2-VASc
categories and points
CHF Hypertension >75 yo (**2 points) DM Stroke (**2 points) Vascular dz Age 65-74 Sex female
CHADS-VASc score interpretation
0 - anticoag not needed
1 - consider antiplatelet or anticoag
2+ anticoag candidate
Pericarditis
- MCC
- Sx
- viral infection MCC
Also bacterial, TB, fungal, idiopathic, neoplasm, etc. - pleuritic chest pain
- less pain sitting forward, worse in recumbency
- effusion and tamponade
- friction rub at L sternal border
Pericarditis
- Tx
- NSAIDS*
- steroids
- Colchicine
- infectious: drainage and abx
Pericarditis
- EKG
- PR depressions
- diffuse ST elevations
High output cardiac failure
- causes
- hyperthyroidism or high metabolic rate
- shunting of blood that increases myocardial O2 demand
- beriberi
- AV fistula
- Pregnancy
- Anemia
Low output cardiac failure
- usu dt depressed ejection fraction
- dilated cardiomyopathy
- chronic HTN
- valvular heart disease
High output cardiac failure sx
palpitations
dyspnea on exertion
decreased exercise tolerance
constrictive pericarditis heart sound
pericardial knock
- accentuated heart sound just before the 3rd heart sound
Restrictive cardiomyopathy
heart sound
S3 dt abrupt cessation of rapid ventricular filling
constrictive pericarditis
- etiology
rare
- impaired filling dt restraint of ventricular diastolic expansion because of a stiff pericardium
- any cause of pericarditis can cause this
Constrictive pericarditis
- sx
- dyspnea, fatigue, peripheral edema
- right sided heart failure: ascites, pedal edema, hepatojugular reflex, JVD
- no pulmonary congestion
MC cause of syncope in pt with non-specific hx
idiopathic
Common causes of syncope
- Reflex: vasovagal
- Orthostatic
- Cardiac
Vasovagal sycope
- orthostatic or emotional stress
Orthostatic syncope
- primary: purely autonomic like Parkinsons or Lewy body dementia
- drug induced: vasodilators, diuretics, thiazines, antidepressants
Cardiac syncope
- bradydysrhythmias
- tachydysrhythmias
- structural heart disease
Chronic HF treatment
- lifestyle
- diuretics: acute pulmonary edema, no mortality benefit
- ACEi: decreased mortality
- BB: decreased mortality in classes II-IV
- Hydralazine with nitrate: dec mortality for AA
- Spironolactone: dec mortality in class III and IV
- digoxin: refractory systolic dysfunction, no mortality benefit
NYHA classification for HF
I: no limitation
II: slight limitation, mild sx with ordinary activities
III: moderate limitation, sx noted with min activity
IV: severe limitation, sx at rest
Hypertrophic cardiomyopathy
- murmur
usu delayed onset
- 3-4/6 grade
- crescendo-decrescendo
- L lower sternal border
- increases with less venous return: sitting to standing or valsalva
Hypertrophic cardiomyopathy
- tx
avoid physical activity
BB
defibrillators and transplant
(no s)
Aortic stenosis leads to what heart changes
- increased LV after load
- concentric LV hypertrophy and then remodeling
- Leads to abnl diastolic function (bc less space)
- leads to concentric hypertrophy to compensate
Aortic stenosis
- sx
dyspnea
chest pain
syncope
Aortic stenosis
- PE
- crescendo-decrescendo systolic murmur
- radiates to carotids
- Paradoxically split S2
- S4 gallop
- murmur will decrease with valsalva
Aortic stenosis
- Age
- RF
- Tx
- older
- Dm and HTN
- valve replacement
Restrictive Cardiomyopathy
- s/sx
- peripheral edema, dyspnea, fatigue (Right sided HF)
Restrictive Cardiomyopathy
- Echo
- Impaired diastolic filling
- preserved systolic function
Restrictive Cardiomyopathy
- EKG
low voltage, non specific changes
Restrictive Cardiomyopathy
- MC cause
amyloidosis
Supraventricular arrhythmias (5)
- sinus brady
- supraventricular tachy
- a fib
- a flutter
- junctional rhythm
Drugs to increase heart rate (sx bradycardia)
- Vagolytic: atropine
- positive chronotrope: epi or dopamine
Overview of treatment of sx tachycardia
- synchronized cardioversion
- antiarrhythmibc: amiodarone, bb, procainamide
Paroxysmal supraventricular tachycardia
- EKG
- two main types
- regular, narrow QRS
- AV nodal reentry tachycardia (AVNRT)
- AV reciprocating tachycardia (AVRT)
AV nodal reentry tachycardia (AVNRT)
Type of PSVT
- 2 pathways
- Both WITHIN the Av node, one slow and one fast
- MC type
AV reciprocating tachycardia (AVRT)
Type of PSVT
- 1 pathway in AV node
- 1 pathway is accessory, outside AV node
- WPW!!
