General Flashcards
Vulvovaginal Candidiasis Presentation
Thick, whitish discharge that has no odor
Significant pruritis of external and internal genitalia
Vaginal area can be edematous with erythema
Discharge has pH 4.0-5.0
Protocol for newborn with HBV+ mother
HBV vaccine + Hepatitis B immune globulin within 12 hr birth Dose 2 @ 1-2mo Dose 3 @ 6 mo If hepatitis status of mother is unknown, give vaccine @ birth, test mother, and if positive give IG within 7d.
COPD with FEV1 50-80%
Stage 2 (Moderate COPD) Long-acting bronchodilators
Lesion? Causes?
“Ringworm” = Trichophyton rubrum or Tinea tonaurans, T mentagrophytes, M canis
Well demarcated plaque with central scaling, usually pruritic.
PNA tx for hospitalized patient NOT in ICU
Beta-lactam (Piperacillin/tazobactam, cefepime, imipenem, or meropenem) + fluoroquinolone (levofloxacin, moxifloxacin) OR aminoglycoside
Centor Criteria for Rapid Strep Test
Patient gets one point for each of the following:
- absence of cough
- enlarged/tender anterior cervical adenopathy
- fever of at least 100.4F
- tonsillar exudates
- pt age 3-14 yr
- Deduct a point for age of 45 or higher
0-1 Points = no further testing and no abx indicated
2-3 points = perform rapid strep or throat culture and tx with antibiotic if positive
4+ points = consider empiric abx
Spermatocele
Asymptomatic nodules, generally found attached to the spermatic cord.
No further tests needed unless diagnosis remains unclear, then can use US.
Sleep aid for transient sleep onset problems?
Zolpidem (ambien) Eszopiclone (Lunesta)
Outpatient PNA treatment
Macrolide (clarithromycin or azithromycin)
OR
Doxycycline
Follow up 3-4d to assess response to therapy
Treatment options for abdominal pain in IBS
Antispasmodics: dicyclomine & hyoscyamine
Low-Dose TCAs
SSRIs if comorbid depression or anxiety
Rifaximin of NO constipation symptoms
Probiotics & peppermint oil
Laryngitis + Pharyngitis?
Most commonly viral in nature and only supportive care is needed.
Outpatient PNA treatment for patient with comorbidities
Fluoroquinolone (levofloxacin, moxifloxicin))
OR
Beta-lactam (amoxicillin, amoxicillin-clavulunate, cefpodoxime, cefuroxime) + macrolide
Symptoms of Alcohol Withdrawal
<12 hour: insomnia, tremors, anxiety, GI upset, diaphoresis, headache, palpitations
12-24 hr: visual, auditory, or tactile hallucinations
24-48 hr: generalized tonic-clonic seizures
48-72 hr: DTs (hallucinations, tachycardia, fever, HTN, etc…)
Hypovolemic Hyponatremia Common Causes
(Urinary Na < 20 mEq/L)
Cerebral Salt Wasting
Skin loss
Diuretic use
GI losses
Mineralcorticoid deficiency
COPD-cough, sputum production, normal spirometry
Stage 0 (At Risk)
Vaccines Address risk factors: smoking, occupational exposure, smoke from cooking/heating fuel
Headache that begins after age 50 y/o especially with jaw pain on chewing
Differential:
- Temporal arteritis
- Mass lesions
Workup:
- neuroimaging
- ESR
Side Effects of Phenothiazines Antiemetics (compazine and phenergan) and tigan?
Drowsiness
Dry mouth
Dizziness
Symptoms of opioid withdrawal
Muscle cramps & arthralgias
Anxiety
Vomiting & diaphoresis
Piloerection
Lacrimation and rhinorrhea
Elevated BP
Insomnia
Scoring Criteria for Risk of Ischemic stroke in First 7 Days after TIA
ABCD2 Criteria
Age ≥ 60 (1 point)
BP ≥ 140/≥90 (1 point)
Clinical Features
- Unilateral Weakness = 2 points
- Isolated speech disturbance = 1 point
- Anything else = 0 points
Duration
- ≥ 60 min = 2 points
- 10-59 min = 1 point
- < 10 min = 0 points
Diabetes = 1 point
Scoring System
Score 0-3 = Low risk
Score 4-5 = moderate risk (`4%)
Score 6-7 = high risk (8 %)
Prophylactic Tx of Cluster Headaches
CCB-nifedipine
Indomethacin
Prednisone
Lithium
Note: to be used only during the attack period
Hypernatremia Common Causes
High Urine Osm (>400 mOsm/kg): Excessive sweating, GI losses
Low Urine Osm (<300 mOsm/kg): Diabetes Insipidus
ACA Stroke Sx
Lower extremity deficits
Cognitive or personality changes
Trichomoniasis Presentation
Thin, frothy, green-yellow or gray malodorous discharge
Vaginal soreness or dyspareunia
Sx/ may be exacerbated during menses
Cervix can have “strawberry” appearance (erythematous with punctuation) or redness of the vagina and perineum
Who should receive imaging for neck pain?
