General Medicine Flashcards
specificity
rule out a disease
sensitivity
rule in a disease
what happens to ppv and npv as prevalence increases
ppv increases and npv decreases
how does affect sensitivity and specificity
it doesn’t only predictive value
Influenza vaccine
Live attenuated, inactivated, recombinant
One dose annually (for all persons ≥18 y), including pregnant women and those with HIV infection
Tetanus, diphtheria, and pertussis
Inactivated, One dose Tdap, then Td booster every 10 y for all adults; one dose Tdap each pregnancy between 27 to 36 weeks’ gestation
Varicella
Live attenuated; For all immunocompetent persons lacking immunity
Herpes zoster
Recombinant
All nonimmunocompromised persons age ≥50 y, including those previously vaccinated with the inactivated vaccine
HPV
Inactivated; Women aged 19-26 y; men aged 11-21 y; men aged 22-26 y who are immunocompromised or who have sex with other men
MMR
Live attenuated
Adults born in 1957 or later without evidence of vaccination or immunity
Meningococcal (MenACWY)
Inactivated, First-year college students residing in dormitories, travelers to endemic areas, military recruits, and exposed persons; asplenia or complement deficiencies; boost
every 5 y if risk remains
Hepatitis A
Inactivated, Any adult requesting immunization and those at high risk
Hepatitis B
Inactivated, Any adult requesting immunization and those at high risk
PNA vaccine
Immunocompetent adults age ≥65
PCV 13
PCV 23, one year after 13
Revaccination after 5 years with PCV 23 only if vaccinated before 65
PNA vaccine in Immunocompetent persons with chronic heart, lung, or liver disease, diabetes mellitus, alcoholism, cigarette smoking
PCV 23 only
Revaccination after 5 years with PCV 23 only if vaccinated before 65
PNA vaccine in Persons with functional (sickle cell disease, hemoglobinopathies) or anatomic asplenia
PCV 13
PCV 23
Revaccination after 5 years with PCV 23
PNA vaccine in Immunocompromised persons with HIV, chronic kidney disease, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, taking immunosuppressant drugs, congenital immunodeficiencies, solid organ transplant
PCV 13
PCV 23
Revaccination after 5 years with PCV 23
PNA vaccine in CSF leaks or cochlear implants
PCV 13
PCV 23, but no revaccination!
indication for asa therapy for primary prevention
adults aged 50-59 years • 10-year CVD risk ≥10% • life expectancy ≥10 years • no increased risk for bleeding • willing to take low-dose aspirin daily ≥10 years
AAA screening
One-time abdominal ultrasonography in all men ages 65-75 y who have ever smoked;
selectively screen men ages 65-75 y who have never smoked
Depression screening
all adults
Diabetes mellitus screening
Ages 40-70 y who are overweight or obese as part of risk assessment for cardiovascular disease
Hypertension screening
All adults; obtain measurements outside of the clinical setting for diagnostic confirmation before
starting treatment
Lipid disorders screening
Universal lipid screening in adults aged 40-75 y as part of risk assessment for cardiovascular
disease
Osteoporosis screening
Women age ≥65 y; postmenopausal women <65 y of age when 10-year fracture risk is ≥9.3%
Chlamydia and gonorrhea screening
All sexually active women age ≤24 y; all sexually active older women at increased risk of infection
HCV screening
One-time screening for adults born from 1945-1965; all adults at high risk
HIV infection screening
One-time screening for all adults ages 15-65 y; at least annually for adults at high risk
Breast cancer screening
Biennial screening mammography for women ages 50-74 y; initiation of screening before age 50 y should be individualized
Cervical cancer screening
Women aged 21-65 y with cytology (Pap smear) every 3 y; in women aged 30-65 y who want to lengthen screening, screen with high-risk HPV testing (preferred) or cytology and high-risk HPV
testing every 5 y
Do not screen women following hysterectomy and cervix removal for benign disease.
Colon cancer screening
All adults aged 50-75 ya. USPSTF recommendations do not support one form of screening test
over another for detecting early stage colorectal cancer in average-risk patients. Available tests
include stool-based, direct visualization, and serology tests .
