General Medicine Flashcards
1
Q
Oral exam station snowflake mnemonic
A
S - Safety (ie. no driving)
N - Next visit/FU
O - Offer (I will be your GP, I will get your old records, I will perform a physical)
P - Prevention
Q - Quit (ie. smoking)
R - Refer (I would refer to ___ if it’s not improving)
S - Start (ie. meds, physio, etc.)
T - Teaching (ie. pamphlets, info sheets, etc)
2
Q
Epi dose for anaphylaxis
A
Adults: 0.5mg IM into lateral thigh (0.5mL of 1:1000)
Peds: 0.01mg/kg of 1:1000 (1mg/mL) to max of 0.3-0.5mg IM
3
Q
Glucocorticoid side effects, chronic use
A
Fragile skin Easy bruising Weight gain HTN Osteoporosis Myopathy GI perforation Increased risk of infections (ie. oral thrush or pneumocystis jiroveci PNA)
4
Q
Classic ages for croup
A
6mo-3y
5
Q
Croup common viruses
A
Parainfluenza virus types 1** (most common) and 3 Rhinovirus RSV Influenza Adenovirus
6
Q
Croup ddx
A
Epiglottitis
Anaphylaxis
Foreign body aspiration or ingestion
Retropharyngeal/peritonsillar abscess
7
Q
Croup dx
A
Clinical
Don’t routinely do XR but if you do, neck XR should show narrowing in subglottilc region (steeple sign)
8
Q
Croup tx
A
Gold standard - dex 0.6mg/kg PO as single dose (works within 2-3h and persists for 24-48h)
Severe: Dex + neb 2.25% racemic epinephrine +/- neb budesonide (may opt deg once)
Adjuncts - cool air, popsicles, humidifier, sitting in bathroom with steam
Observe for ~4h to see improvement before d/c
9
Q
Typical croup course
A
Symptoms typically last 3d (peak at 24-48h) but may persist for up to 1wk
Symptoms often worse at night
FLUCTUATING course
If >1wk, return for reassessment
Beware of secondary bacterial infection - pt gets better but then suddenly gets worse
10
Q
Ear exam acronym
A
COMPT
- Colour (Gray, white, red, yellow)
- Other (bubbles, air/fluid interface, scarring, perforation)
- Mobility (absent, reduced, normal, hyper mobile)
- Position (Normal, retracted, bulging)
- Translucency (opaque, translucent)
11
Q
Primary otalgia ddx
A
OM OE Trauma Foreign body Impacted cerumen Eustachian tube dysfunction Perichondritis Barotrauma
12
Q
Secondary otalgia ddx
A
Odontogenic causes TMJ disorders Upper cervical spinal dysfunction Parotitis Lymphadenitis Pharyngeal disorders Tonsillitis
13
Q
Primary otalgia not to miss ddx
A
Neoplasms Skull-base osteomyelitis Herpes zoster Acute mastoiditis Cholesteatoma
14
Q
Secondary otalgia not to miss ddx
A
Trigeminal neuralgia
Glossopharyngeal neuralgia
Head and neck malignancies
Temporal arteritis
15
Q
Common bacterial causes for Otitis media (4)
A
Strep pneumo
H-influenza
Moraxella catarrhalis
Streptoccocus pyogenes
16
Q
Common viral causes for OM (3)
A
RSV
Influenza
Rhinovirus
17
Q
When to use abx for OM
A
All children 6mo-2y with BILATERAL AOM
Toxic appearing child
Persistent ear pain for 48h
Fever >39C within past 48h
18
Q
If not giving abx for OM, f/u plan
A
Consider if mild ear pain, temp <39C in past 48h
F/U in 48h
19
Q
OM treatment (incl duration)
A
High dose amox (75-90mg/kg/d split into 2 or 3 doses)
- x10d if 6mo-2yr or recurrent OMs
- x5d if >/=2yr
Adults: amox/clav 875/125 BID
If tympanovstomy tubes - ciprodex 4 drops BID x 7d
Symptoms should resolve within 48h
Re-evaluate at 10d if symptoms not resolved
20
Q
Recurrent acute otitis media
A
> /= 3 distinct and well-documented episodes of AOM within 6mo or >/= 4 episodes within 12mo
- Refer to ENT, hearing test
- May require prophylactic abx, tympanostomy tubes, adenoidectomy or adenotonsillectomy
21
Q
Ped UTI oral abx tx
A
NOTE: If <2mo, Amp + Gent IV x 10d Keflex (good E.Coli coverage and other gram neg rods) Septra Macrobid (only for cystitis) Amox-clav (not first choice)
22
Q
Ped UTI IV abx tx
A
CTX
Cipro (if >1yo)
Amp + Gent
23
Q
Anaphylaxis
A
Need any ONE of the following
- Acute onset (min-hrs) involving skin/mucosa and at least 1 of respiratory compromise and/or drop in blood pressure
- 2 or more organ systems – skin/mucosa, respiratory, CVS, or GI rapidly after exposure
- Drop in BP after exposure to a known allergen
- Infants and children: Low systolic BP (Age specific) or >30% drop in systolic BP
* <70mmHg for 1mo to 1 year
* <70mmHg + (2 x age) for 1-10yo
- Adults: Systolic BP <90mmHg or 30% drop from baseline
24
Q
Which peds patients should get kidney/bladder U/S following UTI/pyelo?
A
- Children < 2y.o. with first febrile UTI
- Children of any age with recurrent febrile UTIs
- Children of any age with UTI who have fam hxof renal or urologic disease, poor growth, hypertension
- Children who do not respond as expected to appropriate antimicrobial therapy
25
Which peds patients should get a renal technetium scan following UTI/pyelo?
4-6mo after acute infection for children with atypical or recurrent UTIs
Generally not required if responded well to tx
26
Which peds patients should get voiding cystourethrogram following UTI/pyelo?
* Children of any age with ≥ 2 febrile UTIs OR
* Children of any age with first febrile UTI AND abnormality on renal U/S OR
* Fever ≥ 39C and pathogen other than E. coli OR
* Poor growth or hypertension
27
Peds PNA tx
Amox 40-90mg/kg/d divided TID
Ampicillin IV
CTX IV
28
HEADSS
```
Home
Education/employment
Activity
Drugs/diet
Safety
Sexuality/suicide
```
29
Asthma dx in patients <6yo
1. Hx (Recurrent wheezing, cough, difficulty breathing, chest tightness)
2. P/E (Confirming airway obstruction/wheeze that improves with SABA)
3. AND absence of alternative explanation
30
Asthma therapeutic trial
Daily moderate dose of ICS and SABA PRN
Trial 8-12wks
Discuss with fam in advance expected clinical improvements
Symptom diary
31
Asthma dx in patients 6-18yo
1. Compatible clinical hx (recurrent wheezing, cough, difficulty breathing and chest tightness)
2. Documented evidence of reversible obstruction or bronchial hyperactivity with LFT
3. If LFT is not available, a p/e finding of wheezing or signs of increased WOB that DEFINITIVELY Improves with SABA can be used as surrogate marker of reversible airway obstruction
32
If spirometry is normal but asthma dx still suspected...
