Family Med/Internal Med Flashcards
1
Q
Common travel meds
A
Atovaquone - proguanil, mefloquine, chloroquine, doxycycline (use one with minimal side effects)
2
Q
Diagnosis of DM
A
Two sugar measurements: Fasting >125, random >200
3
Q
Treatment of HTN in diabetic
A
First line medication ALWAYS ACE inhibitor or ARB - protection of kidneys. Contraindication: leg edema or cough
4
Q
Treatment of HTN in non-diabetic
A
Amlodipine first line or hydroclorothiazide (chlorthalidone) or ACE inhibitor/Arb
5
Q
Treatment of DM
A
Metformin for 2-3 months, treatment goal <6.5/7 (Depending on source).
If close to goal: add Glipizide
If >8.5: add insulin
6
Q
Cellulitis
A
Greater than 1cm erythema surrounding wound
7
Q
Amlodipine
A
Max dose 10mg, side effect: edema
8
Q
Benazapril
A
Max dose 40mg, side effect cough
9
Q
Sleep apnea
A
Suspect in short, obese male. Neck circumference: >37cm. Causes R-sided heart failure - LE edema
10
Q
Insulin recombinate U500s
A
concentrated regular insulin (500 units). Dose of 0.2mL = 100 units. Releases some insulin immediately, some slowly
11
Q
Treatment of skin infection
A
Keflex (cephalexin) 500mg TID x 5 days
12
Q
Treatment of UTI
A
Keflex (cephalexin) 500 mg TID x 5 days
13
Q
Common causes of right-sided heart failure
A
Sleep apnea, pulmonary HTN
14
Q
CHADS
A
Congestive Heart Failure Hypertension Age >75 Diabetes Stroke (+2)
15
Q
Acute renal insufficiency
A
Think: Prerenal (low blood flow), intrinsic renal damage, postrenal (obstruction
Albumin/Creatinine ratio, SPEP
16
Q
Chronic kidney disease
A
> 3 months of decreased GFR
Stage 3: GFR 30-59
Stage 4: 15-29
Stage 5: <15
17
Q
Nausea/vomiting in pregnancy
A
B6
Doxylamine 25mg
18
Q
Using ACE/Arb
A
Diabetic HTN
HTN with microalbumin rate >0.3. Increase dose to treat HTN but NOT to treat microalbumin
19
Q
Management of diabetes
A
Foot exam annually
Eye exam annually
A1c q6 months for controlled, q3 months for uncontrolled
Lipid panel and urine albumin-to-creatinine ratio annually
20
Q
Side effect of decreased oxygen
A
Cerebral edema (can cause syncope), long term: polycythemia, cor pulmonale, R-sided heart failure. Use O2 to prevent cor pulmonale.
21
Q
Causes of neuropathy
A
Diabetes, idiopathic, alcohol use, medications, vasculitis, amyloidosis, connective tissue disease, low B12, toxicity (metals)
22
Q
Best SSRI for anxiety
A
Zoloft (sertraline)
23
Q
Best SSRI for depression
A
Fluoxetine (Prozac)
24
Q
Refractory insomnia
A
Try prazosin, then Paxil, then amitriptyline
25
Chronic pain tx
Can use TCA (nortriptyline)
26
Treatment after MI
Beta blocker, ACE inhibitor , statin, dual-antiplatelet therapy (for at least one year)
27
Down syndrome screening
Pediatric: echocardiogram for congenital heart disease
Childhood hearing screen and always check for recurrent otitis media
Ophthalmic exam annually
Thyroid function annually
Celiac disease monitoring at one year old
CBC for leukemia and iron-deficiency anemia
28
Treatment of uncontrolled asthma
```
leukotriene modifier (like montelukast) + inhaled glucocorticoid + LABA (long-acting beta agonist) = triple-controller therapy
-If also have allergies, you can add omalizumab
```
29
Dosing prednisone
Low dose <10mg for chronic use
High dose >40mg for acute conditions like COPD exacerbation or MI
Medium dose is the in between
30
Workup for hematuria
Urine sample, cytology, CT urogram, cystoscopy
31
Monitoring DM
AIc goal <7%
If unstable, check A1c every three months
If stable, check every six months
Lipid panel and microalbumin annually
32
Atrial fibrillation treatment
Rate control: beta blocker of calcium channel blocker
Anticoagulation (depending on CHADS score)
Rhythm control: only if symptomatic - (Amiodarone)
33
New onset hyperkalemia cause
CHECK MEDS (could be caused by ACE inhibitor (Lisinopril) which decreases RAAS and decreases aldosterone - decreased sodium uptake and decreased potassium excretion. This is renal tubular acidosis type 4
34
New onset hypokalemia cause
Could be from diuretic
35
Three rules of wound care
1. Take away offending agent (pressure, infection, edema)
2. Remove dead skin with abrasion
3. Keep wound moist to maintain healthy granulation tissue with Vaseline, duoderm
36
5 main types of antibiotics to KNOW!!
1. Cephalexin/Keflex: 1st generation cephalosporin: Skin infection (mostly caused by strep and staph)
2. Amoxicillin: beta lactam: ear, sinus, throat infections
3. Sulfamethoxazole-Trimethoprim/bactrim: UTI
4. Azithromycin: Macrolide: CAP
5. Ciprofloxacin: Fluoroqunilone: reserved for last resort
37
Insomnia tx
Sleep onset: choose short-acting medication: zaleplon, zolpidem, triazolam, lorazepam, or remelteon
Sleep maintenance: longer-acting medication: zolpidem ER, eszopiclone, temazepam, estazolam, doexpin (low dose), suvorexant
38
CHF
Symptoms: SOB with exertion. When worse - orthopnea and peripheral edema.