Lung cancer screening
Annual low-dose CT scan in high-risk patients (adults ages 55-80 y with a 30-pack-year smoking history, including former smokers who have quit in the last 15 y)
Prostate cancer
Men aged 55-69 y should make an informed decision about prostate cancer screening with their clinician. Routine screening for men ≥70 y is recommended against.
diagnosis: Postnasal drainage, frequent throat clearing, nasal
discharge, cobblestone appearance of the
oropharyngeal mucosa, or mucus dripping down
the oropharynx
Upper airway cough syndrome
-Tx with First-generation antihistamine-decongestant
combination or intranasal glucocorticoid
diagnose: Asthma, cough with exercise or exposure to cold
Cough-variant asthma
- use methacholine or exercise challenge
- standard asthma tx may take 6 months to take effect
Taking ACE inhibitor cough
ACE-inhibitor cough Stop ACE inhibitor, substitute ARB; takes approximately 1 month to respond
Normal chest x-ray findings, normal spirometry, and
negative methacholine challenge test w/ chronic cough
Possible nonasthmatic eosinophilic bronchitis
Diagnosis with Sputum induction or bronchial wash for eosinophils
Treat with inhaled glucocorticoids; avoid sensitizer
what is another term for chronic fatigue`
Systemic exertion intolerance disease
tx for SEID
no great tx but CBI and graded exercise can help
Dix hallpike findings in Peripheral vertigo
Latency of nystagmus (lag time between maneuver and onset of nystagmus) 2-40 s Duration of nystagmus <1min Severity of symptoms Severe Fatigability (findings diminish with repetition) Yes Direction of nystagmus Horizontal with rotational component; never vertical
Dix hallpike findings in central vertigo
Latency of nystagmus (lag time between maneuver and onset of nystagmus)- None Duration on Nystagmus - >1 min Severity of symptoms- Less severe Fatigability- No Direction of Nystagmus- Can be vertical, horizontal, or torsional
BPPV findings
Brief vertigo (10-30 s) and nausea associated with abrupt head movement (turning over in bed). Treat with Epley maneuver (canalith repositioning procedure)
Vestibular neuronitis findings
Severe and longer lasting vertigo (days), nausea and often vomiting
Labyrinthitis findings
Similar to vestibular neuronitis but with hearing loss
Meniere disease triad
vertigo, hearing loss, tinnitus
acoustic neuroma findings
hearing loss, tinnitus, unsteadiness, facial nerve involvement
Restless legs syndrome characteristics
An uncomfortable or restless feeling in the legs most prominent at night and at rest, associated
with an urge to move and alleviated by movement
Look for iron deficiency
Periodic limb movement disorder characteristics
Repetitive stereotypic leg movement during sleep and during quiet wakefulness
Central sleep apnea syndrome characteristics
Repetitive pauses in breathing during sleep without upper airway occlusion
Associated history of HF or CNS disease
Obstructive sleep apnea syndrome characteristics
Upper airway obstruction during inspiration in sleep
History of snoring, witnessed pauses in respiration, large shirt collar size, and daytime sleepiness
Shift-work sleep disorder characteristics
Shift-work sleep disorder History of insomnia associated with shift work (permanent night shifts)
Sleep deprivation characteristics
Six hours or less of sleep is associated with daytime sleepiness and performance deficits
Narcolepsy characteristics
Daytime sleepiness with cataplexy, hypnagogic hallucinations, and sleep paralysis frequently
coexisting with other sleep disorder
Tx for insomnia
• CBT (first-line therapy)
• sleep hygiene practices (regular bedtimes and waking times; spending no more than 8 hours in bed; using bed only for
sleep)
• avoiding caffeine, nicotine, alcohol, and electronic devices before sleep
• melatonin for short-term insomnia resulting from travel or shift work
tx for restless leg
dopaminergic agents (pramipexole or ropinirole) or with levodopa-carbidopa. Give FeS if ferritin <75
diagnose patient with A prodrome of nausea, diaphoresis, pallor, and brief loss of consciousness (<1 min) with rapid recovery and absence of postsyncopal confusion
vasovagal
diagnose patient with syncope preceding pressure on the carotid sinus (tight collar, sudden turning of head)
carotid sinus hypersensitivity
diagnose patient with syncope and association with specific activities (urination, cough, swallowing, defecation)
situational syncope
diagnose syncope with Brainstem neurologic signs and symptoms
Posterior circulation vascular disease; consider subclavian steal syndrome if preceded by upper extremity exercise
diagnose syncope Related to exercise or associated with angina
Obstruction to LV outflow: AS, HCM; also PE and PH
diagnose syncope Syncope with sudden loss of consciousness without prodrome
Arrhythmia, sinoatrial and AV node dysfunction (ischemic heart disease and associated
with use of β-blockers, calcium channel blockers, and antiarrhythmic drugs)
diagnose syncope after eating a meal
Postprandial syncope, often in older adult patients
what are some test you should not order when patient has syncope
EP study (Rarely helpful and almost always the incorrect answer), carotid vasc studies, brain imagine, cardiac enzymes and EEG
what is Olecranon bursitis
inflammation of a bursa that lies in the posterior aspect of the elbow and presents as a fluid-filled mass
PE distingishing character of olecranon bursitis
does not cause restriction or pain with range of motion of the elbow whereas joint pathology will cause pain and restricted movement.
