Family Med EOR Flashcards
1
Q
MC org endocarditis
A
- Native value infection: strep viridian’s (staph aureus and enterococci)
- IVDU: S. aureus (tricuspid valve)
- Prosthetic valve: s. aureus
2
Q
Endocarditis treatment
A
- empiric
- native valve: vanc +/- cefazolin
- Ill with HF: gentamicin + cefepime + vanc
- Valve replacement if refractory or abscess
3
Q
Endocarditis prophylaxis
A
- 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)
4
Q
Endocarditis
- criteria for dx name
- criteria
A
- Duke Criteria
- 2 major, 1 major and 1 minor, 5 minor
5
Q
Endocarditis
Major criteria
A
- two + blood cultures with typical org
- echo with new valvular regurgitation
6
Q
Endocarditis
minor criteria
A
- 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
7
Q
First line BB therapy for CVD
A
AM
Atenolol and metoprolol
8
Q
Nitrates
- special dx instructions
- effect
A
- 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
9
Q
CCB in CVD
- effect
A
- coronary vasodilation and after load reduction
- reduces contractility
- 2nd line to BB and NTG
10
Q
FEV1/FVC
- obstructive
- restrictive
A
- obstructive: reduced ratio dt reduced FEV1
- restrictive: normal ratio with reduced FEV1 and FVC
11
Q
how should asthma spirometry respond to albulterol
A
FEV1 or FVC increase > 12%
12
Q
What type of med should be avoided in asthmatics
A
beta blockers
13
Q
Asthma
- CXR
- ABG
A
- hyperinflation
- hypocarbia: have increased respiratory rate. If normal or high, may be sign of impending respiratory failure
14
Q
Intermittent Asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
A
- ≤ 2 days/week
- ≤ 2 times a month
- no interference
- ≤ 2 times a week
- FEV1 >80% predicted
- 0-1 exacerbations
15
Q
Mild persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
A
- > 2 days/week, not daily
- 3-4 times a month
- minor
- many but not all days
- FEV1 >80% predicted
- > 2 times a year
16
Q
moderate persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
A
- daily
- > once a week, not nightly
- Some interference
- Daily
- FEV1 60-80% predicted
- multiple
17
Q
severe persistent asthma
- daytime sx
- nighttime sx
- interference with activities
- SABA use
- FEV1
- exacerbations c steroids
A
- multiple times daily
- daily
- extremely limited
- several times a day
- FEV1 < 60% predicted
- multiple
18
Q
Asthma therapy steps
A
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
19
Q
COPD
- MC cause of exacerbations
A
- infection
- noncompliance
- cardiac disease
20
Q
COPD
- overview of treatment meds
A
- Beta agonist and anticholinergic
- +/- ICS
- theophylline for refractory disease (less effective and more ADR vs. inhaled bronchodilators)
21
Q
Ipatroprium bromide
- brand
- type of med
A
- atrovent
- anti-muscarinic inhaled: antagonists M1 and M3 to prevent bronchoconstriction
22
Q
SABA example brand and generic
A
- Albuterol / proventil HFA
- Levalbuterol / Xopenex HFA
23
Q
How are LABAs used differently in asthma and COPD
A
- 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
24
Q
LABA example brand and generic
A
- Salmeterol / Serevent diskus
25
SAMA example brand and generic
ipatroprium / atrovent
26
LAMA example brand and generic
tiotroprium / spiriva
27
ICS two examples brand/generic
- Fluticasone / flovent
| - budensonide / pulmicort
28
2 Combo ICS and LABA that are common
- fluticasone + salmeterol (Advair)
| - budensonide + formoterol (Symbicort)
29
biologic used in asthma
omalizumab (Xolair) vs. IgE
30
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?
31
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
32
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
33
CAP
| - CXR findings
- patchy airspace opacities to lobar consolidation with air bronchograms
34
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
35
MC pathogen
- CAP
- HAP
- VAP
- CAP: s. pneumoniae
- HAP: s. aureus (MSSA and MRSA), pseudomonas
- VAP: acinetobacter, stenotrophomonas maltophilia
36
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
37
CAP treatment
KNOW charts
38
when to admit CAP
CURB 65 score:
- confusion
- uremia
- respiratory rate
- blood pressure
- >65 yo
<1: no hosp
1-2: hosp
3+: ICU
39
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)
40
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)
41
TB treatment
| - latent
(negative CXR, sputum, or both)
| 9 months INH
42
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
43
Small cell lung cancer
| - s/sx
- recurrent pneumonia
- anorexia, weight loss
- weakness
- cough
44
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
45
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
46
Small cell lung cancer
| - tx
- limited: chemo and radiation
| - extensive: chemo only, radiation of responsive to chemo
47
small cell lung caner
| - prognosis
- limited: 10-13% 5y
| - extensive: 1-3% 5y
48
non-small cell lung cancer
| - etiology
squamous cell carcinoma MC
49
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
50
non-small cell lung cancer
| - associated sx
- SIADH
- ectopic ACTH
- PTH-like secretion
- hypertrophic pulmonary osteoarthropathy
51
non-small cell lung cancer
| - dx
same as small cell lung cancer
52
non-small cell lung cancer
| - tx
- surgery (unless metastatic outside of chest)
- radiation adjunct to sx
- chemo- uncertain benefit
53
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
54
OSA
| - diagnostics
- polysomnography (definitive): 5+ episodes of apnea, hypogea, respiratory related arousals per hour
- CBC: erythrocytosis
- Thyroid: r/o hypothyroid
- ABG: CO2 >45 mmHg
55
OSA
| - treatment
- weight loss
- CPAP (curative)
- BiPAP if O2 < 90%
- tracheostomy is definitive tx
56
Tobacco dependence
| - 4 meds
- bupropion (zyban)
- nicolette gum (nicolette)
- nicotine patch
- verenicline (chantix)
57
MOA
- bupropion (zyban)
- nicolette gum (nicolette)/nicotine patch
- verenicline (chantix)
- norepinephrine/dopamine reuptake inhibitor
- nicotinic cholinergic receptor agonist
- partial cholinergic receptor agonist
58
ALT vs. AST specific organs
ALT more specific for the Liver
| AST found in several tissues
59
when is alk phos elevated
obstruction to bile flow in any part of the bile tree (cholestasis)
60
There is one cause of diarrhea that is associated with a random other disease, what is it?