Diastolic: Can't fill
- Commonly due to HTN (causes stiff ventricle) and afib (causes loss of atrial kick). Can also be due to hypertrophic cardiomyopathy or infiltrative diseases (amyloidosis or sarcoidosis)
- Treat with diuretic and rate control
Systolic: can't pump
- Commonly due to MI (malfunctioning ventricle wall). Can also be caused by HTN, aortic stenosis, mitral regurg
- Treat with ACE inhibitor, diuretic, and rate control
39
Chronic dry cough differential
1. Allergic rhinitis is most common. Tx: flonase, possibly antihistamines
2. ACE inhibitor therapy
3. GERD: can present with heartburn. Tx: PPI
4. Cystic fibrosis: more likely in younger population
40
Claudication differential
Causes: neurogenic or peripheral vascular disease
Neurogenic: Can be from radiculopathy or spinal stenosis/myelopathy
- Radiculopathy: nerve compressed where it leaves cord. Surgery is last case scenario, commonly L4-5
- Myelopathy: spinal cord compression, usually from spinal stenosis. Surgery is warranted because it may cause paralysis
Vascular: Increases with walking but relieves when standing and immediately when sitting down
Neurogenic: Increases with walking but does not resolve with standing and takes a few minutes to resolve when sitting. Relieved when leaning over shopping cart!
41
Vertigo differential
Central process (brain stem) or vestibular (more common)
Vestibular can be:
1.Meniere's disease: triad of vertigo, hearing loss, tinnitus
2. eustachian tube dysfunction: signs of allergic rhinitis or recurrent ear infections - will have NEGATIVE Dix hallpike maneuver. Sxs for longer periods of time
3. BPPV: otolith in the ear, sxs only last for a few seconds, ROTATIONAL nystagmus with dix hallpike
42
Chronic kidney disease differential
Common causes:
1. Diabetes: usually has microalbuminemia and large kidneys
2. Hypertenion: usually NO microalbuminemia and small kidneys
3. Other things
Workup: renal ultrasound to rule out obstruction, microalbumin
Treatment: maintain blood sugars and blood pressures
AVOID NSAIDS
43
Acute kidney injury
Causes: prerenal, intrinsic, post-renal
-prerenal: decreased blood volume, CHF, liver disease, ACE inhibitor, NSAIDs
-intrinsic: nephritic syndromes, nephrotic syndromes, acute interstitial nephritis, acute tubular necrosis
-post-renal: obstruction
Workup: per protocol. Obtain SPEP and UPEP if workup otherwise normal
44
Symptoms of cervical spinal stenosis
Ataxia and lower extremity weakness - affecting dorsal column
45
Management of gout
Allopurinol if >3-4 flares in one year. No need to titrate based off of uric acid levels, titrate more based on flares.
If big joint - treat with allopurinol sooner.
If tophi - treat more aggressively.
46
Common inherited causes of hypercoagulability
```
Factor V Leiden mutation
Prothrombin gene mutation
Protein S deficiency
Protein C deficiency
Antithrombin deficiency
```
47
Angioedema
Swelling of soft tissue, usually face but can be extremities or genitals
Caused by mast cell degranulation (urticaria, pruritis, hypotension, anaphylaxis), histamine release (urticaria but no respiratory or circulatory symptoms), or bradykinin (ONLY swelling)
Workup: CBC, CMP, ESR, CRP, C4
-Hereditary angioedema (C1 inhibitor deficiency)
ACE inhibitors
Specific trigger
Treatment depends on severity and cause. Triggered angioedema can be treated with epinephrine, glucocorticoids, and antihistamines
48
Early identification of sepsis
QSOFA standard:
- RR >22
- Change in mentation
- Systolic blood pressure <100
49
Bilirubin level for scleral icterus
2.5-3 minimum
50
Choledocholithiasis
Biliary obstruction from a stone
Elevated AST, ALT, but cholestatic picture with elevated bilirubin, GGT, and alk phos greater than AST/ALT
-Elevated direct bili indicates obstruction (can have obstruction even with normal alk phos)
US can show dilation or stone
In patients with prior cholecystectomy, US that show dilation can be normal or sign of stone.
Continue with MRCP (dye and imaging of duct) or ERCP (scope, can remove stone at time of scope)
51
Charcot's triad
RUQ pain, fever, jaundice - symptoms of acute cholangitis
52
Reynolds' pentad
RUQ pain, fever, jaundice, hypotension, altered mental status
53
Antibiotics used for GI infections
Ampicillin (covers gram positive - enterococcus), gentamycin (covers gram negative enterics), and metronidazole (covers anaerobes)
54
Piperacillin-tazobactam (Zosyn)
Antibiotic that mostly covers everything (gram positives, gram negatives, and anaerobes)
55
Congestive heart failure
<40% EF: Systolic heart failure
40-50% EF: CHF with borderline ejection fraction
>50% EF: Diastolic heart failure
56
Acute exacerbation of CHF
Causes: MI, infection, food change, under-medicated, atrial fibrillation, renal failure, hypertensive crisis, drugs, anything else that shocks the body
Dosing of Lasix: at least twice the dose of home dose. An IV dose is 2x as much as oral dose
Goal for discharge: 1-1.5L removed, best measured by daily weight changes but can also be monitored by input/output
Management of HFREF:
-Drugs to treat symptoms: diuretics, beta blockers (not during acute exacerbation), ACE inhibitors, ARBs, ARNI, hydralazine plus nitrate, digoxin, and aldosterone antagonists
-Prolongation of patient survival: beta blockers, ACE inhibitors, ARNI, hydralazine plus nitrate, and aldosterone antagonists.