tx of olecranon bursitis
Aspirate a bursa if tender or warm to analyze fluid for crystals and infection. NSAIDs and rest (if noninfectious) are first-line
treatments.
how is lateral epicondylitis caused
caused by overuse that involves
pronation and supination with the wrist flexed.
tx for lateral epicondylitis
stretching and strengthening exercises and avoidance of activities that cause pain. Braces may be useful when exacerbating activities cannot be avoided. Oral and topical NSAIDs provide
short-term relief. Do not inject glucocorticoids.
red flags of cauda equina syndrome
- urinary retention or incontinence
- diminished perineal sensation
- bilateral motor deficits
signs of herniated disc
- radiation down leg
- positive straight leg raising
• weakness of the ankle and great toe dorsiflexion (L5)
• loss of ankle reflexes (S1)
• less commonly, loss of knee reflex (L4)
spinal stenosis characterized as
neurogenic claudication—radiating back pain and lower extremity numbness—that is exacerbated by
walking and spinal extension but improved by sitting and leaning forward. A widebased gait and/or abnormal Romberg test are highly specific (>90%) for spinal stenosis. MRI establishes the diagnosis.
best tx for sciatica
conservative tx
Neoplastic epidural spinal cord compression treatment
a surgical emergency. Begin management by administering dexamethasone and obtaining immediate MRI of the entire spine
PE for patellafemoral syndrome
firmly compressing the patella against the femur and moving it up and down along the groove of the femur, reproducing
pain.
Prepatellar bursitis
h anterior knee pain and swelling anterior to the patella and is often caused by trauma or
repetitive kneeling. Perform a joint aspiration to rule out infection if warmth and erythema are present.
Anserine bursitis
knee pain that is worse with activity and at night. The anserine bursa is located medially about 6
cm below the joint line. Anserine bursitis is common in patients with OA.
tx for bursitis
- rest
- ice
- NSAIDs
- local glucocorticoid injection for persistent symptoms
Iliotibial band syndrome
knife-like lateral knee pain that occurs with vigorous flexion-extension activities of the knee (running
where is tenderness on meniscus injury
Tenderness usually localizes to the joint line on the affected side and with tibial rotation as the leg is extended
when do you do surgery on meniscus
Surgery for acute meniscal tears is reserved for
mechanical symptoms that persist beyond 4 weeks
greater trochanter pain syndrome
characterized by lateral point tenderness and full range of motion except for painful
resisted abduction.
risk factors for osteonecrosis of the hip
alcoholism, sickle cell disease, SLE, and prolonged glucocorticoid use.
early vs late diagnosis of osteonecrosis
Diagnose early osteonecrosis with hip MRI. Advanced disease will show flattening of the femoral head on x-ray.
when to get ankle xray
cannot bear weight or if bone pain is localized to the
lateral or medial malleolus, base of the fifth metatarsal, or the navicular bone
what is mortons neuroma
pain, numbness, and tingling in the forefoot, usually between the third and fourth
toes, aggravated by walking on hard surfaces and wearing tight
or high-heeled shoes.
dequervian tenosinovitis
young women with pain on the radial side of the wrist during pinch grasping or thumb and wrist movement
finkelstein test
Pain elicited by flexing the thumb into the palm, closing the fingers over the thumb, and
then bending the wrist in the ulnar direction is confirmatory
what are secondary causes of carpal tunnel syndrome
hypothyroidism, diabetes mellitus, pregnancy, paraproteinemias, and RA of the wrist.