Methacholine challenge or exercise challenge (typically require respirologist referral)
33
Asthma symptom control checklist
```
In the past 4 wks has the patient had:
-daytime asthma symptoms >2x/wk
-any night symptoms due to asthma
-reliever needed for symptoms >2x/wk
-any activity limitation due to asthma
-FEV1 or peak flow <80% of personal best?
If 0 pts = well controlled asthma
If 1-2 pts = partly controlled asthma
If >/= 3 pts = uncontrolled asthma
```
34
Asthma general tx plan
1. SABA reliever
2. Low-dose ICS + SABA reliever
3. Med/high dose ICS + SABA inhaler OR Low dose ICS/LABA combo (ie. Symbicort)
35
Symbicort
Budesonide/Formoterol (ICS/LABA)
36
Advair
Fluticasone/Salmeterol (ICS/LABA)
| Diskus or MDI
37
Zenhale
Mometasone/formoterol (ICS/LABA)
38
Breo Ellipta
Fluticasone/vilanterol
39
Pulmicort
Budesonide
40
Alvesco
Ciclesonide (ICS)
41
Flovent
Fluticasone
42
Drugs which can trigger or exacerbate asthma
Beta blockers
Aspirin and NSAID drugs
ACEi
43
Typical age for bronchiolitis
<2yo
44
Most common cause of bronchiolitis
RSV
45
2 recommended tx for bronchiolitis
Oxygen (to keep sat >90%, typically via nasal cannula or blow-by) and hydration (Promote PO, NG or IV if needed)
46
Eating d/o SCOFF questions
Do you make yourself Sick b/c you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone (14lbs) in 3mo?
Do you believe you're Fat when others say you're thin?
Would you say that Food dominates your life?
47
Wellbutrin and eating disorder
C/I due to increase in sz risk
48
Potential complications from eating disorder
Amenorrhea
Cardiac dysfunction secondary to myocardial wasting (bradycardia, prolonged QTc, ST elevation, arrhythmias, pericardial effusion, orthostatic BP changes, poor peripheral circulation)
Osteopenia/osteoporosis
Sick euthyroid syndrome (TSH normal but decreased T4 --> T3 conversion = hypothyroid symptoms)
Abnormal liver enzymes
Electrolyte disturbances (hypoglycaemia, hypophosphatemia, hypokalemia)
49
Pharmacotherapy for eating disorder
SSRI - Fluoxetine
| Esp helpful for binging
50
Screen time recommendations for peds
<2yo: not recommended
2-5yo: <1h/d
Avoiding screens at least 1h before bedtime
51
Typical 1st line pharmacotx for ADHD
Methylphenidate/Ritalin
| Concerta (Methylphenidate XR)
52
2nd line tx for ADHD
Dextroamphetamine (ie. dexedrine, Vyvanse)
| Dextroamphetamine and amphetamine salt combos (ie. adderrall)
53
F/U of pt on stimulant medication
q3mo, P/E annually
| Height, weight, BP, pulse
54
Questionnaire for ADHD
SNAP IV - usually get parent and teacher to complete
55
Ddx for ADHD to explore
```
Hearing impairment
Developmental delay
Learning disorder
Mood disorder
Conduct disorder
Other psych issues
Psychosocial - fam stress, relationship issues, abuse, parental expectations
```
56
C/I to ADHD meds
```
Tx with MAOI
Symptomatic CV dz
Glaucoma
Advanced arteriosclerosis
Untreated hyperthyroidism
Known hypersensitivity or allergy to the products
Mod-Severe HTN
```
57
ADHD dx
Inattention and/or hyperactivity-impulsivity that interferes with functioning/development
Present PRIOR to age 12
present in 2 or more settings (ie. school, home, work, friends/fam)
Persist >/= 6mo
58
Common comorbid dx with ADHD
```
Oppositional defiant disorder (up to 50%)
Conduct d/o
Anxiety
Depression
Learning disabilities
```
59
P/E for ADHD
```
Dysmorphic features (ie. FAS)
Growth rate
BP
Cardiac exam (if meds to be considered)
Other potential causes for behaviour - vision loss, hearing loss, enlarged tonsils/OSA
```
60
Anxiety dx
```
AND I C REST
Anxious, nervous or worried
No control over worry
Duration >6mo of 3 or more of:
Irritability
Concentration impairment
Restlessness
Energy decreased
Sleep impairment
Muscle tension
```
61
Anxiety diagnoses
```
GAD
Panic d/o
Social phobia
Specific phobia
Social anxiety
Agoraphobia
PTSD
OCD
```
62
SSRI S/E
* Sexual dysfunction
* Drowsiness
* Dizziness
* Headache
* Dry mouth
* Blurred vision
* Rash/itching
* GI abnormalities (nausea and diarrhea)
* Insomnia
* Withdrawal on discontinuation
* Weight gain
* ALWAYS DISCUSS RISK OF INCREASED SUICIDALITY AT START OF MEDICATION (increase energy before improving mood)
* Ultimate risk factor for suicidality is untreated depression/anxiety!
* TAKES ABOUT 6 WKS TO TAKE EFFECT
63
SSRI you have to worry about high doses with QTc
Citalopram/escitalopram
64
Anxiety medical ddx
Hyperthyroid
Pheochromocytoma
R/O causes for panic attack symptoms (ie. PE, MI)
SUBSTANCE ABUSE
65
MSE acronym
```
ASEPTIC
Appearance and behaviour
Speech
Emotion (Mood/affect)
Perception
Thought content and process
Insight and judgement
Cognition
```
66
Anxiety workup to exclude medical cause
CBC
Fasting glucose
TSH
Urine toxicology
67
Anxiety pharmacotherapy
1st line : SSRI, SNRI
| 2nd line: TCA, benzo
68
Depression ddx
Disruptive mood dysregulation disorder
MDD
Persistent depressive d/o (Dysthymia)
Premenstrual dysphoric disorder
Substance/medication-induced depressive disorder
Depressive d/o due to another medical condition (ie. hypothyroid, hypoadrogenism)
69
Depression diagnostic criteria
```
SIGECAPS
Sleep changes
Interest loss
Guilt (worthless)
Energy (lack)
Cognition/concentration
Appetite (wt loss)
Psychomotor (agitation or lethargic)
Suicide/death preoccupation
```
70
MDD pharmacotherapy
1st line: SSRIs, SNRIs
| 2nd line: TCAs, MAOs
71
Seroquel
Quetiapine
| Atypical antipsychotic
72
Canadian low risk drinking guidelines
Women: 10 drinks per wk, no more than 2 drinks/d
Men: 15 drinks per wk, no more than 3 drinks/d
Plan non-drinking days every week to minimize tolerance and habit formation
Special occasions: No more than 3 drinks (for women) and 4 drinks (for men) on a single occasion
73
Alcohol use in youth
<19 not recommended
| Never more than 1-2 drinks at a time, never more than 1-2x per week
74
Standard drink
12oz beer
12 oz cooler/cider
5oz wine
1.5oz distilled alcohol
75
CAGE questionnaire for alcohol use
Have you ever felt you need to CUT down on your drinking?