- Lown-Ganong-Levine syndrome
Two conduction patterns in PSVT
- Orthodromic (MC): impulse down normal AV node, returns via accessory. Narrow complex tachycardia
- Antidromic: impulse down accessory and returns via normal pathway. WIDE complex tachycardia
PSVT management
- Stable narrow complex
- vagal maneuver
- Adenosine
- AV node blockers (BB, CCB)
PSVT management
- Stable wide complex
- anti-arrhythmics: amiodarone
* * procainamide if suspect WPW
PSVT management
- unstable
synchronized cardioversion
*definitive: radiofrequency ablation
A. fib
- types
- paroxysmal: self terminating in 7 days +/- recurrent
- Perisistent: >7 days, requires termination (med or electrical)
- Permanent: persistent >1 year. Refractory to cardioversion or not tried
- Lone: all of the types without evidence of heart dz
A fib
- rate vs. rhythm control
Rate control usu preferred over rhythm control
- rhythm may be used in younger pts with lone a fib
A. Fib
- Rate control management
- BB (Metoprolol)
- CCB (diltiazem*, verapamil)
- Digoxin: preferred pts with hypotension or CHF
A. fib
- rhythm control
- synchronized cardioversion preferred
- Pharm: ibutilide, flecainide, sotalol, amiodarone
- Ablation
When can A. fib be cardioverted?
- AF present <48 hours
- 3-4 weeks of antiocoag AND TEE shows no atrial thrombi
A. Fib
- Unstable tx
synchronized cardioversion
A. Fib
- Anticoagulation
Based on CHADS-VASc score
- NOACS: Dabigatran (direct thrombin inhibitor) and Factor Xa inhibitors (apixaban, edoxaban, rivaroxaban)
- Warfarin (INR 2-3)
- dual anti platelet therapy (ASA + clopidogrel) but inferior to above two
A. flutter
- stable management
- unstable management
- definitive management
- vagal, BB, CCB
- synchronized cardioversion
- ablation
** same anticoag as a. fib
What dysrhythmia has capture beats and fusion beats?
ventricular tachycardia
- fusion: indicates 2 foci of pacemaker cells
- capture: return of atrial control
Torsades de pointes
- causes
- drugs prolong QT
- Class IA antidysrhythmics
- Class IC antidysrhythmics
- cyclic antidepressants
- erythromycine
- methadone
Ventricular dysrhythmias
- overview
- unpredictable, unstable, lethal dt compromised stroke volume and coronary flow
- wide, bizarre QRS
Ventricular tachycardia
> = 3 PVS and rate >100
- prolonged QT can cause
Torsades de pointes
- MC cause
hypomagnesemia
Ventricular tachycardia
management
- stable
- unstable
- stable: antiarrhythmics (Amiodareon)
- Unstable with pulse: synchronized cardioversion
- Unstable no pulse: defibrillation and CPR
Torsades de pointes
- management
- IV mg
- correct electrolyte abnormalities
Wolf Parkinson White
- pathway
- EKG
- bundle of Kent
- pre-excitation of ventricle
- Slurred, wide QRS with delta wave, short PR
Wolf Parkinson White
- management stable if wide complex
- vagal maneuvers
- antiarrhythmics: procainamide preferred
- AVOID AV nodal blockers (ABCD: adenosine, BB, CCB, Digoxin) bc can cause preferential conduction through fast pathway = worsening tachy
Wolf Parkinson White
- management unstable
- synchronized cardioversion
Wolf Parkinson White
- Definitive tx
ablation
Medical management of Long QT syndrome
- metoprolol if hemodynamically stable
Long QT syndrome
- QT interval definition
- > 480 ms w/ sycope
- >500 ms no sx
Holiday Heart syndrome
- A fib, a flutter, atrial tachycardia after etoh
- present with palpitations
- usu spont converts 24-48 hrs
- Observe pt is first step
Multifocal atrial tachycardia
- > 3 P wave morphologies
- Rate 100 to 180
- Irregular rate
- secondary to COPD, hypoxia, pulmonary HTN
- Management: O2, tx underlying condition, rate control
Hyperkalemia and EKG
- peaked T wave
- dropped P wave and widened QRS
- Sine wave
Does Type 1 second degree heart block need treatment?