Shoulder pain with overhead reach, limited rom without weakness likely
tendonitis
shoulder pain with significant weakness
rotator cuff tear
Severe shoulder pain and frank weakness (inability to maintain the arm at 90 degrees of abduction)
complete rotator cuff rupture
s lateral deltoid pain that is aggravated by reaching suggests
impingement syndrome
impingement pain pattern accompanied by stiffness and loss of active and passive external rotation or abduction suggests
frozen shoulder
what is localized to the distal end of the clavicle and is most pronounced when the patient reaches
across the body to the opposite shoulder.
Acromioclavicular joint pain
aggravated by any shoulder movement. Pain owing to biceps tendinitis is aggravated by lifting and
wrist supination.
Glenohumeral joint pain
Bicep tendon rupture
traumatic event but may be spontaneous and presents with a visible or palpable
mass near the elbow or mid arm (“Popeye sign”) and ecchymosis
immediate indication for surgery in shoulder injury
acute full-thickness tear in
younger patients
Constant shoulder pain with normal shoulder examination
suggest
referred pain (e.g., Pancoast tumor) or neuropathic pain (e.g., cervical spine radiculopathy
ACC indication for starting statin
- patients with clinical ASCVD,
- patients with an LDL cholesterol level of 190 mg/dL or higher,
- patients with diabetes mellitus who are aged 40 to 75 years with an LDL cholesterol level of 70 to 189 mg/dL and no clinical
ASCVD, and - patients without clinical ASCVD or diabetes and an LDL cholesterol level of 70 to 189 mg/dL and estimated 10-year
ASCVD risk of 7.5% or higher
lab studies when starting statin
- baseline fasting lipid panel ALT level
* monitor ALT and CK only if a patient develops symptoms of hepatic or muscle disease
complications of weight loss banding procedures
Intractable nausea and vomiting
Marginal ulcers, stomal obstruction
gastric bypass complications (7)
Stomal stenosis Cholelithiasis Nephrolithiasis Dumping syndrome Anatomic stricture or ulceration Bacterial overgrowth Micronutrient deficiencies: folate; vitamins B1, B6, B12, C, A, D, E, and K; iron; zinc; selenium; and copper
sleeve gastrectomy complications
Staple-line bleeding, stenosis (dysphagia and vomiting), and staple-line leakage
lab findings in adrogen steroid abuse
elevated hemoglobin and suppressed LH and FSH levels.
contraindications for PDE5
nitrate therapy in any form and in men with a history of nonarteritic anterior ischemic optic neuropathy. They should be used with caution in men taking α-blockers
alternative medication when pde5 ins contraindicated
Intraurethral or intracavernous alprostadil
medication that can tackle both bph and ED
tadalafil
indication for Transurethral resection of the prostate or transurethral needle ablation
severe urinary symptoms,
urinary retention, persistent hematuria, recurrent UTIs, or kidney disease clearly attributable to BPH
symptoms of testicular torsion
Absence of the cremasteric reflex on
the affected side is nearly 99% sensitive for torsion. The testis is usually high within the scrotum and may lie transversely. Doppler
flow ultrasonography demonstrates diminished blood flow to the affected testicle. Testicular elevation will not relieve pain.
epididymitis pain location
posterior and superior aspects of the testicle
how can you differentiate epididymitis from torsion
in epididymitis . Pain may decrease with testicular elevatio
US finding in orchitis and epididymitis
normal or increased blood flow to the testicle
and epididymis.
orchitis character
viral infection (mumps) or extension of a bacterial infection from epididymitis or UTI. The testicle is diffusely tender.
tx of epididymotis >35 vs < 35
n men younger than 35 years with epididymitis, treat with ceftriaxone and doxycycline.