Do you feel ANNOYED by others complaining about your drinking?
Do you ever feel GUILTY about your drinking?
Do you ever drink an EYE OPENER in the morning to relieve the shakes?
Men - two yes responses is +ve
Women - one yes response is +ve
76
CRAFFT questionnaire for teens
Have you ever ridden in a CAR driven by someone/including yourself who was high or had been using EtOH or drugs?
Do you ever use EtOH or drugs to RELAX, feel better about yourself or fit in?
Do you ever use EtOH or drugs while you are by yourself ALONE?
Do you ever FORGET things you did while using alcohol or drugs?
Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use?
Have you ever gotten into TROUBLE while you were using alcohol or drugs?
77
Signs/symptoms suggesting alcohol use
```
MCV > 96
Elevated GGT, AST, ALT (esp AST:ALT > 2:1)
GERD, HTN, diabetes, pancreatitis
Chronic non-cancer pain
Alcohol on breath
```
78
3 categories for recovery goals
1. Substance use and tx (ie. reduce use to x days/wk, listen to recovery podcast, 12-step meetings xtimes/wk, etc.)
2. Exercise or wellness goal
3. Creative/spirtual/community/relationship goals (ie. reconnect with old friend, call mom once a week, go to church)
79
Benzo contraindications
```
Severe respiratory insufficiency
Hepatic dz
Sleep apnea
Myasthenia gravis
Narrow angle glaucoma
```
80
Neuropathic pain tx options
Gabapentin
Pregabalin
TCAs
SNRIs
81
Acute alcohol withdrawal tx options
Benzos (CIWA protocol)
| Anticonvulsants - gabapentin, carbamazepine, valproic acid
82
Delirium tremens signs/symptoms
Presents 48-72h after last drink, can last btwn 1-5d
Severe confusion, disorientation
Hallucinations
Severe autonomic hyperactivity - ie. tachycardia, HTN, hyperthermia, agitation and sweating
NOTE DIFFERENCE BTWN DT AND ALCOHOLIC HALLUCINOSIS
83
Alcohol use disorder recovery tx
1st line: Naltrexone, acamprosate
2nd line: Topiramate, gabapentin
Not recommended, refractory cases only: Disulfiram
84
Naltrexone prescribing notes
Wait 7d after last opioid use for opioid-dependent patients
| Mu-opioid receptor antagonist (will precipitate opioid withdrawal)
85
Delirium tremens risk factors
* Hx of sustained drinking
* Hx of EtOH withdrawal sz
* Hx of DT
* Age >30
* Presence of concurrent illness
* Presence of significant EtOH withdrawal in presence of elevated blood alcohol concentration
* Longer period since last drink
86
Nicotine patch prescribing
Start 1-4wks before quit date
Peak level 6-12h after
Apply new patch each morning
If >/=10 cigs/d:
21mg/d for 6wks
14mg/d for 2wks
7mg/d for 2 wks
if <10cigs/d or <45kg
14mg/d for 6wks
7mg/d for 2 wks
87
Common S/E from nicotine patch
Skin reaction
Sleep disturbance
Other possible symptoms - heart palpitations, chest pains, N/V, GI complaints, mouth and throat pain, mouth ulcers, hiccups and coughing with oral forms of NRT
88
NRT treatment regimen
Often start with one form of NRT (ie. patch), then choose one short-acting NRT for breakthrough cravings as needed (ie. gum, lozenge, mouth spray or inhaler)
89
Smoking cessation pharmacotherapy options
1. Varenicline/champix
90
Varenicline MOA
Partial agonist and antagonist at alpha and beta receptors
Partial agonist function --> release of dopamine --> reduces withdrawal and cravings
Partial antagonist function --> reduces reinforcing effect of nicotine b/c no longer able to bind
91
Varenicline S/E
Irritability, restlessness, insomnia, constipation, other GI problems, abnormal dreams, nausea**
92
Varenicline dosing info
Patients choose a quit date
Start Varenicline tx 1-2wks BEFORE this date then completely stop
Can be done with NRTs
93
Major C/I with Wellbutrin
Decreases sz threshold
| C/I in pts with hx of seizure d/o
94
Infertility workup
```
Day 3 LH, FSH, estradiol
+/- AMH
Prolactin
TSH
Pelvic U/S
Semen analysis
=/- mid-luteal phase serum progesterone (1wk before expected menses)
```
95
Monthly pregnancy %
20: 30-40%
25: 25-35%
30: 20-30%
40: 5-7%
45: 1-2%
96
Ddx for female infertility
```
PCOS
Infrequent/absent ovulation
Endometriosis
Uterine fibroids
Cervical factors
Pelvic adhesions
Tubal blockage
HyperPRL
Inherited thrombophilia
Immune factors
Genetic causes
Thyroid dz
```
97
Assisted reproductive technologies
```
Intrauterine insemination (IUI)
IVF
```
98
2 main agonist therapies for opioid use disorder
Suboxone (buprenorphine/naloxone)
| Methadone
99
Methadone MOA
Full opioids agonist
100
Suboxone MOA
Partial opioid agonist
High affinity to mu receptor (quickly alleviates withdrawal) but has LOW intrinsic activity (less euphoria, sedation, nausea, constipation, hypotension, resp depression)
101
Naloxone MOA
Opioid antagonist
| ONLY bioavailable if injected
102
Suboxone initiation
Aim for COWS >12 (need to be in slight withdrawal)
Low initial dose (i.e one to two 2mg/0.5mg SL tabs)
Monitor for 2h --> if withdrawal symptoms remain, give additional 2-4mg (max 12mg/3mg on day 1)
Next day, give single dose of total dose received on day 1
Increase in 4mg increments up to max of 16mg total
Most stabilize on 16-25mg/d
103
Common classes of meds that methadone interacts with
Antiretrovirals
Anti-fungals
Rifampin
104
Methadone and ECG changes
Prolongs QTc interval
| Consider getting ECG esp when on high doses
105
Opioid use disorder b/w
```
CBC
Liver function panel
HIV, hepatitis A, B and C
Syphilis serology
TB testing when appropriate
Pregnancy test
ECG if indicates (ie. when escalating dose, fam hx of sudden cardiac death)
```
106
Methadone initiation
Start at 20-30mg on first day
Titrate up in 5-10mg increments q3-5d over several weeks
Stable dose 60-120mg/d
107
Common false +ve on urine drug testing
Amphetamine
108
Common false -ve on urine drug testing
Clonazepam, lorazepam
109
Red flags for breast CA
* Breast lumps
* Nipple discharge
* Unusual nipple or areolar skin changes (ie. crusting, scaling, dimpling)
* Nipple inversion
110
SNOOP mnemonic for dangerous secondary headaches
Systemic symptoms: fever, weight loss, night sweats
Secondary risk factors: HIV, cancer, immune compromise
Neurologic symptoms or signs: anything focal? Papilledema? Confusion?
