High Yield Flashcards
What is Prinzmetal’s Angina
Coronary vasospasms that lead to transient ST elevations
Usually without an MI
Sx of Prinzmetal’s Angina
Chest pain, usually at rest
Occurs in the mornings with hyperventilation
Emotional stress or cold exposure
Not usually due to exertion
Dx of Prinzmetal’s Angina
EKG: Transient ST elevations
Angiography: No fixed stenotic lesions
Tx of Prinzmetal’s Angina
CCB
Nitrates prn
If acute sx present: ASA and Heparin until atherosclerosis is ruled out
What is Atrial Fibrillation
Irregularly irregular rhythm
No P-waves seen, usually at a rate of 350-600 bpm
How can you control Atrial Fibrillation
Rate Control with Vagal Maneuvers or Beta-Blockers
Rhythm Control with Cardioversion
If you cardiovert, the person must be on anticoagulation for 3-4 weeks prior to cardioversion
What is given for stroke prevention in a person with A.Fib
Warfarin or ASA Decision based on CHADS2 CHF HTN Age >75 DM Stroke, TIA, Thrombus (2 points) High risk: >2 points = Warfarin with INR 2-3 Moderate Risk: 1 = Warfarin or ASA Low Risk: 0 = Nothing or ASA
Sx of Atrial Fibrillation
Tachycardia, Palpitations, Fatigue
What is an Aortic Dissection
Tear in the innermost layer of the aorta (intima)
Usually due to cystic medial necrosis
What are risk factors for Aortic Dissection
HTN
Age 50-60yrs
Vasculitis, trauma, family hx
Collagen Disorders (Marfans, Ehlers-Danlos)
Sx of Aortic Dissection
Sudden onset of severe, tearing, ripping knife-like chest pain that radiates to the back
Decreased Peripheral Pulses
Variation in pulses between left and right side
HTN
Aortic Regurgitation
Dx of Aortic Dissection
MRI Angiography is gold standard
CT with contrast is becoming test of choice
CXR: Widening of mediastinum
Trans Esophageal Echo
Tx of Aortic Dissection
Surgery if in Ascending and with Sx
Medications with Non-Selective Beta Blockers (Labetalol) with Sodium Nitroprusside for Descending
What is Multifocal Atrial Tachycardia
Rhythm characterized by varying P-Wave morphologies with marked irregular PP intervals
Rate is 100-140 bpm
Seen with COPD
Sx of Multifocal Atrial Tachycardia
Palpitations
ASsociated with severe COPD
Tx of Multifocal Atrial Tachycardia
Treat underlying disease
Verapamil
May progress to A. Fib in some patients
What is Wolff-Parkinson-White
An accessory AV pathway via Kent bundles
They produce short PR intervals with delta waves (preexication) at the onset of a wide and slurred QRS complex which leads to early depolarization
Sx of Wolff-Parkinson-White
Palpitations, Syncope, Rapid, Regular Rhythm
Tx of Wolff-Parkinson-White
Vagal Maneuvers
Antiarrhythmics such as Procainamide, Amiodarone
Radiofrequency ablation is definitive
What is Mitral Stenosis
Obstruction of flow from the LA to LV
Leads to Pulmonary HTN
What causes Mitral Stenosis
Rheumatic heart disease
Sx of Mitral Stenosis
Right sided HF Pulmonary HTN, Hemoptysis Atrial Fibrillation Mitral Facies (flushed cheeks) Fatigue, exertional dyspnea, orthopnea
What murmur is heard with Mitral Stenosis
Diastolic Rumble at the Apex
Opening snap
Tx of Mitral Stenosis
Valvotomy in young pts
Repair preferred over Replacement
Dx of Mitral Stenosis
Ultrasound
What is Orthostatic Hypotension
A decreased in systolic blood pressure of 20 mmHg or a decrease in diastolic blood pressure of 10 mmHg within three minutes of standing, when compared to sitting or supine position
What causes Orthostatic Hypotension
Dehydration
Blood Loss
Neuro, cardiovascular or endocrine issues
Sx of Orthostatic Hypotension
Dizziness, lightheadadness, blurred vision, weakness, fatigue, Nausea, Palpitations, Headache
Syncope, Dyspnea, Chest Pain, Neck and Shoulder pain
Dx of Orthostatic Hypotension
Head-Tilt Table Test if autonomic dysfunction suspected
Measure BP: Lay flat for 5 minutes, then 1 minute after standing, and 3 minutes after standing
Heart rate increases of 100 bpm or by >30 bpm may indicate hypovolemia
Tx of Orthostatic Hypotension
Increased sodium intake
Fludrocortisone (causes Na retention)
Midodrine, an alpha-agonist that causes arterial and venous constriction
Indomethacin (NSAID) inhibits vasodilation
What is considered Hypertension
140/90 on 2 different readings for 2 different visits
What are complications of HTN
CAD, HF, TIA, STroke, Encephalopathy, Renal Stenosis, Retinal Hemorrhages
Sx of HTN
Fundoscopic: Papilledema means advanced stage, Arterial narrowing, A-V nicking, Soft exudates
Striae, Bruits over renal arteries
Tx of HTN
Goal is <140/90 If Diabetic or chronic renal disease: >130/80 Lifestyle Modification, Diet, Weight loss, Exercise, Limit Alcohol HCTZ is 1st line Furosemide Ace-I CCB Beta-Blockers Alpha-Blockers