ONE HIGH-RISK FACTOR: age > 65, dangerous mechanism of action, or numbness/tingling in extremities
IS THERE A LOW RISK FACTOR? Simple rear-end collision, patient ambulatory at scene, absence of neck pain at scene, absence of c-spine tenderness (if no to any of these, need imaging).
CAN PT ACTIVELY ROTATE NECK 45 DEGREES TO L AND R, regardless of pain. (“No” requires imaging)
Characteristics that make palpitations more likely to be cardiac in origin?
Male
Description as “irregular heartbeat”
Personal hx of heart disease
Event duration > 5 min
Iron Deficiency Tx
Oral ferrous sulfate @ 325mg (65mg elemental iron) TID for ~6-8wk
Pt with malabsorption, CKD, HF, or significant blood loss may need IV iron
Oral Herpes Tx
Topical antiviral
Chronic suppression can decrease frequency of symptomatic recurrence and asymptomatic viral shedding
Treatment for mild acne
Topical antibiotics + Benzoyl peroxide gel + topical retinoids
Improvement occurs over 2-5 months
Apply topical retinoids at night and topical antibiotics and benzoyl peroxide gel in the day
Fever 1-4wk post-op
Infectious
- SSI
- C-Diff
- Cather-related infection
- Device-related infection
- Abscess
Non-infectious:
- Med toxicity
- DVT/PE
- Thrombophlebitis
Symptoms of tobacco withdrawal
Headaches
Irritability, depresison, anxiety
Cognitive & attention deficits
Sleep disturbances
Increased appetitie
Trichomonias Treatment
Oral metronidazole given in single 2g oral dose
1 week of 500mg BID metronidazole for both and partner
Involvement of GI tract in Crohn Disease vs. Ulcerative Colitis
CROHN DISEASE: extends from mouth → anus (mostly ileum and colon), skip lesions, rectum usually spared ULCERATIVE COLITIS: always involves rectum with continuous lesions
Treatment for PID
Outpatient management: ceftriaxone 250mg IM + doxycycline 100mg BID for 14d +/- metronidazole 500mg BID for 14d
If patient is pregnant, presents with fever and vomiting, or if surgical intervention cannot be ruled out, should be treated inpatient.
Acral Letiginous Melanoma
Most common melanoma in African Americans and Asians
Flat, irregular, dark-brown or black lesions that occur on the palms, soles, and under nails
HTN Tx in nonblack patient >60 y/o
CCB
Thiazide diuretic
ACE inhibitor/ARB
Ottowa Knee Rules
- Age 55 or older
- Isolated patella tenderness
- Tenderness of the head of the fibula
- Inability to flex the knee to 90 degrees
- Inability to bear weight for 4 steps immediately and in the exam room
Clinical Manifestations of Crohn Disease vs. Ulcerative Colitis
CROHN DISEASE: diarrhea, only bloody if colitis
ULCERATIVE COLITIS: bloody diarrhea
Prehn Sign
Testicular pain relieved upon elevation of the testicle while the patient is supine.
COPD with FEV1 < 30%
Stage 4 (Very severe COPD) Long-term O2 therapy Possible surgical intervention
Lesion? Treatment?
Tinea capitis
Systemic therapy necessary for cure
- Griseofulvin 4-8wks (1st line)
- Fluconazole 3-4wk
- Can also use terbinafine, itraconazole, fluconazole, and ketoconazole
Topical ketoconazole shampoo or selenium sulfide lotion may kill spores on hair.
Rosacea Treatment
First line = oral antibiotics like minocycline and doxycycline
Can also use topical metronidazole, antibiotics, and sodium sulfacetamide
Treatment for sleep Maintenence problem?
