General Medicine Flashcards
Oral exam station snowflake mnemonic
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)
Epi dose for anaphylaxis
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
Glucocorticoid side effects, chronic use
Fragile skin Easy bruising Weight gain HTN Osteoporosis Myopathy GI perforation Increased risk of infections (ie. oral thrush or pneumocystis jiroveci PNA)
Classic ages for croup
6mo-3y
Croup common viruses
Parainfluenza virus types 1** (most common) and 3 Rhinovirus RSV Influenza Adenovirus
Croup ddx
Epiglottitis
Anaphylaxis
Foreign body aspiration or ingestion
Retropharyngeal/peritonsillar abscess
Croup dx
Clinical
Don’t routinely do XR but if you do, neck XR should show narrowing in subglottilc region (steeple sign)
Croup tx
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
Typical croup course
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
Ear exam acronym
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)
Primary otalgia ddx
OM OE Trauma Foreign body Impacted cerumen Eustachian tube dysfunction Perichondritis Barotrauma
Secondary otalgia ddx
Odontogenic causes TMJ disorders Upper cervical spinal dysfunction Parotitis Lymphadenitis Pharyngeal disorders Tonsillitis
Primary otalgia not to miss ddx
Neoplasms Skull-base osteomyelitis Herpes zoster Acute mastoiditis Cholesteatoma
Secondary otalgia not to miss ddx
Trigeminal neuralgia
Glossopharyngeal neuralgia
Head and neck malignancies
Temporal arteritis
Common bacterial causes for Otitis media (4)
Strep pneumo
H-influenza
Moraxella catarrhalis
Streptoccocus pyogenes
Common viral causes for OM (3)
RSV
Influenza
Rhinovirus
When to use abx for OM
All children 6mo-2y with BILATERAL AOM
Toxic appearing child
Persistent ear pain for 48h
Fever >39C within past 48h
If not giving abx for OM, f/u plan
Consider if mild ear pain, temp <39C in past 48h
F/U in 48h
OM treatment (incl duration)
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
Recurrent acute otitis media
> /= 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
Ped UTI oral abx tx
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)
Ped UTI IV abx tx
CTX
Cipro (if >1yo)
Amp + Gent
Anaphylaxis
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
Which peds patients should get kidney/bladder U/S following UTI/pyelo?
- 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
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
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
Peds PNA tx
Amox 40-90mg/kg/d divided TID
Ampicillin IV
CTX IV
HEADSS
Home Education/employment Activity Drugs/diet Safety Sexuality/suicide
Asthma dx in patients <6yo
- Hx (Recurrent wheezing, cough, difficulty breathing, chest tightness)
- P/E (Confirming airway obstruction/wheeze that improves with SABA)
- AND absence of alternative explanation
Asthma therapeutic trial
Daily moderate dose of ICS and SABA PRN
Trial 8-12wks
Discuss with fam in advance expected clinical improvements
Symptom diary
Asthma dx in patients 6-18yo
- Compatible clinical hx (recurrent wheezing, cough, difficulty breathing and chest tightness)
- Documented evidence of reversible obstruction or bronchial hyperactivity with LFT
- 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
If spirometry is normal but asthma dx still suspected…
Methacholine challenge or exercise challenge (typically require respirologist referral)
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
Asthma general tx plan
- SABA reliever
- Low-dose ICS + SABA reliever
- Med/high dose ICS + SABA inhaler OR Low dose ICS/LABA combo (ie. Symbicort)
Symbicort
Budesonide/Formoterol (ICS/LABA)
Advair
Fluticasone/Salmeterol (ICS/LABA)
Diskus or MDI
Zenhale
Mometasone/formoterol (ICS/LABA)
Breo Ellipta
Fluticasone/vilanterol
Pulmicort
Budesonide
Alvesco
Ciclesonide (ICS)
Flovent
Fluticasone
Drugs which can trigger or exacerbate asthma
Beta blockers
Aspirin and NSAID drugs
ACEi
Typical age for bronchiolitis
<2yo
Most common cause of bronchiolitis
RSV
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)
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?