What is Acute Bacterial Parotitis
Inflammation and infection of the partoid gland
What pathogen is most commonly associated with Parotitis
S. Aureus
Sx of Parotitis
Swelling of gland
Increased pain and swelling with meals
Tenderness and erythema of duct opening
What causes Acute Bacteria Parotitis
Usually due to dehydration or with chronic illness
Underlying Sjogren
Ductal obstruction usually by mucous plug
Tx of Parotitis
IV Abx: Nafcillin
Hydration, warm compresses, Lemon drops, massage of gland
Can take 2-3 weeks to heal
If Chronic: CT the person or Ultrasound
What is Cerumen Impaction
Wax buildup
What is recommended cleaning to avoid Cerumen Impaction
Usually self-cleansing
Clean external opening with washcloth over index finger without entering canal
Tx of Cerumen Impaction
Detergent ear drops (hydorgen peroxide and carbamide peroxide), mechanical removal, suction, or irrigation
Irrigation with warm water to avoid vestibular caloric response
Sx of Cerumen Impaction
Hearing loss (Conductive)
What is Papilledema
Optic disk swelling due to raised intracranial pressure
Usually bilateral
What causes Chronic Papilledema
Intracranial HTN and Cerebral Venous Sinus Occlusion
Space Occupying Lesion (Tumor) in brain, Abscess in brain
Increased CSF production
Cerebral edema
Sx of Papilledema
Headache, N/V
Vision usually well preserved
Dx of Papilledema
MRI or CT first to r/o mass effect
Lumbar puncture to check CSF pressure
Fundoscopic shows swollen optic disc with blurred margins
Tx of Papilledema
Diuretics (Acetazolamide) to decreased production of aqueous humor and CSF
What is an Orbital Floor “blowout” fracture
Fracture of the orbital floor (maxillary, zygomatic, palatine)
Sx of Blowout Fracture
Decreased visual acuity
Diplopia especially with upward gaze
Enophthalmos (sunken eye)
Orbital Emphysema (eyelid swelling with blowing the nose)
Epistaxis, Anesthesia to Anteriomedial Cheek
Dx of Blowout Fracture
CT scan
Tx of Blowout Fracture
Nasal Decongestants to decrease pain Avoid blowing nose Prednisone to decrease edema Abx (Unasyn or Clindamycin) Surgical Repair
What is a 2nd Degree Superficial Partial Thickness Burn Depth Appearance Sensation Capillary Refill Prognosis
Depth: Epidermis + Superficial portion of dermis
Appearance: Erythematous, pink, moist, weeping, Blistering
Sensation: Most painful of all burns, Very tender to touch
Capillary Refill: Refill intact, blanches with pressure
Prognosis: Heals in 2-3 weeks, No scarring
What is a 2nd Degree Deep Partial Thickness Burn Depth Appearance Sensation Capillary Refill Prognosis
Depth: Epidermis into deep portion of dermis
Appearance: Red, yellow, pale white, dry, Blistering
Sensation: Not usually painful
Capillary Refill: Absent
Prognosis: 3 weeks-2 months, Scarring Common
What is Molluscum Contagiosum
Benign viral infection of the Poxviridae family
Highly Contagious
Sx of Molluscum Contagiosum
Single or multiple dome-shaped, flesh colored to pearly-white, waxy papules with central umbilication
Curd-like material expressed from center if squeezed
Tx of Molluscum Contagiosum
Usually resolves in 3-6 months Imiquimod or Podophyllin Cryosurgery Electrodessication Topical Retinoids for severe cases in HIV
What is Thyroiditis
Hashimoto Thyroiditis due to Autoimmunity
Subacqute Thyroiditis
Infectious Thyroiditis
What is hashimotos Thyroiditis
Autoimmune, Most common thyroiditis in US
Elevated serum antithyroid antibodies attack thyroid gland
Sx of Hasimotos Thyroiditis
Hypothyroidism: Slow metabolism, fatigue, depression, weight gain
Dx of Hashimoto’s Thyroiditis
Positive thyroid antibodies
Thyroblobulin Antibodies present
Tx of Hashimotos Thyroiditis
Levothyroxine
What is Hepatic Encephalopathy
A state of disordered central nervous sytem function resulting from failure of the liver to detoxify noxious agents of the gut or hepatocellular dysfunction and portosystemic shunting
Cirrhosis is a cause
Sx of Hepatic Encephalopathy
Mild Confusion, Drowsiness, Stupor, Coma
High ammonia levels from protein breakdown
Asterixis (flapping tremor)
Dx of Cirrhosis
Ultrasound
Tx of Hepatic Encephalopathy
Lactulose: Converted to lactic acid which pulls ammonia into gut
Neomycin: Antibiotic that decreases ammonia-producing flora
Protein Restriction
What is IBD
Ulcerative Colitis and Crohn’s Disease
What is Ulcerative Colitis
Limited to Colon, begins in rectum and moves up
Mucosa and submucosa only
Sx of Ulcerative Colitis
LLQ colicky main
Tneesmus, Urgency