C. jejuni is associated with guillaine-barre
61
what marker is used to track colon cancer
CEA
62
AST and alk phos lab results
| - Acute hepatitis
AST >10-20
| alk phos <3
63
AST and alk phos lab results
| - chronic hepatitis, cirrosis, tumor
AST < 10
| Alk phos <3
64
AST and alk phos lab results
| - extra-hepatic obstruction
AST >4
| Alk phos >4 (very high)
65
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
66
PT - clotting factors
II, VII, IX, X
(extrinsic pathway)
prolonged in advanced liver disease
67
LFTs in cirrhosis or metastatic liver dz
often nl or low bc there is a reduction in healthy functioning hepatocytes
68
Anal fissure
| - MC site
posterior anal midline
| below or distal to dentate line
69
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
70
Anal fissure
| - dx
- endoscopy: bleeding + 2 mo of tx
- sigmoidoscopy: pts <50 with no fam hx of colon cancer
- colonoscopy if suspicion for crohns
71
Anal fissure
| - tx
Acute
- fiber, water
- sitz bath
- topical anesthetic, vasodilator (nifedipine and NTG)
Chronic
- Botox
- lateral sphincterotomy (Gold standard)
72
Anal fissure
| - prevention
- proper anal hygiene
- high fiber diet, fluids, avoid straining
- avoid anal trauma
- prompt tx of diarrhea
73
Anorectal fistula
| - MC location
interspincteric
74
Anorectal fistula
| - MCC
anorectal abscess
75
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
76
Anorectal fistula
| - dx
- Anoscopy to look for internal opening
77
Anorectal fistula
| - tx
Simple:
- fustolotomy
- simple ligation of internal fistula tract
- fistulectomy (larger wound, longer healing, more incontinence vs. fistulotomy)
Complex
- Seton
78
Hemorrhoid
| - internal vs. external
Internal
- superior rectal plexus (insensate area)
- above dentate line
External
- inferior rectal plexus
- distal to dentate line
79
Hemorrhoids
| - tx
- conservative management first line
- rubber band ligation: protrudes with defecation, enlarged, intermittent bleeding
- closed hemorrhoidectomy: permanently prolapsed
80
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
81
Colon cancer
| - MC type
adenocarcinoma
| villous > tubular
82
Colon cancer
| - s/sx
- abd pain
- change in bowel habit
- weight loss
- hematochezia
83
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
84
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
85
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
86
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
87
how to use CEA with CRC
NOT for screening
| - useful for baseline and recurrence surveillance
88
PUD
| - 3 MCC
- h. pylori
- NSAIDs
- zollinger-ellison syndrome
(smoking, ETOH, coffee, emotional stress, dietary factors)
89
PUD
| - dx
- endoscopy: to dx ulcers, r/o malignancy
- barium swallow
- h. pylori testing
- biopsy (gold standard)
- serum gastrin measurement for zollinger-ellison
90
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
```
91
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
92
Gastritis
| - etiology
- NSAIDS **
- ASA
- h. pylori
- etoh, cigs, caffeine
- physiologic stress
93
Gastritis
| - S/sx
- epigastric pain
- no relationship with eating
- dyspepsia
- abd pain
94
Gastritis
| - dx
- upper GI endoscopy with bx (1st line)
| - h. pylori testing
95
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
96
Acute viral gastroenteritis
- MC norwalk virus (rotavirus, enterovirus)
- fecal-oral
- MC cause of acute diarrhea
- n/v
- supportive
97
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
98
travelers diarrhea
| - tx
- Cipro empiric
- resistent, children, preg: azithromycin
- Bismuth-subsalicylate: 60% effective
99
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)
100
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
101
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
102
HUS
- AKI
- thrombocytopenia
- hemolytic anemia
103
Enteroinvasive E. coli
- food
- cramping, watery diarrhea
- positive fecal leukocytes
- tx: hydration, peptol-bismol, imodium
104
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
105
Amylase or lipase for pancreatitis?
both but Lipase is much more specific
106
what are the randon criteria
```
glucose
calcium
hematocrit
BUN
ABG
LDH
AST
WBC
```
107
Pancreatitis
| - most accurate testing
CT
108
Pancreatitis
| - Tx for mild
- NPO
- IV fluids
- electrolyte balance
- pain control
109
Pancreatitis
| - tx for severe
- ICU
| - Enteral nutrition via NJ tube X 72 hr
110
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
111
Chronic pancreatitis
| - tx
- Pain control
- NPO
- Pancreatic enzymes, H2 blockers, insulin,
- frequent, small-volume, low-fat meals
- Pancreaticojejunostomy or whipple
112
Chronic pancreatitis
| - cComplications
- Narcotic addiction
- DM
- Malabsorption
- pseudocyst
- CBD obstruction
- B12 malabsorption
113
Markers for
- Ulcerative colitis
- Crohns
- UC: ANCA
| - Crohns: ASCA
114
Ulcerative colitis
- LLQ
- Tenesmus, bloody or pus diarrhea
- small but frequent bowel movement
- fever, weight loss, anorexia
- No skip lesions
115
Ulcerative colitis
| - extra intestinal sx
- scleritis and episcleritis
- primary sclerosing cholangitis
- erythema nodosum
- pyoderma gangrosum
- ankylosing spondylitis
116
What three conditions/diseases are fecal leukocytes positive?