Onset: sudden, maximal at onset
Older >50
Pattern change: first, worst or different
Provocative factors - positional, cough/sex/exertion, pregnancy
111
Features (signs and symptoms) of headache that make it more worrisome
```
Age of onset >50
Sudden onset
Positional nature of headache
Hx trauma
New onset HIV
Hx of any cancer
Systemic illness
Focal symptoms or signs
Fever
Neck stiffness
Papilledema
```
112
Headache ddx
```
Migraine w/ or w/out aura
Tension headache
Cluster headache
Temporal arteritis
Idiopathic intracranial HTN
SAH
Bacterial meningitis
Medication overuse headache
```
113
Lifestyle management for headaches
```
Regular meals
Sleep
Stress reduction - Meditation, activity pacing
Reduce caffeine
Exercise
Headache diary
```
114
Pharmacologic management for headaches
Simple analgesia - Acetaminophen 1000mg, ibuprofen 400mg or Naproxen 500mg, Cambia 50mg packet
Triptans (migraine specific) - ie. Sumatriptan, zolmitriptan
115
Major triptan s/e
Chest tightness/discomfort
116
Headache prophylaxis: when to do it
Headache >3d/month, no response to acute rx
Headache >8d/mo, due to risk of medication overuse
Disability despite acute meds
117
Headache prophylaxis
```
Tricyclics (ie. amitriptyline)
BB (ie. propranolol)
CCB (ie. verapamil)
Anticovulsants (ie. valproate, topiramax) - for severe chronic migraines
Botox
```
118
Headache supplements
Riboflavin (standard adult dose 400mg daily)
Coenzyme q10
Magnesium
119
HIV transmission counselling
* Most ppl get HIV by having unprotected vaginal or anal sex with someone who has HIV
* Can also be passed during unprotected oral sex (low risk)
* Can be passed through sharing drug equipment (i.e needles)
* Can be passed to others even if you don’t have symptoms
* CANNOT be spread by casual contact (ie. kissing, sharing drinking glasses)
120
Most common STI
Chlamydia
121
Who to screen for chlamydia
* Symptomatic
* At-risk asymptomatic patients - women <24yo, pregnant, new or many sexual partners, MSM, sexually active HIV-infected individuals of any age
* Note - persons who engage in receptive anal intercourse (particularly MSM) warrant screening at both urogenital and rectal sites
* Any pt with documented gonococcal infix should also undergo chlamydia testing
* Any pt who has been treated for chlamydia should be rescreened 6mo after tx
122
How long after tx should pts be retested for chlamydia
3mo
123
Management of pt with recent known exposure to chlamydia (1-2wks)
Treat empirically
124
Components of complete tx of chlamydia
* Pregnancy test
* Active antimicrobial therapy
* Directed or empiric tx for concomitant gonococcal infection
* Testing for other STIs
* Discussion of need for HIV testing if HIV status is not known
* Counselling on abstinence of 1wk following tx
* Counselling to return for persistent or recurrent symptoms
* Retesting to evaluate for recurrent infection
* Tx of sexual partners (within 60d prior to infection or last known partner)
125
Chlamydia tx
Azithro 1g PO single dose
OR Doxy 100mg PO BID x 7d
Alternatively erythromycin or levofloxacin or ofloxacin
126
Who should receive test of cure for chlamydia tx
Pregnant patients
Persistent symptoms
Use of regimen with inferior cure rates (ie. erythromycin, amoxicillin)
Compliance uncertain
127
When to perform test of cure for chlamydia infection
No earlier than 3 wks after tx completed
128
Reportable STIs in BC
Chlamydia
Gonorrhea
Syphilis
HIV/AIDS
129
Gonorrhea microbiology
Gram negative coccus
130
Second most common STI
Gonorrhea
131
Sequelae of untreated STIs
```
PID
Perihepatitis/Fitz-Hugh-Curtis Syndrome
Infertility
Higher risk of ectopic pregnancy
Infection during pregnancy can lead to increased risk of PROM, preterm delivery, low birthweight infant
```
132
Characteristics of fitz-hugh-curtis syndrome
Sharp pleuritic pain to RUQ, n/v, fever
133
Female presentation chlamydia/gonorrhea
Cervicitis - abN vaginal d/c, intermenstrual vag bleeding, post-coital bleeding
Urethritis - dysuria, pyuria
Proctitis
conjunctivitis, pharyngitis, genital lymphogranuloma venerereum, reactive arthritis
134
Complications of pregnancy from chlamydia/gonorrhea
Chorioamnionitis, PROM, preterm birth, low birth weight, SGA, spontaneous abortions
135
Male presentation chlamydia/gonorrhea
```
Urethritis
Epididymitis
Prostatitis
Proctitis
conjunctivitis, pharyngitis, genital lymphogranuloma venerereum, reactive arthritis
```
136
Dx for chlamydia/gonorrhea
Men - first catch urine, urethral swab
Women - vaginal swab, endocervical swab
NAAT vs culture (culture gives you abx susceptibility)
Culture - urethral swab, cervical specimen, rectal specimen, pharyngeal specimen
Rectal or throat swab if symptomatic
137
Gonorrhea tx
Ceftriaxone 250mg IM single dose or cefixime 800mg PO AND azithromycin 1g PO single dose or doxy 100mg PO BID x 7d (chlamydia tx)
138
When to rescreen for gonorrhea tx
6mo after tx (all patients)
139
Why perform test of cure for gonorrhea
Only for:
* Pt dx with gonococcal pharyngeal infection
* Pt treated with non-recommended regimen
* Tx failure suspected
* Antimicrobial resistance to tx is documented
* Compliance uncertain
* Re-exposure to untreated partner suspected
* PID or disseminated gonoccal infection dx
* Pt is pregnant
2-3 wks after tx if via NAAT
3-7d after tx if via culture (needed for pregnant pts)
140
Plagiocephaly orthosis most effective when initiated at or before age of...