Zaleplon (Sonata)
Rome Criteria for IBS
Recurrent abdominal pain or discomfort at least 3d/month for the past 3 months with at least 2 or more of the following…
- Improvement with defecation
- Onset associated with change in frequency of stool
- Onset associated with change in form (appearance) of stool
Primary amenorrhea evaluation in pt with secondary sex characteristics
- Labs: pregnancy test, TSH, prolactin
- Progestin challenge
- If no withdrawal bleeding from progestin, do estrogen-progestin challenge to distinguish inadequate estrogen production from outflow tract obstruction
Causes of fever intra-operatively up to 24 hr after surgery
Infectious:
- Preexisting infection
- Bacteremia from urologic procedures
- Intraperitoneal leak (up to 36 hr)
- Invasive soft-tissue infection
- TSS
Non-infectious:
- Surgical trauma
- Meds
- Blood products
- Malignant hyperthermia
Treatment for Lyme Disease
EARLY LOCALIZED DZ: amoxicillin or doxycycline for 2-3wk
EARLY DISSEMINATED DZ: IV ceftriaxone or cefotaxime + chloramphenicol for 2-3wk
Common causative organisms of epididymitis?
Sexually active men < 35 y/o = N. gonorrheae or Chlamydia (less commonly d/t ureaplasma or mycoplasma)
Monogamous men > 35 y/o = Enterobacter in association with prostatitis
Amelanotic Melanoma
Non-pigmented melanoma —> often missed or confused for eczema, SCC, fungal infection, etc…
2nd line treatment for rhinosinusitis
Amoxicillin-clavulanic acid, 2nd or 3rd gen cephalosporin (cefuroxime, cefaclor, cefprozil), fluoroquinolones, or 2nd gen macrolides (azithromycin, clarithromycin)
Use one of these if patient failes initial regimen or have recurrent or severe dz
COPD with FEV1 ≥ 80%
Stage 1 (Mild COPD) Short-acting bronchodilators
7-Valent Pneumococcal Vaccine (PCV7)
Usual Schedule = one dose @ 2, 4, 6, and 12-15 months All healthy children 24-59 months who have NOT completed their primary immunizations for PCV7 should get one dose
Causes of fever 1d-1wk post-op
Infectious:
- UTI
- PNA
- SSI
- Cather-related infection
- Cellulitis
- Viral URI
- Pre-existing infection
Non-Infectious
- Acute MI
- Alcohol/drug withdrawal
- Gout
- Pancreatitis
- PE/DVT
- Benign post-op fever
Common description of ventricular premature beats?
“Flip-flopping” in chest
Random, episodic, and instantaneous
Nodular Melanoma
Most aggressive melanoma, 2nd most common Often black but can also be brown, blue, tan, or red
Imaging in Legg-Calve-Perthes Disease
Early on x-rays may be normal but as diseae progresses can get collapse, flattening, and widening of femoral head
Hypokalemia Presentation
Fatigue, muscle aches
ascending muscle weakness or cramps
Rhabdo
EKG Changes: U waves, ST depression, flattened T-waves
Side effects of reglan?
Prokinetic → diarrhea and extrapyramidal reactions
Spurling Test (aka Neck Compression Test)
Requires patient to bend his/her head to the side and rotate the head toward the side of pain, while the examiner exerts downward pressure.
Will reproduce upper extremity symptoms in patient with nerve root injury (high specificity but low sensitivity for cervical radiculopathy)
IF maneuver causes discomfort only, likely mechanical pain
Headahce with sudden onset, max severity, or new/different headache?
Differential:
- SAH
- Pituitary apoplexy
- Hemorrhage into mass lesion or vascular malformation
- Mass lesion
Workup:
- Neuroimaging
- LP if neuroimaging negative
Labs for limp w/pain in Child
CBC if concern for malignancy, inflammatory arthritis, or infection
ESR + CRP if infectious or rheumatologic cause suspected
ASO titer if recent pharyngitis
Chlamydia & ghonorrhea titers if sexually active
Metabolic Syndrome
3 or More of the Following…
- Waist circumference > 102 cm (M) or 88cm (F)
- Hypertriglyceridemia (>150 mg/dL)
- Low HDL: <40 (M) or <50 (F)
- Fasting plasma glucose > 100 or diagnosed T2DM
Characteristics of neck pain d/t osteoarthritis or spondylosis?
Pain aggravated by movement
worse after activities
associated with a dull-ache
limited ROM
Microscopy in Crohn Disease vs. Ulcerative Colitis
CROHN DISEASE: noncaseating granulomas ULCERATIVE COLITIS: no granulomas
B12 Deficiency Treatment
1000 ug IM daily for 7 days —> weekly for 4 wk —> monthly for lifetime
1000-2000 ug PO in similar regimen
Cerebellum stroke sx
Ipsilateral imb and gait ataxia
Diagnostic Criteria for Bacterial Vaginosis
Three out of four…
- Thin, homogenous vaginal discharge
- Vaginal pH > 4.5
- Positive KOH “whiff” test (fishy odor on KOH prep)
- Presence of clue cells in wet mount
Side effects of Zofran?