- ulcerative colitis
- ischemic colitis
- infectious diarrhea
117
When you avoid colonoscopy in UC
severe disease - to avoid risk of perforation or toxic megacolon
118
UC
| - treatment
- Sulfasalazine
- steroids
- immunosuppressants
- proctocolectomy (curative)
119
Crohns
- Mouth to anus
- terminal ileum
- flares and remissions
- transmural inflammation
- fistulas and bowel lumen narrowing
- RLQ pain
120
Crohns
| - extra intestinal manifestations
- uveitis
- arthritis
- erythema nodosum
- aphthous oral ulcers
- cholelithiasis
- nephrolithiasis
121
Crohns
| - dx
- Endoscopy/colonoscopy: cobblestone appearance, psuedopolyps, skip lesions, rectal sparing
- Abd CT
- Upper GI with small bowel follow through for ileum or fistulas
122
Crohns
| - Tx
- mesalamine/sulfasalazine
- prednisone for acute exacerbations
- Metronidazole
- Immunosupression
- bile acid sequestrates
- sx: SBO
123
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
124
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
125
Ischemic colitis
| - tx
- IV fluids
- hemodynamic stabilization
- bowel rest
- no vasoconstrictive drugs
- empiric abx
- 20% require surgery (peritonitis) - bowel resection with colostomy
126
Appendicitis
| - etiology
- lumen obstructed by hyperplasia of lymphoid tissue MC
| - obstruction > stasis > bacterial growth and inflammation
127
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
128
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
129
Cholelithiasis/biliary colic
| - overview
- epigastric, RUQ pain
- steady
- often after eating
- radiates to scapula
(in the gallbladder)
130
Acute cholecystitis
| - overview
- severe epigastric, RUQ pain
- radiates to scapula
- Fever, nausea, vomiting
- + Murphy sign
(gall bladder)
131
Ascending cholangitis
| - overview
- abd pain, jaundice, fever (Charcot triad)
- Triad + confusion and hypotension (Reynolds pentad)
- hepatomegaly
- icterus
132
Gallstone pancreatitis
| - overview
- severe epigastric pain
- pain radiates to back
- n/v
- elevated lipase
- elevated ALT
133
Progression of gallbladder disease
- biliary colic
- acute cholecystitis
- choledocholithiasis
- ascending cholangitis
134
Cause of acute (ascending) cholangitis
stasis and infection of biliary tract
135
Treatment of cholangitis
broad spectrum abx (piperacillin-tazobacam)
| - biliary drainage (ERCP)
136
Spontaneous peritonitis
- past history of what
- presenting sx
- chronic liver disease, cirrhosis
| - fever, chills, abd pain
137
Spontaneous peritonitis
- PE
- labs
- diagnosis made via what
- ascites, shifting dullness
- PMNs >250, WBC >1,000, pH <7.34
- analysis of ascites fluid
138
Spontaneous peritonitis
- MCC org
- tx
- e. coli, strep spp
| - IV abx (3rd gen cephalosporin), ? albumin
139
Vitamin A
- source
- functions
- risk groups
- liver, fish oil, fortified milk, eggs
- vision, epithelial cell maturity, resistance to infection, antioxidant
- elderly, etoh, liver dz
140
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
141
Vitamine C
- source
- function
- risk group
- citrus, strawberry, broccoli, greens
- collagen synthesis, hormone function, neurotransmitter synthesis
- etoh, elderly men
142
Vitamin C
- deficiency sx
- toxicity
- scurvy (poor wound healing, petechiae, bleeding gums)
| - diarrhea
143
Vitamin D
- source
- functions
- at risk groups
- fortified milk
- calcium regulation, cell differentiation
- elderly, shut-in, low sun exposure
144
Vitamin D
- deficiency
- toxicity
- rickets, osteomalacia
| - hypercalcemia (tetany), kidney stones, soft-tissue deposits
145
Vitamin D
| - tx
- ergocalciferol
146
Vitamin Bs
| - list
- B1 thiamin
- B2 riboflavin
- B3 niacin/nicotinic acid
- B6 pyridoxine
- B12 cobalamin
147
B1 Thiamin
- source
- fn
- at risk group
- pork, grain, beans
- carb metabolism, nerve function
- etoh**, poverty
148
B1 thiamin
| - deficiency sx (3)
1. Beriberi
2. Wernicke's encephalopathy
3. Korsakoff's dementia
149
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
150
Wernicke's encephalopathy
- Ataxia
- global confusion
- ophthalmoplegia (paralysis or abnl of ocular muscles)
151
Korsakoff's dementia
- memory loss (esp short term)
- confabulation
- irreversible...
152
B2 riboflavin deficiency
- source
- function
- at risk group
- milk, spinach, liver, grain
- energy
- No risk group
153
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
154
B3 niacin
- sources
- functions
- at risk group
- bran, fish, meat
- energy, fat metabolism
- poverty, etoh
155
B3 niacin
| - deficiency
Pellagra (3 Ds)
- dermatitis (photosensitive)
- Diarrhea
- dementia
156
B6 pyridoxine
- source
- function
- at risk
- animal protein, spinach, salmon
- protein metab, hemoglobin, nt synthesis
- adolescent, etoh
* * INH use
157
B 6 pyridoxine
| - deficiency
- HA, sideroblastic anemia, seizure, flaky skin, stomatitis and glossitis
- peripheral neuropathy*
158
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
159
B12 cobalamin
| - deficiency
- Neuro: paresthesias, gait abnl, memory loss, dementia
- GI: anorexia, diarrhea, **glossitis
- Macrocytic (megaloblastic) anemia: inc MCV + hypersegmented neutrophils
160
B12 cobalamin
| - 4 etiologites
1. pernicious anemia
2. strict vegans
3. malabsorption
4. reduced intrinsic factor production
161
Pernicious anemia and B12 deficiency
- autoimmune destruction or loss of gastric intrinsic cells
- reduced/no intrinsic factor
- dx: ab testing, Schilling test
162
Malabsorption and B12 deficiency
- alcoholism
| - disease affecting ileum (Crohn's, celiac dz)
163
What can reduce the production of intrinsic factor?