Wellbutrin and eating disorder
C/I due to increase in sz risk
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)
Pharmacotherapy for eating disorder
SSRI - Fluoxetine
Esp helpful for binging
Screen time recommendations for peds
<2yo: not recommended
2-5yo: <1h/d
Avoiding screens at least 1h before bedtime
Typical 1st line pharmacotx for ADHD
Methylphenidate/Ritalin
Concerta (Methylphenidate XR)
2nd line tx for ADHD
Dextroamphetamine (ie. dexedrine, Vyvanse)
Dextroamphetamine and amphetamine salt combos (ie. adderrall)
F/U of pt on stimulant medication
q3mo, P/E annually
Height, weight, BP, pulse
Questionnaire for ADHD
SNAP IV - usually get parent and teacher to complete
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
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
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
Common comorbid dx with ADHD
Oppositional defiant disorder (up to 50%) Conduct d/o Anxiety Depression Learning disabilities
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
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
Anxiety diagnoses
GAD Panic d/o Social phobia Specific phobia Social anxiety Agoraphobia PTSD OCD
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
SSRI you have to worry about high doses with QTc
Citalopram/escitalopram
Anxiety medical ddx
Hyperthyroid
Pheochromocytoma
R/O causes for panic attack symptoms (ie. PE, MI)
SUBSTANCE ABUSE
MSE acronym
ASEPTIC Appearance and behaviour Speech Emotion (Mood/affect) Perception Thought content and process Insight and judgement Cognition
Anxiety workup to exclude medical cause
CBC
Fasting glucose
TSH
Urine toxicology
Anxiety pharmacotherapy
1st line : SSRI, SNRI
2nd line: TCA, benzo
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)
Depression diagnostic criteria
SIGECAPS Sleep changes Interest loss Guilt (worthless) Energy (lack) Cognition/concentration Appetite (wt loss) Psychomotor (agitation or lethargic) Suicide/death preoccupation
MDD pharmacotherapy
1st line: SSRIs, SNRIs
2nd line: TCAs, MAOs
Seroquel
Quetiapine
Atypical antipsychotic
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
Alcohol use in youth
<19 not recommended
Never more than 1-2 drinks at a time, never more than 1-2x per week
Standard drink
12oz beer
12 oz cooler/cider
5oz wine
1.5oz distilled alcohol
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
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?
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
3 categories for recovery goals
- Substance use and tx (ie. reduce use to x days/wk, listen to recovery podcast, 12-step meetings xtimes/wk, etc.)
- Exercise or wellness goal
- Creative/spirtual/community/relationship goals (ie. reconnect with old friend, call mom once a week, go to church)
Benzo contraindications
Severe respiratory insufficiency Hepatic dz Sleep apnea Myasthenia gravis Narrow angle glaucoma
Neuropathic pain tx options
Gabapentin
Pregabalin
TCAs
SNRIs
Acute alcohol withdrawal tx options
Benzos (CIWA protocol)
Anticonvulsants - gabapentin, carbamazepine, valproic acid
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
Alcohol use disorder recovery tx
1st line: Naltrexone, acamprosate
2nd line: Topiramate, gabapentin
Not recommended, refractory cases only: Disulfiram
Naltrexone prescribing notes
Wait 7d after last opioid use for opioid-dependent patients
Mu-opioid receptor antagonist (will precipitate opioid withdrawal)
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
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
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
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)
Smoking cessation pharmacotherapy options
- Varenicline/champix
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
Varenicline S/E
Irritability, restlessness, insomnia, constipation, other GI problems, abnormal dreams, nausea**
Varenicline dosing info
Patients choose a quit date
Start Varenicline tx 1-2wks BEFORE this date then completely stop
Can be done with NRTs
Major C/I with Wellbutrin
Decreases sz threshold
C/I in pts with hx of seizure d/o
Infertility workup
Day 3 LH, FSH, estradiol \+/- AMH Prolactin TSH Pelvic U/S Semen analysis =/- mid-luteal phase serum progesterone (1wk before expected menses)
Monthly pregnancy %
20: 30-40%
25: 25-35%
30: 20-30%
40: 5-7%
45: 1-2%
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
Assisted reproductive technologies
Intrauterine insemination (IUI) IVF
2 main agonist therapies for opioid use disorder
Suboxone (buprenorphine/naloxone)
Methadone
Methadone MOA
Full opioids agonist
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)
Naloxone MOA
Opioid antagonist