Not always, can be a normal variant (they 2 second degree is NEVER normal)
What does obesity do to BNP?
decreases level
BNP level
- dx HF
- definite rule out HF
- HF if >500
- <100 eliminates HF
Alternative therapy to ASA (allergy) during acute coronary syndrome
clopidogrel
Special considerations in RV infarct
- become preload dependent bc RV impaired and relies on passive flow to LV
- hypotension = IV fluids to increase preload
- Nitrates are CI
First steps to care for acute MI
- cardiac monitor (look for dysrhythmias)
- peripheral IV
- O2
- ASA
- NTG (as long as not RV or right heart)
Meds given post MI
- ASA
- BB
- Statin
- ACEi
(reduced mortality)
What med is sometimes used during and surrounding coronary artery procedures
abciximab (GP IIb/IIIa inhibitor)
- prevents platelet adhesion and thrombus formation
Antiplatelet meds
- ASA
- clopidogrel
- ticagrelor
- prasugrel
MC cause of sudden cardiac arrest and death
Ischemic heart disease
Common cardiac finding in heart failure with respiratory distress
third heart sound (S3 gallop)
- high likelihood ratio of CHF
What common drug can worsen the sx of heart failure?
NSAIDs
beta blockers to use in HF
- bisoprolol
- carvedilol
- metoprolol
STEMI ST elevation evolution
- hyperacute T wave
- J point elevation
- ST segment elevation
- Q wave formation, loss of R wave
- T wave inversion
Med overview for chronic stable angina
- statin
- Antihypertensive (BB first line)
- antiplatelet (ASA)
- NTG
hypertriglicertidemia pancreatitis
- xanthomas on extensor surfaces of arms, legs, buttocks, back
- hepatosplenomegaly
- DM, etoh, obese, pregnant, hx pancreatitis
1st line med to tx:
- LDL
- triglycerides
- HDL
- statins
- fibrates
- niacin
Niacin medication
- main effect
- ADR
- vitamin B3
- increase HDL
- flushing, HA, warm sensation, itching
- hyperuricemia (gout)
- hyperglycemia
Statins
- aka
- main effect
-
- HMGcoA reductase inhibitors
- inhibits rate-limiting step in hepatic cholesterol synthesis and increases LDL receptors so more LDL removed from blood
Statin
- ADR
- when to give
- myositis, myalgia, rhabdomyolysis
- Hepatitis: LFTs first 3 mo
- bedtime
Fibrates
- main effect
- MOA
- names
- decrease triglycerides
- inhibits peripheral lipolysis and reduces hepatic TGL production
- gemfibrozil
- fenofibrate
Fibrates
- ADR
- myositis, myalgias
- esp with concomitant statin us
- gallstones
Bile acid sequestrants
- main effect
- MOA
- names
- bind bile acid, blocking reabsorption
- reduce cholesterol pool, removes LDL from blood
- most useful + statin or niacin
- cholestyramine, colestipol, colesevelam
Bile acid sequestrants
- ADR
- GI
- inc LFTs
- inc triglycerides (dont’ use in pt with elevated TGL)
Ezetimibe
zetia
- inhibits cholesterol absorption in intestine
- lowers LDL
- increased LFTs, esp with statin use
What is the only lipid lowering agent that is safe in pregnancy
bile acid sequestrates
HTN
- urgency
- emergency
- urgency: HTN w/o end organ damage
- emergency: HTN + end organ damage
*damage: encephalopathy, cardiac ischemia, renal ischemia
HTN emergency management
Reduce MAP 25% first hour, normalize bp next 8-24 hours
- reduce >25% might result in end-organ ischemia
- IV labetalol or nicardipine
HTN goals
- <60 yo
- > = 60 yo
- CKD
- DM
- <140/90
- <150/90
- <140/90
- <140/90
HTN initial meds
- non AA
- thiazide
- CCB
- ACEi / ARB
HTN initial meds
- AA
- thiazides
- CCB
HTN initial med
- CKD
- ACEi or ARB
Amiodarone ADR
- MC
- others
- MC: hypotension
- blue-gray discoloration
- corneal microdeposits
- hypo/hyperthryoid
- interstitial lung dz
- hepatitis
- epididymitis
- etc
Amiodarone
- MoA
- inhibits outward K channels
- prolongs the duration of the action potential
Mitral stenosis
- RF
- sound
- position
- stethoscope
- rheumatic heart dz
- diastolic
- low-pitched decrescendo at cardiac apex
- may appear in pregnancy
- best in left lateral decubitus
- bell
MCC tricuspid regurg
elevated R heart pressure
Aortic regurgitation
- diaphragm
- left sternal border
- accentuated when pt leans forward
- diastolic
- high pitched, blowing, decrescendo
What condition must be avoided in aortic stenosis?
hypotension - pt is preload dependent
- ensure hydrated
- Avoid vasodilators and diuretics
MCC tricuspid stenosis
Rheumatic heart disease
Prinzmetal angina
- daily prophylaxis meds
- MC pt
- MC time of onset
- EKG
- Two contributing factors
- CCB or nitrates to prevent vasoconstriction
- women <50
- early morning
- ST segment elevation
- smoking and cocaine
Best anticoagulation for pregnant woman
LMW heparin
DVT, etc.
