IM Boards Flashcards
Preferred modality to work up possible CAD in patients with LBBB
In patients with left bundle branch block undergoing myocardial perfusion imaging, **vasodilator-induced stress **is preferred to exercise or dobutamine because of the potential for false-positive septal perfusion abnormalities.
Vasodilators:
-dipyridamole
-regadenoson
-adenosine
Concerns with ranolazine
-QT prolongation
-P-450 3A4 (CYP3A4)
dose reduction is indicated in patients receiving moderate inhibitors of cytochrome P-450 3A4 (CYP3A4), such as verapamil and diltiazem. Ranolazine should not be used in combination with strong CYP3A4 inhibitors (clarithromycin, itraconazole, ketoconazole, several HIV medications) because of resultant increases in ranolazine serum levels.
Who might benefit from extended (>12 months) DAPT after STEMI/NSTEMI?
-diabetes
-depressed LVF
-saphenous vein graft stenting
Duration of DAPT after DES for chronic stable angina
6 months (but less i.e. 3 months if high bleeding risk)
Anti-arrhythmic classes
Drug classes:
IB: sodium channel blockade (lodicaine, mexiletine)
IC: sodium channel blockade (flecanide, propafenone)
II: beta blockers (metoprolol, propranolol, carvedilol, atenolol, bisoprolol, nadolol)
III: potassium channel blockade (sotalol, dofetilide)
IV: nondihydropyridine calcium channel blockers (verapamil, diltiazem)
Multichannel blockers: amiodarone, dronedarone
Adenosine receptor agonists: adenosine
Cardiac glycoside: digoxin
Note:
-classes I and III are most effective as antiarrhythmics, but also the most pro-arrthymic
Class IC anti-arrhythmics
Flecainide and propafenone are the most commonly used class I agents (IC); they are primarily used to treat atrial arrhythmias and usually in conjunction with AV nodal blockers to prevent 1:1 atrial flutter.
Toxicity can manifest as QRS widening.
Class IC agents are contraindicated in patients with ischemic or structural heart disease because of the risk for promoting ventricular arrhythmias and death.
Class III anti-arrhythmics
Class III agents sotalol and dofetilide are used to treat atrial and ventricular arrhythmias.
Class III antiarrhythmic therapy typically is initiated in an inpatient setting, with regular assessment of the corrected QT interval (QTc) and caution exercised in patients with kidney disease.
Dofetilide is particularly notorious for common and dangerous drug-drug interactions.
Amiodarone, a class III multichannel blocker, is frequently used to treat patients with recurrent ventricular tachycardia (VT) or AF. Amiodarone has a low risk of pro-arrhythmia; however, it is associated with thyroid, liver, lung, and eye toxicities as well as neurologic side effects. Thyroid and liver function should be monitored every 6 months, and pulmonary function testing and ophthalmologic examination should be performed annually. Amiodarone interacts with many drugs, including warfarin, statins, and digoxin. Dronedarone, another class III multichannel blocker, can be used in patients with paroxysmal AF and no overt heart failure.
Amiodarone toxicity
Amiodarone, a class III multichannel blocker, is frequently used to treat patients with recurrent ventricular tachycardia (VT) or AF.
Amiodarone has a low risk of pro-arrhythmia; however, it is associated with thyroid, liver, lung, and eye toxicities as well as neurologic side effects. Thyroid and liver function should be monitored every 6 months, and pulmonary function testing and ophthalmologic examination should be performed annually.
Amiodarone interacts with many drugs, including warfarin, statins, and digoxin.
Dronedarone, another class III multichannel blocker, can be used in patients with paroxysmal AF and no overt heart failure.
Postural orthostatic tachycardia syndrome (POTS)
Postural orthostatic tachycardia syndrome (POTS) is another condition that often presents with tachycardia. POTS is a form of dysautonomia characterized by orthostatic intolerance and excessive tachycardia, particularly with standing.
Diagnostic criteria for POTS include an increase in heart rate of 30/min or more or an increase to greater than 120/min within 10 minutes of standing. The diagnosis is often confirmed with tilt-table testing.
Behavioral modification, compression stockings, exercise training, and increased fluid intake are important components of therapy. Medical therapy for POTS is highly variable and may include β-blockers, ivabradine (off-label use), fludrocortisone, selective serotonin reuptake inhibitors (off-label use), midodrine, and pyridostigmine (off-label use).
Atrioventricular Nodal Reentrant Tachycardia
AVNRT accounts for two thirds of all cases of SVT, not including cases of AF and atrial flutter. It is caused by a reentrant circuit within the AV node that uses both the fast and slow pathways. AVNRT is characterized by a short RP interval with a retrograde P wave inscribed very close to the QRS complex.
(best seen in lead V1, appearing as a pseudo r′ wave.)
AVNRT may be terminated with vagal maneuvers or adenosine. AV nodal blockers (β-blockers or calcium channel blockers) are used to prevent recurrent AVNRT. In patients with recurrent AVNRT and those who do not tolerate or prefer to avoid long-term medical therapy, catheter ablation should be considered. Catheter ablation of AVNRT has a high success rate, although it is associated with a 1% risk for injury to the AV node necessitating pacemaker implantation.
Atrioventricular Reciprocating Tachycardia
AVRT is an accessory pathway–mediated tachycardia that is often observed as preexcitation (delta wave) on ECG. Early ventricular activation over the accessory pathway causes shortening of the PR interval, and the initial part of the QRS complex is slurred because of premature ventricular depolarization in the myocardial tissue adjacent to the accessory pathway.
In AVRT, **conduction is anterograde over the AV node (orthodromic, narrow-complex AVRT) in 90% to 95% of cases; conduction is anterograde over the accessory pathway (antidromic, wide-complex AVRT) in the remaining cases.
**
Wolff-Parkinson-White (WPW) syndrome is defined by symptomatic AVRT with evidence of preexcitation on resting ECG. AF occurs in up to one-third of patients with WPW syndrome. Rapid conduction over an accessory pathway in AF can result in ventricular fibrillation (VF) and sudden cardiac death (SCD), although this occurs in less than 1% of cases of WPW syndrome.