Bloody Diarrhea, Hematochezia
What do you see in a colonoscopy with Ulcerative Colitis
Uniform inflammation, ulcerations in rectum/colon, sandpaper appearance
Pseudo Polyps
What role does surgery have in Ulcerative Colitis
Curative
What is Crohn’s Disease
Affects any segment of GI from mouth to anus
Most common in terminal ileum
Transmural in nature
Sx of Crohn’s Disease
RLQ abdominal pain, weight loss
Diarrhea with no visible blood
What do you see in a colonoscopy with Crohn’s Disease
Skip Lesions, Cobblestone appearance
What role does surgery have in Crohn’s Disease
Non-Curative
Dx of IBD
Colonoscopy for both UC and Crohns
Upper GI series in acute flares with Crohns
Flex Sigmoidoscopy in acute flares with UC
Tx of IBD
Aminosalicylates (Oral Mesalamine, Topical Mesalamine, Sulfasalazine)
Corticosteroids
Immune Modifying Agents (6-mercaptopurine, Azathioprin, Methotrexate)
Anti-TNF Agents (Adalimumab, infliximab, certolizumab)
What is Acute Appendicitis
Obstruction of the appendix
Usually due to a fecalith
Inflammation, malignancy or foreign body
Sx of Acute Appendicitis
Anorexia, Periumbilica/epigastric pain that eventually is localized to RLQ
Nausea, Vomiting
Rebound tenderness, rigidity and gurading
Rovsing Sign: RLQ pain with LLQ palpation
Obturator Sign: RLQ pain with internal and external hip rotation with bent knee
Psoas Sign: RLQ pain with right hip flexion/extension (raise leg vs. resistance)
McBurney’s Point Tenderness: 1/3 distance from anterior superior iliac spine
Dx of Acute Appendicitis
CT Scan
Ultrasound, Leukocytosis
Tx of Acute Appendicitis
Appendectomy
What is Clostridum Difficile
Nosocomial/Iatrogenic
Organism overgrowht secondary to alteration of normal flora
Usually seen after abx use (Clindamycin) or Chemo
Sx of C. Diff
ABdominal cramps, diarrhea, fever, tenderess
Lymphocytosis
Pseudomembranous Colitis
Tx of C. Diff
Metronidazole
Vancomycin 2nd line
What is Primary Biliary Cirrhosis
Idiopathic autoimmune disorder of intrahepatic small bile ducts
Leads to decreased bile salt excretions, cirrhosis and End-Stage Liver Disease
Seen in middle-age women
Sx of Primary Biliary Cirrhosis
Asymptomatic, Usually incidental with high ALP
Fatigue, Pruritis, Jaundice, RUQ discomfort, Hepatomegaly
Dx of Primary Biliary Cirrhosis
Positive Anti-Mitochondrial Antibody
Increased ALP and Increased GGT
Increased ALT, AST, Bilirubin
Liver Biopsy
Tx of Primary Biliary Cirrhosis
Ursodeoxycholic Acid is 1st line: Reduces Progression
Cholestyramine and UV lights for Pruritis
-Cholestyramine binds bile acid in gut, reduces bile salts’ irritant effect on skin
What is a hemothorax
A type of Pleural Effusion
Gross blood in pleural space
Usually due to chest trauma
Sx of a Hemothorax
Asymptomatic Dyspnea Pleuritic chest pain Cough Decreased fremitis, Decreased breath sounds, dullness to percussion
Dx of Hemothorax
CXR: Se menisci (blunting of costophrenic angles)
Lateral Decubitus films are best
Tx of Hemothorax
If small, can observe
If large, Thoracentesis
If Traumatic: Surgical Exploration if more than 1,000 mL of blood are removed immediately after tube thoracostomy, if there is continued bleeding from chest, or repeated blood transfusions are required to maintain dynamically stable
What is COPD
Progressive irreversible airflow obstruction
Due to loss of elastic recoil and increased airway resistance
Includes Emphysema and Chronic Bronchitis
What are risk factors for COPD
Smoking
Alpha-1-Antitrypsin Deficiency (Alpha-1-Antitrypsin is protective for elastin in lungs from damage by WBC)
Occupational, Environmental exposures
What is Emphysema
Abnormal permanent enlargement of terminal airspaces
What is Chronic Bronchitis
Productive cough for >3months for 2 consecutive years
Sx of Emphysema
Accessory muscle use, tachypnea, prolonged expiration, hyperinflation, decreased breath sounds, decreased fremitus, barrel chest, Cachectic with pursed lip breathing
Sx of Chronic Bronchitis
Productive cough, Prolonged Expiration, Rales, Crackles, Rhonchi, WSheezing, Obese and Cyanotic
Dx of COPD
Pulmonary Function Tests are Gold Standard: Shows obstruction with decreased FEV1, Decreased FVC, and Decreased FEV1/FVC Ration (<70%). Shows Hyperinflation with Increased lung volumes, Increased RV, Increased TLC
CXR: Hyperinflation, Flat Diaphragm, Decreased Vascular Markings
EKG: Cor Pulmonale (RVH, RAE, RAD)
Tx of COPD
Oxygen is the only thing that will decrease mortality
Anticholingerigs + Beta-2-Agonists shows to be more effective when used together
Bronchodilators
-Anticholinergics (Tiotropium, Ipratoprium)