Management of HFPEP: Treat underlying cause
57
Side effect of ACE/Arb
Hyperkalemia. Always order chemistry panel one week after starting an ACE or Arb to assess for hyperkalemia. ESPECIALLY if patient is on a diuretic which further increases risk of hyperkalemia
58
Difference between metoprolol tartrate and metoprolol succinate
Tartrate: short-acting - usually dosed as BID
Succinate: long-acting - usually dosed as once a day. Recommended for tx of heart failure
59
Difference in treatment for HFREF vs HFPEP
HFREF: Ace inhibitor, beta blocker, diuretic, aldosterone antagonist (if adequate renal function and without hyperkalemia), ICD for refractory heart failure
HFPEF: diuresis, BP control, prevention of tachycardia. NO BENEFIT to: ACE inhibitor, spironolactone is questionable
60
Lactated ringers
Hydrates, provides electrolytes, diureses, and reduces acidity
61
Definition of shock
Hypotension and organ damage
Hypotensive shock: excessive bleeding, dehydration
Cardiogenic shock: Anything cardiac related
Distributive shock: anaphylaxis, PE
Septic shock: sepsis
62
Atrial fibrillation
Common causes:
- Mitral stenosis
- Hypertension
- Cardiomyopathies
Treat for:
- to avoid thromboembolic issues (stroke, arterial emboli) - treat those at high risk (CHADs score >2)
- Other complications are due to tachycardia (RVR)
Treatment for rate:
- Beta blockers and calcium channel blockers act on the AV node so they affect heart rate but will also decrease BP
- Digoxin completely blocks the AV node to decrease HR
- Amiodarone stabilizes the heart - decreases HR and rhythm
63
Thrombocytopenia
Causes: decreased production, increased use (consumption in the body), or sequestration by the spleen
The patient can still have surgery with 50 count.
<10 is when we worry about intracranial hemorrhage
64
HIT
Herparin-induced thrombocytopenia - a risk of using heparin.
4T score can calculate pre-test probability for someone developing HIT
65
PERC score
Used to determine those at a LOW risk of PE and includes the following:
- Age <50 years
- Heart rate <100 beats/minute
- Oxyhemoglobin saturation ≥95 percent
- No hemoptysis
- No estrogen use
- No prior DVT or PE
- No unilateral leg swelling
- No surgery/trauma requiring hospitalization within the prior four weeks
66
Wells criteria
Used to determine someone who is at high risk for PE (>4) and includes the following:
- Clinical symptoms of DVT (leg swelling, pain with palpation) -3 pts
- Other diagnosis less likely than pulmonary embolism -3.0 pts
- Heart rate >100 -1.5 pts
- Immobilization (≥3 days) or surgery in the previous four weeks 1.5 pts
- Previous DVT/PE 1.5 pts
- Hemoptysis 1.0 pts
- Malignancy 1.0 pts
67
Fractionated sodium
Anything less than 2% indicates pre-renal cause.
Calculated by serum Na and Creatinine and urine Na and Creatinine
Use fractionated urea if patient is on Lasix (if low, they are not putting out much)
68
Hypocalcemia correction
Hypocalcemia needs to be corrected with albumin.
Normal albumin is 4.
For every 1 point drop in albumin, you add 0.8 to the calcium score
69
Non-anion gap metabolic acidosis
- Increased acid generation (lactic acidosis, ketoacidosis)
- Loss of bicarbonate (diarrhea)
- Diminished renal acid excretion (RTA)
70
"Flash" pulmonary edema
- dramatic form of ADHF, caused by an acute increase in left ventricular diastolic pressure from any of the following:
- myocardial ischemia
- acute severe mitral regurgitation
- hypertensive crisis
- acute aortic regurgitation
- stress-induced cardiomyopathy
71
Fluoroquinolones
Covers gram + and gram -
| Worry about QT prolongation and tendon ruptures
72
Cephalosporins
Covers some gram + and gram - and pseudomonas
| -can cross-react with penicillins
73
Macrolides
gram +, atypicals
74
Carbapenems
Broad spectrum
75
Astronium
gram - only, no cross reaction with penicillins
76
Amiodarone dosing
600mg daily for one week, 400mg daily for two weeks, then 200mg daily after for maintenance
77
Disseminated intravascular coagulation
Elevated D-dimer, thrombocytopenia, and increased coagulation studies
78
Workup of anemia
First obtain peripheral blood smear, then reticulocyte count.
-Retic count tells if bone marrow is intact. If it is low, then bone marrow is NOT intact. If it is high, bone marrow is intact but the body is using RBC somewhere else
79
Ventricular tachycardia
Causes:
- Electrolyte abnormalities (HYPERkalemia, HYPOcalcemia, HYPOmagnesia)
- A fib with bundle branch block
- Coronary artery disease with ischemia due to poor perfusion
- Medications (digoxin)
80
Paroxysmal ventricular contraction
Don't treat!
| If symptomatic, you can treat with beta blocker
81
TSH in elderly
Normal is higher because it adjusts upward with age
82
D-dimer with elderly
Normal is higher because it adjusts upward with age
| -Add 0 to your age and that's what d-dimer should be
83
How to interpret ECG
1. Rate: multiple bottom by 6 or count boxes (300, then 150, then 100, then 75, then 60)
2. Rhythm: Is it regular or no? Is there a p wave for every QRS?
3. Axis: Find isoelectric node and then perpendicular to that (use II for +/-)
4. Intervals: PR: <1 big box, QRS: <3 little boxes
5. Waves: Look at p wave in v1. If inverted, dipolar, or M - indicates left atrial enlargement. If TALL skinny M("peaked" called por pulmonale), then right atrial enlargement
6. ST segments: Are there elevations or depressions?
7. Bundle branch blocks:
- RBBB: Look at V1 and V6: V1 will have bunny ears, V6 will have big R and big S
- LBBB: V1 is W and V6 is M
84
Hemoglobin level at which we transfuse
7 but it is also case-based
85
Why use nitro drip over SL?