Risk stratification for SCD can be performed with exercise testing, although more frequently, patients are referred for electrophysiology testing for both risk stratification and curative ablation. Catheter ablation is first-line therapy for patients with WPW syndrome. The success rate for ablation is high but is dictated by the location of the accessory pathway. Antiarrhythmic therapy is second-line therapy.
In asymptomatic patients with preexcitation on ECG, management is controversial. Invasive testing is generally not required unless the patient has a high-risk occupation, such as a commercial airline pilot.
Who needs anticoagulation in atrial fibrillation?
The 2019 American College of Cardiology/American Heart Association/Heart Rhythm Society focused update on AF recommends anticoagulation to prevent stroke in patients with nonvalvular AF who have a CHA2DS2-VASc score of 2 or greater in men or 3 or greater in women.
American College of Chest Physicians: one or more non-sex CHA2DS2-VASc stroke risk factors (score of ≥1 in men or ≥2 in women).
Anticoagulation options for atrial fibrillation
-warfarin (vitK antagonist)
-dabigitran (direct thrombin inhibitor)
-Xa inhibitors: rivaroxaban, apixaban, edoxaban
Only warfarin should be used for valvular AF (moderate/severe mitral stenosis or mechanical valve prosthesis)
Dabigitran is SUPERIOR to warfarin (and has less intracranial bleeding), but has higher risk of GI bleeding and dyspepsia
Apixaban is SUPERIOR to warfarin and has less bleeding risk everywhere.
Rivaroxaban and edoxaban are noninferior to warfarin, but have less major bleeding.
Of the Xa inhibitors, apixaban is bid (and has lower bleeding risk)
DOAC reversal
**Andexanet alfa or 4-factor prothrombin complex concentrates **are recommended for life-threatening bleeding due to rivaroxaban, apixaban, or edoxaban.
Idarucizumab is a dabigatran-reversal agent available for emergency invasive or surgical procedures or in cases of uncontrolled or life-threatening bleeding.
Management of patient with stable coronary artery disease and atrial fibrillation
Rivaroxaban
In patients with AF and stable CAD, treatment with rivaroxaban alone is noninferior to rivaroxaban plus aspirin in the prevention of the composite end point of stroke, systemic embolization, myocardial infarction (MI), need for revascularization, or death from any cause. Rivaroxaban monotherapy also is associated with significantly less bleeding.
Management of atrial fibrillation in HFrEF
In patients with heart failure with reduced ejection fraction, recent clinical trials have shown that catheter ablation of AF is associated with a favorable effect on morbidity and mortality compared with medical therapy.
Management of atrial fibrillation in HFrEF
In patients with heart failure with reduced ejection fraction, recent clinical trials have shown that catheter ablation of AF is associated with a favorable effect on morbidity and mortality compared with medical therapy.
Management of atrial flutter
Management of anticoagulation in the setting of chronic atrial flutter is similar to that for AF; however, a rhythm control strategy is favored in atrial flutter because rate control may be difficult and often requires high doses of more than one AV nodal blocker. Catheter ablation is the definitive treatment for typical atrial flutter because of a very high success rate (>95%) and low complication rate. Oral anticoagulation in patients with atrial flutter without ablation is approached in the same manner as in patients with AF.
Differential diagnosis of wide complex tachycardia
The differential diagnosis for wide-complex tachycardia include “
-SVT with aberrancy
-preexcited tachycardia (antidromic AVRT)
-ventricular paced rhythms
-VT (most common)
Key features of VT on EKG
Key features of VT on ECG include
-AV dissociation
-fusion beats
-capture beats
Several important clinical and ECG features can distinguish VT from other conditions. The presence of irregular jugular venous pulsations of greater amplitude than normal venous waves (cannon waves) signal the presence of atrioventricular dissociation and support the diagnosis of VT. Wide-complex tachycardias that are positive in lead aVR, have a QRS morphology that is concordant (all predominantly positive or negative) in the precordial leads, have QRS morphology other than typical right or left bundle branch block, and exhibit extreme axis deviation (“northwest” axis) are usually VT. Fusion beats (supraventricular and ventricular impulses coinciding to produce a hybrid complex) (arrows in the ECG shown below) and capture beats (a sinus conducted beat producing a normal QRS) are all highly suggestive of VT. Of importance, the fact that the patient is awake, alert, and interactive and/or has a measurable blood pressure does not exclude VT.
Management of ventricular tachycardia
Hemodynamic instability:
-immediate direct current cardioversion
-IV amiodarone if VT persists or recurs after cardioversion.
-if ST-elevation MI –> emergency revascularization
Hemodynamically stable (and not in the setting of an acute MI)
-IV procainamide
-IV amiodarone or sotalol may also be considered.
In patients with idiopathic VT, calcium channel blockers, especially verapamil, and β-blockers are first-line therapy. (Catheter ablation if medical options fail)
Indications for ICD
Patients with sustained ventricular arrhythmias (>30 seconds) or cardiac arrest without a reversible cause have a class 1 recommendation for secondary-prevention ICD placement.
ICD placement is recommended for the primary prevention of SCD in patients with ischemic or nonischemic cardiomyopathy, ejection fraction less than 35%, and New York Heart Association functional class II or III heart failure.
Permanent pacemaker indications
-symptomatic bradycardia without reversible cause
-permanent atrial fibrillation with symptomatic bradycardia
-alternating bundle branch block
-complete heart block, high-degree atrioventricular (AV) block, or Mobitz type 2 second-degree AV block, irrespective of symptoms
EAST-AFNET 4
In patients with recently diagnosed atrial fibrillation and concomitant cardiovascular conditions, **early rhythm control **(antiarrhythmic drugs or ablation) reduces the primary composite end point of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome compared with usual care.
VT vs other conditions
Several important clinical and ECG features can distinguish VT from other conditions.
The presence of irregular jugular venous pulsations of greater amplitude than normal venous waves (cannon waves) signal the presence of atrioventricular dissociation and support the diagnosis of VT.
