GP Flashcards
Diagnosis of Diabetes
Clinical symtoms (polyuria, polydipsia, unexplained weight loss) + random glucose or 2 hr 75 g glucose test >11 mmol/l + fasting glucose >7 mmol/l
Rapid Acting Insulin
Lispro, aspart, or glulisine
Long Acting Insulin
Insulin detamir (Levemir) lnsulin glargine (Lantus)
5 causes of Secondary Hypertension
CHAPS - Cushings, Hyperaldosteronism, Aortic Coarctation, Pheochromocytoma, Stenosis of the renal artery
Female Athlete triad
ammenorhea, eating disorder, osteoporosis
Treatment of chalmidya and gonorrhea
Gonorreha - ceftraixone 125 mg IM single dose and chlamidya - doxycline 100 mg BID 7 DAYS or azithromycin 1 g orally
Warfarin therapy indications
first episode DVT with transient risk factors: 3 months first episode DVT with ongoing risk factors - consider indefinite therapy first episdoe with no identifiable risk factors - 6-12 months or indefinite recurrent - indefinite
Treatment of acute sinusitis
symptoms improving within 5 days - symptomatic moderate symptoms that persist for more than 5 days - corticosteroids severe and resistant to corticosteroids - clarithromycin
Impotence
Inability to achieve or maintain an erection
Min number of sperm needed for pregnancy
1 million
Treatment of cluster headaches
abortive - oxygen, triptans, octreotide, dihyrdoergotamine prophylaxis - verapmail, ergotamine, prednisone, indomethacin
Hypercholestermia and HTN
beware that statins and verapamil together can lead to rhabdomyolysis and verapamil inhibits cytochrome p450 that normally breaks down statins
Treatment of V tachycardia
Amiodarone
Most common fractured bone in lower leg in children
Tibia
Prevntion of contrast induced nephropathy
Hydration with sodium bicarbonate
Indications for tonsillectomy
Recurrent, confirmed bacterial tonsillitis (>4 times/year), irrespective of the type of bacteria Compliations of acute tonsillitis such as peritonsilar abscess or septicaemia originating from the tonsils Peritonsillar abscess in a patient <40 years of age Suspected malignancy including marked asymmetry or ulceration Airway obstruction caused by sleep apnea, tonsils or disorder of dental occlusion Chronic tonsillitis is a relative indication – if causing bad breath, sore throat, gaggin and symptoms do not decrease with follow up
Treatment of athletes foot
Before putting on anti-fungals need to diagnose by taking a culture of scrappings - terbinafine 250 mg once/day for 12 weeks or itroconazole 200 mg bid 1 week/month for 3 months
Best initial therapy for acute cardiogenic pulmonayr edema
LMNO Loop Diuretics Morphine (venous dilation decreases preload) Nitrates Oxygen
Rhinitis medicamentosa
If you use decongestants for more than 3 days you get a rebound congestion on drug withdrawal. When used for several months, these agents can cause a rhinitis that is difficult to treat
Xerosis
pathologic drying of the that is especially common in the elderly and exacerrabated by winter and low humidity
Treatment of central vs nephorgenic DI
Central - vasopressin or desmopressin Nephrogenic - diuretics
Complications of nasogastric feeding
Diarrhea (most comon) - add anti-diarrheal agents to feed, aspiration, ucleration of nasal and esophageal tissues leading to strictures
Breast cancer incidence
1 in 9 will be diagnosed and 1 in 27 will die from breast cancer
Match elevated ACE elevated methylmanionic acid reduced haptoglobin elevated protoporphyrin
elevated ACE - sarcoidosis elevated methylmanionic acid - vitamin b12 deficiency reduced haptoglobin - hemolytic anemia elevated protoporphyrin - lead poisoning or iron deficiency
Preferred antibiotics for anerobic infection in the mouth
Clindaymycin or amoxicillin
Treatment of acne
Mild - topical benzoyl peroxide and/or topical antibiotics (erythromycin, clindamycin Moderate - Tetracycline, Doxycycline, erythromycin Severe - Oral isoretinoin (Accutane)
Causes of acanthosis nigricans