In men older than 35 years or those engaging in anal intercourse, treat with ceftriaxone and a fluoroquinolone
tx for prostitis
trimethoprim-sulfamethoxazole or fluoroquinolone for 4 to 6 weeks. For patients who appear toxic, hospitalize and add gentamicin to a fluoroquinolone.
which women are candidate for breast cancer prophylaxis
Women age >35 years
with a 5-year breast cancer risk of ≥1.7% or with lobular carcinoma in situ
breast cancer prophylaxis
- tamoxifen before menopause
* tamoxifen and raloxifene, or exemestane after menopause
when to test for BRCA gene
(one or more first-degree relatives on the same side ≤50 years with breast cancer or invasive ovarian cancer; two
or more relatives at any age with breast, prostate, or pancreatic cancer
screening recs when patient has BRCA gene
- breast cancer screening with MRI beginning at age 25 years, then mammography beginning at age 30 years
- ovarian cancer screening with pelvic examinations, ultrasonography, and CA-125 measurement
breast cancer screening guideline USPFTF
biennial screening mammography
for average-risk women beginning at age 50 years
work up for breast lump in women < 30
Simple cyst
complex cyst
- Consider observation to assess resolution within 1 or 2 menstrual cycles
- If persistent, choose ultrasonography
- If simple cyst on ultrasound, aspirate and repeat clinical breast examination in 4-6 weeks
If complex cyst on ultrasound, perform mammography and fine-needle aspiration or
core-needle biopsy
If aspirate fluid is bloody or a mass persists following aspiration, choose mammography and biopsy
If solid on ultrasound, choose mammography and obtain tissue diagnosis
work up for Palpable breast lump or mass and age ≥30 years
Mammography: If BI-RADS category 1-3 (benign or close follow-up recommended),
obtain ultrasonography and follow protocol above; if BI-RADS category 4-5
(suspicious or highly suspicious), obtain tissue diagnosis
work up for breast skin changes < 30
think mastitis and tx with abx and clinical observation for 2 w if not improved consider work up if >30yo
work up for breast skin changes >30yo
Perform bilateral mammography: If normal, obtain skin biopsy; if abnormal or indeterminate, obtain needle biopsy or excision (also consider skin punch biopsy)
cervical cancer screening
21 to 65 years with cytology (Pap test) every 3 years. The screening interval can be increased to every 5 years in women aged 30 to 65 years by either performing high-risk HPV testing (preferred) or combining cytology and high-risk HPV testing
contraindications for combination ocps
• uncontrolled hypertension • breastcancer • VTE • liverdisease • migraine with aura >35yo and smokes >15 cigs
emergency birth control options
- over-the-counter levonorgestrel
* prescription ulipristal
When can you use systemic hormone therapy in menopause
healthy women <60yo and within 10 years of menopause
systemic hormone therapy for women with intact uterus should include
progesterone
how to treat postmenopausal vaginal symptoms
vaginal lubricants or topical estrogen
treatment with systemic hormone therapy in women >5 yrs is associated with
increase risk of breast ca
ovulatory causes of abnormal uterine bleeding
- thyroid disease
- bleeding disorder
- structural abnormalities (uterine fibroids or polyps)
what is anovulatory bleeding
irregular in terms of flow and cycle duration because lack of ovulation and the resultant lack of cyclic progesterone cause endometrial hyperplasia and irregular bleeding.