**Wide-complex tachycardias **that are positive in lead aVR, have a QRS morphology that is concordant (all predominantly positive or negative) in the precordial leads, have QRS morphology other than typical right or left bundle branch block, and exhibit extreme axis deviation (“northwest” axis) are usually VT. Fusion beats (supraventricular and ventricular impulses coinciding to produce a hybrid complex) and capture beats (a sinus conducted beat producing a normal QRS) are all highly suggestive of VT.
Of importance, the fact that the patient is awake, alert, and interactive and/or has a measurable blood pressure does not exclude VT.
Symptomatic PVCs
Beta blocker or calcium channel blocker
First-line treatment for symptomatic premature ventricular contraction suppression is β-blocker or calcium channel blocker therapy; β-blockers are preferred in patients with ventricular dysfunction.
Ambulatory ECG monitoring can help clarify the burden of premature ventricular contractions (PVCs); patients with PVCs that account for more than 10% to 15% of beats may be at risk for PVC-induced cardiomyopathy.
Brugada syndrome
*Brugada pattern *is distinguished by a structurally normal heart (normal echocardiogram) and right precordial ECG abnormalities, including ST-segment coving (concave or linear downsloping ST segment) in leads V1 through V3 with or without right bundle branch block.
Brugada syndrome is the association of Brugada pattern with ventricular fibrillation, arrhythmogenic syncope, or cardiac arrest.
Brugada syndrome has an increased prevalence in men and persons of Asian descent.
Arrhythmic events, including sudden cardiac death, in patients with Brugada syndrome are more common at night, during sleep.
Abnormalities on ECG may be intermittent and may be elicited by fever or pharmacologic challenge with sodium channel blockade, such as procainamide infusion.
Idiopathic ventricular tachycardia
Idiopathic ventricular tachycardia occurs in the absence of structural heart disease, typically manifesting as palpitations in the third to fifth decades of life, often triggered by stress, emotion, or sleeplessness.
ICD placement is generally unnecessary in idiopathic VT, owing to the benign prognosis and high efficacy of other therapies.
Anticoagulation for Afib in patients with PCI
Among patients with atrial fibrillation who have undergone percutaneous coronary intervention for acute coronary syndrome, double therapy with clopidogrel or ticagrelor plus a direct oral anticoagulant is recommended over triple therapy with an oral anticoagulant, aspirin, and P2Y12 inhibitor to reduce the risk for bleeding.
Contraindication for class IC antiarrhythmics
Flecainide and other class IC antiarrhythmic agents (propafenone) are contraindicated in patients with ischemic heart disease.
Others:
-ischemic or structural heart disease
-sinus node dysfunction
-second- or third-degree AV block or bundle branch disease without a pacemaker
Management of atrial fibrillation in heart failure
Aggressive efforts to achieve **rhythm control **in patients with atrial fibrillation and concomitant heart failure decrease morbidity and mortality.
Adenosine contraindication
Patients with bronchospastic lung disease should not receive adenosine.
Severe aortic stenosis
Severe aortic stenosis is typically defined by:
-small valve area (≤1.0 cm2) ,
-high peak velocity (>4 m/s), and/or
-high mean gradient (>40 mm Hg)
There are two patient subsets in which severe aortic stenosis may be present with a small valve area and either low velocity or low gradient:
(1) patients with severe LV dysfunction and low cardiac output (low-flow, low-gradient aortic stenosis) and
(2) patients with preserved LV function and paradoxical low-flow, low-gradient aortic stenosis.
Indications for aortic valve replacement
-presence of symptoms (e.g., dyspnea, angina, presyncope, syncope, or heart failure)
-LV systolic dysfunction (ejection fraction <50%) in an asymptomatic patient or a –concomitant cardiac surgical procedure for other indications (e.g., coronary artery bypass grafting or ascending aorta surgery).
Aortic valve replacement is reasonable in asymptomatic patients with very severe aortic stenosis and low surgical risk and asymptomatic patients with abnormal results on supervised exercise testing, such as poor exercise tolerance, abnormal ECG changes, or hypotension during testing.
Severe aortic regurgitation
-jet width that occupies 65% or more of the LV outflow tract
-vena contracta (the width of the regurgitant jet at its most narrow portion) greater than 0.6 cm
-holodiastolic flow in the descending aorta
-regurgitation volume of 60 mL or more
-effective regurgitant orifice area of 0.3 cm2 or greater
Severe mitral stenosis
-mitral valve area of 1.5 cm2 or less, which usually corresponds to a mean mitral gradient of more than 5 to 10 mm Hg at a normal heart rate
Treatment of mitral stenosis
Percutaneous balloon mitral commissurotomy (PBMC) is the procedure of choice for patients with significant rheumatic mitral stenosis when the valve is pliable and not severely calcified. PBMC is indicated for symptomatic patients with severe rheumatic mitral stenosis and favorable valve morphology and is reasonable in asymptomatic patients with severe rheumatic mitral stenosis and a pulmonary artery systolic pressure greater than 50 mm Hg. PBMC should not be performed in patients with LA thrombus or moderate or severe mitral regurgitation, both of which are optimally evaluated with TEE. In appropriately selected patients, the success rate with PBMC is 95%, and complications occur in fewer than 5% of patients.
Mitral valve surgery is indicated in patients with severe mitral stenosis, New York Heart Association functional class III or IV symptoms, and a nonpliable valve and in asymptomatic patients with severe mitral stenosis undergoing concomitant cardiac surgery for another indication.
Severe mitral regurgitation
Severe primary mitral regurgitation is defined by several parameters, the most common of which are an effective regurgitant orifice area of 0.4 cm2 or larger, regurgitant volume of 60 mL or more, and vena contracta of 0.7 cm or larger.
Mechanical aortic valve INR
2.5
or 3 if higher risk for thrombosis
Mitral prosthesis INR
3
(mechanical mitral: 2.5-3.5)
Bioprosthetic anticoagulation
Warfarin for 3-6 months
INR 2.5
Anticoagulation in prosthetic valves
Adding aspirin (75-100 mg/d) to warfarin in patients with a mechanical prosthesis decreases the risk for stroke and death and may be considered in patients who have an indication for antiplatelet therapy when the bleeding risk is low. Low-dose aspirin is reasonable for all patients with a bioprosthesis.