DM2 Obesity Familial Drung induced Malignant (gastric cancer) PCOS
Preferred site for emergent airway entry is
Through cricothyroid membrane above the cricoid cartilage. Note that during controlled circumstances, the preferred site would be the between the tracheal rings or thyroid isthmus
Patients taking isoniazid should also take what
Vitamin B6 (Pyridoxine) otherwise can result in coma, seizures, pins and needles sensation
Medical Management of Aortic Dissection
Beta blocker to decrease BP to 110 mmHg followed by nitroprusside
Thrombolytics contraindications
Severe hypertension Stroke within the preceeding 2 months Active bleeding Surgery within the preceeding 2 months Neoplasms or vascular abnormalities
Thrombolytics contraindications
Severe hypertension Stroke within the preceeding 2 months Active bleeding Surgery within the preceeding 2 months Neoplasms or vascular abnormalities
Secondary causes of osteoporosis
Decreased BMI Corticosteroids Vitamin D deficiency Excessive alcohol Hypogonadism
Differential Diagnosis for Hematuria
Generalized Medication - anti- coagulants Hemoglobinopathies - Anemia Leukemia Localized Neoplasm Infection - Tuberculosis, UTI Trauma Stones Glomerulonephritis
Casue of rheumatic Fever
Group A beta hemolytic streptococcus
Radical Prostatecomy
Prostate, seminal vesicles and ampula of vas deferens are removed
Investigations and treatment for BPH
Ix: Urine fr microscopy and culture, U&E to assess renal function, PSA. Urine flow test to see flor and urinary volume against time. U/S to assess urinary bladder volume and upper tract dilatation. Transrectal ultrasound and biopsy if BPH suspected. Voiding diary to see how bothersome symptoms are to patients
Tx:
Conservative - watchful waiting if symptoms are mild
Medical - alpha blockers which relax the prostatic smooth muscle tone increasing urinary flow and helping with obstructive symptoms. Side effect: Postural hypotension
5 alpha reductase inhibitors which block the conversion of testosterone to the more potent dihydrotestosterone
Surgical - Transurethral resection of the prostate (TURP) - patient palced in lithomy position and a resectoscope placed through urethra and diathermy is used to cut away the prostate. Diathermy is also used to minimize bleeding. Three way cathether is used to irrigate the bladder until the fluid is no longer blood stained
[Complications of TURP
General vs Specific
Early vs late
Early : Septic shock, bleeding and transurethral syndrome (absorption of hypotonic irrigation leading to electrolyte abnormalities 0 hyponatremia, fluid overload and hemolysis, brain edema. Treat transurethral syndrome with fluid restriction, diuretics and close observation. Note that saline solution cannot be used as it limits the use of diathermy
Late: Secondary hemmorhage, urethral strictures, impotence (65-80% experience retrograde ejaculation), recurrent prostatic growth and recurrent symptoms
Causes of bladder outlet obstruction
Urethral stricutres due to trauma, catherization or STI’s
BPH
Prostate cancer
Complications of BOO
Infections
Urinary stasis
Acute painful urinary retention
Chronic painless urinary retention
Hydronephrosis
Bladder calculi
Renal impairment
Treatment of Ca. P
Early - Radical prostatectomy, brachytherapy
Advanced - Medical - LHRH agonists, anti-androgens
Surgical - TURP
How do you differentiate between kidney and spleen
Kidney
- ballatable (place one hand on the abdomen - keep still and the other on the renal angle - raise)
- moves vertically down on inspiration
- resonant to percussion due to overlying colon
Spleen
- Notch
- Moves towards the right iliac fossa on inspiration
- Dull to percussion
Course of the ureter and sites of obstruction by stone
- Start at renal pelvis at L1/2 (12th rib), trabel down along the line of transverse processes towards the sacroiliac joint (where they cross over the iliac vessels). Travel downwards towards the ischial spines and then forward to the bladder.