- drugs: PPIs and H2RA
- gastric bypass sx
- atrophic gastritis
164
Folate
- source
- fun
- at risk group
- green leafy veg, OJ, grain, organ meat
- DNA synthesis
- etoh, pregnancy
165
Folate
| - deficiency sx
- megaloblastic anemia
- sore tongue
- diarrhea
- mental disorders
166
How to diagnose metabolic syndrome
3 of the 5:
1. Abd obesity (waist >102 men, >88 women)
2. Triglycerides >150 or on drug tx for triglycerides
3. HDL <40 men <50 women
4. BP >130/85 or drug tx for HTN
5. glucose >100 or drug tx for hyperglycemia
167
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)
168
PE difference in three types of conjunctivitis
- Bacterial: mucopurulent discharge, red, not pruritic
- Viral: watery discharge, red, pruritic
- Allergic: rare discharge, cobblestoning, red, pruritic
169
nystagmus with water in ear
COWS
- Cold Opposite
- Warm Same
170
Bilateral discharge on day 3 of life in neonate
- Gonococcal ophthalmia neonatorum
| - topical 0.5% erythromycin applied after birth to prevent
171
Three types of neonatal conjunctivitis and time of presentation
1. Chemical: first 24 hours, secondary to use of topical agents to prevent gonococcal conjunctivitis
2. Gonococcal: 3-5 days after birth
3. Chlamydia: 5-10 days after birth
172
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
173
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
174
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
175
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
176
Hodgkin Lymphoma
- incidence
- Assoc with what
- Bimodal: 20s and >50s, MC males
| - Epstein-Barre virus
177
Hodgkin Lymphoma
| - Clinical
- Painless lymphadenopathy
- alcohol may induce lymph node pain
- Advanced: night sweats, weight loss, cyclical fever
178
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
179
Non-Hodgkin lymphoma
- Overview
- Risk factors
- lymphocyte neoplasm
- MC >50 yo
- ** peripheral lymph nodes
- RF: age, immunosuppression (HIV)
180
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
181
Non-Hodgkin lymphoma
| - managment
- unpredictable course
| - rituximab
182
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
183
Multiple Myeloma
| - Risk Factors
- >65 yo
- AA
- Men
184
Multiple Myeloma
| - Clinical manifestations
BREAK
- Bone pain (MC spine and ribs): osteolytic, destructive lesions
- Recurrent infection dt leukopenia
- Elevated calcium
- Anemia
- Kidney failure
185
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
186
Multiple Myeloma
| - Tx
- autologous stem cell transplant
187
Acute Lymphocytic Leukemia (ALL)
- pathophys
- distribution
- RF
- malignancy of lymphoid stem cells
- MC childhood (3-7 yo)
- RF down syndrome
188
Acute Lymphocytic Leukemia (ALL)
| - clinical
- Pancytopenia --> Fever (MC)
| - CNS: HA, stiff neck, vision
189
Acute Lymphocytic Leukemia (ALL)
- PE
- DX
- hepatosplenomegaly, lymphadenopathy
| - Bone marrow: hyper cellular >20% blasts
190
Acute Lymphocytic Leukemia (ALL)
| - Tx
- chemo
191
Chronic Lymphocytic Leukemia (CLL)
- pathophys
- Clinical
- B cell clonal malignancy
| - Most asx, incidental finding on CBC, fatigue MC
192
Chronic Lymphocytic Leukemia (CLL)
| - Dx
- well differentiated lymphocytes with "smudge cells"
| - Pancytopenia
193
Acute Myeloid leukemia (AML)
| - common population
- MC acute leukemia in adults (>50)
194
Acute Myeloid leukemia (AML)
| - Clinical
- pancytopenia: anemia, splenomegaly, gingival hyperplasia
| - Leukostasis: WBC>100,000
195
Acute Myeloid leukemia (AML)
| - Dx
Bone marrow bx:
- Auer Rods
- >20% blasts
196
Chronic Myelogenous Leukemia (CML)
- pathophys
- age
- clinical
- granulocyte proliferation
- Usu >50 yo
- most asx until blastic crisis, splenomegaly
197
Chronic Myelogenous Leukemia (CML)
| - Dx
- Philadelphia chromosome (tx with imatinib)
| - Very high WBC counts
198
Abx vs. MRSA
- Bactrim
- Rifampin (rapid resistance when used alone)
- Clindamycin (GI)
- Tetracyclines
199
Causes of erythema multiform
* target-like lesions
- herpes simplex (MC viral cause)
- Mycoplasma
- Sulfonamides
- PCN
- barbituates
- Phenytoin
- etc
200
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
201
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
202
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
203
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
204
Type III hypersensitivity
- antibodies
- examples
(immune complex)
- IgG or IgM deposition and subsequent complement activation
- serum sickness, SLE, RA
205
Type IV hypersensitivity
- Antibodies
- examples
(cell mediated- delayed)
- T cells activated vs. surface bound antigens
- Contact dermatitis
- TB skin test
- Transplant rejection
206
Burn classification
| - list types
- Superficial
- Superficial partial
- Deep partial
- Full
207
Superfiical burn
- epidermis only
| - pain, red, mild swelling
208
Superficial partial burn
- dermis: papillary region
| - Pain, blisters, splotchy skin, severe swelling
209
Deep partial burn
- Dermis: reticular region
| - white, leathery, relatively painless
210
Full burn
- Hypodermis (subcut tissue)
| - charred, insensate, eschar formation
211
Amide vs. Ester anesthetics
Amides (have two Is)
- lidocaine, mepivicaine, bupivicbine, prilocaine, ropivacaine)
Esters (have one I)
- Procaine, chloroprocaine
212
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
213
Bullous Pemphigoid
| - Clinical
- prodrome: red, itchy, urticarial or papular eruption
- *Tense bullae, rupture to form erosions
- rare mucous membrane involvement (oral mainly)
- negative Nikolsky
214
Bullous Pemphigoid
| - Dx
- Immunoflourescence: ab fluorescente along BM
| - H&E of skin: subepidural blister, eosinophils in superficial dermis, C3 deposition epidermal BM zone
215
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
216
Pemphigus Vulgaris
| - clinical
- flaccid bullae
- mucosal erosions (usu oral)
- Nikolsky sign
217
Pemphigus Vulgaris
| - Dx
- Immunoflourescence: chickenwire pattern (vs. basement membrane in BP)
- Histology: intraepidermal blister formation
218
Bullous Pemphigoid and pemphigus vulgarisms tx
steroids: topical and systemic
219
Urge incontinence
- Common causes
- Sx
- Tx
- stroke, alzheimers, parkinsons, BPH
- urgency, frequency, day or night
- Anticholinergic drugs (WHAT)
220
Stress incontinence
- Common causes
- Sx
- Tx
- urologic procedure, multiple childbirths
- small volume urine loss coughing or laughing
- topical estrogen
221
Overflow incontinence
- Common causes
- Sx
- Tx
- BPH, fecal impaction
- Poor stream, incomplete emptying
- alpha-adrenergic blockers (WHAT)
222
Atonic bladder
- Common causes
- Sx
- Tx
- DM neuropathy, stroke
- loss of bladder control
- Intermittent cath
223
Acute Lymphocytic leukemia
| - brief overview
- MC childhood leukemia
- 75% affects b-cell precursors, 20% T-cell
- good prognosis
224
Chronic lymphocytic leukemia
| - brief overview
- MC adult leukemia
- smudge cells
- worst prognosis
225
Acute myelogenous leukemia
| - brief overview
- more common adults vs. children
- Auer rods
- Fair prognosis, worse than ALL
226
Chronic myelogenous leukemia
| - brief overview
- Mostly adults
- Philadelphia chromosome
- Basophilia on smear
- Good prognosis
227
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
228
Deep tendon reflexes test what nerves?