-Beta-2 Agonists (Albuterol, Terbutaline, Salmeterol)
-Theophylline
Corticosteroids (not used alone)
What is Asthma
Reversible hyperirritability of the tracheobronchial Tree
Results in bronchoconstriction and inflammation
Sx of Asthma
Dyspnea, Wheezing, Cough, Prolonged expiration with wheezing, hyperresonance
Dx of Asthma
Peak Expiratory Flow Rate: PEFR >15% from initial attempt indicates response to treatment (confirmed Asthma)
PFT is gold standard: Increased RV, Increased TLC
Tx of Asthma
SABA 1st \+Low dose ICS \+Low-dose ICS + LABA or Medium-dose ICS \+Medium-dose ICS + LABA \+High-Dose ICS + LABA \+High-dose ICS + LABA + Oral systemic corticosteroid
What are examples of Short-Acting Beta Agonist (SABA)
Alubetrol
Terbutaline
Epinephrine
What are examples of Long-Acting Beta Agonists (LABA)
Salmeterol, Budenoside, Formoterol, Fluticasone/Salmeterol (Advair)
What are examples of Inhaled Corticosteroids
Beclomethasone, Flunisolide, Triamcinolone
What is considered intermittent Asthma and what is the treatment of choice
<2x/day or >2x/week
Night: <2x/month
SABA: Albuterol inhaler
What is considered mild persistent Asthma and what is the treatment of choice
>2x/wk Night: 3-4x/month SABA + Low-Dose ICS (Albuterol + Beclomethasone/Flunisolide/Triamcinolone) FEV1 > 70%
What is considered moderate persistent Asthma and what is the treatment of choice
Daily sx Night: >1x/wk SABA + Low-Dose ICS + LABA (Albuterol + Beclomethasone + Salmeterol) OR SABA + Medium-Dose ICS FEV1 40-70%
What is considered severe persistent Asthma and what is the treatment of choice
Sx all day every day Night: Nightly SABA + High-Dose ICS + LABA Albuterol + Beclomethasone + Salmeterol) FEV1 <40%
What are the pathogens associated with Typical Pneumonia
S. Pneumo
H. Influenza
Kelbsiella
S. Aureus
What do you see on Xray with Typical Pneumonia
Lobar Pneumonia
Sx of Typical Pneumonia
Sudden onset of fever, productive cough with purulent sputum, pleuritic chest pain, Tachycardia, Tachypnea, Dullness to percussion, increased tactile fremitus, Egophony
What are the pathogens associated with Atypical Pneumonia
Mycoplasma
Chlamydia
Legionella
Viruses
What do you see on Xray with Atypical Pneumonia
Diffuse, Patchy Infiltrates
Sx of Atypical Pneumonia
Low Grade Fever
Dry, non-productive cough
Myalgias, malaise, sore throat, headache, N/V/D
Crackles, Rhonchi
Tx of Community Acquired Pneumonia (outpatient)
Macrolide or Doxycycline
Tx of Community Acquired Pneumonia (inpatient)
Beta-Lactam + Macrolide
or
Broad spectrum Fluoroquinolones (Levofloxacin, moxifloxacin, gemifloxacin)
Tx of Community Acquired Pneumonia (ICU)
Beta-Lactam + Macrolide
or
Beta-Lactam + Broad Spectrum Fluoroquinolone
Tx for Hospital Acquired Pneumonia
Need to cover for Pseudomonas
Beta-Lactam + Aminoglycoside/Fluoroquinolone
If MRSA suspected: Vancomycin
What is Acute Respiratory Failure
Respiratory dysfunction resulting in abnormalities of oxygenation or ventilation severe enough to threaten the function of vital organs
Sx of Acute Respiratory Failure
Hypoxemia, Dyspnea, Cyanosis, Restlessness, Confusion, Anxiety, Delirium, Tachypnea, Bradycardia, Tachycardia, HTN, Tremor
Dyspnea, Headache
Tx of Acute Respiratory Failure
Tx underlying disease
Maintenance of adequate gas exchange
Supportive Care
Oxygen, Positive Pressure Ventilation
Tracheal Intubation indicated if: Hypoxemia despite supplemental oxygen, upper airway obstruction, impaired airway protection, inability to clear secretions, respiratory acidosis, progressive fatigue, tachypnea, apnea
Mechanical Ventilation: Apnea, Acute Hypercapnia, Severe Hypoxemia, Progressive patient fatigue despite appropriate treatment
What pathogen causes Pertussis
Bordetella Pertussis
Whooping Cough
Sx of Pertussis
Catarrhal Stage: Insidious onset with lacrimation, sneezing, coryza, anorexia, malaise
Paroxysmal Stage: Bursts of rapid, consecutive coughs followed by deep, high ptiched inspiration (whoop)
Convalescent Stage: Beings 4 weeks after onset with decrease in frequency and severity of paroxysms of cough
WBC Elevated
Dx of Pertussis
Clinical or Nasopharyngeal Culture
PCR
Prevention of Pertussis
Vaccine (DTaP)
Adults tend to be reservoirs so Tdap vaccine for adolescents and adults
Pregnant women should receive a dose of Tdap for each pregnancy regardless of prior vaccination history
Tx of Pertussis
Erythromycin, Azithromycin, Clarithromycin
What is Acute Lymphocytic Leukemia
KIDS
Most common childhood malignancy
B-Cells, T-Cells
>20% BLASTS
Sx of ALL
Pancytopenia, Fatigue, Lethargy, Bone Pain