Serotonin antagonist → dizziness and headache
Psoriasis Treatment
Topical corticosteroids
Topical pimercrolimus if located in perinatal and genital regions, face, or ear canals
For systemic/generalized psoriasis can use MTX or retinoids
Headache that is increasing in severity and frequency, brought on by valsalva or physical exertion
Differential:
- Mass lesion
- Subdural hematoma
- Medication overuse
Workup:
- Neuroimaging
- Drug screen
Cervical dystonia (torticollis) treatment?
Botulinum toxin
Major vs. Intermediate Clinical Predictors for Preop Cardiac Evaluation
MAJOR CLINICAL PREDICTORS: (need coronary evaluation prior to surgery): unstable coronary syndromes, decompensated CHF, arrhythmia, severe valvular disease
INTERMEDIATE CLINICAL PREDICTORS: (determine functional capacity) mild angina, prior MI, compensated CHF, DM, renal insufficiency
Testicular pain with absent cremaster reflex AND positive prehn sign?
Epididymitis
Hernias
Orchitis
Cancer
Most likely cause of pancreatitis with elevated ALT?
Gallstones
CCB that can be used for migraine prophylaxis? (Not first line)
Verapamil
Ottowa Ankle Rules
- Bony tenderness of the posterior edge or tip of the distal 6 cm of either the medial or lateral malleolus
- Tenderness in the midfood coupled with point tenderness over the bony aspects of base on 5th metatarsal or the navicular
- Unable to bear weight
Pharmacology for stimulant withdrawal
Metylphenidate
Propranolol
Desipramine
Bupropion
COPD with FEV1 30-50%
Stage 3 (Severe COPD) Inhaled steroids
Antibiotics indicated for diarrhea
Ciprofloxacin 500 mg BID for 3d
Azithromycin in single 1000 mg dose in adults or 10mg/kg in kids for 3 days
Noninvasive E coli can use rifaximin (200 mg TID for 3 days)
Septic arthritis in infants and toddlers?
Usually associated with systemic signs like fever; child will often lay with their hip abducted and externally rotated to reduce pain
Elevated ESR, WBC, and CRP
Kids < 4 mo = GBS or staph
Kids < 5yr = Staph or Strep pyogenes
Hypervolemic Hyponatremia Common Causes
HF
Cirrhosis
Nephrosis
Kocher Criteria for Risk of Septic Arthritis
Criteria:
- Fever > 101.3
- Non-weight bearing
- ESR > 40
- WBC > 12,000
1 criteria = 3% chance
2 criteria = 40% chance
3 criteria = 93% chance
Hyperkalemia Causes
Meds: ACE inhibitors, ARBs, potassium-sparing diuretics
Intracellular Shifts: acidosis, insulin deficiency, burns
Reduced renal excretion: insufficiency, Addison’s disease, RTA IV
Clinical presentation of uterine leiomyoma?
Usually asymptomatic
Can cause low midline pressure and menorrhagia or metorrhagia.
Who should get statin therapy?
- Pt 21-75 y/o with clinical CVD
- Pt >21 y/o with LDL cholesterol ≥ 190
- Pt 40-75 y/o with diabetes and LDL ≥ 70
- Pt 40-75 y/o with a 10yr CVD risk ≥ 7.5% and LDL ≥ 70 mg/dL
Vertebrobasilar stroke Sx
Motor or sensory loss in all 4 extremities
Crossed signs
Disconjugate gaze
Nystagmus
Dysarthria
Dysphagia
HTN tx in African American Pt
CCB
Thiazide diuretic
Superficial Spreading Melanoma
Spreads superficially before moving vertically
Most commonly occurs on the legs in women and torso in men
Raised borders and brown lesions w/whites, greys, pinks, or blues
Treatment for constipation-predominant IBS
Soluble fiber
Polyethylene Glycol
Lubiprostone (Amitiza) = selectively activates chloride channels
Linaclotide = stimulates cGMP production to increase motility and fluid secretion
Intussusception
2nd most common cause of GI bleed in children (Meckel’s diverticulum is #1)
Will present with abdominal pain, vomiting, bloody stool, and palpable “tube-like” mass in abdomen
MCA Stroke Sx
Aphasia if dominant hemisphere
Contralateral hemiparesis
Sensory loss
Spatial neglect
Contralateral impaired conjugate gaze
1st Line Tx Rhinosinusisits
Amoxicillin or Bactrim for 10-14d
Symptoms of stimulant withdrawal
Paranoia
Depression, anxiety, irritability
Somnolence
Pyschomotor retardation
Increased appetite
Lentigo Melanoma
Least common overall, but most common in Hawaii
Most common in elderly on sun-damaged skin.