```
Triceps: C7
Biceps: C5/C6
Brachioradialis: C6
Patellar: L4
Achilles: S1
```
229
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
230
Ortolani vs. Barlow
Barlow: dislocate hip
Ortolani: reduce hip
Both clunk :)
231
Sign of colchicine toxicity
severe gastroenteritis
232
What drug is commonly used to treat RA and lupus?
Hydroxychloroquine (also malaria)
233
Hydroxychloroquine
| - common ADR to screen for
- Corneal and macular toxicity
| - Annual ophthalmologic exam
234
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
235
Autoantibodies
| - Lupus
* ANA
- Anti-dsDNA
- Anti-Smith
(also Anti-SSA/Ro)
236
Autoantibodies
| - Sjogren
* ANA
- Anti-La/SS-B
(also Anti- SSA/Ro
237
Autoantibody
| - CREST
*ANA
| Anti-centromere
238
Autoantibody
| - Inflammatory myopathy
*ANA
| Anti-Jo1
239
Autoantibody
| - RA
Rheumatoid factor
240
Autoantibody
| - Primary biliary cholangitis
Anti-mitochondrial antibody
241
Migraine
| - Acute exacerbation
- Triptans
- Ergots
- NSAIDs
- Acetaminophen
- Antiemetics
242
Migraine
| - prophylaxis
- Propranolol
- verapamil
- Amytriptyline
- Valproic acid, topiramate
- Botox
243
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
244
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
245
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
246
Croup
| - Overview
- laryngotraceobronchitis
- URI-like sx, seal barking cough, stridor, worse at night
- hypoxia is UNcommon
- Tx: cool humidified air, racemic epinephrine, dexamethasone
247
RSV
- fever, tachypnea, wheezing, nasal flaring, retractions
- CXR: diffuse infiltrates
- bronchiolitis: mucus and inflamed bronchiole wall
248
Pneumonia
| 5 common bacteria
1. Strep pneumonia: MC CAP, often follows URI or influenza, acute onset
2. H. influenza: often after URI, COPD
3. Staph aureus: may follow influenza, cavitary, MRSA
4. Klebsiella: etoh, DM, immunocompromised, LTAC, aspiration
5. Pseudomonas: chronic lung dz, mechanical ventilation
249
Legionella Pneumonia
- epidemics possible
- Water source and air travel
- Pleuritic chest pain, bradycardia, GI sx, neuro sx, hyponatremia
- CXR: alveolar infiltrates
250
Postinfluenza pneumonia
- MC staph aureus
- necrotizing pneumonia
- CXR: multiple cavitary lesions
251
Pneumonia
| - Atypical orgs (5)
- mycoplasma pneumonia: young adults
- Legionella: humidifier, hot tube, air conditioning, pleural effusion, GI/neuro, hyponatremia
- Chlamydia
- Coxiella burnetii
- Chlamydia psittaci
252
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
253
Pertussis
| - 3 stages
- Catarrhal (7-10D): mild fever, cough, coryza, conjunctivitis *most contagious
- Paroxysmal (7-28D): spasmodic cough -> inspiratory whoop
- Convalescent (months): decreasing cough
254
Pertussis
| - tx
Macrolides (Azith, erythema)
*Bordetella pertussis
255
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
256
Fine crackles
- characteristics
- Clinical
Characteristics
- discontinuous
- fine, high pitched
- end of inspiration
- not cleared by cough
Clinical
- pneumonia
- HF
- Chronic bronchitis
- asthma
- COPD
257
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
258
Wheeze
- characteristics
- Clinical
Characteristics
- continuous
- high pitched, musical
- MC in expiration
- small airways
Clinical
- asthma
- COPD
- HF
259
Rhonchi
- characteristics
- Clinical
Characteristics
- continuous
- low-pitched and coarse, loud, snoring/moan
- MC in expiration
- coughing may clear
Clinical
- Obstructed trachea
- bronchitis
- pneumonia
260
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
261
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
262
Two main types of lung cancer
Small cell and non-small cell
263
Small cell lung cancer high points
- Central ("S" central)
- Small cell
- Squamous cell
264
Non-small cell lung cancer 3 types
- Adenocarcinoma (MC), peripherally located
- Squamous cell: starts centrally, hypercalcemia
- large cell carcinoma
265
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
266
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
267
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
268
Dry age-related macular degeneration
MC
- drusen
- gradual loss of vision
- macular thinning
- not total blindness
269
Wet age-related macular degeneration
- neovascularization
- less common
- sudden loss of vision
- bleeding, leakage of fluid
- more severe central vision loss vs. dry
270
Duke criteria
| - major criteria
- two separate blood cultures pos for typical orgs
| - positive echo
271
Duke criteria
| - minor criteria
- heart condition
- IVDU
- temp >38
- vascular phenomena
- Immunological phenom
- one positive culture but doesn't meet major criteria
272
What Duke criteria needed to dx endocarditis
2 major
1 major + 3 minor
5 minor
273
what orgs are typical for endocarditis
- strep viridan
- strep bovis
- HACEK
- staph aureus
- enterococci
274
Vascular signs of endocarditis
- major arterial emboli
- septic pulmonary infarct
- mycotic aneurysm
- intracranial hemorrhage
- conjunctival hemorrhage
- Janeway lesion
275
Immunological signs of endocarditis
- glomerulonephritis
- Osler nodes
- Roth spots
- rheumatoid factor
276
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
277
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
278
Treatment for olecranon bursitis
Compression and NSAIDs
| can also aspirate but second line
279
Medication for acute low back pain
1st line: NSAIDs, acetaminophen
2nd Line: cyclobenzaprine, diazepam
3rd line: opioids, tramadol
Also:
antidepressants, steroids, anti-epileptics
280
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
281
What is Dupuytren's contracture associated with?