CNS sx: Headache, stiff neck, visual changes, vomiting
Pallor, Fatigue, Petechiae, Bruising
Hepatosplenomegaly
Dx of ALL
Bone marrow: Hypercellular with More than 20% blasts
Tx of ALL
Oral Chemo (Imatinib, Hydroxyurea) 90% remission
What is Chronic Lymphocytic Leukemia
50yrs or older
Most common leukemia in adults
Sx of CLL
Asymptomatic, usually noted on blood tests
Fatigue, Increased infections, Lymphadenopathy, splenomegaly, hepatomegaly
Dx of CLL
Peripheral Smear: Well-differentiated lymphocytes with scattered SMUDGE CELLS
Tx of CLL
Observation if indolent
Chronic: Oral Chemo
Acute Blastic Crisis: Oral chemo (combination is best)
What is Acute Myeloid Leukemia
50yrs or older
>20% blasts
Sx of AML
Anemia, Thrombocytopenia, Neutropenia
Splenomegaly, gingival hyperplasia
Leukostasis (WBC >100,000)
CNS sx: Headaches, confusion, TIA, CVA
Dx of AML
Auer Rods
?2-% blasts in bone marrow
Tx of AML
Combination Chemo
BMT
What is Chronic Myeloid Leukemia
Overproduction of myeloid cells
Sx of Chronic Myeloid Leukemia
Most Asymptomatic
Blastic Crisis causes sx (acute leukemia)
Dx of Chronic Myeloid Leukemia
Philadelphia Chromosome
WBC > 100,000
Increased LDH
Splenomegaly
Tx of CML
Oral Chemo
What is G6PD Deficiency
A hereditary enzyme defect that causes episodic hemolytic anemia because of the decreased ability of red blood cells to deal with oxidative stress
Associated with Heinz bodies that cause RBC membrane damage and removal by spleen
Sx of G6PD Deficiency
Hemolysis due to oxidative stress by infection or exposure to drugs (Sulfa, Bactrim, Quinolones)
Dx of G6PD Deficiency
Hgb < 8 g/dL
Bite cells seen in peripheral blood smear
Blister Cells
Heinz Bodies
Tx of G6PD Deficiency
None
Avoid things that cause oxidative stress like drugs and certain foods
What is Disseminated Intravascular Coagulation
Results from uncontrolled local or systemic activation of coagulation which leads to depletion of coagulation factors and fibrinogen as well as thrombocytopenia as platelets are activated and consumed
Associated with sepsis, cancer, trauma, and burns
Sx of Disseminated intravascular coagulation
Bleeding at multiple sites such as IV catheters or incisions
Dx of Disseminated Intravascular Coagulation
Early: Platelet and fibrinogen are normal
Progressive thrombocytopenia, Prolonged PT time
Elevated D-Dimer
Schistocytes on blood smear
HELLP Syndrome (Hemolysis, Elevated Liver Enyzmes, Low Platelets)
Tx of Disseminated Intravascular Coagulation
Tx underlying disorder (Antimicrobials, chemo, surgery, delivery if pregnant)
Blood products only if significant hemorrhage
What vaccinations are indicated for a person who received a Splenectomy
Pneumococcal
Meningococcal C Vaccine
Hib vaccine
Usually given 2 weeks prior to splenectomy or 2 weeks post-splenectomy
What is Bell Palsy
Idiopathic facial paresis of lower motor neuron type
Involves facial nerve
Thought to be due to reactivation of herpes simplex or varicella zoster virus
Sx of Bell Palsy
Facial paresis
Pain in ear first, then weakness but only lasts for a few days
Ipsilateral restriction of eye closure, difficultly eating
Taste disturbance
Inability to wrinkle forehead, smile on affected side, loss of nasolabial fold, drooping of corner of mouth
Tx of Bell Palsy
Spontaneous recovery without treatment
Steroids (Prednisolone) increases chances of full recovery if started early
Acyclovir or Valacyclovir only indicated when evidence of herpetic vesicles on external ear canal
What is a Subarachnoid Hemorrhage
Sudden, Thunderclap headache
Worst headache of my life
Arterial bleed between the arachnoid and pia
How does a Subarachnoid Hemorrhage occur
Usually a Berry aneurysm rupture, AVM
Sx of Subarachnoid Hemorrhage
Thunderlap sudden headache, worst headache of my life, stiff neck, photophobia, delirium
Dx of Subarachnoid Hemorrhage
CT
If Negative, do LP: Xanthochromia (RBC), Increased CSF pressure and no focal neurological sx
Tx of Subarachnoid Hemorrhage
Supportive
Bed rest, stool softeners, anti-anxiety meds
What is a Brain Abscess
Presents as an intracranial space-occupying lesions and arises as a sequela of disease of ear or nose
Sx of Brain Abscess
Headache, Drowsiness, Inattention, Confusion, Seizures
Signs of increased intracranial pressure then focal neurologic deficits
Dx of Brain Abscess
CT: shows area of contrast enhancement surrounding low-density core
MRI
Tx of Brain Abscess
IV antibiotics and surgical drainage (aspiration or excision)
Ceftriaxone, Metronidazole, Vancomycin
Serial CT scans every 2 weeks to show abscess removal
Dexamtheasone to reduce edema or IV Mannitol