- Common sites of obstruction are the pelviureteric junction, sacroiliac junction where theureter crosses the iliac vessels and the vesicoureteric junction
Treatment of ureteral stones
conservative - <4mm 90% pass, <7 mm 50% will mass
surgical - < 2 cm in size or in the upper third of kidney = Extracorporeal Shock Wave Lithotripsy and if that fails urethrescope
>2 cm = percutaneous removal
Stone in the lower third of kidney = ureteroscopy
DDx Dysuria
Infectious: cystitis, uretheritis, prostatits, epididymitis, orchitis, cervicitis, vulvovaginitis, vestibulitis, perineal inflammation/infection, TB
Neoplasm: RCC, UCC, Penis, Prostate, BPH, Vaginal/vulva
Calculi: Bladder, kidney, ureteral stone
Inflammatory: drug side effects, autoimmune, seronegative arthropathies, interstitial cystitis, pelvic pain syndrome
Hormonal: Endometeriosis, hypogonadism
Trauma: Catheter insertion, post-coital cystitis
Psychogenic: Somatization, MDD, stress
Other: Foreign body, contact sensitivity
Acute vs Chronic retention
Acute - medical emergency, pain and anuria with normal bladder volume, can lead to bladder rupture, immediate catherization needed
Chronic - assymptomatic, greatly increased bladder volume with detrusor hypertrophy and atony (later), intermittent catherization
Casues of Urinary Retention
Outflow obstructioon
- bladder neck/urethra - stone, neoplasm, clot, foreign body
- prostate - BPH, prostate cancer, prostatitis
- urethra - stricture, phimosis, traumatic disruption
Bladder innervation
- stroke, DM, post pelvic surgery, spinal cord (disc herniation, MS, injury)
Pharmacologic
- antihistaimes, anticholingerics, narcotics, antihypertensives (methyldopa)
Differential Diagnosis for Lumps in the Neck
Based on anatomical region: Posterior triangle
- cystic hygroma (cysts of watery fluid)
- dermoid cysts (cystic teratoma found at sites of embryological fusion)
Anterior triangle
- branchial cyst (retained elements of branchial cyst, lined wiht sq. epithelium, filled with cholesterol)
- branchial fistual/sinus
- chemodectomas (carotid body tumors that arise in front of the SCM)
Midline
- Goitre - diffusely swollen (graves, hashimoto, subacute thryoiditis, iodine deficiency, ingestion of goitrogens)
multiple nodules(cysts, adenomas) solitary nodule (cyst, tumor), adenomas, malignant tumors (follicular, papillary, lymphoma, anaplastic, medullary)
- parathyroid adenoma (very rarely is it a palpable neck lump)
Complications of Thryoid Surgery
Acute hemmorhage - LIFE THREATENING as it can casue airway compression. Intubate and remove sutures to evacuate hematoma
Recurrent laryngeal nerve damage - unilateral leads to voice horaseness, bilateral leads to airway obstruction requiring tracheostomy
Damage to the parathyroid glands - either due to their poor blood supply or inadvertent ecision producing hypocalcemia resulting in tetany (Trousseau’s, Chvostek’s)
Hypothyroidism
Discuss the staging of melanoma
Breslow thickness - dept of tumor in millimeters and give a good indication of prognosis
<0.76 99% survival over a 5 year period
- 76-1.50 - 90%
- 51-4.0 - 70%
>4 - <50%
The Clark level refers to how deep the tumor has penetrated into the layers of the skin.
Level I: confined to the epidermis (top-most layer of skin); called “in situ” melanoma; 100% cure rate at this stage
Level II: invasion of the papillary (upper) dermis
Level III: filling of the papillary dermis, but no extension in to the reticular (lower) dermis
Level IV: invasion of the reticular dermis
Level V: invasion of the deep, subcutaneous tissue
Define Hemoptysis and what are the main Causes of Hemopytsis
Hemoptysis is defined as >100-600 ml of blood in a24 hour period. The causes listed below can cause erosion of an artery or capillary in the pulmonary circulation and expectoration of blood. The greatest danger in massive hemptysis is not exsanguination but aspiration due to airway flooding with blood.