ONLY bioavailable if injected
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
Common classes of meds that methadone interacts with
Antiretrovirals
Anti-fungals
Rifampin
Methadone and ECG changes
Prolongs QTc interval
Consider getting ECG esp when on high doses
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)
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
Common false +ve on urine drug testing
Amphetamine
Common false -ve on urine drug testing
Clonazepam, lorazepam
Red flags for breast CA
- Breast lumps
- Nipple discharge
- Unusual nipple or areolar skin changes (ie. crusting, scaling, dimpling)
- Nipple inversion
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
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
Headache ddx
Migraine w/ or w/out aura Tension headache Cluster headache Temporal arteritis Idiopathic intracranial HTN SAH Bacterial meningitis Medication overuse headache
Lifestyle management for headaches
Regular meals Sleep Stress reduction - Meditation, activity pacing Reduce caffeine Exercise Headache diary
Pharmacologic management for headaches
Simple analgesia - Acetaminophen 1000mg, ibuprofen 400mg or Naproxen 500mg, Cambia 50mg packet
Triptans (migraine specific) - ie. Sumatriptan, zolmitriptan
Major triptan s/e
Chest tightness/discomfort
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
Headache prophylaxis
Tricyclics (ie. amitriptyline) BB (ie. propranolol) CCB (ie. verapamil) Anticovulsants (ie. valproate, topiramax) - for severe chronic migraines Botox
Headache supplements
Riboflavin (standard adult dose 400mg daily)
Coenzyme q10
Magnesium
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)
Most common STI
Chlamydia
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
How long after tx should pts be retested for chlamydia
3mo
Management of pt with recent known exposure to chlamydia (1-2wks)
Treat empirically
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)
Chlamydia tx
Azithro 1g PO single dose
OR Doxy 100mg PO BID x 7d
Alternatively erythromycin or levofloxacin or ofloxacin
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
When to perform test of cure for chlamydia infection
No earlier than 3 wks after tx completed
Reportable STIs in BC
Chlamydia
Gonorrhea
Syphilis
HIV/AIDS
Gonorrhea microbiology
Gram negative coccus
Second most common STI
Gonorrhea
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
Characteristics of fitz-hugh-curtis syndrome
Sharp pleuritic pain to RUQ, n/v, fever
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
Complications of pregnancy from chlamydia/gonorrhea
Chorioamnionitis, PROM, preterm birth, low birth weight, SGA, spontaneous abortions
Male presentation chlamydia/gonorrhea
Urethritis Epididymitis Prostatitis Proctitis conjunctivitis, pharyngitis, genital lymphogranuloma venerereum, reactive arthritis
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
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)
When to rescreen for gonorrhea tx
6mo after tx (all patients)
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)
Plagiocephaly orthosis most effective when initiated at or before age of…
6mo
Treatment for torticollis
Physiotherapy
Honey should not be given until age
12mo
Conditions to always counsel patients on with undescended testicles
Testicular torsion
Inguinal hernia
Eczema distribution toddlers
Scalp, forehead, cheeks, extensor surfaces
Eczema distribution older children/adolescents
Flexural areas of neck, elbows, wrists, knees, ankles
Eczema distribution adults
Flexural area, hands, feet, face
Alternative treatment to steroid creams for atopic dermatitis
Topical calcineurin inhibitors
For pts >2yo
Ie. Tacrolimus ointment (Protopic)
When to treat asymptomatic bacterial vaginosis
Pregnancy
Prior to IUD insertion or gone procedure
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
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
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
Trichomoniasis tx
Metronidazole 500mg PO BID x 7d or 2g PO x 1d
Trichomoniasis symptoms
Inflammation (pruritus), frothy yellow d/c and elevated pH
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
Trichomoniasis partner tx
Partners always need to be tx regardless of symptoms
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
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
Investigations for hyperprolactinemia
PRL
MRI sella
TSH
Renal function
Hyperprolactinemia treatment
1st line: Dopamine agonist (ie. cabergoline, bromocriptine)
2nd line: estradiol + progestin
Men: testosterone
Transphenoidal sx
Main differential for persistent forceful projectile vomiting in infant
Pyloric stenosis
Get U/S!