What does C5 nerve control
Arms and hands
Sx of C5 injury
Can raise arms and bend elbows
Some or total paralysis of wrists, hands, trunk and legs
Can speak using diaphragm, but breathing will be weakened
Will need assistance with most ADL
What function does UMN have
Connects cortex to LMN (in spinal cord)
Neurotransmitter glutamate transmits nerve impulses from UM to LMN (via glutamate receptors on receiving LMN)
What causes UMN lesions
Stroke (CVA)
MS
Cerebral Palsy
Brain or Spinal Cord Damage
Sx of UMN Lesions
Spacity (Hypertonia) with Increased DTR due to removal of inhibitory influence of cortex
Weakness
No Fasciculations
Upward Babinksi reflex (extension of great toe and fanning outward of other toes)
Little or No Muscle Atrophy
What is Nephrolithiasis
Stones in the urinary system
Most are Calcium, Uric Acid, Struvite Stones, or Cystine
Sx of Nephrolithiasis
Renal Colic: Sudden onset of constant upper/lateral back pain over the CVA radiating to groin
Nausea/Vomiting
Inability to find comfortable position
Positive CVA tenderness
Dx of Nephrolithiasis
Urinalysis: Microscopic hematuria
Noncontrast CT is 1st diagnostic test
Renal Ultrasound
Tx of Nephrolithiasis
Stones <5mm spontaneous passage, give IV fluids, analgesics, and antiemetics
Stones >7mm Shock wave lithotripsy, Uretoscopy with stent, Percutaneous Nephrolithotomy (usually reserved for large stones >10mm or Struvite)
What is Bipolar Disorder Type 1
More than 1 manic episode and occasional Major Depressive Epsidoes
What is Mania
Abnormal and persistent elevated, expansive or irritable modd that lasts for at least 1 week with marked impairment of social/occupational functions
Tx of Bipolar Disorder Type 1
Mood Stabilizers: 2nd or 1st generation antipsychotics
May add SSRI for depressive sx
Cognitive, Bheavioral, and Interpersonal therapy
What is Bipolar Disorder Type 2
Hypomania + Major Depressive Disorder
Hypomania: Period of elevated expansive or irritable mood for at least 4 days, does not cause impairment of social/occupational functions
Tx of Bipolar Disorder Type 2
Mania: Lithium, Valproate, 2nd generation antipsychotic
Depression: Lithium, Valproate, Carbamazepine, 2nd Generation antipsychotics
Mixed: Atypical antipsychotics, Valproate
What are features of Bacterial Vaginosis
Due to decrease in lactobacilli, leads to overgrowth of normal flora
Vaginal odor, worse after sex, Pruritis
Thin, homogenous, watery grey-white fish rotten smell
Dx of Bacterial Vaginosis
Clue Cells
Few WBC
Tx of Bacterial Vaginosis
Metronidazole (Flagyl) x 7 days
No douching
What are features of Trichomoniasis
Pear shaped flagellated protozoa
Sexually Transmitted
Vulvular pruritis, erythema, dysuria
Sx of Trichomoniasis
Copious malodorous discharge Frothy yellow green discharge, worse with menses Strawberry Cervix (Cervical Petechiae)
Dx of Trichomoniasis
Mobile Protozoa on wet mount
Tx of Trichomoniasis
Metronidazole (Flagyl) 2g oral 1x or 500mg bid PO x7days
What are features of Candida Vulvovaginitis
Overgrowth of Candida Albicans
Sx of Candida Vulvovaginitis
Vaginal and vulvar erythema, swelling, burning, pruritis
Burning when urine touches skin
Thick curd-like/cottage cheese discharge
Dx of Trichomoniasis
Hyphae, Yeast on KOH prep
Tx of Candida
Fluconazole PO 1x
Intravaginal antifungals like Nystatin, Miconazole
What are features of Chlamydia
Chlamydia Trachomatis
Most common cause of cervicitis
May have mucopurulent cervicit, increased frequency, dysuria, abdominal pain, post coital bleeding
Dx of Chlamydia
LCR, Cultures
Tx of Chlamydia
Azithromycin 1g PO 1x or Doxycycline 100mg PO bid x10days
Treat for gonorrhea too
What are features of Gonorrhea
Neisseria Gonorrheae
Vaginal dischrage, cervicitis, increased frequency, dysuria
Dx of Gonorrhea
Culture, DNA
Tx of Gonorrhea
Ceftriaxone 250mg IM 1x
Cefixime
What are features of Chancroid
Haemophilus Ducreyi
Genital Ulcer: Soft, shallow, PAINFUL may have foul discharge
Painful inguinal lymphadenopathy
Tx of Chancroid
Azithromycin
Ceftriaxone
What are features of HPV
Oncogenic: 16 and 18
Genital Warts: 6, 11
Flat, papular, pedunculated or flesh colored growths, cauliflower like lesions
Dx of HPV
Whitening with acetic acid on cervix
Colposcopy, biopsy to look for dysplasia or cancer
Tx of HPV
Cryotherapy, surgical removal
Discuss Pap Smear Management
Every 2 years starting at 21-29 Every 3 years after 30 Stop after 65 If Positive HPV and greater than 25 -Cytology and HPV testing in 12 months or Genotype for HPV 16, 18 If ASCUS and greater than 25yrs -HPV testing: If Negative repeat pap and HPV in 3 years, if Positive Colposcopy with biopsy If ASC-H -Colposcopy If LSIL -Colposcopoy with Biopsy -If Negative HPV repeat cytology in 1 year -If HPV Positive, Colposcoy with biopsy