Main causes of hemoptysis include bronchits, bronchietasis, malignancy, TB, pneumonia, lung abscess, vasculitis, PE
Treatment: Bronchoscopy to identify site of bleeding followed by pulmonary arterial catherization
Causes of Esophageal Perforation and Signs of Esophageal Perforation
Signs - widened mediastinum, penumomediastinum, crackling sound under the sternum,
Casues: Instruemnt induced, medication induced (KCl) or caustic injury (pills dont pass immediately into the stomach - important to take pills upright and with fluids) , Barrets esophagus, Esophageal ulcer rupture, Boerhave syndrome (increased esophageal pressure, decreased intrathoracic pressure from chronic and excessive coughing, vomiting)
Leriche syndrome
Triad of symmetric atrophy of bilateral lower extremities, impotence and hip, thigh and buttock claudication due to aortoiliac occlusion
Radiological signs of
esophageal rupture
acute pancreatitis
perforated duodenal ulcer
esophageal rupture - penumomediastinum, mediastinal widenining, creptius under sternm
acute pancreatitis - left pleural effusion
perforated duodenal ulcer - air under diaphgragm
Define Episadias, hypospadias, peyronie’s disease
Episadias = abnormal urethral opening on the dorsal surface of the penis
Hypospadias = abnormal urethral opening on the ventral surface of the penis
Peyronie’s disease = fibrosis of the penis shaft causes an a bend upon erection
Casues of priapism
Low flow: leukemia, durg (prazosin), sicke cell disease, impotence treatment gone wrong
High flow: pudendal artery fistula from trauma
Causes of impotence
Vascular - decreased blood flow (test with papverine/PGE1 vascular injections)
Endocrine: decreased testosterone
Anatomic: Peyronies disease or other structural abnormality of erectily apparatus
Medications: Clonidine
Psychogenic: depression, anxiety
Neurologic: damage to nerves, DM, MS
DDx for RIF Mass
Acute Appendicitis
Cecal tumor
Soft tissue tumor (sarcoma)
Lymph node mass
TB
Actinomycosis
Transplant kidney
Iliac anneurysm
Causes of exopthalmos
Bilateral - Graves
Unilateral - Graves, tumors of the eyes (neurofibroma, granuloma, dermoid, optic nerve glioma), cavernous sinus thrombosis, pseudotumors of the orbit
Cardiac Tamponade
Accumulation of 100-200 ml of fluid in the stiff pericardial sac. Triad: Hypotension, Elevated jugular veins and Tachycardia. CXR shows small pleural effusion with normal cardiac sillhoute without tension pneumothorax
Signs on CXR of aortic injury from blunt chest trauma
Widened mediastimun
Left sided Hemothorax with right leaning mediastinum
Disruption of cardiac contours
Signs on CXR of esophageal rupture
Pneumomediastinum, pleural effusion
Diagnosis is confirmed with water soluble contrast esophagography
Signs of Mycoardial Contusion
Sternal fracture
New arrtyhmia
Tachycardia
Signs of Diaphragmatic Rupture
Abdominal pain referred to the shoulder, loss of diaphragmatic contours and diaphragmatic contents above diaphragm
Signs of Bronchial Rupture
Pneumothorax that does not resolve with chest tube placement, pneumomediastinum and subcutaeneous emphysema
Triad of chronic pancreatitis and clinical features
Triad = inflammation, pancreatic cell loss (necrosis), fibrosis
Clinical features = abdominal pain, DM, steatorrhea
DDx for epigastric pain
Gastritis/PUD
Perforated viscus
Acute cholecystitis
SBO
Ruptured AAA
Mesenteric ischemia/infarction
Biliary colic
Inferior MI/pneumonia
Cause of recurrent largyneal nerve palsy voice hoarseness
vocal cord abduction and adducion can occur with phonation but not with inspiration
Contraindications for lap cholecystectomy
Absolute Generalized abdominal sepsis
Major bleeding disorders
Late pregnancy
Relative Morbid Obesity
Choledocholithiasis
Obstructive jaundice
Acute gallstone pancreatitis
Intra-abdominal malignancy
Complications of lap cholecystectomy
(1) Conversion to open procedure (5%)
(2) Common bile duct / hepatic duct damage
(3) Cystic duct leak
(4) Bleeding
(5) Biloma
(6) Post-operative shoulder tip pain
(7) Retained bile duct stones
(8) Late hernia formation at port sites
Zenkers diverticulum
Outpouching of the pharynx between the upper border of the cricopharyngeus muscle and the lower border of the inferior cosntrictor muscle of the pharynx. Corresponds to a weak area called Killian’s dehiscence. Pharygenal pouches are caused by peristaltic activity pumping against resistance from uncoordinated muscle spasm. Though the deficit occurs posteriorly, swelling usually bulges to hte left side of the neck.