Nitro drip is less likely to cause hypotension.
86
Most common SE of nitro?
Headache from vasodilation of the brain
87
Treatment of NSTEMI
Needs to have full anticoagulation until cath
ASA + clopidigrel
Statin (stabilize plaque)
Nitro for chest pain (drip less likely to cause hypotension)
Ace inhibitor
Beta blocker
88
Level of magnesium that we try to maintain for cardiac stability
2
89
Level of potassium that we try to maintain for cardiac stability
4
90
When to use a straight cath
Urinary retention with bladder scan showing PVR >300mL. If unsuccessful, then use catheter
91
Score for major bleeding risk
```
HAS-BLED
hypertension
Renal disease
Liver disease
Stroke history
Prior major bleeding or predisposition
Labile INR
AGE >65
Medication that predisposes to bleeding
Alcohol use
```
92
Normal BP for age >65
150 systolic
93
Causes for acute encephalopathy
Infection (meningitis, encephalitis, sepsis)
Autoimmune encephalopathy
Trauma
Seizure (epileptic encephalopathy, post-ictal)
Toxins (drugs, heavy metal, CO)
Metabolic disturbances (uremia, increase in ammonia, glucose, lactic acid, electrolytes)
HTN (renal disease or heart disease)
Hypoxia encephalopathy (nearly drowning, prolonged resuscitation, vascular)
Hemorrhage (traumatic, spontaneous)
Malignancy (primary brain, metastatic)
Increased intracranial pressure/hydrocephalus
94
Blood glucose goals
Fasting and before meals: 80-130
1-2 hours post-meal: <180
Before bed: 100-130
Can be higher for patients having other chronic illnessss
95
Duration of abx for community acquired pneumonia
5 days
96
Treatment of CAP in hospital
Azithromycin 500mg loading dose followed by 250mg for five days total
Rocephin
97
How long does warfarin take to work?
48 hours
So you have to bridge with lovenox!
Bridging also prevents pro-thrombotic state during initiation of warfarin
98
Lab findings in DIC
All levels up besides fibrinogen.
| Factor 8 is made in endothelium so it will be normal in liver injury but low in DIC
99
Treatment of CAP
Augmentin!
100
Rhabdomyolysis
Elevated CK, blood(myoglobin) in urine, elevated AST/ALT
-Usually presents with hyperkalemia and hyperphosphatemia
Worry about kidney injury: myoglobin is toxic to tubules and also forms casts
Treatment is to flush out the kidneys
Treatment for hyperkalemia are fluids, diuresis, and potassium binders (Kayexalate)
101
Central pontine myolysis
Occurs from overcorrecting sodium too rapidly
| Symptoms: new neurological deficits, altered mental status
102
Causes of DKA
Infection, ischemia, insulin, intoxication
103
Insulin
Long-acting: Lantus (glargine), detimir, NPH
Short-acting: Lispro (Novolog), Novelin (regular insulin)
Dosing in hospital:
0.5units/kg insulin for the total day. Divide 50/50 between long and short acting
104
Prokinetic agents
Erythromycin, metoclopramide
105
Severe aortic stenosis
40: pressure gradient across valve
4: velocity across valve
0. 8/1: diameter of valve
106
Gram negative antibiotic coverage
```
Piperacillin-tazobactam
3rd generation cephalosporin
Impipenem
Fluoroquinolones (Cipro, levofloxacin)
Aminoglycosides (Gentamicin)
Bactrim
Aztreonam
```
107
Gram positive antibiotic coverage
```
ampicillin
piperacillin
early generation cephalosporins
fluoroquinolones
vancomycin
```
108
Anaerobic coverage
metronidazole
clindamycin
Zosyn (pip-tazo)
Unasyn (amp-sulbactam)
109
Hypertensive urgency cutoff
220/120
110
Hypertensive emergency treatment protocol
25% reduction MAP in 2-6 hours with drip
| Then switch to orals
111
HTN med for heart failure/CAD
Beta blocker, ACE inhibitor
112
HTN med for stroke
ACE and thiazide
113
HTN med for CKD
ACE/Arb except for not stage four
114
HTN med for diabetes
ACE/Arb especially If microalbuminuria
115
dihydropyridine CCB side effects
felodipine, amlodipine
| peripheral edema
116
ACEs/Arbs
Increase in creatinine
Increase in K+
Only ACE cause dry cough and angioedema through bradykinin
117
Thiazides
HCTZ and chlorthalidone
Decrease K+
Decrease urinary calcium to treat kidney stones
118
Beta blockers
Heart failure with reduced EF and CAD
| SE: Decreased HR
119
Aldosterone antagonist
Spironolactone and expleronone
Increase in K+
Gynecomastia
Uses: CHF class 3 or primary hyperaldosteronism
120
Combo dilators
```
Hydralazine (arterial dilator) can cause reflect tachycardia and drug-induced lupus
Isosorbide Dinitrate (venous dilator): should not be used with other nitrates or PDE5
```
Together: Bidell used in CHF
121
Alpha antagonists
Terazosin, doxazosin
Used for BPH
SE: orthostatic hypotension
122
Meds not to use for HTN
Clonidine - reflect hypertension
Non-dihydropyridine CCB such as verapamil and diltiazem - used for rate control for afib.