6mo
141
Treatment for torticollis
Physiotherapy
142
Honey should not be given until age
12mo
143
Conditions to always counsel patients on with undescended testicles
Testicular torsion
| Inguinal hernia
144
Eczema distribution toddlers
Scalp, forehead, cheeks, extensor surfaces
145
Eczema distribution older children/adolescents
Flexural areas of neck, elbows, wrists, knees, ankles
146
Eczema distribution adults
Flexural area, hands, feet, face
147
Alternative treatment to steroid creams for atopic dermatitis
Topical calcineurin inhibitors
For pts >2yo
Ie. Tacrolimus ointment (Protopic)
148
When to treat asymptomatic bacterial vaginosis
Pregnancy
| Prior to IUD insertion or gone procedure
149
Symptomatic bacterial vaginosis tx
Metronidazole 500mg PO BID x 7d
OR Metronidazole gel 0.75% x one applicator (5g) once a day intravaginally x 5d
OR Clindamycin cream 2% x one applicator (5g) intravaginally once a day for 7d
Alternate tx: Metronidazole 2g PO in a single dose OR Clindamycin 300mg PO BID x 7d
Single dose oral flagyl has higher relapse rate at one month
CanesBalance x 7d tx - helps reset vaginal pH
150
Bacterial vaginosis tx in pregnancy
Metronidazole 500mg PO BID x 7d or Clindamycin 300mg PO BID x 7d
Systemic rather than intravag tx is recommended in pregnancy
151
BV and pregnancy (screening and risks)
* ROUTINE screening in pregnancy is NOT recommended during pregnancy unless it is high risk pregnancy
* If high risk, screen at 12-16wks
* Risk of BV during pregnancy: PROM, chorioamnionitits, PTL, pre-term birth, post-c/s endometritis
152
Trichomoniasis tx
Metronidazole 500mg PO BID x 7d or 2g PO x 1d
153
Trichomoniasis symptoms
Inflammation (pruritus), frothy yellow d/c and elevated pH
154
Trichomoniasis pregnancy
May be a/w PROM, preterm birth, low birth weight
Note ASYMPTOMATIC PREGNANT women do NOT need to be treated
Tx: Metronidazole 2g PO in single dose for symptom relief OR metronidazole 500mg PO BID x 7d
155
Trichomoniasis partner tx
Partners always need to be tx regardless of symptoms
156
Causes for hyperprolactinemia
Prolactinoma
Hypothyroid (TRH inhibits PRL secretion)
Idiopathic
Drugs (ie. antipsychotics, SSRIs)
Chronic renal dz (inhibits PRL clearance)
Physiologic: pregnancy, nipple stimulation (not significant for non-lactating women/men), stress, food (minimal), chest wall injury
157
Clinical manifestations of hyperprolactinemia
Galactorrhea
Irregular menstrual cycles
Poor bone density
Headache/visual disturbances related to prolactinoma
Men: Hypogonadotropic hypogonadism (decreased T), ED, infertility, galactorrhea
158
Investigations for hyperprolactinemia
PRL
MRI sella
TSH
Renal function
159
Hyperprolactinemia treatment
1st line: Dopamine agonist (ie. cabergoline, bromocriptine)
2nd line: estradiol + progestin
Men: testosterone
Transphenoidal sx
160
Main differential for persistent forceful projectile vomiting in infant
Pyloric stenosis
| Get U/S!
161
Criteria for uncomplicated vaginal yeast infection
* Sporadic, infrequent episodes (= 3 epis/y)
* Mild-mod signs/symptoms
* Probable infection with Candida albicans
* Healthy, nonpregnant woman
* Immunocompetent woman
162
Criteria for complicated vaginal yeast infection
* Severe signs/symptoms
* Candida species other than C. Albicans (ie. C. Glabrata)
* Pregnancy, poorly controlled diabetes, immunosuppression, debilitation
* Hx of recurrent (>/=3/y) culture-verified vulvovaginal candidiasis
163
Yeast infection tx
```
Fluconazole 150mg PO x1 dose
OR Clotrimazole (Canesten) topical x 7d
```
164
Yeast infection tx during pregnancy
Topical clotramiazole x 7d
165
Age indication for Shingrix
>50yo
166
Time frame after Zostavax to give shingrix
At least 1y
167
Time frame after shingles to give shingrix
At least 1y
168
Shingrix schedule
2 doses at least 2-6mo apart
| No booster needed
169
Indications to dose reduce apixaban
```
Any 2 of:
1. Age >/= 80yo
2. Body weight =60kg
3. Serum creatinine >/= 133
then reduce dose from 5mg BID to 2.5mg BID
```
170
Don't miss abdo pain causes in peds
Intussusception
Appendicitis
Volvulus
Meckel's
171
3 most common causes of SBO
Adhesions
Bulges (hernias)
Cancers
172
4 most common causes of LBO
Cancer
Diverticulitis
Volvulus
Fecal impaction
173
RUQ pain ddx
```
Hepatitis
Gallstones
Cholangitis
Cholecystitis
Liver abscess
```
174
Epigastric pain ddx
Peptic ulcer
Esophagitis
Pancreatitis
Gastric CA
175
LUQ pain ddx
Splenic abscess
Splenic rupture
Splenic infarct
176
Flank pain ddx
Renal colic
| Pyelonephritis
177
Peri-umbilical ddx
Early appendicitis
Mesenteric adenititis
Meckel's diverticulitis
178
RLQ pain ddx
Late appendicitis
Crohn's dz
Ectopic preg
Ovarian cyst
179
Suprapubic pain ddx
UTI
Urinary retention
Testicular torsion
180
LLQ pain ddx
Diverticulitis
UC
Ectopic pregnancy
Ovarian cyst
181
Red flags for abdo pain
```
VWBAD
Vomiting
Weight loss
Bleeding - hematemesis or melena or anemia
Anorexia (Age > 50)
Dysphagia
```
182
Lifestyle GERD management
```
Weight loss
Smoking cessation
Cut down EtOH, caffeine, spicy foods, foods with high fat content, carbonated beverages, peppermint
Avoid meals 2h before bed
Sleep with head of bed elevated
```
183
Pharmacotx for mild GERD
```
Anatacids (ie. Tums)
H2 blockers (ie. Zantac, Pepsid)
```
184
Pharmacy tx for mod/severe GERD
PPI challenge x 8wks
185
Omeprazole standard and low maintenance dose
| Brand name
20mg, 10mg
| Losec
186
Pantoprazole standard and low maintenance dose
| Brand name
40mg, 20mg
| Pantoloc, Tecta
187
Rabeprazole standard and low maintenance dose
| Brand name
20mg, 10mg
| Pariet
188
Risks a/w PPIs
* Risk of C.diff
* Microscopic colitis
* Magnesium malabsorption
* Calcium and # risk
* If Ca supplementation is needed, suggest Ca Citrate (does not require acid for absorption)