Infective endocarditis diagnosis
Modified Duke criteria
The diagnostic criteria for definite IE include either two major criteria, one major criterion plus three minor criteria, or five minor criteria. Possible IE requires one major criterion and one minor criterion, or three minor criteria. IE is excluded when there is a firm alternative diagnosis, resolution of IE syndrome with antibiotic therapy for 4 days or less, or no pathologic evidence of IE at surgery or at autopsy with antibiotic therapy for 4 days or less.
(2 + 0; 1+3; or 0 + 5)
Major Criteria
- Blood culture positive for infective endocarditis
Typical microorganisms consistent with infective endocarditis from two separate blood cultures: Viridans streptococci, Streptococcus bovis, HACEK group (Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella spp., and Kingella kingae), Staphylococcus aureus; or community-acquired enterococci, in the absence of a primary focus; or
Microorganisms consistent with infective endocarditis from persistently positive blood cultures, defined as follows:
At least two positive cultures of blood samples drawn 12 h apart; or
All of three or a majority of at least four separate cultures of blood (with first and last samples drawn at least 1 h apart)
Single blood culture positive for Coxiella burnetii or antiphase I IgG antibody titer >1:800
- Evidence of endocardial involvement
Echocardiogram positive for infective endocarditis (TEE recommended in patients with prosthetic valves, rated at least “possible infective endocarditis” by clinical criteria, or complicated infective endocarditis [paravalvular abscess]; TTE as first test in other patients), defined as follows:
Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation; or
Abscess; or
New partial dehiscence of prosthetic valve
New valvular regurgitation (worsening or changing of pre-existing murmur not sufficient)
Minor Criteria
- Predisposition, predisposing heart condition, or injection drug use
- Fever (temperature >38°C [100.4°F])
- Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, and Janeway lesions
- Immunologic phenomena: glomerulonephritis, Osler nodes, Roth spots, and rheumatoid factor
- Microbiologic evidence: positive blood culture but does not meet a major criterion as noted abovea or serologic evidence of active infection with organism consistent with infective endocarditis
Endocarditis prophylaxis
-History of endocarditis
-Cardiac transplantation with valve regurgitation due to a structurally abnormal valve
-Prosthetic valve
-Prosthetic material used for cardiac valve repair, including annuloplasty rings and clips
-Left ventricular assist device
-Unrepaired congenital heart disease
-Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device
-A defect that has been repaired with prosthetic material (surgical or catheter-based) within the previous 6 months
-Surgical or transcatheter pulmonary artery valve or conduit placement, such as Melody valve and Contegra conduit
TAVR vs SAVI
TAVI is recommended in preference to SAVR for symptomatic patients with severe aortic stenosis who are older than 80 years or for younger patients with a life expectancy less than 10 years. TAVI is also recommended for symptomatic patients of any age with severe aortic stenosis and a high or prohibitive surgical risk if predicted postprocedure survival is more than 12 months with an acceptable quality of life. For symptomatic patients aged 65 to 80 years, either SAVR or TAVI is appropriate following shared decision making.
Bicuspid valvulopathy management
In patients with a bicuspid valve undergoing surgery for severe aortic stenosis or regurgitation, surgical repair of the ascending aorta is advised when the aortic diameter is greater than 4.5 cm. In the absence of surgical indications for a stenotic or regurgitant aortic valve, surgical repair of the ascending aorta or aortic sinuses is advised when the aortic diameter is greater than 5.5 cm or when the diameter is greater than 5.0 cm in a patient with additional risk factors for dissection (family history, rate of progression ≥0.5 cm/year).
If discrepancy between resting echo and cardiac symptoms in mitral stenosis
In patients with rheumatic mitral stenosis and a discrepancy between resting echocardiographic findings and clinical symptoms, exercise echocardiography or exercise testing during cardiac catheterization is recommended to further assess the valve.
If discrepancy between resting echo and cardiac symptoms in aortic stenosis
Guidelines recommend cardiac catheterization to evaluate patients with suspected significant aortic stenosis when there is a discrepancy between the clinical evaluation and the echocardiogram.
If discrepancy between resting echo and cardiac symptoms in mitral regurgitation
For patients in whom there is a discrepancy between physical examination findings and transthoracic echocardiographic assessment of mitral regurgitation severity, cardiac magnetic resonance imaging or transesophageal echocardiography should be used to quantitatively assess mitral regurgitation and resolve the discrepancy.
When to intervene in aortic regurgitation
In symptomatic patients with severe aortic regurgitation, aortic valve surgery is indicated regardless of left ventricular systolic function.
In asymptomatic patients with chronic severe aortic regurgitation and left ventricular systolic dysfunction (ejection fraction ≤55%), aortic valve surgery is indicated.
Light’s criteria
Any one of:
-ratio of pleural fluid protein to serum protein >0.5
-ratio of pleural-fluid lactate dehydrogenase [LDH] to serum LDH > 0.6
-pleural-fluid LDH > two thirds of the upper limit of normal for serum LDH
= EXUDATIVE (most likely malignancy or infection)
Treatment of ovarian cancer with BRCA1/2 mutation
Debulking plus adjuvant platinum-taxane chemotherapy, followed by maintenance PARP inhibitor (if platinum sensitive)
Women with advanced ovarian cancer and BRCA mutations who achieve some response to platinum-based chemotherapy should receive subsequent maintenance therapy with a poly (ADP-ribose) polymerase inhibitor.
PARP inhibitor is also recommended in those without BRCA1/2 mutations, but the benefit is less
Polymyalgia rheumatica labs
Elevated ESR, normal CK
Best statin in CKD
Atorvastatin (hepatically cleared and may have beneficial effect on proteinuria)
Definition for pulmonary hypertension
Pulmonary artery pressure > 20
Most common cause of kidney disease in poorly controlled inflammatory disorders (e.g., ankylosing spondylitis)
Patients with long-standing, poorly controlled ankylosing spondylitis can develop renal (AA) amyloidosis, the major cause of kidney disease in these patients.