123
CAD spectrum definitions
Asymptomatic CAD:
-No pain, <50% occlusion
Stable angina:
- Pain with exertion, relieved with rest
- No heart damage so no biomarkers
- No ST changes
- 70% occlusion
Unstable angina:
- Pain with rest
- No heart damage so no biomarkers or ST changes
- 90% occlusion
NSTEMI
- Pain with rest
- Heart damage so elevated biomarkers
- No ST changes
- 90% occlusion
STEMI
- -Pain with rest
- Heart damage so elevated biomarkers
- ST elevation
- 100% occlusion
- Supply ischemia - NO supply of O2 so heart will die if not intervened
Stable angina, unstable angina, NSTEMI are demand ischemia - not total occlusion. If you decrease heart work load, you can get more O2 to heart and decrease sxs
Unstable angina, NSTEMI, and STEMI require hospitalization
124
Diamond classification of CAD
Substernal
Worse with exertion
Improved with nitro
3/3=typical
2/3=atypical
1/3
125
CAD Risk factors
```
Hypertension
Diabetes
Smoking
Hyperlipidemia
Obesity
```
Male >45
Female >55
Family history
126
Chest pain workup
ECG
If ST elevations - go straight to cath
If no ST elevations - obtain Troponin (peak first and last longer)
If elevated, go to cath urgently but not emergently
Then, is this coronary ischemia? Answer with stress test. If positive - go to cath electively.
127
Treatment for ACS
Morphine
Oxygen
Nitrates
Aspirin
```
BB
ACE-inhibitor
Statin
Heparin
Clopidogrel
```
Nitrates for someone with continued angina after initial episode.
If they get stent - you give clopidogrel
90 minutes to get cath
60 minutes to get TPA
128
Workup for CHF
BNP (may falsely elevate in ESRD)
Echo - systolic or diastolic
Left heart cath to determine if there is ischemia
129
Treatment of CHF by class
Class 1: No limitations
Class 2: No symptoms with ADLs
Class 3: Symptoms with ADLs
Class 4: Symptoms at rest
All get BB and ACE inhibitor
Class 2 and worse get diuretic
Class 3 and worse get isosorbide dinitrate or spironolactone
Class 4 near death, get inotrope like dobutamine
If EF <35% and NOT class 4, the patient gets AICD
If ischemic, get ASA and statin
Everyone: smoking cessation and fluid <2L/day, NaCl <2g/day
130
CHF exacerbation workup
CXR, BNP, ECG, Troponin
131
Treatment for CHF exacerbation
```
Lasix
Morphine
Nitrates
Oxygen
Position
```
132
Who HAS to be on a statin
1. Vascular disease
2. REALLY high LDL
3. LDL 70-189 with age 40-75 and DM
4. LDL 70-189, with age 40-75 and calculated risk (HTN, smoking, obesity, age, family history)
133
Statin strength and dose
High intensity: Atorvastatin 40, 80 or rosuvastatin 20, 40
Moderate: same as above but lower dose
Even lower are the others
134
Before you start statin
Obtain Lipids, A1c, CK, and LFTs for baseline
Lipids annually
A1c only if diabetic
Only recheck CK if myalgias
Only recheck LFTs if hepatitis
135
Cholesterol meds
Statin, lowers LDL, myositis and hepatitis
Fibrates lower total but increase HDL, myositis and hepatitis
Ezetimibe and bile resins, lower LDL, diarrhea
Niacin, lower LDL but raise HDL, flushing (prophylax with ASA)
136
Diagnosis of GERD
PPI and lifestyle modifications for six weeks
If no improvement, get ECG and biopsy
Patients with alarm symptoms (N/V, anemia, weight loss) go straight to EGD
137
Tx of GERD
Just GERD: PPI
Metaplasia to columnar epithelium: (barrett's), increase PPI
Dysplasia (precancer): PPI and local ablasion - radiofrequency ablasion, laser, or cryo
Adenocarcinoma - stage and resect
Meta and dys requires surveillance EGDs
138
Ulcerative colitis versus Crohn's
UC:
- 20-30 year-old
- Continuous lesions, only in the colon
- Biopsy: superficial with crypt abscesses
- Sxs: bloody diarrhea
- Cancer: Increased risk of colon cancer. Screening colonoscopy at year 8, then yearly
- Extra-intestinal: primary sclerosing cholangitis, and PNCA
- Surgery: Colectomy is curative
Crohn's disease:
-20-30 and 50-75
-Skip lesions, entire GI tract
-Biopsy: transmural, non-caseating granulomas
-Sxs: Watery diarrhea, multiple bowel movements per day and water loss
-No associatiation with colorectal cancer
-Extra-intestinal: Fistulas, If affecting the terminal ileum: B12 and fat issues. If affecting the duodenum: Irone deficiency and osteopenia
Surgery: Reserved for complications (fistulotomy, drain abscesses)
139
Treatment of IBD
Mild: 5-ASA compounds (Mesalamine) good for UC more than Crohn's
Moderate: Immunemodulators such as 6MP, azathrioprine, methotrexate, good for BOTH
Severe: Crohn's: TNF inhibitors (infliximab)
UC: surgical resection
With flare up:
- Rule out infection (C diff)
- Treat with prednisone
- Treat with antibiotics (cipro and metronidazole)
140
Chronic diarrhea causes
Diarrhea >4weeks (not infectious)
Secretory: high volume, just water
- Osmolar gap: normal
- Fecal WBC: none
- Fecal RBC: none
- Mucous: none
- Changes NPO: none
- Nocturnal sxs: yes
- Fecal fat: none
Osmotic/Malabsorption: something that can't be absorbed so water leaves cells into lumen
- Osmolar gap: elevated
- Fecal WBC: none
- Fecal RBC: none
- Mucous: none
- Changes NPO: yes
- Nocturnal sxs: none
- Fecal fat: + fat
