IM 4 Flashcards by Maggie Musso

2 major treatment issues to address in all patients with new-onset AF?

Rate or rhythm control strategy
Risk stratification for prevention of systemic embolization

Current evidence suggests that there is no significant difference in morbidity and mortality rates, including embolic risk between the rate and rhythm control strategy

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Systemic thromboembolism is a major cause of long-term morbidity in patients with AF - how is this managed?

Warfarin (or newer oral anticoagulants) significantly reduce this risk in patients at moderate to high risk of thromboembolic events; CHA2DS2VASc score for risk stratification

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Scoring of CHA2DS2-VASc?

Congestive heart failure
HTN
A2 = Age 75+
DM
S2 = Stroke/TIA/Thromboembolism
Vascular disease (prior MI, PAD, or aortic plaque)
A = Age 65-74
Sc = female

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Risk/Rx - CHA2DS2Vasc?

0 = low risk, no antithrombotics
1 = intermediate risk, none or aspirin or oral anticoagulants
2+ = high risk, oral anticoagulants

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The high incidence of UTIs in women is primarily due to?

The shorter length of the female urethra

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Presentation of acute epididymitis?

Unilateral testicular pain
Epididymal edema
Dysuria, frequency (with coliform infection)

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The causative organism of acute epididymitis can be predicted based on the age of the patient - discuss.

> 35 - bacteriuria related to bladder outlet obstruction (eg, BPH) -> ascending coliform bacteria such as E. coli

<35 - STI with C. trachomatis or N. gonorrhea

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Dx acute epididymitis?

UA/cultures

NAAT for chlamydia and gonorrhea

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Rx acute epididymitis?

If STI - ceftriaxone/doxycycline

If coliform - levofloxacin

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Classic presentation of Hyperosmolar Hyperglycemic State?

Gradual hyperglycemic symptoms (polyuria, polydipsia, etc.), AMS in an older patient with DM2

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Lab findings in HHS?

Glucose >1000 mg/dL
Normal pH and bicarbonate
Normal AG
Negative or small serum ketones
Serum osmolality >320 mOsm/kg

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Initial management of HHS?

Aggressive hydration with normal saline
IV insulin
Careful monitoring and supplementation of potassium

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Why are arterial pH and AG typically normal in HHS (as opposed to DKA)?

Unlike DKA, HHS is caused by a relative rather than absolute insulin deficiency, and accumulation of ketoacids will be minimal.

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Why is fluid replacement the most important initial step in management HHS?

Severe hyperglycemia induces an osmotic diuresis, which can lead to a deficit of 8-10 L in total body water; aggressive rehydration improves tissue perfusion and responsiveness to insulin therapy

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Presentation - infectious epiglottitis?

Rapidly progressive and life-threatening
Fever, sore throat, drooling, muffled voice
Airway obstruction (stridor, dyspnea)
Pooled oropharynx secretions
Laryngotracheal tenderness

Commonly presents in adults with DM, obesity, and preceding URI

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In adults, most cases of infectious epiglottitis are caused by what bacteria?

S. pneumoniae, H. influenzae

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Whereas children classically have abrupt onset of drooling, dysphagia, and distress in the setting of infectious epiglottitis, adults present…?

…more subtly, with sore throat, fever, and laryngotracheal tenderness to palpation. With worsening of the swelling, difficulty swallowing, pooled oral secretions, and respiratory compromise can develop

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Dx epiglottitis?

Direct visualization or soft-tissue lateral neck radiograph (enlarged epiglottis, loss of the vallecular air space, and or distended hypopharynx)
Radiographs may also help exclude other conditions

[If significant respiratory compromise, establish airway prior to considering neck radiograph]

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Most common type of leukemia in the US?

Chronic lymphocytic leukemia

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Clinical presentation of CLL?

Classic hallmark: dramatic lymphocytosis

Lymphadenopathy (cervical, supraclavicular, axillary), HSM, mild thrombocytopenia and anemia, often asymptomatic, though may present with extreme fatigue, B symptoms, infection, or weigh loss

Almost always seen in the elderly (median age - 70)

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Peripheral smear findings of CLL?

Mature lymphocytes with the presence of smudge cells (pathognomonic)

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Dx CLL?

Severe lymphocytosis and smudge cells
Flow cytometry
Lymph node and bone marrow biopsy not generally needed

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Prognosis of CLL?

Median survival 10 years

Worse prognosis with multiple chain lymphadenopathy, HSM, anemia/thrombocytopenia

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Complications of CLL?

Infection
AI hemolytic anemias
Secondary malignancies

What is chronic myeloid leukemia?

Myeloproliferative disease of neutrophil lineage Peripheral smear shows a massive leukocytosis with a variety of neutrophil precursor cells

What is hairy cell leukemia?

Rare lymphocytic leukemia that often presents with splenomegaly and pancytopenia (including leukopenia)

Management of acute low back pain (<4 weeks)

Maintain moderate activity NSAIDs or acetaminophen Consider muscle relaxants, spinal manipulation, brief course of opioids

Management of chronic low back pain (12+ weeks)?