AA amyloidosis most commonly affects the kidneys, manifesting as proteinuria and, eventually, renal insufficiency.
Analgesic nephropaty
Analgesic nephropathy may develop after years of NSAID use and typically presents with abnormalities on routine urinalysis, including pyuria, proteinuria, and hematuria.
Chronic kidney disease and end-stage kidney disease can develop in some patients.
Interstitial nephritis
Interstitial nephritis can be caused by a variety of medications, including NSAIDs, antibiotics, and proton pump inhibitors. Symptoms may include fever, rash, and eosinophilia/eosinophiluria.
All patients will have a rise in serum creatinine levels as well as pyuria, hematuria, and proteinuria.
Leukocyte casts are typically seen on urinalysis.
Pre-eclampsia vs SLE flare
Clues to an SLE flare include markers of lupus activity, such as rising anti–double-stranded DNA antibody titers and falling serum complement levels. The serum urate level is often elevated in preeclampsia but not in SLE flares.
Treat SLE flare with glucocorticoids
Migraine and OCPs?
OCPs ok if no aura, but contraindicated if aura
Complication of chronic use of nitrous oxide inhalants
Vitamin B12 deficiency and subacute combined degeneration of the spinal cord.
Myelopathy, myeloneuropathy, and subacute combined degeneration have been reported in abusers of nitrous oxide, as have mood disorders and psychosis.
Manage acute uncomplicated diverticulitis
Current guidelines based on high-quality evidence strongly recommend that antibiotics be avoided in select patients with uncomplicated diverticulitis.
Immunocompromised patients with acute diverticulitis and those with systemic infection or associated comorbidities should be treated with antibiotics.
When to get colonoscopy if there is a family history of colon cancer
If colorectal cancer is diagnosed in a first-degree relative aged less than 60 years or two or more first-degree relatives at any age, colonoscopy should begin at age 40 years or 10 years earlier than the age of the youngest first-degree relative at diagnosis, whichever comes first.
Relapsing polychondritis
Relapsing polychondritis is a chronic inflammatory disease involving the cartilage (but not noncartilaginous structures) of the ears, nasal bridge (saddle nose deformity), joints, and trachea, as well as involvement of the connective tissue of the eye.
Treatment
-NSAIDs and dapsone for mild symptoms and high-dose glucocorticoids for initial management of acute and/or severe involvement
-oral immunosuppressants (e.g., methotrexate) may be added. The tumor necrosis factor inhibitors infliximab and adalimumab and the anti–interleukin-6 agent tocilizumab may also be effective.
Treatment of exercise-induced asthma
Initial pharmacologic therapy for exercise-induced bronchoconstriction can include administration of either an inhaled short-acting β2-agonist (SABA), such as albuterol, or low-dose budesonide-formoterol, 15 minutes before exercise.
(A decrease in FEV1 of greater than 10% within 30 minutes of exercise is diagnostic of EIB)
Treatment of xerostomia in Sjögren’s
Nonpharmacologic therapies are the first-line treatment of Sjögren syndrome–related oral dryness, including local moistening with water, sugar-free acidic candies, lozenges, and/or mechanical stimulants (such as sugar-free chewing gum).
Pharmacologic stimulation of salvia with cevimeline (cholinergic muscarinic agonist) or pilocarpine (muscarinic agonist) is indicated for oral dryness not relieved with nonpharmacologic therapies.
Type I autoimmune pancreatitis
Manifestation of ** IgG4 disease**
Symptoms: painless jaundice
CT: diffusely enlarged pancreas with indistinct borders and delayed contrast enhancement.
Diagnosis: >10 IgG4-positive cells/hpf (significantly elevated serum IgG4 is also suggestive)
Other organ involvement: can be any organ, but commonly lymph nodes, salivary glands, and the biliary system. Retroperitoneal fibrosis may also be related to IgG4 disease.
Treatment: high-dose prednisone taper (failure should prompt consideratio of other diagnoses); for relapse, can repeat steroids or use immunomodulators (6-mercaptopurine, azathioprine, mycophenolate, or rituximab)
Diagnostic criteria for AIP are known by the acronym HISORt (diagnostic Histology, suggestive Imaging, Serology with elevated serum IgG4, Other organ involvement, or Response to therapy with glucocorticoids)
Type II autoimmune pancreatitis
AKA idiopathic duct-centric pancreatitis
does not demonstrate IgG4-positive cells but is instead characterized by granulocytic lesions.
Type 2 AIP may be associated with inflammatory bowel disease.
Who needs hepatitis B immune globulin after exposure?
HBIG is indicated if the source patient is positive for HBV and the healthcare worker is a vaccine nonresponder (anti-HBs <10 mU/mL), is unvaccinated, or is incompletely vaccinated.
When HBIG is indicated, it should be administered as soon as possible after exposure and ideally within 7 days.
Ankle-brachial index interpretation
In healthy persons, the ankle pressure should be the same as or slightly higher than the brachial pressure; therefore, a normal resting ABI is between 1.00 and 1.40.
In the presence of atherosclerotic narrowing of the limb arteries, the downstream blood pressure and concomitant ABI value is lower. A resting ABI of 0.90 or less is diagnostic for PAD and correlates with abnormalities seen on imaging of the arterial tree.
A resting ABI greater than 1.40 indicates the presence of noncompressible, calcified arteries in the lower extremities and is considered uninterpretable. This is most commonly found in patients with diabetes mellitus and/or advanced chronic kidney disease. In patients with an ABI greater than 1.40, a toe-brachial index is used for diagnosis. A toe-brachial index less than 0.70 is diagnostic for PAD.
Exercise ankle-brachial index testing can be useful if there is a high clinical suspicion for peripheral artery disease but normal resting ankle-brachial index measurements.
Urticarial vasculitis
Urticarial vasculitis is characterized by urticarial lesions that last longer than 24 hours and that burn and sting rather than itch; wheals that resolve with hyperpigmentation; and associated systemic symptoms, such as fever and joint pain.
Skin biopsy is diagnostic.