Inflammatory
- Osmolar gap
- Fecal WBC: +
- Fecal RBC: +
- Mucous: +
- Changes NPO
- Nocturnal sxs
- Fecal
stool osmolar gap: measured osm (290) - 2*(Na+K)
- If number high, there isn't a lot of other stuff, then #<50 = secretory
- If number is low, there is more osmals, >100 = osmotic diarrhea
Usual suspects:
- Laxative
- Medications
- Lactose intolerance
- C diff
- Celiac sprue
141
Workup for chronic diarrhea
Fecal RBC, fecal WBC, stool osmol, fecal fat
Secretory: hormones, EGD with biopsy, C. diff
Inflammatory: colonoscopy
Osmotic: H&P, EGD and biopsy, dz-specific
142
VIPoma
Tumor that secretes VIP (tells intestines to go) = chronic diarrhea
Dx: VIP level
Tx: resection
143
Zollinger-Ellison syndrome
Gastrinoma which stimulates parietal cells to acid release which causes virulent PUD and diarrhea
Dx: Gastrin level
-If <250, you have ruled out
-If >1600, you have ruled in
-If in between, you get secretin stimulation test
If postitive, localize with somatostatin receptor sonography (SRS)
Tx: resection
144
Carcinoid syndrome
Tumor that secretes serotonin
Causes R sided heart fibrosis, flushing, and diarrhea
Dx: 5HIAA in urine, CT scan to stage
Tx: resection
145
PFT finding of obstructive lung disease
FEV1/FVC that is reduced
| -asthma or COPD
146
Treatment of asthma exacerbation
Oxygen to keep above 90%
Nebulizers (albuterol and ipratropium)
Assess peak expiratory flow rate
Go home: if peak expiratory flow rate is >70% - treat with inhalers and prednisone
Go to ICU if increased O2 demand, rising CO2, decreased lung sounds or PEFR of <50% - treat with ventilator, IV methylprednisolone, contin. nebulizers
-If patient still not better, can treat with racemic epi, subQ epi, and magnesium
Go to floor: Nebulizers that transition to inhalers and IV steroids that transition to oral. Eventually get spaced out
147
COPD pathophysiology
Loss of surface area of alveoli
-CO2 retention (no O2 exchange) so no hypoxemia
Increase AP diameter and prolonged expiration, breathing through pursed lips
=PINK puffers
148
Bronchitis pathophysiology
Inflammation of the airways
Decreased O2 = cyanosis
Decreased O2 in the lungs causes vasoconstriction which can cause pulmonary HTN and heart failure and edema
=BLUE BLOATERS
149
Treatment of COPD
```
SABA
Then SABA + LAMA (piotropium)
Then SABA + LAMA + LABA (do not need ICS to prescribe LABA)
Then SABA + LAMA+LABA+ICS
LAMA+LABA+ICS + PDE4 inhibitors
Then all above + oral steroids
```
Corticosteroids (ICS, PO, IV)
Oxygen (spO2<88% or PaO2 <55 with goal of spO2 88-92%)
Prevention: vaccines (flu, pneumococcal), smoking cessation
Dilators (short acting, long acting, orals)
E-
Rehab
150
Treatment of asthma
```
SABA
SABA+ICS
SABA+ICS+LABA
SABA+higher dose ICS+LABA
then all above +Oral steroids
```
Must have ICS before you prescribe LABA
151
Treatment of COPD exacerbation
Order CXR, ABG, and ECG
Tx: abx (doxycycline, azithromycin)
Bronchodilators (albuterol, ipratropium) q30minutes
Steroids: PO - prednisone, IV=methylprednisolone
152
Screening for colon cancer
Age >50
Colonscopy q10
sigmoidoscopy q5 with FOBT q3
FOBT or FIT q1
153
Screening for lung cancer
Age 55-80
30pyear history
quit <15 years ago
Low dose CT scan
154
AAA screening
Men
>65
Smoking history
With one-time ultrasound of abd (but CT works)
155
Osteoporosis screennig
Women
>65
DEXA scan
Treat with bisphophonates (Vitamin D and calcium should be PROPHYLACTIC)
156
Hep C screening
```
Baby boomer (1945-1965)
Hep C antibody
```
157
HIV screening
Everyone once and those with risks, with ELISA
158
Hypertension screening
Everyone, every visit
| Best way is ambulatory monitoring
159
Diabetes screening
Those with HTN
| A1c
160
Hyperlipidemia screening
Men >35 or >20 with CAD risk factor
Women >45 or >20 with CAD risk factor
Lipid panel
161
Depression screening
PHQ-9
162
Mobility screening
Get up and go
163
Abx for community acquired PNA
Hospital: ceftriaxone and azithromycin
Home: Oral version of azithromycin
Moxi = IV or PO (always wrong on test)
164
Abx for hospital acquired pneumonia
Covering for MRSA and pseudomonas
| Hospital: Vanc and pip/tazo
165
Abx for meningitis
ceftriaxone, vancomycin, +/-steroids, +/- ampicillin
166
Abx for UTI
```
Amoxicillin - pregnant
Nitrofurantoin - woman
Bactrim - no renal failure
Ceftriaxone - hospitalized pyelo
Cipro - ambulatory pyelo
```
167
Abx for cellulitis
Vancomycin in hospital because assume MRSA
| Can use Clinda or Bactrim
168
Community acquired pneumonia organisms
```
Strep pneumo
Moraxella
H flu (COPD, smoke)
Klebsiella (EtOH)
Staph aureus (post-viral)
Legionella (immunosuppressed)
```
Treat with ceftriaxone and axithromycin OR moxifloxacin
169
Hospital acquired pneumonia organisms
Within 90 days of exposure to hospital or after 48 hours of being in hospital
Pseudomonas
MRSA
Tx: Vanco and pip/tazo
170
Treatment of lung abscess
Ceftriaxone and clindamycin
171
PCP
HIV AIDS CD4 ct <200
Sputum silver stain
Tx: Bactrim +/- steroids (hypoxemic or low PaO2)
172
When to admit for PNA
CURB 65 or PSI
173
What makes cystitis complicated?