what are causes of anovulatory bleeding
- PCOS
- hypothyroidism or hyperthyroidism
- hyperprolactinemia
- chronic liver or kidney disease
- medications (antidepressants, antipsychotics, chemotherapy)
for postmenopausal patient with abnormal uterine bleed what endometrial thickness indicates biopsy
> 4mm
treatment of ovulatory abnormal bleeding
tx endocrine causes
or surgical re sect structural abnormalities
tx of anovulatory abnormal bleeding
- for women who wish to preserve fertility
medroxyprogesterone acetate used for the second half of the menstrual cycle - for women who do not wish to preserve fertility
- combination ocp
- levonorgestrel iud
is all postmenopausal bleeding abnormal
yes
if you see Pelvic heaviness, abnormal uterine bleeding, infertility, and enlarged uterus on bimanual examination or ultrasonography think
uterine fibroids
if you see Chronic pelvic pain worse before and during menses, associated with dysmenorrhea think
Endometriosis
if you see pelvic pain and History of sexual abuse and normal physical examination and ultrasonography think
chronic pelvic pain syndrome
if you see Urinary frequency, urgency, nocturia, and dysuria; suprapubic pain possibly relieved with voiding; and examination that shows vestibular and suprapubic tenderness think
Interstitial cystitis
testing for chronic pelvic pain
pregnancy and pelvic/transvag us
how to diagnose endometriosis
lesions can be visualized by laparoscopy, the gold standard for diagnosis, but is not required for medical therapy if other causes have been ruled out
tx for endometriosis
nsaids then ocp if nsaids are ineffective
bacterial vaginoisis PE, pH, whiff test, microscopic and other tests
PE: Thin, white discharge with “fishy” odor but without irritation or pain
pH:>4.5
whiff test + after KoH
microscope: squamous epithelial cells covered with bacteria that obscure edges (“clue cells”)
other test: nucleic acid test available but not gold standard
candida vaginitis PE, pH, whiff test, microscopic
PE: External and internal erythema with itching and irritation; nonodorous; white, curd-like discharge
pH: <4.5
Whiff: negative
Microscope: Budding yeast and pseudohyphae
trichimoniasis PE, pH, whiff test, microscopic and other tests
PE: Frothy, yellow discharge; erythema of the vagina and cervix (“strawberry cervix”) pH: >4.5 Whiff: negative microscope: motile trichomonads other test: NAAT Gold standard
bacterial vagninosis tx
Oral or topical metronidazole or clindamycin (safe during pregnancy)
vaginal candidiasis tx
Topical (e.g., fluconazole, miconazole, clotrimazole)
Single dose of oral fluconazole (contraindicated during pregnancy); less effective in complicated conditions (e.g., diabetes, HIV infection)
combination if recurrent
trich tx
Oral metronidazole and also for male partner (safe during pregnancy). Test for other STIs. Retest within 3 months of treatment.
If you see Unilateral then bilateral purulent discharge without pain or visual disturbance think and tx
DX: Bacterial conjunctivitis
Tx: Topical fluoroquinolones or bacitracin-polymyxin; culture not needed
if you see Conjunctivitis associated with herpes zoster rash think and tx
Dx Herpes zoster
Tx Emergency ophthalmology referral involving ophthalmic division of fifth cranial nerve conjunctivitis
if you see Unilateral then bilateral conjunctivitis with daytime think and tx
dx Viral conjunctivitis
tx Supportive care watery or mucoid discharge
if you see Itching and tearing of the eyes, nasal congestion think and tx
dx Allergic conjunctivitis
Tx Topical vasoconstrictors, NSAIDs, ocular antihistamines, cromolyn
if you see Pain, photophobia, inflammation confined to corneal limbus, corneal irregularity, edema think and tx
dx: Iridocyclitis or keratitis Consider associated spondyloarthropathies, sarcoidosis, and herpes zoster;
tx: emergency
ophthalmology referral
if you see Unilateral deep ocular pain, nausea, vomiting, fixed nonreactive pupil, shallow anterior chamber think and tx
dx: Acute angle-closure
glaucoma
Tx:Emergency ophthalmology referral
if you see Severe ocular pain that worsens with eye movement and light exposure; a raised hyperemic lesion that may be
localized or diffuse and obscures the underlying vasculature think and tx
dx Scleritis Commonly associated with collagen vascular and rheumatoid diseases;
tx emergency ophthalmology
referral
if you see Nonpainful red, flat, superficial lesion that allows visualization of the underlying vasculature
Dx: Episcleritis
Tx: Self-limited; no treatment required
If you see Red eye with scales and crusts around the eyelashes or dandruff-like skin changes and greasy scales around the eyelashes think and tx
dx; Blepharitis Staphylococcus (crusting) or seborrheic dermatitis (greasy scales, dandruff);
tx warm compresses, washing with mild detergent, topical antibiotics
dry and wet age related macular degeneration
dry: deposition of extracellular material (drusen) in the macular region of one or both eyes and may cause
diminished visual acuity
wet: dry AMD will progress to develop new vessel growth under the retina (wet AMD).
retinal detachment symptoms
Symptoms are floaters, flashes of light (photopsias), and squiggly lines, followed by a sudden, peripheral visual field defect that resembles a black curtain and progresses across the entire visual field.
eye emergency
central retinal artery occlusion cause by and symptoms
thrombi or emboli. Patients are usually elderly and present with profound and sudden painless vision loss.