When urticarial vasculitis is accompanied by decreased serum complement (C3 or C4), it is classified as hypocomplementemic urticarial vasculitis; these cases are strongly associated with systemic lupus erythematosus and glomerulonephritis.
Treatment of severe hypertriglyceridemia
Patients with persistent fasting severe hypertriglyceridemia (**triglycerides ≥500 **mg/dL) are at risk for acute pancreatitis.
Diet: low fat
Supplement: omega-3 fatty acid
Therapy: fibrate (fenofibrate)
Clostridium perfringens–associated necrotizing fasciitis and myonecrosis treatment
Surgery and penicillin + clindamycin
Vibrio vulnificus–associated severe necrotizing skin and soft tissue infection treatment
Surgery and ceftazidime + doxycycline
Infection usually occurs in immunocompromised patients (particularly with liver disease) after consumption of raw shellfish, such as oysters, or skin trauma incurred in warm sea waters, such as the Gulf of Mexico, or brackish water.
Aeromonas hydrophila–associated necrotizing skin and soft tissue infection treatment
Ciprofloxacin + doxycycline
Lacerations and puncture wounds sustained in aquatic environments, including fresh water and brackish water, particularly during warmer weather months, can result in wound infection. Aeromonas infections of the skin, soft tissue, and blood stream are more likely to occur in patients with underlying immunocompromising conditions such as cirrhosis and cancer.
Right ventricular hypertrophy on EKG
-Tall (dominant) R wave in lead V1
-Persistent precordial S waves
-Evidence of right atrial enlargement (P pulmonale)
-Right axis deviation or indeterminate axis
-rSr’ in lead V1
-Right ventricular strain pattern (ST segment depression and asymmetric T wave inversions in leads V1 to V3)
Size of (unconcerning) pulmonary nodule that does NOT require follow up
< 6 mm
Uric acid crystals (urine)
Uric acid crystals can take on a variety of appearances, such as rhomboids, barrels, rosettes, needles, or hexagonal plates.
When to prescribe triptans
After failed NSAIDs
Treatment of hypercalcemia of malignancy
-severe/symptomatic: isotonic saline and calcitonin
Bisphosphonates (zolendronic acid) take up to 4 days to work. Denosumab can be used when bisphosphonates are contraindicated (kidney failure)
No furosemide unless heart or kidney failure
Treatment of cytokine release syndrome
Chimeric antigen receptor T-cell therapies are highly effective; however, patients with a high disease burden may develop dangerous cytokine release syndrome.
The clinical presentation of cytokine release syndrome can range from mild, with fever, malaise, and myalgia, to a severe inflammatory syndrome characterized by vascular leak, hypotension, pulmonary edema, cardiac dysfunction, kidney dysfunction, liver failure, coagulopathy, multiorgan system failure, and even death.
Treatment protocols include early **supportive care **with antipyretics for lower grades of CRS and **high doses of glucocorticoids with cytokine-blocking monoclonal antibodies (e.g., tocilizumab) **for higher grades of CRS. The patient should also be evaluated for infection-related sepsis.
Blood pressure in ischemic stroke
In patients not eligible for thrombolytic therapy, the blood pressure (BP) threshold for initiating antihypertensive therapy is greater than 220/120 mm Hg; reduction of BP by 15% during the first 24 hours may then be reasonable.
A target blood pressure less than 130/80 mm Hg is considered a reasonable therapeutic target for most patients. In the first 48 hours, however, and especially in patients with symptomatic intracranial stenosis, lowering blood pressure is associated with neurologic worsening.
Orthopaedic comlpication of chronic bisphosphonate therapy
Chronic bisphosphonate therapy can be associated with atypical subtrochanteric femoral fracture.
Increased femoral cortical width on plain radiography is a risk factor for the development of bisphosphonate-related atypical subtrochanteric femoral fracture.
Disseminated zoster definition and precaution
Immunocompetent: >2 dermatomes OR vesicular lesions that cross the midline
Immunocompromised: any dermatomal invomvement
Precautions: airborne and contact
VSD vs ASD
The presentation of an isolated VSD depends on the VSD size and pulmonary vascular resistance. Small VSDs are usually asymptomatic. A palpable systolic murmur (thrill) is often noted at the left sternal border, accompanied by a loud holosystolic murmur that obliterates the S2. Small VSDs do not cause left heart enlargement or pulmonary hypertension, and the ECG and chest radiograph reveal normal findings. VSD closure is not indicated for patients with a small left-to-right shunt and no chamber enlargement or valve disease, but periodic clinical evaluation and imaging are recommended. Patients with small VSDs do not require activity restrictions.
An adult with an atrial septal defect (ASD) most often presents with dyspnea, atrial arrhythmias, or right heart enlargement. Physical examination findings include elevation in venous pressure, a right ventricular lift, fixed splitting of the S2, a pulmonary midsystolic flow murmur, and, when there is a large shunt, a tricuspid diastolic flow rumble. The ECG demonstrates right axis deviation and incomplete right bundle branch block, and the chest radiograph generally demonstrates features of right heart enlargement and enlarged pulmonary arteries with increased pulmonary blood flow.
Treatment of symptomatic hyponatremia
The initial treatment of symptomatic hyponatremia is acutely increasing the serum sodium by 3 to 4 mEq/L (3-4 mmol/L) with 3% saline infusion.
In the treatment of symptomatic hyponatremia, simultaneous administration of desmopressin with 3% saline infusion results in a more predictable and safer increase in serum sodium.
Omalizumab indication in asthma
Omalizumab (anti-IgE) is indicated in patients with severe persistent asthma inadequately controlled with standard therapy who have elevated IgE levels and sensitivity to multiple allergens, as documented by skin testing, or elevated serum allergen-specific IgE.
Mepolizumab and reslizumab asthma indication
Mepolizumab and reslizumab are anti-interleukin-5 mAbs: Severe asthma associated with elevated eosinophil levels, regardless of IgE level.