* Vit B12 malabsorption; absorption of B12 supplements is NOT affected
* Acute interstitial nephritis
189
Oral abx tx for diverticulitis
Tx duration 7-10d
Cipro 500mg PO q12h + metronidazole 500mg PO q8h
OR Levo 750mgPO daily + metronidazole 500mg PO q8h
OR Septra DS q12h + Metronidazole q8h
OR Amox-clav 875mg PO q8h
OR Moxi 400mg PO daily
190
Diverticulitis management counselling
Abx
Reassess clinically 2-3d after initiation of abx tx and weekly thereafter until complete resolution of symptoms
Rpt imaging is NOT indicated unless pt fails to improve clinically
Colonoscopy after complete resolution of symptoms
191
Hallmark signs for Crohn's
```
Fatigue
Prolonged diarrhea with abdo pain
Weight loss
Fever
+/- gross bleeding
```
192
Extra-intestinal manifestations of Crohn's disease
```
Arthritis
Erythema nodosum
Pyoderma gangrenosum
Uveitis
Primary sclerosing cholangitis
Vit B12 deficiency
Osteoporosis
Renal stones
Venous/arterial thromboembolism from hyper coagulability
Oral mucosal lesions
Psoriasis
Ankylosing spondylitis
```
193
Investigations for IBD
```
Hb
ESR
CRP
Folate
B12
Lytes - Na, K
Albumin
Fecal calprotectin
Antibody tests -pANCA, ASCA
Stool C&S, O&P, c.diff
Colonoscopy/biopsy
CT abdo (r/o abscess)
AXR (r/o obstruction, perforation, toxic dilatation)
```
194
Potential complications from IBD
```
Toxic dilatation
Stricture
Internal fistulae
Abscess
Perianal complications
Gallstones
Renal calculi
Psychological
Risk of carcinoma (colon CA)
```
195
Crohn's treatment - acute exacerbation
Prednisone 40mg PO daily
| Loperamide, Tylenol
196
Crohn's treatment - maintenance
5-ASA (Mesalazine)
+/- abx (Cipro + Flagyl) in pts who do not tolerate 5-ASA and do not improve within 3-4wks
Immunosuppression (Azathioprine, methotrexate)
Immunomodulators (ie. Infliximab, TNF-antagonist)
Surgery last resort
197
Ulcerative colitis clinical presentation
```
Rectal bleeding
Diarrhea +/- blood
Abdo cramps/pain with defecation
Tenesmus, urgency, incontinence
Systemic symptoms - fever, anorexia, weight loss, fatigue in severe cases
```
198
UC treatment - acute
Steroids (ie. methylprednisone 30mg IV q12h)
199
UC treatment - maintenance
5-ASA (topical suppository or enema, oral)
Immunosupressants for refractory cases (ie. azathioprine)
Biologics (ie. Infliximab)
200
Absolute C/I to OCP
```
Known/suspected pregnancy
Undx abN vaginal bleeding
Prior thromboembolic events, thromboembolic disorders, active thrombophlebitis
Cerebrovascular or CAD
E-dependent tumours (breast, uterus)
Impaired liver fxn a/w acute liver dz
Congenital hypertriglyceridemia
Smoker age >35yo
Migraines with focal Neuro symptoms (excl aura)
Uncontrolled HTN
```
201
Thromboembolic d/o C/I in OCP users
Factor V Leiden
Protein C or S
Antithrombin III
202
Relative C/I to OCP
```
Migraines (non-focal with aura <1h)
DM complicated by vascular dz
SLE
Controlled HTN
Hyperlipidemia
Sickle cell anemia
Gallbladder dz
```
203
Syphilis test
Treponemal (EIA) - reactive vs nonreactive
| vs non-treponemal (RPR, VDRL) - quantitative ab
204
Syphilis tx - early
Benzine penicillin G 2.4 million U in single dose
205
Syphilis tx - late or tertiary
Benzathine penicillin G 2.4 million U weekly x 3 wks to total of 7.2 million U
206
Gluten found in what types of foods
```
BROW foods
Barley
Rye
Oats
Wheat
```
207
Genes a/w celiac
HLA-DQ2
| HLA-DQ8
208
Investigations to order celiac
```
Serum tTG-IGA
If +ve --> requires endoscopy with small bowel bx
Fe
Ca
B12
```
209
Emergency contraception options
```
Plan B (Progestin pill)
Copper IUD
Ulipristal acetate (Ella)
```
210
Copper IUD for emergency contraception
Most effective
| 99% effective if inserted up to 5d after unprotected intercourse
211
Plan B for emergency contraception
Least effective
Reduces change of pregnancy by ~50% if taken up to 72h after unprotected intercourse
Some efficacy up to 5d after
212
When to take plan B
If you forgot to take one of your oral contraceptive pills for more than a 24-hour period and you engaged in unprotected intercourse during the day of the missed pill or within five days before the missed pill, consider taking Plan B® to prevent an unwanted pregnancy
213
When to start contraception after ulipristal acetate
5d after
214
C/I to progesterone only contraception
Current breast CA
Pregnancy
Hypersensitivity to progesterone
215
C/I to IUD
```
Pregnancy
Current, recurrent or recent (within 3mo) STI or PID
Puerperal sepsis
Immediate post-septic abortion
Severely distorted uterine cavity
Unexplained vaginal bleeding
Cervical or endometrial cancer
Malignant trophoblastic dz
Breast CA (Current)
Copper allergy
```
216
Combined hormal contraception options
OCP
Evra patch
Nuva ring
217
Progesterone only contraception options
Micronor
Depo-provera
IUD
218
Evra patch
1 patch weekly
Similar s/e to OCP + local skin irritation
May be less effective in women weighing >90kg
219
Vaginal contraceptive ring
1 ring monthly
| Similar s/e to OCP + vaginitis, leukorrhea, vag discomfort, expulsion
220
Combined contraception MOA
Inhibits ovulation
Endometrial effects
Cervical mucus effects
Tubal peristalsis
221
Progesterone only contraception MOA
Cervical mucus changes
Impaired sperm motility
Possible inhibition of ovulation
222
Micronor
1 pill daily, no pill-free interval
| S/E: Irregular bleeding, headache, bloating, acne, breast tenderness
223
Depo provera
1 injection IM q12-13wks
Amenorrhea occurs in 55-60% of users at 12mo
S/E: menstrual irregularities, HA, decreased libido, nausea, breast tenderness, weight gain, mood effects (not proven in studies)
Risks: delayed return of fertility, decreased BMD
224
Common S/E from contraception
Nausea, breast tenderness, headaches, and unscheduled bleeding
These symptoms are typically mild and resolve within a few cycles.