Chronic venous insufficiency
- cause
- sx
- MC vascular diorder
- incompetent venous valves
- lower extremity pain or discomfort
- worse when standing or seated with feet down
- better with elevation and walking
Chronic venous insufficiency
- s/s
- abnl venous dilation
- telangiectatsias
- varicose veins
- edema
- inflammation
- dermatitis
- ulceration
Chronic venous insufficiency
- RF
- age
- fam hx
- inc body mass
- smoking
- lower leg trauma
- venous thrombosis
- pregnancy
Tx and length of time to tx for DVT
dabigatran or warfarin X 12 months min
Pneumonia
- h. influenza
- 2nd mc cause CAP
- more common with underlying pulm dz like COPD, CF, etc
Pneumonia
- mycoplasma pneumoniae
- MC cause of atypical (walking) pneumonia
- mc in school aged children, college, military
- *bullous myringitis
Pneumonia
- staph aureus
- often after viral infection like flu
Pneumonia
- anearobes
- aspiration pneumonia
- MC R lower lobe
Pneumonia
- mc route of infection
microaspiration of oropharyngeal secretions
typical pneumonia
- MC org
- CXR
- clinical manifestations
- s. pneumoniae
- lobar pneumonia
- fever, cough c sputum, pleuritic chest pain, rigors, tachypnea and tachycardia
Typical pneumonia
- PE
- bronchial breath sounds
- dullness to percussion
- tactile fremetis
- egophany
- inspiratory rales
CXR pneumonia
- abscess formation
- upper lobe with bulging fissure, cavitations
- s. aureus
- klebsiella
Sputum pneumonia
- rusty
- current jelly
- strep pneumonia
- klebsiella
Percussion results
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- dullness
- dullness
- hyperresonanace
fremitus
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- increased
- decreased
- decreased
Breath sounds
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- Bronchial, egophony
- decreased
- decreased
Pneumonia Treatment
- CAP outpatient
- Macrolide or doxy
- fluoroquinolone if recent abx use
Pneumonia Treatment
- CAP inpatient
beta lactam (ceftriaxone) & macrolide or FQ
Pneumonia Treatment
- HAP
- pseudomonas risk
- piperacillin/tazobactam or cefepime + amino glycoside OR levofloxacin or moxifloxacin
HTN
Thiazide diuretics
- MoA and effect
- increased Na and H2O excretion at distal convulsed tubule = reduced blood volume
- tx of choice in uncomplicated HTN
HTN
Thiazide diuretics ADR
- hyponatremia
- hypokalemia
- hypercalcemia
- hyperuricemia
- hyperglycemia
*careful in gout, DM
HTN
Loop diuretics
- MoA
- inhibits water transport across loop of Henle
- excretes water, Na, Cl, K
- Strongest diuretic
HTN
Loop diuretics
- ADR
- CI
- volume depletion
- hypokalemia
- hyperglycemia
- metabolic alkalosis
- ototoxicity
- CI: sulfa allergy
HTN
K-sparing diuretics
- MoA
- inhibits aldosterone-mediated Na/H2O absorption
- week diuretic, best used with loops to min K loss
HTN
K-sparing diuretics
- ADR
- CI
- hyperkalemia
- gynecomastia w/ spironolactone
- CI: renal failure, hyponatremia
HTN
ACEi
-MoA
- reduces synthesis of Angiotensin II and aldosterone
- renoprotective
- cardioprotective
HTN
ACEi
- ADR
- 1st dose hypotesion
- Azotemia/renal insufficiency
- hyperkalemia
- cough
- angioedema
- hyperuricemia
HTN
ACEi
- CI
pregnancy (ARBS too)
HTN
CCB
two types
- dihydropyridines: potent vasodilation. (amlodipine, nifedipine)
- non-dihydropyridines: cardiac contractility and conduction, vasodilation
(verapamil and diltiazem)
HTN
with what comorbidity is non-dihydropyridine used?
HTN with A fib
HTN
CCB
- ADR
- HA
- dizzy
- lightheaded
- flushing
- peripheral edema
Verapamil: constipation
HTN
CCB
- CI
CHF and 2/3rd degree heart block
Weber test
- conductive: lateralizes to impaired ear
- neurosensory: lateralizes to the good ear
Rinne test
- conductive: bone conduction louder than air on impaired ear
- neurosensory: air louder than bone conduction. Might not hear the bone conduction