Treatment of levodopa-induced dyskinesia
Amantadine (glutamate N-methyl-D-aspartate receptor antagonist)
(Deep brain stimulation for refractory cases)
Management of levodopa “wearing off” phenomenon
Typical strategies to address end-of-dose wearing-off phenomenon include increasing the dose of levodopa or adding a catechol-O-methyltransferase inhibitor (entacapone), a dopamine agonist (ropinirole), or a monoamine oxidase type B inhibitor (selegiline). All of these strategies, however, can aggravate the dyskinesia.
Renal tubular acidoses
Type 1 (hypokalemic distal) renal tubular acidosis [defect in urine acidification] is characterized by a normal anion gap metabolic acidosis, hypokalemia, urine pH >6.0, and calcium phosphate kidney stones.
Type 2 (proximal) renal tubular acidosis [defect in reclaiming bicarbonate] is characterized by a normal anion gap metabolic acidosis, hypokalemia, glycosuria (without hyperglycemia), low-molecular-weight proteinuria, and renal phosphate wasting. (This is known as Fanconi syndrome when all features are present.)
Type 4 (hyperkalemic distal) RTA is due to aldosterone deficiency or resistance and is associated with a mild normal anion gap metabolic acidosis and hyperkalemia,
Which leukemia is most storngly associated with DIC?
APL (acute promyelocytic leukemia)
Normal maximum diameter of the abdominal aorta
3 cm
Treatment of chronic tophaceous gout with a persistently elevated urate level above target (>6)
Pegloticase
Pegloticase is recombinant pegylated uricase administered intravenously every 2 weeks. All patients should be screened for glucose-6-phosphate dehydrogenase (G6PD) activity before administration of pegloticase; low activity of G6PD poses a risk for hemolytic anemia and methemoglobinemia, and pegloticase is contraindicated in that setting. Pegloticase rapidly lowers the serum urate level, and prophylactic therapy (colchicine, NSAIDs, or glucocorticoids) must be administered concurrently with treatment.
Formation of antibody to pegloticase may occur (30%-50% of patients) and cause severe infusion reactions. Serum urate level must be checked before each infusion. After the initial dose, a serum urate level greater than 6.0 mg/dL (0.35 mmol/L) on two consecutive assessments indicates loss of efficacy due to antibody formation, necessitating discontinuation of pegloticase. Pegloticase should not be given with any other urate-lowering therapy so that interpretation of the serum urate level before each infusion is clear.
DIC labs
Typical findings of disseminated intravascular coagulation include thrombocytopenia, prolonged coagulation measures, hypofibrinogenemia, and elevated D-dimer level.
Preferred PrEP regimen for HIV
Tenofovir disoproxil fumarate (TDF) and emtricitabine
Cabotegravir is another option (q2mo, ok in kidney disease)
Once-daily tenofovir alafenamide (TAF) and emtricitabine is approved for HIV PrEP for men at high risk
If impending respitaroty failure in asthma
Intubate (NOT BiPAP)
In patients with asthma exacerbation, upright posture, inability to speak in full sentences, diaphoresis, flaring of the nares, and use of accessory muscles during inspiration are signs of impending respiratory failure.
In patients with severe asthma, a normal or elevated PCO2 may signal impending respiratory failure and the need for intubation and mechanical ventilation.
Treatment of gastric varices
In patients with gastric varices, contrast-enhanced cross-sectional imaging should be performed to determine the best treatment.
For isolated gastric varices due to splenic vein thrombosis, splenectomy can be performed to decompress varices. If the portal vein is patent and a suitable splenorenal shunt is available, balloon-occluded retrograde transvenous obliteration of varices can be considered. If the anatomy of the hepatic veins and portal vein branches is favorable, a transjugular intrahepatic portosystemic shunt may be an option. To determine the best therapy, contrast-enhanced cross-sectional imaging is required.
Management of gross hematuria in IgA nephropathy
Observation
Synpharyngitic hematuria and hematuria after exertion are common and usually benign (unless increased creatinine, hypertension, or proteinuria)
Steroids NOT indicated unless rapidly progressing renal insufficiency
Struvite crystals
UTI with Proteus, or other urea-splitting organisms such as Klebsiella or, less frequently, Pseudomonas; these bacteria secrete urease, which enzymatically hydrolyzes urea into carbon dioxide and ammonium, which markedly increases urine pH and results in the precipitation of magnesium ammonium phosphate, also known as struvite.
Struvite crystals are recognized by their coffin-lid appearance. Struvite crystals can rapidly form large stones in the renal pelvis and are responsible for the creation of staghorn calculi, which are stones that bridge two or more renal calyces.
Patients with infection caused by urea-splitting organisms have the typical signs and symptoms of UTI. However, these stones may become persistently infected despite antibiotic therapy and are a source of significant morbidity and mortality due to sepsis. Percutaneous nephrolithotomy is the first-line treatment for most patients.
How to treat persistent hyperglycemia
The American Diabetes Association (ADA) recommends initiation of insulin therapy for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (target 140-180)
Treatment consists of **basal, prandial, and correctional insulin **
Management of hepatic adenoma in men
**Resection **
Factors posing an increased risk for malignant transformation of hepatic adenomas include adenomas greater than 5 cm in diameter, adenomas with β-catenin activation, or adenomas found in men.
Oral contraceptives should be discontinued in women with hepatic adenomas with follow-up CT or MRI at 6-month intervals to confirm stability or regression in the size of the lesion.
Management of hepatic adenoma in women
Oral contraceptives should be discontinued in women with hepatic adenomas with follow-up CT or MRI at 6-month intervals to confirm stability or regression in the size of the lesion.
Cancer associated wityh Sjögren syndrome
Lymphoma
Mucosa-associated lymphoid tissue lymphomas. Risk factors include parotid gland enlargement, depressed C4 complement level, elevated rheumatoid factor level, elevated anti-Ro/SSA and/or anti-La/SSB antibody levels, monoclonal gammopathy, and cryoglobulinemic vasculitis.
If thyroid nodule and low TSH
Patients with thyroid nodules and a suppressed thyroid-stimulating hormone level should be evaluated with thyroid scintigraphy with radioactive iodine uptake.