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
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
Yeast infection tx
Fluconazole 150mg PO x1 dose OR Clotrimazole (Canesten) topical x 7d
Yeast infection tx during pregnancy
Topical clotramiazole x 7d
Age indication for Shingrix
> 50yo
Time frame after Zostavax to give shingrix
At least 1y
Time frame after shingles to give shingrix
At least 1y
Shingrix schedule
2 doses at least 2-6mo apart
No booster needed
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
Don’t miss abdo pain causes in peds
Intussusception
Appendicitis
Volvulus
Meckel’s
3 most common causes of SBO
Adhesions
Bulges (hernias)
Cancers
4 most common causes of LBO
Cancer
Diverticulitis
Volvulus
Fecal impaction
RUQ pain ddx
Hepatitis Gallstones Cholangitis Cholecystitis Liver abscess
Epigastric pain ddx
Peptic ulcer
Esophagitis
Pancreatitis
Gastric CA
LUQ pain ddx
Splenic abscess
Splenic rupture
Splenic infarct
Flank pain ddx
Renal colic
Pyelonephritis
Peri-umbilical ddx
Early appendicitis
Mesenteric adenititis
Meckel’s diverticulitis
RLQ pain ddx
Late appendicitis
Crohn’s dz
Ectopic preg
Ovarian cyst
Suprapubic pain ddx
UTI
Urinary retention
Testicular torsion
LLQ pain ddx
Diverticulitis
UC
Ectopic pregnancy
Ovarian cyst
Red flags for abdo pain
VWBAD Vomiting Weight loss Bleeding - hematemesis or melena or anemia Anorexia (Age > 50) Dysphagia
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
Pharmacotx for mild GERD
Anatacids (ie. Tums) H2 blockers (ie. Zantac, Pepsid)
Pharmacy tx for mod/severe GERD
PPI challenge x 8wks
Omeprazole standard and low maintenance dose
Brand name
20mg, 10mg
Losec
Pantoprazole standard and low maintenance dose
Brand name
40mg, 20mg
Pantoloc, Tecta
Rabeprazole standard and low maintenance dose
Brand name
20mg, 10mg
Pariet
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
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
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
Hallmark signs for Crohn’s
Fatigue Prolonged diarrhea with abdo pain Weight loss Fever \+/- gross bleeding
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
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)
Potential complications from IBD
Toxic dilatation Stricture Internal fistulae Abscess Perianal complications Gallstones Renal calculi Psychological Risk of carcinoma (colon CA)
Crohn’s treatment - acute exacerbation
Prednisone 40mg PO daily
Loperamide, Tylenol
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
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
UC treatment - acute
Steroids (ie. methylprednisone 30mg IV q12h)
UC treatment - maintenance
5-ASA (topical suppository or enema, oral)
Immunosupressants for refractory cases (ie. azathioprine)
Biologics (ie. Infliximab)
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
Thromboembolic d/o C/I in OCP users
Factor V Leiden
Protein C or S
Antithrombin III
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
Syphilis test
Treponemal (EIA) - reactive vs nonreactive
vs non-treponemal (RPR, VDRL) - quantitative ab
Syphilis tx - early
Benzine penicillin G 2.4 million U in single dose
Syphilis tx - late or tertiary
Benzathine penicillin G 2.4 million U weekly x 3 wks to total of 7.2 million U
Gluten found in what types of foods
BROW foods Barley Rye Oats Wheat
Genes a/w celiac