Pyelonephritis
Penis
Plastic (foley catheter)
Procedure
174
Treatment of different types of cystitis
Uncomplicated - 3 days
Complicated - 7 days
Pyelonephritis - 10 days
Perinephric abscess - 14 days
175
Urethritis
```
STD: Gonorrhea, chlaymdia
Presents with discharge
Dx: GC/Chl swab or urine
Tx: ceftriaxone x1 IM + azithromycin x 1PO or doxy x7 days
Screen for HIV
```
176
Asymptomatic bacteriuria
Gram negative rods and GBS
Screened in pregnant and those undergoing urologic procedure
Pregnancy: treat with amoxicillin.
Repeat screen for test of cure
177
Treatment of pyelo
IV: ceftriaxone
PO: Cipro
Patient with pyelo that does not improve - worry about perinephric abscess (CT or US).
Tx: continue abx for 14 days and I&D
178
Treatment of cellulitis
Strep: cephalexin (Keflex)
Staph: Bactrim, clindamycin
TOXIC
Strep: Pip/tazo, amp/clavulonate
Staph: Vanc, linezolid, Clinday
179
Osteomyelitis
Caused by hematogenous spread or direct wound inoculation
Pt usually has wound where you can probe the bone or recurrent cellulitis
Dx: 1st XR. If negative, MRI. Best test is bone biopsy
Tx: debridement, 4-6wks of abx
180
Gas gangene
C. perfringes
Pt: penetrating wound contaminated with crepitus
Dx: 1st XR that shows gas
Tx: debridement, penicillin + clinda
181
Necrotizing fasciitis
Strep and staph
Pt presents with cellulitis, super sick, rapidly spreading or abx doesn't help, pain out of proportion or crepitus
Blue-gray discoloration
Dx: XR that shows gas
Tx: surgical debridement, ceftriaxone, clinda, amp
182
Most common bug to cause osteomyelitis
staph aureus
If sickle cell - salmonella
If penetrating wound - pseudomonas
If diabetic foot - polymicrobial (cover for pseudomonas)
If oyster/cirrhotic, think vibrio fulmificus
If gardening - sporothrix
183
AAA
Caused by atherosclerosis
usually asymptomatic finding on imaging for another reason (may be tender mass with back pain)
Tx: >3.5 requires yearly screening
>4.5 requires screening q6 months
>5.5cm OR >0.5cm growth in 6 months requires surgery
184
Aortic dissection
Caused by HTN
Tearing chest pain that radiates to the back
Asymmetric BP between arms
Widened mediastinum on CXR
Dx: CT angiogram is best. TEE is equivalent to MRI if can't do angiogram
Type A: right next to heart. Needs operation. May need aortic valve replacement.
Type B: past arch. Medically with IV beta blockers
185
Anterior shoulder dislocation
Any trauma
Abduction, external rotation
Axillary nerve might be affected causing deloid paresthesias
Relocate and sling
186
Posterior shoulder dislocation
significant trauma
Abduction, internal rotation
Relocate and sling
187
Colles' fracture
Older lady
Osteoporosis
Breaking fall with outstretched wrist
Broken radius and ulna, dorsally displaced\
188
Monteggia fracture
Blocking upward from downward blow.