DM
282
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
283
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
284
Cauda Equina
- imagining
- injury of what
- MRI lumbar spine
| - lumbosacral nerve roots
285
Low back pain red flags (4)
1. night pain, weight loss (tumor)
2. fevers, chills, sweats (bone/disk infection)
3. acute bony tenderness (fracture)
4. morning stiffness in young adult (ankylosing spondylitis)
286
Mallet finger
- forced flexion of DIP -> rupture of extensor tendon
- splint in full extension or hyperextension
- can lead to swan neck deformity
287
Swan neck deformity
- hyperextension of PIP
| - flexion of DIP
288
Boutonniere deformity
- hyperextension of the DIP
| - flexion of the PIP
289
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
290
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
291
MC shoulder and hip dislocation
- Shoulder: anterior
| - Hip: posterior
292
How to image suspected spinal stenosis?
MRI of lumbar spine
293
Ganglion cyst
- location
- tx
- dorsum of wrist at scapholunate joint
| - observation, needle aspiration of cyst, sx
294
CHA2DS2-VASc
| categories and points
```
CHF
Hypertension
>75 yo (**2 points)
DM
Stroke (**2 points)
Vascular dz
Age 65-74
Sex female
```
295
CHADS-VASc score interpretation
0 - anticoag not needed
1 - consider antiplatelet or anticoag
2+ anticoag candidate
296
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
297
Pericarditis
| - Tx
- NSAIDS*
- steroids
- Colchicine
* infectious: drainage and abx
298
Pericarditis
| - EKG
- PR depressions
| - diffuse ST elevations
299
High output cardiac failure
| - causes
- hyperthyroidism or high metabolic rate
- shunting of blood that increases myocardial O2 demand
- beriberi
- AV fistula
- Pregnancy
- Anemia
300
Low output cardiac failure
- usu dt depressed ejection fraction
- dilated cardiomyopathy
- chronic HTN
- valvular heart disease
301
High output cardiac failure sx
palpitations
dyspnea on exertion
decreased exercise tolerance
302
constrictive pericarditis heart sound
pericardial knock
| - accentuated heart sound just before the 3rd heart sound
303
Restrictive cardiomyopathy
| heart sound
S3 dt abrupt cessation of rapid ventricular filling
304
constrictive pericarditis
| - etiology
rare
- impaired filling dt restraint of ventricular diastolic expansion because of a stiff pericardium
- any cause of pericarditis can cause this
305
Constrictive pericarditis
| - sx
- dyspnea, fatigue, peripheral edema
- right sided heart failure: ascites, pedal edema, hepatojugular reflex, JVD
- no pulmonary congestion
306
MC cause of syncope in pt with non-specific hx
idiopathic
307
Common causes of syncope
- Reflex: vasovagal
- Orthostatic
- Cardiac
308
Vasovagal sycope
- orthostatic or emotional stress
309
Orthostatic syncope
- primary: purely autonomic like Parkinsons or Lewy body dementia
- drug induced: vasodilators, diuretics, thiazines, antidepressants
310
Cardiac syncope
- bradydysrhythmias
- tachydysrhythmias
- structural heart disease
311
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
312
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
313
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
314
Hypertrophic cardiomyopathy
| - tx
avoid physical activity
BB
defibrillators and transplant
(no s)
315
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
316
Aortic stenosis
| - sx
dyspnea
chest pain
syncope
317
Aortic stenosis
| - PE
- crescendo-decrescendo systolic murmur
- radiates to carotids
- Paradoxically split S2
- S4 gallop
- murmur will decrease with valsalva
318
Aortic stenosis
- Age
- RF
- Tx
- older
- Dm and HTN
- valve replacement
319
Restrictive Cardiomyopathy
| - s/sx
- peripheral edema, dyspnea, fatigue (Right sided HF)
320
Restrictive Cardiomyopathy
| - Echo
- Impaired diastolic filling
| - preserved systolic function
321
Restrictive Cardiomyopathy
| - EKG
low voltage, non specific changes
322
Restrictive Cardiomyopathy
| - MC cause
amyloidosis
323
Supraventricular arrhythmias (5)
- sinus brady
- supraventricular tachy
- a fib
- a flutter
- junctional rhythm
324
Drugs to increase heart rate (sx bradycardia)
- Vagolytic: atropine
| - positive chronotrope: epi or dopamine
325
Overview of treatment of sx tachycardia
- synchronized cardioversion
| - antiarrhythmibc: amiodarone, bb, procainamide
326
Paroxysmal supraventricular tachycardia
- EKG
- two main types
- regular, narrow QRS
- AV nodal reentry tachycardia (AVNRT)
- AV reciprocating tachycardia (AVRT)
327
AV nodal reentry tachycardia (AVNRT)
Type of PSVT
- 2 pathways
- Both WITHIN the Av node, one slow and one fast
- MC type
328
AV reciprocating tachycardia (AVRT)
Type of PSVT
- 1 pathway in AV node
- 1 pathway is accessory, outside AV node
- WPW!!