Unscheduled bleeding can also occur outside of CHC initiation, and amenorrhea can develop as well
225
Don't miss abdo pain causes in adults
Ruptured AAA
| Ruptured ectopic pregnancy
226
Dizziness don't miss dx
```
ACS
PE
Stroke
Dissection
Hypoglycemia
```
227
Ddx for peripheral vertigo
```
Idiopathic
Meniere's
BPPV
Acoustic neuroma
Trauma
Drugs
Labyrinthitis/Vestibular neuritis
```
228
HINTS test for vertigo
Head Impulse
Nystagmus
Test of Skew
229
Reassuring HINTS exam
Abnormal head impulse
Horizontal unidirectional nystagmus
No skew deviation
(all support peripheral vertigo)
230
3 classes of drugs that suppress vestibular system
1. Antihistamines
2. Benzodiazepines
3. Antiemetics
231
Tx for BPPV
Epley's maneuver
Pharmacotherapy with antihistamine, benzos, antiemetic or serc
Vestibular rehab
Steroids have no role
232
Meniere's triad
Vertigo
Tinnitus
Hearing loss
233
Condition for which serc is actually indicated
Meniere's
234
Meniere's etiology
Endolymphatic hydrops (excessive build up of endolymphatic fluid) cause distortion and distention of the membranous, endolymph-containing portions of labyrinthine system
235
Meniere's dx
* >/=2 spontaneous episodes of vertigo, each lasting 20min-12h
* Audiometrically documented low-to mid-frequency sensorineural hearing loss in affected ear
* Fluctuating aural symptoms (reduced or distorted hearing, tinnitus or fullness) in affected ear
* Symptoms not better accounted for by another vestibular dx
236
Meniere's tx
Dietary triggers (high salt intake, caffeine, EtOH, nicotine, MSG, allergies)
Stress
Vestibular rehab
Pharm: Betahistine 8-16mg PO TID
Diuretics (HCTZ, Lasix)
Benzos
Very severe, unresponsive to lifestyle - systemic glucocorticoids (Prednisone 50mg PO x 7d), intratympanic glucocorticoids weekly up to 3x
237
Vestibular neuronitis/labyrynthitis
Viral or post-viral inflammatory disorder affecting CNVIII
Pure vestibular neuritis - auditory fxn preserved
Labyrynthitis: Unilateral hearing loss
Presents - severe vertigo with N/V, gait instability (fall toward affected side)
238
Vestibular neuronitis/labyrynthitis tx
Prednisone x 10d taper
Symptomatic tx of N/V
Vestibular rehab
239
Ramsay Hunt
VZV reactivation
| Triad of ipsilateral facial paralysis, ear pain and vesicles in auditory canal or on auricle
240
Ramsay hunt tx
Valacyclovir 1g PO TID x 7-10d AND prednisone 1mg/kg x 56d without taper
241
1st degree AV block
Prolonged PR interval (>200ms)
Causes:
-Pts with slow resting HR
-Underlying structural abN of node
-Increase in vagal tone that causes reduction in rate of impulse conduction
-Drugs that impair slow nodal conduction (ie. BB, CCB)
-MI
-Infiltrative and dilated cardiomyopathies
-Certain muscular dystrophies
Tx:
No tx if asymptomatic
242
Wolff-Parkinson White Syndrome
```
Pre-excitation plus palpitations
Re-entry rhythm involving AV node, atria, accessory AV pathway (Kent bundle) and ventricles
ECG changes characterized by:
- Delta wave (slurred slow rise of QRS)
- Short PR
- Prolonged QRS
```
243
Ddx for narrow complex tachycardia
```
Regular:
-ST
-SVT
-AVNRT
-AVRT
-Aflutter
Irregular:
-AFib
-Aflutter with variable AV conduction
-Multifocal atrial tachycardia
```
244
Ddx for wide complex tachycardia
```
Regular:
-VTach
-SVT with aberrancy (BBB)
Irregular:
-Afib with BBB
-Aflutter with BBB
```
245
Pericarditis tx
Viral: Combo tx with colchicine and and NSAIDs
| Tx duration: Treat while symptomatic then tapering once pt is symptom free for at least 24h. Colchicine continued x 3mo.
246
PE ECG findings
```
S1QIIITIII
Present in 10-15% of cases of PE
-Large S wave in lead I
-Small Q wave in lead III
-Inverted T-wave in lead III
Inverted T-waves in anterolateral leads and rightward axis
```
247
Causes for prolonged QT
```
Hypothermia
HypoK
HypoMg
HypoCa
Acute MI
Elevated intracranial pressure
Drugs with Na channel blocking agents (ie. TCAs,)
Congenital prolonged WT syndrome
```
248
Sinusitis PODS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal purulence/discoloured postnasal Discharge
AnoSmia (loss of Smell)
249
Diagnosing bacterial sinusitis
>7d
MUST have nasal obstruction or nasal purulence/discoloured postnasal discharge AND at least one other PODS
Consider if worsening after 5-7d
Symptoms persist >7d without improvement
Presence of purulence for 3-4d with high fever
250
2 most common pathogens associated with sinusitis
Strep pneumo
| H. influenza
251
5 step sinusitis treatment
1. Intranasal steroids (Nasonex 2 sprays/d)
2. Nasal saline rinse
3. Advil
4. Decongestant (Can use Advil Sinus)
5. Steam
252
Sinusitis abx
1st line: Amox 500mg PO TID or 875mg BID
If beta-lactam allergy: Doxy 100mg PO BID or 200mg PO daily
2nd line: Amox-clav 500mg/125mg PO TID or 875/125mg PO BID
x 5-7d
253
Buckle fracture
Occurs at distal metaphysic where bone is most porous
Usually in younger children
Tx: Removable splint for immobilization, possible below elbow vast depending on degree of initial pain/anticipated activity of child, parental preference
Splint x 3wks
Increased risk of break x 6wks
F/U GP
No need for Ortho f/u if uncomplicated
Consider ortho f/u if radius and ulna #, bowing of arm, diminished ROM, continued pain, parental concerns
254
CURB-65
```
Confusion
BUN >7
RR >/= 30
Systolic BP <90mmHg or Diastolic -60mmHg
Age >/=65yo
Inpt tx if >1
```
255
COPDe low risk mgmt (<4 exacerbations/yr and at least 2 of increased sputum purulence, increased sputum volume, increased dyspnea)
1. O2 to keep sat 88-92%
2. ANTIBIOTICS
Amox 1g PO TID
OR
Doxy 200mg PO once then 100mg PO BID
OR
Septra 1DS tab PO BID
Treat 5-7d
3. Prednisone 40-60mg PO daily x 5d
4. SABA +/- SAMA
256
COPDe high risk mgmt (>4 exacerbations/y and at least 2 of increased sputum purulence, increased sputum volume, increased dyspnea) OR failure of first line agents above OR abx in past 3mo
1. O2 to keep sat 88-92%
2. ANTIBIOTICS
Amox-clav 875-125mg PO BID x 5-10d
OR
Cefuroxime 500-1000mg PO BID x 5-10d
OR
Levofloxacin 750mg PO x5d
OR
Azithromycin 500mg PO daily x 3d
OR
Clarithromycin 500mg PO BID or 1000mg PO XR x 5-10d
3. Prednisone 40-60mg PO daily x 5d
4. SABA +/- SAMA
257
Wellen's sign
Biphasic T-wave pattern high specific for large proximal LAD obstructive lesion
Best treated with PCI
Does not respond well to medical management
258
3 red flags of red eye
1. Pain
2. Decreased acuity