HLA-DQ2
HLA-DQ8
Investigations to order celiac
Serum tTG-IGA If +ve --> requires endoscopy with small bowel bx Fe Ca B12
Emergency contraception options
Plan B (Progestin pill) Copper IUD Ulipristal acetate (Ella)
Copper IUD for emergency contraception
Most effective
99% effective if inserted up to 5d after unprotected intercourse
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
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
When to start contraception after ulipristal acetate
5d after
C/I to progesterone only contraception
Current breast CA
Pregnancy
Hypersensitivity to progesterone
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
Combined hormal contraception options
OCP
Evra patch
Nuva ring
Progesterone only contraception options
Micronor
Depo-provera
IUD
Evra patch
1 patch weekly
Similar s/e to OCP + local skin irritation
May be less effective in women weighing >90kg
Vaginal contraceptive ring
1 ring monthly
Similar s/e to OCP + vaginitis, leukorrhea, vag discomfort, expulsion
Combined contraception MOA
Inhibits ovulation
Endometrial effects
Cervical mucus effects
Tubal peristalsis
Progesterone only contraception MOA
Cervical mucus changes
Impaired sperm motility
Possible inhibition of ovulation
Micronor
1 pill daily, no pill-free interval
S/E: Irregular bleeding, headache, bloating, acne, breast tenderness
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
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
Don’t miss abdo pain causes in adults
Ruptured AAA
Ruptured ectopic pregnancy
Dizziness don’t miss dx
ACS PE Stroke Dissection Hypoglycemia
Ddx for peripheral vertigo
Idiopathic Meniere's BPPV Acoustic neuroma Trauma Drugs Labyrinthitis/Vestibular neuritis
HINTS test for vertigo
Head Impulse
Nystagmus
Test of Skew
Reassuring HINTS exam
Abnormal head impulse
Horizontal unidirectional nystagmus
No skew deviation
(all support peripheral vertigo)
3 classes of drugs that suppress vestibular system
- Antihistamines
- Benzodiazepines
- Antiemetics
Tx for BPPV
Epley’s maneuver
Pharmacotherapy with antihistamine, benzos, antiemetic or serc
Vestibular rehab
Steroids have no role
Meniere’s triad
Vertigo
Tinnitus
Hearing loss
Condition for which serc is actually indicated
Meniere’s
Meniere’s etiology
Endolymphatic hydrops (excessive build up of endolymphatic fluid) cause distortion and distention of the membranous, endolymph-containing portions of labyrinthine system
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
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
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)
Vestibular neuronitis/labyrynthitis tx
Prednisone x 10d taper
Symptomatic tx of N/V
Vestibular rehab
Ramsay Hunt
VZV reactivation
Triad of ipsilateral facial paralysis, ear pain and vesicles in auditory canal or on auricle
Ramsay hunt tx
Valacyclovir 1g PO TID x 7-10d AND prednisone 1mg/kg x 56d without taper
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
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
Ddx for narrow complex tachycardia
Regular: -ST -SVT -AVNRT -AVRT -Aflutter Irregular: -AFib -Aflutter with variable AV conduction -Multifocal atrial tachycardia
Ddx for wide complex tachycardia
Regular: -VTach -SVT with aberrancy (BBB) Irregular: -Afib with BBB -Aflutter with BBB
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.