What is a Molar Pregnancy
Hydatidiform: Neoplasm due to abnormal p lacental development with trophoblastic tissue proliferation arising from gestational tissue
Complete: Egg with no DNA fertilized by 1 or 2 sperm (46xx)
Partial: Egg fertilzied by 2 sperm
Sx of Molar Pregnancy
Painless vaginal bleeding
Uterine size/date discrepancies
Hyperemesis Gravidarum
Choriocarcinoma
Dx of Molar Pregnancy
Beta-HcG is markedly elevated (>100,000), Low maternal serum alpha-fetoprotein
Ultrasound: snowstorm or cluster of grapes apperance, no products of conception seen in complete
Tx of Molar Pregnancy
Uterine suction curettage ASAP
If METS: Chemo (Methotrexate) which destroys trophoblastic tissue
What is Dysfunctional Uterine Bleeding
Abnormal frequency/intensity of menses due to nonorganic causes
-Amenorrhea, Cryptomenorrhea, Menorrhagia, Metrorrhagia, Menometrorrhagia, Oligomenorrhea
Dx of Dysfunctional Uterine Bleeding
Diagnosis of Exclusion
Need to exclude organic cause (Reproductive, systemic iatrogenic causes)
Workup includes: Hormone levels, transvaginal ultrasound, endometrial biopsy
Tx of Dysfunctional Uterine Bleeding
OCP, Progesterone, GnRH
Hysterectomy, Endometrial Ablation
What is Gout
Uric Acid Deposition in soft tissues, joints, and bones
Usually caused by purine rich foods (alcohol, liver, oily fish, yeast) causing rapid change sin uric acid concentrations
Diuretics, ACE-I, Ethambutol, ASA, ARBs also cause it
Sx of Gout
Monoarthropathy with joint erythema, swelling and stiffness
Podagra: 1st MTP joint involvement
Knees, Feet, and Ankles are common
Tophi Deposition
Uric acid neprholithiasis and nephropathy
Dx of Gout
Arthrocentesis: Negatively birefringent needle-shaped urate crystals
Xrays: Rat Bite, punched out erosions
Tx of Gout
Acute: NSAIDS (Indomethacin), Colchicine is 2nd line
Chronic: Allopurinol, Febuxostat, Uricosuric Drugs, Colchicine
What is Rheumatoid Arthritis
Chronic inflammatory disease with persistent symmetric polyarthritis with bone erosion, cartilage destruction and joint structure loss
T-Cell Mediated
Sx of Rheumatoid Arthritis
Fevers, Fatigue, Weight Loss, Anorexia
Small Joint Stiffness: MCP, Wrist, PIP, Knee
Worse in the morning, better as day goes on
Morning joint stiffness >60min
Swollen, tender, erythematous boggy joint, swan neck deformity, Ulnar deviation at MCP
Dx of Rheumatoid Arthritis
Positive RF
Positive Anti-Citrullinated Peptide Antibodies (Anti-CCP)
Arthritis in more than 3 joints, morning stiffness, disease duration longer than 6 weeks
Xray: Narrow joint space, subluxation deformities, ulnar deviation of hand
Tx of Rheumatoid Arthritis
DMARDS (Methotrexate, Hydroxychloroquine)
NSAIDS for pain control
Low-Dose Steroids
What is Osteoarthritis
Chronic disease due to articular cartilage damage and degeneration
Obesity is a risk factor
Found on weight bearing joints, knees, hips, cervical/lumbar spine, hip
Sx of Osteoarthritis
Evening joint stiffness, better with rest, worse as day progresses
Herberden’s Nodes, Bouchard’s Nodes
Dx of Osteoarthritis
Joint space narrowing
Osteophytes
Subchondral cysts/sclerosis
Tx of Osteoarthritis
NSAIDS
Acetaminophen in elderly due to bleeding risk with NSAIDS
Corticosteroid injections
What is Reactive Arthritis
Reiter's Syndrome Autoimmune response to infection in another part of the body Asymmetric inflammatory artrhtis Conjunctivitis/Uveitis Urethritis, Cervicitis
What pathogen is associated with Reactive Arthritis in young people
Chlamydia
Sx of Reactive Arthritis
Can’t see, can’t pee, can’t climb a tree
- Conjunctivitis
- Urethritis
- Arthritis
Dx of Reactive Arthritis
HLA-B27
Increased WBC, Increased ESR
Synovial Fluid: WBC <8,000, BActerial culture is negative (aseptic)
Tx of Reactive Arthritis
NSAIDS
Abx to treat underlying systemic infection that triggered disease
If no response, methotrexate, steroids, anti-TNF agents
What is Septic Arthritis
Infection in the joint cavity
This is an emergency
What pathogens are seen in Septic Arthritis
S. Auerus is most common
N. Gonorrhea in sexually active young people
Streptococci
Sx of Septic Arthritis
Single, swollen warm and painful joint that is tender to palpation
Fevers, chills, sweats, myalgias, malaise, pain
Dx of Septic Arthritis
Arthrocentesis: WBC >50,000, primarily PMNs, gram stain and culture
Tx of Septic Arthritis
- Gram Positive Cocci
- Gram Negative Cocci
- Gram Negative Rods