CRAO exam and tx
Funduscopic examination reveals an afferent pupillary defect and cherry red fovea that is accentuated by a pale retinal background. Treatment may include measures to lower the intraocular pressure and emergent ophthalmology consultation.
CRVO cause and symptoms
thrombus, with sudden, painless, unilateral visual loss.
crvo exam and tx
Funduscopic examination may reveal afferent pupillary defect, congested retinal veins, scattered retinal hemorrhages, and cotton wool spots in the region of occlusion. Immediate ophthalmologic consultation is necessary
conductive hearing loss weber and rhinne and causes
Weber: Louder in the affected ear
rhinne :Decreased in the affected ear (bone conduction > air conduction)
causes: Cerumen impaction, foreign body,
otitis media, otosclerosis
sensorineuro hearing loss weber rhinne and causes
weber:Louder in the good ear
rhinne: As loud or louder in the affected ear
(air conduction > bone conduction)
causes: Presbyacusis, Meniere disease,
acoustic neuroma, sudden
sensorineural hearing loss
ramsey hunt syndrome
caused by varicella-zoster viral
infection and characterized by facial nerve paralysis, sensorineural hearing loss, and vesicular lesions on and in the ear canal
what is malignant otitis externa
systemic toxicity and evidence of infection spread beyond the ear canal (mastoid bone, cellulitis) and is typically found in older adult patients with type 2 diabetes or patients who are immunocompromised. Most commonly caused by Pseudomonas aeruginosa.
bacterial sinusitis signs
- persistent symptoms (lasting >10 days)
- severe symptoms or fever (lasting 3-4 days)
- “double-sickness” characterized by worsening symptoms following a period of improvement over 3 to 4 days
first line choice for sinusitis
augmentin or doxy if allergy not zpack
centor criteria
- fever (subjective)
- absence of cough
- tender anterior cervical lymphadenopathy
- tonsillar exudates
Management is based on the number of Centor criteria present:
- <3: neither test nor treat with antibiotics
* ≥3: obtain a rapid antigen detection test (RADT); management is based on results
what should you consider with severe pharyngitis and usually prolonged symptoms with negative RADT in adolescents and young adults
Fusobacterium necrophorum
what is Lemirre syndrome
septic thrombophlebitis of the internal jugular vein resulting in metastatic pulmonary infections.
tx for strep throat and fusobacterium
Select oral penicillin for 10 days. Choose a macrolide for patients allergic to penicillin. F. necrophorum is treated with ampicillin-sulbactam.
duration of tx for first episode of depression
Initiate treatment and continue at the dosage required to achieve remission for an additional 4-9 months
duration of tx for first recurrence
Increase maintenance treatment to one to two times the inter-episode interval (for example, choose 18-36 months if the second episode occurs
18 months after the first episode)
Three or more recurrences of depression, recurrence
within 1 year of successful treatment, or suicide attempt
life time maintenance therapy
serotonin syndrome signs for mild and severe diseases
Mild symptoms include nausea, vomiting, flushing,
and diaphoresis. Severe symptoms include hyperreflexia, myoclonus, muscular rigidity, and hyperthermia.
drugs associated with serotonin syndrome
SSRIs, MAOIs, St. John’s
wort, trazodone, dextromethorphan, linezolid, tramadol, or buspirone
Conditions which mimics bipolar syndrome
thyrotoxicosis, partial-complex seizures, SLE, and glucocorticoid side effects.
what would giving ssri as monotherapy to a bipolar patient do
can unmask mania in patients with untreated bipolar disorder.