| Item strikes ulna, breaking ulna and displacing radius
189
Galezzia
Downward block from upward blow
| Item strikes radius, breaking radius and displacing ulna
190
Scaphoid fracture
Fall on outstretched hand
Pain at anatomic snuffbox
XR normal on day 1
Cast anyway due to vascular compromise
191
Boxer's fracture
Punch against wall
| 4th and 5th digits break
192
Hip fracture
A lot of trauma or old lady with osteoporosis
Shortened and externally rotated
If there is fracture of femoral head - need to do prosthesis
193
EtOH intoxication
Alcoholic beverages
No anion gap
Osmolar gap
Supportive
194
Isopropyl alcohol
Rubbing alcohol
No anion gap
Osmolar gap
Supportive
195
Ethylene glycol
Anti-freeze (causes renal failure)
Anion gap
Osmolar gap
Prevent breakdown to toxic metabolites with fonepizole or EtOH
196
Methanol
"Moonshine" can lead to blindness
Anion gap
Osmolar gap
Prevent breakdown to toxic metabolites with fonepizole or EtOH
197
Acetaminophen toxicity
AST, ALT >1000
Dx: Acetaminophen level 4 hours and 16 hours after ingestion
Tx: N-acetylcystine
198
Salicylate toxicity
Aspirin
Early: tinnitus, n/v, vertigo, respiratory alkalosis
Late: AG acidosis, obtunded in coma, hyperpyrexia
Dx: Salicylate level
Tx: Alkalinization of urine and diuresis
199
Carbon monoxide toxicity
```
Smoke inhalation with HA, n/v, delirium
Affinity for hemoglobin greater than O2. O2 delivery is compromised
Pulse ox = 100%
Dx: ABG for carboxy hemoglobin
Tx: 100% FiO2 and possibly hyperbarics
```
200
Cyanide toxicity
Nitroprusside, smoke inhalation
Super sick, cherry red skin or cherry red blood
Dx: clinically
Tx: thiosulfate
201
Organophosphate toxicity
```
Weapons of terror
Pesticides
Myasthenia gravis medications
Block Ach-esterase
Salivation
Lacrimation
Urination
Defication
GI upset
Emesis
Dx: clinical
Tx: Atropine and pralidoxime
```
202
Symptoms of bipolar disorder
```
E + 3 of following
>1 week
Distractibility
Insomnia
Grandiosity
Flight of ideas
Agitation/activities
Sexual exploits
Talkative
Elevated mood
Racing thoughts
```
203
Treatment of anorexia
Anti-psychotic (and CBT) unless associated with OCD, MDD in which case you'd treat with SSRI or SNRI
204
Treatment of bulemia
SSRI/SNRI (and CBT)
| NEVER buproprion
205
Symptoms of depression
```
>2 weeks
Need 5 of following:
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor retardation
Suicide
```
206
Screening for substance use disorder
Cut down
Anger
Guilty
Eye opener
```
For adolescents:
Car
Relax
Alone
Friendships
Forget
Trouble
```
207
Stages of change
```
Pre-contemplative - denial
Contemplative - acceptance
Preparation - first steps
Action -actual behavior change
Maintenance - sustain behavior change
```
208
Difference between nightmares and night terrors
Nightmares: dreams gone bad. REM so no tone, easy to wake up and remember
Any age
No treatment
Night terrors: Non-REM,
active behaviors while asleep
Tone, doesn't remember
Child - will outgrow
209
Insomnia
Trouble falling asleep or sleep <6 hours per night
```
Tx: Sleep hygiene
If not helpful, then:
Diphenhydramine
Trazodone
Quetiapine
Zolpidem - last resort
```
210
Protocol for anti-depressants
Use one med at one dose for six weeks before making adjustments
Treat at least six months at effective dose
Give at least six weeks for washout before starting next med
Combo of therapy and meds are best!
211
SSRIs
Escitalopram
Fluoxetine
Paroxetine
Sertraline
SE: sexual dsyfunction
decreased libido
prolonged ejaculation
212
SNRIs
Desvenlafaxine
Duloxetine
Cleaner but more expensive
213
Atypical antidepressants
Buproprion
Smoking cessation without weight gian
Do not use in bulemia because decreased seizure threshold
214
Serotonin modulators
Mirtazapine - sleep aid and appetite stimulant
| Trazodone - sleep aid (can cause priapism)
215
Tricyclic antidepressants
Triptylines, imipramine and doxepin
Treat enuresis
Mostly used in neuropathic pain
SE: convulsions, cardiac toxicity, and coma
216
MAOIs
Selegeline
Phenylzine
Causes hypertensive emergency especially when eating wine or cheese (increase in tyramine)
217
Typical antipsychotics
Work by inhibiting D2 receptors
Block D2 in mesolimbic: decreased POS symptoms
Block D2 in nigrostriatal: EPS
Block D2 in tubuloinfundibular: gynecomastia, galactorrhea, ammenorrhea
Acetylcholine SE: dry mouth, urinary retention
Haloperidol, fluphinezine, chloridiazine, chlorpromazine
218
Atypical antipsychotics
```
D2 antagonism and Serotonin antagonism
Quetiapine - sleepy
Olanzapine - weight gain, DM
Risperidone - EPS
Aripiprazole
Ziprasidone
Clozapine - BEST but last resort 2/2 agranulocytosis
```
QT prolongation and EPS
219
Development of female puberty
Breasts 8
Axillary hair 9
Growth 10
Menarch 11
220
Causes of precocious puberty
Tumor that secretes FSH/LH in anterior pituitary
Ovarian cyst (granulosa-theca that secretes estrogen or sertoli-lydig that secretes testosterone)
Congenital adrenal hyperplasia or tumor that secretes DHEA or testosterone
221
Workup for precocious puberty
Bone age. If 2 year younger than age then:
GnRH stim test. (Leuprolide)
If it stimulates LH then axis is working and it is central process. Follow with MRI. If tumor - resect. If no tumor, then it is constitutional. (Treat with continuous leuprolide to delay puberty so growth is not stunting)
If stim does NOT change LH, then there is peripheral lesion - US of abdomen (adrenals), US of ovaries, test for DHEAS and testosterone, 17OH progesterone to look for CAH.
CAH (treat with steroids)
Tumor (resect)
222
Delayed puberty workup
No secondary sex characteristics by 13 or no bleeding by 15
Get bone age and FSH/LH
If FSH/LH are increased: hypergonadotropic - usually due to karyotype
If FSH/LH are not elevated: hypogonadotropic (prolactin, TSH, urine pregnancy, CBC, LFT, EFR, MRI to rule out lesion)
If everything is negative, this is constitutional delay. Just wait - no need for growth hormone!
223
Workup for infertility
Male first
Mucous smoosh test. If abnormal, treat with estrogen or artificial insemination
Then check if she's ovulation with basal temp, blood progesterone, endo biopsy, or OTC urine LH. If anovulatory - treat with clomiphine
If normal, then do hysterosalpingogram to assess for structural abnormalities.
if normal, do laparoscope to look for endometriosis (tx with laser ablation, OCP, estrogen)