- Lown-Ganong-Levine syndrome
329
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
330
PSVT management
| - Stable narrow complex
- vagal maneuver
- Adenosine
- AV node blockers (BB, CCB)
331
PSVT management
| - Stable wide complex
- anti-arrhythmics: amiodarone
| * * procainamide if suspect WPW
332
PSVT management
| - unstable
synchronized cardioversion
| *definitive: radiofrequency ablation
333
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
334
A fib
| - rate vs. rhythm control
Rate control usu preferred over rhythm control
| - rhythm may be used in younger pts with lone a fib
335
A. Fib
| - Rate control management
- BB (Metoprolol)
- CCB (diltiazem*, verapamil)
- Digoxin: preferred pts with hypotension or CHF
336
A. fib
| - rhythm control
- synchronized cardioversion preferred
- Pharm: ibutilide, flecainide, sotalol, amiodarone
- Ablation
337
When can A. fib be cardioverted?
- AF present <48 hours
| - 3-4 weeks of antiocoag AND TEE shows no atrial thrombi
338
A. Fib
| - Unstable tx
synchronized cardioversion
339
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
340
A. flutter
- stable management
- unstable management
- definitive management
- vagal, BB, CCB
- synchronized cardioversion
- ablation
** same anticoag as a. fib
341
What dysrhythmia has capture beats and fusion beats?
ventricular tachycardia
- fusion: indicates 2 foci of pacemaker cells
- capture: return of atrial control
342
Torsades de pointes
| - causes
- drugs prolong QT
- Class IA antidysrhythmics
- Class IC antidysrhythmics
- cyclic antidepressants
- erythromycine
- methadone
343
Ventricular dysrhythmias
| - overview
- unpredictable, unstable, lethal dt compromised stroke volume and coronary flow
- wide, bizarre QRS
344
Ventricular tachycardia
>= 3 PVS and rate >100
| - prolonged QT can cause
345
Torsades de pointes
| - MC cause
hypomagnesemia
346
Ventricular tachycardia
management
- stable
- unstable
- stable: antiarrhythmics (Amiodareon)
- Unstable with pulse: synchronized cardioversion
- Unstable no pulse: defibrillation and CPR
347
Torsades de pointes
| - management
- IV mg
| - correct electrolyte abnormalities
348
Wolf Parkinson White
- pathway
- EKG
- bundle of Kent
- pre-excitation of ventricle
- Slurred, wide QRS with delta wave, short PR
349
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
350
Wolf Parkinson White
| - management unstable
- synchronized cardioversion
351
Wolf Parkinson White
| - Definitive tx
ablation
352
Medical management of Long QT syndrome
- metoprolol if hemodynamically stable
353
Long QT syndrome
| - QT interval definition
- >480 ms w/ sycope
| - >500 ms no sx
354
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
355
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
356
Hyperkalemia and EKG
1. peaked T wave
2. dropped P wave and widened QRS
3. Sine wave
357
Does Type 1 second degree heart block need treatment?
Not always, can be a normal variant (they 2 second degree is NEVER normal)
358
What does obesity do to BNP?
decreases level
359
BNP level
- dx HF
- definite rule out HF
- HF if >500
| - <100 eliminates HF
360
Alternative therapy to ASA (allergy) during acute coronary syndrome
clopidogrel
361
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
362
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)
363
Meds given post MI
- ASA
- BB
- Statin
- ACEi
(reduced mortality)
364
What med is sometimes used during and surrounding coronary artery procedures
abciximab (GP IIb/IIIa inhibitor)
| - prevents platelet adhesion and thrombus formation
365
Antiplatelet meds
- ASA
- clopidogrel
- ticagrelor
- prasugrel
366
MC cause of sudden cardiac arrest and death
Ischemic heart disease
367
Common cardiac finding in heart failure with respiratory distress
third heart sound (S3 gallop)
| - high likelihood ratio of CHF
368
What common drug can worsen the sx of heart failure?
NSAIDs
369
beta blockers to use in HF
- bisoprolol
- carvedilol
- metoprolol
370
STEMI ST elevation evolution
- hyperacute T wave
- J point elevation
- ST segment elevation
- Q wave formation, loss of R wave
- T wave inversion
371
Med overview for chronic stable angina
- statin
- Antihypertensive (BB first line)
- antiplatelet (ASA)
- NTG
372
hypertriglicertidemia pancreatitis
- xanthomas on extensor surfaces of arms, legs, buttocks, back
- hepatosplenomegaly
- DM, etoh, obese, pregnant, hx pancreatitis
373
1st line med to tx:
- LDL
- triglycerides
- HDL
- statins
- fibrates
- niacin
374
Niacin medication
- main effect
- ADR
- vitamin B3
- increase HDL
- flushing, HA, warm sensation, itching
- hyperuricemia (gout)
- hyperglycemia
375
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
376
Statin
- ADR
- when to give
- myositis, myalgia, rhabdomyolysis
- Hepatitis: LFTs first 3 mo
- bedtime
377
Fibrates
- main effect
- MOA
- names
- decrease triglycerides
- inhibits peripheral lipolysis and reduces hepatic TGL production
- gemfibrozil
- fenofibrate
378
Fibrates
| - ADR
- myositis, myalgias
* esp with concomitant statin us
- gallstones
379
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
380
Bile acid sequestrants
| - ADR
- GI
- inc LFTs
- inc triglycerides (dont' use in pt with elevated TGL)
381
Ezetimibe
zetia
- inhibits cholesterol absorption in intestine
- lowers LDL
- increased LFTs, esp with statin use
382
What is the only lipid lowering agent that is safe in pregnancy
bile acid sequestrates
383
HTN
- urgency
- emergency
- urgency: HTN w/o end organ damage
- emergency: HTN + end organ damage
*damage: encephalopathy, cardiac ischemia, renal ischemia
384
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
385
HTN goals
- <60 yo
- >= 60 yo
- CKD
- DM
- <140/90
- <150/90
- <140/90
- <140/90
386
HTN initial meds
| - non AA
- thiazide
- CCB
- ACEi / ARB
387
HTN initial meds
| - AA
- thiazides
| - CCB
388
HTN initial med
| - CKD
- ACEi or ARB
389
Amiodarone ADR
- MC
- others
- MC: hypotension
- blue-gray discoloration
- corneal microdeposits
- hypo/hyperthryoid
- interstitial lung dz
- hepatitis
- epididymitis
- etc
390
Amiodarone
| - MoA
- inhibits outward K channels
| - prolongs the duration of the action potential
391
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
392
MCC tricuspid regurg
elevated R heart pressure
393
Aortic regurgitation
- diaphragm
- left sternal border
- accentuated when pt leans forward
- diastolic
- high pitched, blowing, decrescendo
394
What condition must be avoided in aortic stenosis?