Diagnostic criteria for somatic symptom disorder
- at least one somatic symptom causing distress or interference with daily life
- excessive thoughts, behaviors, and feelings related to the somatic symptom(s)
- persistent somatic symptoms for at least 6 months
diagnose when a patient adopts a physical symptom for the purpose of gain
malingering
what to think if a patient adopts symptoms to remain in the sick role
factitious disorder
what to think if a patient has abnormal sensation or motor function (such as limb weakness) that is not
explained by a medical condition and is inconsistent with physical examination findings.
conversion disorder
what to think if the patient has excessive worry about general health and preoccupation with health-related activities
illness anxiety disorder (previously hypochondriasis)
tx for anorexia vs bulemia
For anorexia nervosa, CBT is considered first-line treatment. Psychotropic drugs do not work.
Patients with bulimia respond to CBT and antidepressants (fluoxetine or imipramine).
bulemia complication symptoms
normal weight
acid-induced dental disease, esophageal tears, electrolyte derangements (low chloride and potassium), and metabolic alkalosis.
incontinence type: Daytime frequency, nocturia, bothersome urgency
Urge incontinence
incontinence type Involuntary release of urine secondary to effort or exertion (sneezing, coughing, physical exertion)
Stress incontinence
incontinence type Urgency and involuntary release of urine
mixed incontinence
incontinence type: Unable to get to bathroom on time because of mental or physical limitations
functional incontinence
Incontinence type Nearly constant dribbling of urine, incomplete
emptying of bladder, high postvoiding residual urine
overflow incontinence
Urge incontinence tx
First-line therapy is bladder training; second-line
therapy is anticholinergic drugs (oxybutynin,
tolterodine)
Stress incontinence tx
First-line therapy is pelvic floor muscle training for
women (Kegel exercises)
Mixed incontinence (urge and stress incontinence) tx
Bladder training and pelvic floor muscle training
Functional incontinence tx
Portable commode, regular prompted urination with
physical assistance to commode, treatment of
underlying disorders
Overflow incontinence tx
Timed urination, intermittent bladder catheterization
who should undergo pre-op pharmacologic stress testing
Patients with an elevated risk of a major adverse cardiac event ≥1% and an estimated functional capacity of <4 METs should
undergo pharmacologic stress testing if the results will change management
other activities that equal >4 METS
climbing a flight of stairs • walking up a hill without stopping • running a short distance • lifting or moving heavy furniture • participating in moderate-exertion sporting activities such as bowling or golf
order a pre-op ekg in which patients
CAD
• significant arrhythmias
• cerebrovascular disease (stroke or TIA)
• PAD
Likely not needed for low risk surgeries
examples of low risk surgeries
(cataract extraction, carpal tunnel release, breast biopsy, inguinal hernia repair)
Patients with a known recent major adverse cardiac event should not undergo surgery within:
60 days of an MI
• 30 days of a bare-metal coronary stent implantation
• 6 months of a drug-eluting coronary stent placement
when to stop AC prior to surgery
Stop warfarin 5 days before surgery.
• Stop apixaban, rivaroxaban, dabigatran 1 to 2 days before surgery if eGFR >50 mL/min/1.73 m2. Stop earlier if eGFR is
lower.
surgeries that you dont need to stop AC
cataract surgery,
dermatologic procedures, endoscopic procedures without biopsy
which patients do NOT need perioperative AC bridging
• Low-risk patients do not receive bridging anticoagulation (bileaflet mechanical aortic valve, AF with CHADS2 score <2,
VTE >12 months ago).
which patients DO need perioperative AC bridging
High-risk patients receive bridging anticoagulation (mitral or caged ball valve or aortic tilting disc aortic mechanical
valve, AF with CHADS2 score >4, rheumatic heart disease, recent CVA or TIA, VTE within the past 3 months
when should you stop heparin, UFH LMWH prior to surgery
Start heparin 36 hours after the last dose of warfarin.
• Stop UFH 4 to 6 hours before surgery.
• Stop LMWH 12 hours before surgery.
when can you restart heparin, warfarin noac after surgery
- Restart heparin 24 hours after surgery.
- Restart warfarin 12 to 24 hours after surgery.
- Restart dabigatran, rivaroxaban, and apixaban 24 hours after surgery