Tan or brown lesions with irregular borders
Gross appearance in Crohn Disease vs. Ulcerative Colitis
CROHN DISEASE: transmural inflammation with linear mucosal ulcerations, cobblestoning, and creeping fat
ULCERATIVE COLITIS: mucosal & submucosal inflammation, pesudopolyps
Common causes of limp WITHOUT pain in child
- Congential dislocation of hip
- Spastic hemiplegia (CP)
- Legg-Calve Perthes
- Leg-length discrepancy
- Proximal focal femoral dysplasia
- Congenital bowing of the tibia
Treatment for IBD
Antidiarrheal meds
Anti-inflammatory meds: aminosalicylates (sulfasalazine), corticosteroids
Immunosuppressive agents
Definitive tx for UC = colectomy
Transient Synovitis in Young Kids
Self-limited inflammatory response that is a common cause of hip pain in kids 3-10 y/o after viral infection
Presentation = gradually increasing hip pain with limp or refusal to walk, low grade or no fever, normal WBC and ESR. Xray is normal or shows moderate swelling.
Common presentation of ovarian cyst?
Unilateral dull pain that can become diffuse & severe if the cyst ruptures.
On physical exam, will feel a smooth, mobile adnexal mass with peritoneal signs if the cyst has ruptured.
Intestinal manifestations of Crohn Disease and Ulcerative Colitis
CROHN DISEASE: fistulas, strictures → bowel obstruction, and abscesses
ULCERATIVE COLITIS: toxic megacolon
HTN Tx in nonblack patient <60 y/o
ACE inhibitor/ARB
Thiazide diuretic
CCB
Diverticulitis Tx
Bowel rest Metronidazole + quinolone
Primary Amenorrhea
Absence of menses at 16 y/o in the presence of normal secondary sex characteristics or absence of menses at 14 y/o in the absence of secondary sex characteristics.
Most common cause = gonadal dysgenesis
Hypokalemia Causes
Decreased net intake
Intracellular Shifts: alkalosis, excess insulin
Renal losses
Extra-renal losses
Rosacea
Stage 1 = persistent erythema often with telangiectasias
Stage 2 = papules & tiny pustules
Stage 3 = Erythema that is deep and persistent with dense telangiectasias and sebaceous hyperplasia and lymphedema
Hypernatremia S/Sx
Anorexia
Muscle Weakness
N/V
Lethargy
Euvolemic Hyponatremia Common Causes
SIADH
Hypothyroidism
Water intoxication
Low solute intake
RTA
Most likely cause of n/v that occurs in the morning before eating?
Pregnancy
Alcohol withdrawal
Increased ICP (meningitis, space-occupying lesions)
Fever > 1 month after surgery
Infectious:
- Blood-transfusion related infection: viral, parasite, etc…
- Infective endocarditis
- Post-pericardiotomy syndrome
- SSI
- Device-related infection
- Vascular graft infection
Non-infectious
- Post-pericardiotomy syndrome
Pharmacology for opiod withdrawal
Methadone
Buprenorphine
Naltrexone
HTN Tx in pt with hx of CAD
beta-blocker
ACE inhibitor/ARB
Vulvovaginal Candidiases Treatment
Uncomplicated: short term intravaginal preparations or single dose oral therapy (fluconazole 150mg)
Keratocanthoma characteristics
May look similar to basal cell carcinoma or nodular SCC, it has much more rapid growth, achieving size of 2.5cm within a few weeks
Thyroid Hormone Dosing
Healthy, non-pregnant adults require ~1.6 ug/kg daily
In patients >50 y/o start with a dose 25-50 ug daily and increase by 25 ug ever 3-4 weeks until optimal dose is reached
In pregnant pt may need up to 30% more than normal
Follow up with TSH Q4-6 weeks initially
Treatment for Diarrhea-Predominant IBS
Loperamide to reduce frequency of loose stools an decrease urgency
Rifaximin = gut bacteriostatic
Alosetron for severe diarrhea of at least 6 months
Meds for Alzheimer Dementia
Cholinesterase Inhibitors: Donepezil, Galantamine, or Rivastigmine
Memantine (NMDA antagonist)
Brugada Syndrome
Ion channel disorer common in asian males and characterized by a RBB and elevation at the J point that is >2mm with a slowly descendign ST segment with a flat or negative T-wave in V1, V2, or V3