3. Anisocoria
259
4 risks of eye steroids
1. Corneal perforation
2. Open angle glaucoma
3. Cataracts
4. Corneal ulcers
260
Iritis
```
Constant photophobia
Miosis, distorted pupil
Blurred vision
Perilimbal haze
Fluoroscein normal
Tx: Referral for steroids (think about systemic cause)
```
261
Scleritis
SEVERE constant boring pain esp at night
Photophobia
PERL
Decreased visual acuity
Whole eye can be DEEP red/blue/purple hue
Fluoroscein normal
Tx: referral for steroids
262
Top cause of scleritis in BC
Syphillis
263
Episcleritis
```
Irritation but no sig pain
Tears, no pus no AM crusting (sealed in by conjunctiva)
PERL
Normal VA
Focal redness
Normal fluorescein
Red area will be mobile if moved with moist q-tip
Tx: Artificial tears
```
264
Keratitis
Inflammation of cornea
Painful & FB sensation, difficulty keeping eye open, miserable
Viral - watery, bacterial - possibly purulent
PERL but may have haze or branching pattern on cornea
Blurred vision, halos around lights
Diffuse erythema, maybe perilimbal
On fluorescein: +HSV - branching pattern, +Bacterial - corneal ulceration
Tx: Refer URGENTLY to ophtho
265
Conjunctivitis
```
NO PAIN just irritation
Viral/allergic --> watery esp in AM
Bacterial --> Pus ESP in AM
PERLA
Normal visual acuity
Diffuse erythema
Normal fluorescein
Tx: If bacterial, erythromycin ointment
If contact lens wearer - copra 0.3% drops 1-2 drops QID x 5-7d
```
266
Glaucoma
```
Acute severe pain, tender, firm
Fixed hazy dilated pupil
Decreased visual acuity
Ciliary flush
Normal fluoroscein
Elevated IOP
Reduce pressure NOW and immediate referral
T.A.P
-0.5% timolol maleate
-1% apraclonidine
-2% pilocarpine
Oral meds may include acetazolamide, two x 250mg tabs in the office
IV meds may include acetazolamide or mannitol
```
267
Cardinal signs for orbital cellulitis
Ophthalmoplegia/diplopia
Decreased VA
Pain with EOM
268
Side effects of topical steroids
- Skin atrophy, dyspigmentation, striae, telangiectasia, acne/rosacea, periorificial dermatitis
* Maximum 4 weeks continuously to same area
269
CURB-65 Score
```
Confusion
BUN >7
RR >/= 30
Systolic BP <90mmHg or Diastolic BP = 60mmHg
Age >/= 65yo
Consider inpt treatment once >1
```
270
Low risk CAP
Low risk of macrolide resistance
Have not used abx within last 3mo
Live in area where there is not a high prevalence of macrolide resistant S.pneumo
271
Low risk CAP tx regimens
Amox + macrolide (ie. azithro, clarithro)
or monotherapy with amox, doxy or macrolide
x5-7d
272
High risk CAP
```
Recent abx use
Major comorbidity (ie. COPD, liver/renal dz, cancer, diabetes, CHF, EtOH, immunosuppression)
```
273
High risk CAP tx regimens
Amox or amox-clav or cefuroxime
| AND azithro or clarithro
274
Special inflammatory marker to consider ordering in pneumonia
Procalcitonin - rises in bacterial infections usually more for typical (ie. strep pneumonia or H. influenza) than atypical
275
1st degree AV block
Prolonged PR interval
276
2nd degree AV Block - Type 1
Progressive PR interval prolongation until non-conducted P-wave
277
2nd degree AV block - Type 2
PR interval remains unchanged prior to P wave that is not conducted
278
HypERcalcemia ECG changes
QT interval shortening
If severe, Osborn/Jwaves may be seen
If extreme, risk of VF arrest
279
Correcting Ca for low albumin
Every albumin drop by 10, Ca increase by 0.2
280
Most common cause of hypercalcemia
Hyperparathyroidism
281
How does hyperparathyroidism cause hypercalcemia
PTH increases Ca reabsorption at distal tubule and bone, decreased PO4 reabsorption at proximal tubule and increased calcitriol
282
HypOcalcemia ECG changes
QT interval prolongation through ST interval lengthening
| TdP may occur but less common than with hypoK or hypoMg
283
Well's criteria for DVT
```
Hx:
-Active CA
-Paralysis or casting-
-Bedridden >3d of sx within 3mo
-Hx of DVT
-Likely alt dx (-2)
Px:
-Calf swelling (>3cm)
-Superficial veins
-Unilateral edema
-Swelling of entire leg
-Localized pain over deep venous system
Low risk = 0
Mod risk = 1-2
High risk >2
```
284
Well's criteria for PE
-Symptoms of DVT (3)
-Other dx less likely (3)
-HR>100 (1.5)
-Immobilization/sx within 4 wks (1.5)
-Previous PE/DVT (1.5)
-Hemoptysis (1)
-Malignancy (1)
PE unlikely =4, PE likely >4
285
PERC score
```
Do if Well's is low
HAD CLOTS:
Hormone use
Age >/=50yo
DVT/PE hx
Coughing blood
Leg swelling
O2 sat <95%
Tachy >/= 100bpm
Sx or trauma requiring hospitalization last 4wks
if ANY are +ve, PERC can't be used to r/o pt
Do a D-Dimer if any are +ve
```
286
Tumour marker for ovarian CA
CA-125
287
Weber #: Type A
Fracture of lateral malleolus distal to syndesmosis
Tibiofibular syndesmosis intact
Deltoid ligament intact
Usually stable
Tx: Occasionally requires ORIF esp if medial malleolus #
288
Weber #: type B
Fracture of fibula at level of syndesmosis
At level of ankle joint, extending superiorly and laterally up fibula
Tibiofibular syndesmosis intact no widening of distal tibiofibular articulation
Variable stability
Tx: Non-weightbearing, refer to orthodox
289
Weber #: Type C
Fracture of fibula proximal to syndesmosis
Above level of ankle joint
Tibiofibular dynesmosis disrupted with widening of distal tibiofibular articulation
Med mall # or deltoid ligament injury present
Tx: UNSTABLE, requires ORIF
290
CHADS65
```
Age >/= 65 --> OAC
CHF
OR HTN
OR Diabetes
OR Prior stroke or TIA --> OAC
If CAD or PAD only --> anti-plt therapy
If no to all of the above --> no antithrombotic
```
291
Valvular AF
Mechanical heart valve
| Rheumatic moderate or severe mitral valve stenosis
292
Non-valvular AF
```
Mitral regurg
Aortic stenosis
Aortic insufficiency
Remote (3-6mo) tissue prosthetic heart valve
Remote (3-6mo) surgical valve repair
```
293
ACS management
Stabilize ABCs
Oxygen if O2 <90%
Antiplt - ASA 320mg AND Clopidogrel (if PCI) or Ticagrelor (if invasive), if CABG considered delay until after coronary angiogram
Anticoag - Unfractionated heparin (if PCI) or LMWH/enoxaparin (if fibrinolysis)
Nitro (avoid in right heart infarcts)
294
Modified parkland formula for burns
For burns >15% BSA children and >20% BSA adults
Ringer's Lactate = 2-4mL x % BSA x weight
Give half in first 8h, the other half in next 16h
Titrate to UO of 30-500cc/h or 1cc/kg/h
295
Trigeminal neuralgia tx
MRI to r/o vascular compression/brain lesion
1st line: Carbamazepine
2nd line: Gabapentin