Intermittent use of NSAIDs or acetaminophen Exercise therapy (stretching/strengthening, aerobic) Consider TCAs, duloxetine

Patients with pneumonia caused by ___ typically present with indolent symptoms such as fever, malaise, and a characteristic foul-smelling sputum.

Anaerobic organisms

Risk factors for aspiration pneumonia?

Upper airway instrumentation (endotracheal or NG tubes), reflux, dysphagia, impaired consciousness, poor dentition (greater quantity of oral anaerobic organisms)

In supine patients, where does aspiration pneumonia occur? In erect patients?

Supine - posterior segments of the upper lobes and superior segments of the lower lobes are most affected Erect - bases of the lower lobes and right middle lobe

ABX coverage for aspiration pneumonia?

Clindamycin (covers anaerobes) Could also do metronidazole + amoxicillin, amoxicillin-clavulanate, or a carbapenem

Presentation with dysphagia to solids and liquids + a dilated esophagus with smooth tapering of the distal esophagus suggests what 2 possible causes?

1. Primary achalasia (loss of peristalsis in the distal esophagus with lack of lower esophageal sphincter relaxation) 2. Pseudoachalasia (due to esophageal cancer)

What helps differentiate between achalasia and pseudoachalasia?

Endoscopic evaluation

Most common cause of infectious mono?

EBV

Clinical features of infectious mono?

Prolonged course (up to 1 month) of mild to moderate fever Tonsillitis/pharyngitis +/- exudates Tender posterior or diffuse cervical lymphadenopathy Significant fatigue +/- HSM +/- Rash after amoxicillin

Dx infectious mono?

Positive heterophile Ab (Monospot) test >25% false negative rate during 1st week of illness Atpyical lymphocytosis Transient hepatitis

Management of infectious mono?

Avoid sports for 3+ weeks (contact sports 4+ weeks) due to risk of splenic rupture

Acute HIV presentation?

Fever, malaise, generalized lymphadenopathy (usually non-tender), rash, diarrhea Tonsillar exudates UNCOMMON

Presentation of thyroid storm?

``` High fever Tachycardiac, HTN, CHF, arrhythmias (eg, AF) Agitation, delirium, seizure, coma Goiter, lid lag, tremor N/V, diarrhea, jaundice ```

Precipitating factors of thyroid storm?

Thyroid or non-thyroid surgery Acute illness (trauma/infection), childbirth Acute iodine load (contrast)

How is thyroid storm diagnosed?

Clinical evaluation

Sensitivity is important for ___ tests; specificity is important for ___ tests (confirmatory vs. screening).

Sensitivity - screening (rule out) Specificity - confirmatory (rule in)

Rx PCP in HIV?

TMP-SMX for 21 days | Adjunctive corticosteroids if severe PCP (decreases mortality)

Indications for corticosteroid use in PCP in HIV?

Partial pressure of oxygen 70 or less or A-a gradient 35+

Adverse effects of TMP-SMX?

Rash, neutropenia, hyperkalemia, elevated transaminases

List 3 alternate oral ABX for mild to moderate PCP.

Dapsone + TMP Primaquine + Clindamycin Atovaquone suspension

List alternative ABX for moderate to severe PCP.

IV pentamidine | Primaquine + IV clindamycin

AE pentamidine?

Nephrotoxicity, hypotension, hypoglycemia, cardiac arrhythmias, pancreatitis, elevated transaminases

Before giving dapsone or primaquine, what must be done?

Check for G6PD deficiency (both can cause hemolytic anemia)

Presentation of PCP in HIV?

``` CD4 <200 Dry cough, exertional dyspnea, fever Bilateral interstitial infiltrates Hypoxia out of proportion to radiographic findings Elevated LDH ```

What is chronic prostaitis/chronic pelvic pain syndrome?

Chronic pelvic pain (pain in the perineum and testes, can radiate to back) for 3+ months without an identifiable cause

Symptoms of chronic prostatitis/chronic pelvic pain syndrome?

Pain in pelvis, perineum, genitalia Irritative voiding symptoms (urgency, hesitancy, etc.) Hematospermia, pain with ejaculation

Physical/lab findings of chronic prostatitis?

Afebrile Little to no prostate tenderness Normal UA and sterile urine culture results

Management of chronic prostatitis?

ABX often helpful in symptom relief (cipro), especially if history of UTI Alpha blockers (tamsulosin) 5-alpha reductase inhibitors (finasteride)

IVDU are more prone to developing infective endocarditis caused by ___.

S. aureus

Fragments of vegetation from endocarditis can embolize to the lungs and cause what appearance on CT?

Nodular infiltrate with cavitation

HIV greatly increases infective endocarditis risk in IVDU, most commonly at the ___ valve. There may not be a murmur - why?

Tricuspid; relatively low pressure gradient across the valve