hypotension - pt is preload dependent
- ensure hydrated
- Avoid vasodilators and diuretics
395
MCC tricuspid stenosis
Rheumatic heart disease
396
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
397
Best anticoagulation for pregnant woman
LMW heparin
| DVT, etc.
398
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
399
Chronic venous insufficiency
| - s/s
- abnl venous dilation
- telangiectatsias
- varicose veins
- edema
- inflammation
- dermatitis
- ulceration
400
Chronic venous insufficiency
| - RF
- age
- fam hx
- inc body mass
- smoking
- lower leg trauma
- venous thrombosis
- pregnancy
401
Tx and length of time to tx for DVT
dabigatran or warfarin X 12 months min
402
Pneumonia
| - h. influenza
- 2nd mc cause CAP
| - more common with underlying pulm dz like COPD, CF, etc
403
Pneumonia
| - mycoplasma pneumoniae
- MC cause of atypical (walking) pneumonia
- mc in school aged children, college, military
- *bullous myringitis
404
Pneumonia
| - staph aureus
- often after viral infection like flu
405
Pneumonia
| - anearobes
- aspiration pneumonia
| - MC R lower lobe
406
Pneumonia
| - mc route of infection
microaspiration of oropharyngeal secretions
407
typical pneumonia
- MC org
- CXR
- clinical manifestations
- s. pneumoniae
- lobar pneumonia
- fever, cough c sputum, pleuritic chest pain, rigors, tachypnea and tachycardia
408
Typical pneumonia
| - PE
- bronchial breath sounds
- dullness to percussion
- tactile fremetis
- egophany
- inspiratory rales
409
CXR pneumonia
- abscess formation
- upper lobe with bulging fissure, cavitations
- s. aureus
| - klebsiella
410
Sputum pneumonia
- rusty
- current jelly
- strep pneumonia
| - klebsiella
411
Percussion results
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- dullness
- dullness
- hyperresonanace
412
fremitus
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- increased
- decreased
- decreased
413
Breath sounds
- pneumonia
- pleural effusion
- pneumothorax or obstructive lung disease
- Bronchial, egophony
- decreased
- decreased
414
Pneumonia Treatment
| - CAP outpatient
- Macrolide or doxy
| - fluoroquinolone if recent abx use
415
Pneumonia Treatment
| - CAP inpatient
beta lactam (ceftriaxone) & macrolide or FQ
416
Pneumonia Treatment
| - HAP
* pseudomonas risk
| - piperacillin/tazobactam or cefepime + amino glycoside OR levofloxacin or moxifloxacin
417
HTN
Thiazide diuretics
- MoA and effect
- increased Na and H2O excretion at distal convulsed tubule = reduced blood volume
- tx of choice in uncomplicated HTN
418
HTN
| Thiazide diuretics ADR
- hyponatremia
- hypokalemia
- hypercalcemia
- hyperuricemia
- hyperglycemia
*careful in gout, DM
419
HTN
Loop diuretics
- MoA
- inhibits water transport across loop of Henle
- excretes water, Na, Cl, K
- Strongest diuretic
420
HTN
Loop diuretics
- ADR
- CI
- volume depletion
- hypokalemia
- hyperglycemia
- metabolic alkalosis
- ototoxicity
- CI: sulfa allergy
421
HTN
K-sparing diuretics
- MoA
- inhibits aldosterone-mediated Na/H2O absorption
| - week diuretic, best used with loops to min K loss
422
HTN
K-sparing diuretics
- ADR
- CI
- hyperkalemia
- gynecomastia w/ spironolactone
- CI: renal failure, hyponatremia
423
HTN
ACEi
-MoA
- reduces synthesis of Angiotensin II and aldosterone
- renoprotective
- cardioprotective
424
HTN
ACEi
- ADR
- 1st dose hypotesion
- Azotemia/renal insufficiency
- hyperkalemia
- cough
- angioedema
- hyperuricemia
425
HTN
ACEi
- CI
pregnancy (ARBS too)
426
HTN
CCB
two types
1. dihydropyridines: potent vasodilation. (amlodipine, nifedipine)
2. non-dihydropyridines: cardiac contractility and conduction, vasodilation
(verapamil and diltiazem)
427
HTN
| with what comorbidity is non-dihydropyridine used?
HTN with A fib
428
HTN
CCB
- ADR
- HA
- dizzy
- lightheaded
- flushing
- peripheral edema
Verapamil: constipation
429
HTN
CCB
- CI
CHF and 2/3rd degree heart block
430
Weber test
- conductive: lateralizes to impaired ear
| - neurosensory: lateralizes to the good ear
431
Rinne test
- conductive: bone conduction louder than air on impaired ear
- neurosensory: air louder than bone conduction. Might not hear the bone conduction