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
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
Sinusitis PODS
Facial Pain/pressure/fullness
Nasal Obstruction
Nasal purulence/discoloured postnasal Discharge
AnoSmia (loss of Smell)
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
2 most common pathogens associated with sinusitis
Strep pneumo
H. influenza
5 step sinusitis treatment
- Intranasal steroids (Nasonex 2 sprays/d)
- Nasal saline rinse
- Advil
- Decongestant (Can use Advil Sinus)
- Steam
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
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
CURB-65
Confusion BUN >7 RR >/= 30 Systolic BP <90mmHg or Diastolic -60mmHg Age >/=65yo Inpt tx if >1
COPDe low risk mgmt (<4 exacerbations/yr and at least 2 of increased sputum purulence, increased sputum volume, increased dyspnea)
- O2 to keep sat 88-92%
- ANTIBIOTICS
Amox 1g PO TID
OR
Doxy 200mg PO once then 100mg PO BID
OR
Septra 1DS tab PO BID
Treat 5-7d - Prednisone 40-60mg PO daily x 5d
- SABA +/- SAMA
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
- O2 to keep sat 88-92%
- 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 - Prednisone 40-60mg PO daily x 5d
- SABA +/- SAMA
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
3 red flags of red eye
- Pain
- Decreased acuity
- Anisocoria
4 risks of eye steroids
- Corneal perforation
- Open angle glaucoma
- Cataracts
- Corneal ulcers
Iritis
Constant photophobia Miosis, distorted pupil Blurred vision Perilimbal haze Fluoroscein normal Tx: Referral for steroids (think about systemic cause)
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
Top cause of scleritis in BC
Syphillis
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
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
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
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
Cardinal signs for orbital cellulitis
Ophthalmoplegia/diplopia
Decreased VA
Pain with EOM
Side effects of topical steroids
- Skin atrophy, dyspigmentation, striae, telangiectasia, acne/rosacea, periorificial dermatitis
- Maximum 4 weeks continuously to same area
CURB-65 Score
Confusion BUN >7 RR >/= 30 Systolic BP <90mmHg or Diastolic BP = 60mmHg Age >/= 65yo Consider inpt treatment once >1
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
Low risk CAP tx regimens
Amox + macrolide (ie. azithro, clarithro)
or monotherapy with amox, doxy or macrolide
x5-7d
High risk CAP
Recent abx use Major comorbidity (ie. COPD, liver/renal dz, cancer, diabetes, CHF, EtOH, immunosuppression)
High risk CAP tx regimens
Amox or amox-clav or cefuroxime
AND azithro or clarithro
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
1st degree AV block
Prolonged PR interval
2nd degree AV Block - Type 1
Progressive PR interval prolongation until non-conducted P-wave
2nd degree AV block - Type 2
PR interval remains unchanged prior to P wave that is not conducted
HypERcalcemia ECG changes
QT interval shortening
If severe, Osborn/Jwaves may be seen
If extreme, risk of VF arrest
Correcting Ca for low albumin
Every albumin drop by 10, Ca increase by 0.2
Most common cause of hypercalcemia
Hyperparathyroidism
How does hyperparathyroidism cause hypercalcemia
PTH increases Ca reabsorption at distal tubule and bone, decreased PO4 reabsorption at proximal tubule and increased calcitriol
HypOcalcemia ECG changes
QT interval prolongation through ST interval lengthening
TdP may occur but less common than with hypoK or hypoMg
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
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
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
Tumour marker for ovarian CA
CA-125
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 #
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
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
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
Valvular AF
Mechanical heart valve
Rheumatic moderate or severe mitral valve stenosis
Non-valvular AF
Mitral regurg Aortic stenosis Aortic insufficiency Remote (3-6mo) tissue prosthetic heart valve Remote (3-6mo) surgical valve repair
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)
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
Trigeminal neuralgia tx
MRI to r/o vascular compression/brain lesion
1st line: Carbamazepine
2nd line: Gabapentin