Causes and management of esophageal perforation
Causes: Trauma during endoscopy, foriegn body, spontaneous rupture from forceful vomitting (Boerhaaves sydnrome), ingestion of corrosive agents
Ix: CXR, CT, Contrast swallow
Tx: NG tube + antibiotics + PPI’s. Srugery to debride the mediastinum and placement of a T tube within the esophagus to provide drainage and formation of a controlled esophago-cutaneous fistula
Nissen fundoplication
Involves mobilizing the fundus of the stomach and wrapping around the lower end of the esophagus creating a high pressure area designed to prevent reflux
Define Peptic ulceration
Ulcer formation associated with acid and can occur at several sites namely duodenum (commonest), stomahc, esophagus, jejunum (Zollinger Ellsion syndrome), Meckels diverticulum (if there is ectopic gastric mucusa)
Can present with pain, dyspepsia, bleeding (acute or chronic), perforation, penetration, obstruction
Complicatroins of Peptic Ulcer Surgery
Early: Hemorrhage, Duodenal Stump leakage, failure of the stomach to empty and billous vomitting (occurig in 10% of patients)
Late: Dumping syndrome (early - right after meal; late - 1-2 hrs after meal), postvagotomy diarrhea, biliary vomitting, anemia (due to lack of intrisinc factor, vitamin B12 and iron), osteomalacia (due to lack of Vitamin D and calcium), recurrent ulceration and malignancy, alklaine gastritis, Blind loop syndrome (proliferation of bacteria in the long blind end loop leading to anemia, malnutrition and weight loss)
DDx of upper GI bleeding
Management of upper GI bleed
2 large IV cannula (14G) for fluid resuscitation
Blood sent for urgent cross match for 4 units, CBC, U&E, clotting (note that intestinal absorption will lead to an elevated urea level)
Urinary catheter to monitor urine output
IV PPI’s and coagulopathies todecrease pH
Endoscopy to determine source of bleeding - injection of adrenaline, endoscopic band ligation, injection sclerotherapy
If endoscopic measures fail, open surgery
Presenting complaints for Meckels diverticulum
Presents similar to appendicitis, bleeding (most common complication in tennagers), volvulus or intussception
Complications of large blood transfusions
Dilutionl thrombocytopneia
DIC (mismatched blood or patients underlying condition)
Coagulation factor dilution or consumption (esp 5, 8)
Hyperkalemia (due to storage)
Hypomagnesemia (occurs as it binds to citrate)
Ctrate toxicity (Citrate binds to Ca and Mg)
Acidosis/Alkalosis
Impaired O2 delivery with left shift of the dissociation curve
Hypothermia from lack of warming blood
Ways of assessing hydration status
Urine outout (most reliable)
Skin turgor
HR
Sunken eyeballs
mucus membranes
Capillary refill time
Treatment of anatomic snuffbox fracture
Non-displaced
- long arm thumb spica cast with hte wrist in in neutral position for 6 weeks followed by a short arm spica splint for an additional 6 weeks until union evident. After immobilization, active ROM exercises to the forearm, wrist and thumb should be performed 6-8 times daily. A wrist and tumb spica splint with the wrist in neutral position should be worn between exercise sessions and at night
Displaced
- ORIF amd then short arm thumb spica for 8-12 weeks until union evident. At 4 months - dynamic wrist flexion and extension. At 6 months - patient uses hand normally
Contraincations for use of succinycholine in rapid sequence intubation
Hyperkalemia is an absolute contraindication. Not to be used in patients with burns (due to rhabdomylysis), tumor lysis syndrome, demyelinating disorders (Guillian Barre)
Define Proteinuria and what are its causes
Normal protein excretion <150 mg/dl, consisting of albuin <30mg/dl of albuin. Rises to >300 mg/dl
Causes: Glomerular or tubular disease
DM
amyloidosis
HTN
interstitial nephritis
heavy metals
mutliple myeloma
pregnancy
CCF
Nephrotoxic drugs for which dose adjustment is needed
Aminoglycosides
Lithium
Digoxin
Ethambutol
Cephalosporins
Tetracycline
Procainamide
Sulfamethoxazole
CABG - which arteries are most commonly blocked and where are grafts taken from?