Gram Positive Cocci: Nafcillin (Vancomycin if MRSA)
Gram Negative Cocci: Ceftriaxone (Cipro if PCN allergy)
Gram Negative Rods: Ceftriaxone + Gentamicin
What is Carpal Tunnel Syndrome
Median Nerve entrapment/Compression
Usually seen with DM
Sx of Carpal Tunnel Syndrome
Parasthesias and Pain of palmar first 3 digits Thenar muscle wasting Weakness in thumb Pain is worse at night Pain is decreased with shaking hands
Dx of Carpal Tunnel Syndrome
Tinel’s Sign: Percussion of median nerve produces sx
Phalen’s Sign: Flex wirsts for 30 seconds produces sx
Tx of Carpal Tunnel Syndrome
Volar Splints
NSAIDS
Corticosteroids
Surgery in refractory cases
What is Dequervain’s Tenosynovitis
Stenosing tenosynovitis of abductor pollicus longus and extensor pollicus brevus
How does Dequervain’s Tenosynovitis occur
Excessive thumb use with repetitive action
Seen in golvers, clerical workers
Sx of Dequervain’s Tenosynovitis
Pain along radial aspect of wrist radiating to forearm especially with thumb extension or gripping, radial styloid pain
Dx of Dequervain’s Tenosynovitis
Positive Finkelstein Test: Pain with ulnar deviation or thumb extension
Tx of Dequervain’s Tenosynovitis
Thumb spica split 3x/wk
NSAIDS for 2 weeks
Steroid Injections
PT
What is Colles Fracture
Distal radial fracture with dorsal angulation
What causes Colles Fracture
FOOSH with wrist extension
Dx of Colles Fracture
Dinner Fork Deformity: Need Lateral view to distinguish from Smith Fracture
What is a complication with Colles Fracture
Extensor pollicus longus tendon rupture
Tx of Colles Fracture
Sugar Tong Splint/Cast If stable (<20 degree angulation) can do closed reduction
How does a Posterior Shoulder Dislocation Occur
Forced Adduction, Internal Rotation
Associated with seizures, shocks, direct trauma
Sx of Posterior Shoulder Dislocation
Adducted, internally rotated
Anterior shoulder is flat, Humeral head is prominent
Tx of Posterior Shoulder Dislocation
Reduction
How does a Radial Head Fracture Occur
FOOSH
Sx of Radial Head Fracture
Lateral (radial) elbow pain, inability to fully extend elbow
Dx of Radial Head Fracture
Fat Pad Sign: Posterior or increased Anterior
Tx of Radial Head Fracture
If non-displaced: Sling, Long arm splint 90 degrees
If displaced: Open Reduction Internal Fixation
What is an Anterior Dislocation of Radial Head
Usually occurs in men who sustain high-force injury
In kids: Subluxation is more common rather than dislocated
Usually occurs after MVA, significant falls, FOOSH injury
Sx of Anterior Dislocation of Radial Head
Person holds elbow flexed at 90 degrees
Resists passive and active ROM at elbow
Elbow is swollen and tender especially at radial head
Tx of Anterior Dislocation of Radial Head
Reduction
What is an Ankle Sprain
Usually involves Anterior Talofibular or Calcaneofibular ligament
Sx of Ankle Sprain
Hear a pop followed by swelling, pain, inability to bear weath
Tx of Ankle Sprain
RICE
NSAIDS
Increase ROM and Conditioning
What are the Ottawa Ankle Rules
Inability to walk more than 4 steps at the time of injury or in the ER AND
Ankle Films: Pain along Lateral Malleolus or Pain along Medial Malleolus
Foot Films: Midfoot Pain or 5th metatarsal or navicular pain
What is Mallet Finger
Avulsion of extensor tendon with sudden blow to the tip of extended finger with forced flexion
Sx of Mallet Finger
Unable to straighten distal finger
It looks flexed at DIP joint
Usually associated with avulsion fracture of distal phalanx
Finger is painful, swollen, and bruised
Tx of Mallet Finger
Splint the DIP joint with uninterrupted extension for 6 weeks
Surgical Pinning
What is Gamekeeper’s Thumb
Ulnar collateral ligamental injury of the thumb
Causes instability of CMP joint
How does Gamekeeper’s Thumb occur
Forced abduction of thet humb
Sx of Gamekeeper’s Thumb
Thumb far away from the other digits
MCP tenderness, weakness in pinch strength
Tx of Gamekeeper’s Thumb
Thumb Spica
Referral to hand surgeon because it affects pincer function
What is Boxer’s Fracture
Fracture at the neck of the 5th metacarpal
How does a Boxer’s Fracture occur
Punch with clenched fist
Tx of Boxer’s Fracture
Ulnar gutter splint with joints in at least 60 degree flexion
How does a Meniscal Tear occur
Degenerative, usually with squatting, twisting, compression or trauma with rotation and axial loading
Sx of Meniscal Tears
Locking, popping, giving way, effusion after activities
Positive Mcmurray’s Sign: Pop or click while tibia is externally and internally rotated
Tx of Meniscal Tears
NSAIDS
Partial weight bearing until ortho follow up
Arthroscopy