CABG - LAD, RCA, Left circumflex artery
Grafts taken from internal mammary/thoracic and great saphenous vein
Definition of Pulsus paradoxus and conditions that cause it
Drop in systolic pressure of >12mmHg due to increase in venous return during inspiration which decreases left ventricular filling and decreases systolic pressure .
Cardiac causes: Cardiac tamponade and pericaditis
Non-cardiac causes: Pneumothorax and Severe asthma
Describe lesion
Umbilicated, flesh colored , firm, dome shaped papules on the trunk. limbs and genital areas are characterized of a rash caused by molluscum contangiosum. This is an infectious rash that can be transmitted by skin to skin transmission and by sexual contact. It is caused by the pox virus, people with immunodeficiency are at increased risk of developing this condition. Rash is non-pruritic
DDx of Postural Hypotension
Drugs (vasodilators, alpha adrengergic antagonists)
Hypovolemia (dehydration, bleeding)
Addisons disease
Hypopituitarism
Autonomic (DM, Shy Drager syndrome)
Idiopathic (with age in the elderly)
Define apex beat
The most inferolateral point of visible or palpable pulsation of the chest wall due to movement of the apex of the heart. It corresponds to the point of maximal impulse. Note that the real apex (anatomical) is below it. The apex is felt as the heart assumes a more spherical shape on contraction and moves closer to the chest wall
Causes of bilateral hilar lymphadenopathy
Infection - TB, mycoplasma
Sarcoidosis
Malignancy - Lymphoma, carcinoma, mediastinal tumors
Organic dust disease
Extrinsic allergic alveolitis
Histocytosis x
DDx granulomatous diseases
Infection - Bacteria - TB, cat scratc Fungi- Cryptococcus
Autoimmune - primary biliary cirrhosis, granulomatous orchitis
Vasculitis - GCA, Takayasu’s arteritis, Polyarteritis nodosa
Organic dust disease (eg silicosis, berylosis)
Idiopathic - Chrons, Sarcoidosis, De Quervains thryoiditis
Extrinsic allergic alveolitis
Histiocytosis X
Causes of cor pulmonale
Lung disease - asthma, COPD, bronchiectasis, pulmonary fibrosis, lung resection
Pulmonary vascular disease - PE, pulmonary vasculitis, sickle cell disease, parasite infestation, pulmonayr HTN
Thoracic cage abnormality - kyphosis, scoliosis, thoracoplasty
Neuromusuclar disease - MG, motor neuron disease, poliomyelitis
Hypoventilation - sleep apnea, enlarged adenoids in childnre
Cerebrovascular disease
Causes of Hypoglycemia
Postprandial Hypoglycemia - Idiopathic, alimentary hyperinsulism (previous gastrectomy)
Fasting Hypoglycemia
- Secondary to overutilization of glucose (insulinoma, exogenous insulin (sulfonylureas), drugs like quinine and pentamidine
- Secondary to imparied glucose production (hormone deficiency (hypopituitarism, adrenal insuficiency), substrate deficiency (malnutiriton), drugs (EtOH, salicyclate toxicity), enzyme defects, cirtical illness, autoimmune hypoglycemia
Motivational Strategies for Behavioural Change
Pre-Contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
Complications of knee replacement
Intra-operative - fracture of the tibia or femur
Immediate - vascular injuries - superifcial femora, popliteal and genicular vessels
Early - DVT, PE, Peroneal nerve palsy, Infection,, fat embolism
Late - infection, loosening, periprosthetic fractures, patellar instability/fracture/disruption of extensor mechanisms
Signs of rhabomyolisis
Treatment of rhabdomylosis
Eleveated creatinine phoshokinase, red blood cells on dipstick but no actual RBC on microscopy, high K
Manitol and alkalinize urine