Pressure ulcer staging
I: Intact skin with nonblanchable redness
II: Partial-thickness loss of dermis; shallow open ulcer with red-pink wound bed without slough
May also present as intact or ruptured serum-filled blister
III: Full-thickness tissue loss; visible subcutaneous fat but not bone, tendon, or muscle
May include undermining or tunneling
IV: Full-thickness tissue loss with exposed bone, tendon, or muscle
Unstageable: Full-thickness tissue loss in which base of the ulcer is covered by slough or eschar
Suspected deep tissue injury: Purple or maroon localized area of discolored but intact skin, or blood-filled blister caused by damage of underlying soft tissue from pressure or shear
CLABSI treatment
Remove line; start antibiotics tatgeting the most likely organism
Babesiosis
Note: can rarely be transmitted via blood products (and can occur up to 6 months after transfusion)
Fever, hemolysis (jaundice, hepatomegaly, splenomegaly)
Hemolytic anemia, thrombocytopenia, elevated aminotransferses and alkaline phosphatase
Intraerythrocytic rings are seen on a peripheral blood smear.
Rx: azithromycin plus atovaquone
Diagnosis of amyloidosis
Diagnosing amyloidosis requires biopsy of the affected tissue that shows the characteristic pathologic findings; to avoid a more invasive biopsy, abdominal fat pad or bone marrow biopsy may be preferred initially.
Which vaccine is contraindicated in HIV regardless of CD4 count?
Live flu
Treatment sequence in inflammatory breast cancer
- preoperative chemotherapy
- mastectomy
- irradiation
Heparin antidote
Protamine
Posttransplant lymphoproliferative disorder (PTLD)
**Epstein-Barr virus (EBV) **causes posttransplant lymphoproliferative disorder (PTLD).
Patients can have fever, pancytopenia, generalized lymphadenopathy, and hepatosplenomegaly.
PTLD risk is higher in patients with a history of pre-existing EBV infection treated with lymphocyte-depleting agents and in those receiving sirolimus and tacrolimus compared with those receiving mycophenolate and cyclosporine.
Treatment of cryptococcal meningitis
1.liposomal amphotericin-B + oral flucytosine
2. lumbar luncture
Folic acid dose in prenatal and pregnanct
0.4-0.8 mg
(no clear guidance on those at increased risk- 1? 4?)
When should pregnant women get TDaP?
Every pregnancy
(between 27 weeks’ and 36 weeks’ gestation)
Biologics for rheumatologic diseases before elective surgery
All nonbiologic disease-modifying antirheumatic drugs should be continued throughout the perioperative period in patients with rheumatologic disease undergoing elective arthroplasty.
With the exception of patients with severe systemic lupus erythematosus, biologic agents should be withheld for one dosing cycle before arthroplasty, with surgery performed just after the next dose would have been due and resumed when the wound shows evidence of healing.
Janus kinase inhibitors, such as tofacitinib, should be withheld for at least 3 days before surgery.
Treatment of cluster headaches
SubQ sumatriptan and oxygen
Management of malignant pleural effusion
Initial treatment of a malignant pleural effusion in patients with expandable lung includes either an indwelling pulmonary catheter or chemical pleurodesis with talc.
In patients with a malignant pleural effusion and a nonexpanding lung, an indwelling pulmonary catheter is the treatment of choice.
Management of gallbladder polyps
Gallbladder polyp size greater than 1 cm is a risk factor for malignancy; treatment for such polyps should be cholecystectomy.
Gallbladder polyps associated with gallbladder stones or primary sclerosing cholangitis are more likely to be neoplastic regardless of the polyp size.
Treatment of Staphylococcal infection in patient with atopic dermatitis
Atopic dermatitis is characterized by xerotic, pink, scaly skin and is most commonly seen on the periocular areas, posterior neck, antecubital and popliteal fossae, wrists, and ankles.
Most localized Staphylococcus aureus infections associated with atopic dermatitis may be treated with a topical antibiotic such as mupirocin.
More severe cases require systemic- TMP/SMX or doxycycline.
Aspergillus on microscopy
hyphal forms with acute-angle (45-degree) branching (on methenamine silver stain)
DVT prophylaxis in outpatients with cancer
Calculate Khorana score
In the absence of contraindications, outpatients with cancer at high risk of VTE (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin.
Treatment of salicylate toxicity
Intravenous sodium bicarbonate administration is used to treat patients with salicylate toxicity, as it increases urinary elimination of salicylate (with a goal of a urine pH >7.5) and protects the patient from central nervous system toxicity.
Treatment of depression in patients on tamoxifen
Antidepressants with strong CYP2D6 inhibition, such as bupropion, fluoxetine, or paroxetine may decrease tamoxifen activation and should be avoided.
Primary hyperparathyroidism vs FHH
Overt hypercalciuria or high-normal levels of urine calcium can help distinguish primary hyperparathyroidism from familial hypocalciuric hypercalcemia, which typically presents with low urinary calcium excretion.
Primary hyperparathyroidism labs
In patients with primary hyperparathyroidism, calcium levels are often only mildly elevated; parathyroid hormone levels may be frankly elevated or inappropriately normal.
Overt hypercalciuria or high-normal levels of urine calcium can help distinguish primary hyperparathyroidism from familial hypocalciuric hypercalcemia, which typically presents with low urinary calcium excretion.
Treatment of mucosa-associated lymphoma tissue (MALT) lymphoma
The treatment of mucosa-associated lymphoma tissue (MALT) lymphomas other than gastric MALT lymphoma may include irradiation for localized disease or rituximab when systemic therapy is required.
Helicobacter pylori eradication therapy has only been definitively proven to be effective for H. pylori–associated gastric mucosa-associated lymphoma tissue lymphomas.
Hyperacute bacterial conjunctivitis
Hyperacute bacterial conjunctivitis is characterized by an abrupt onset and extensive purulent discharge. It is usually associated with gonococcal infection in a sexually active adolescent or adult. It is vision threatening, and emergent ophthalmology referral is necessary
Health care workers and tetanus vaccination
Health care workers are at increased risk for pertussis and should receive the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine regardless of when they received their last tetanus and diphtheria toxoids vaccine.
In addition to pertussis, health care workers are also at increased risk for influenza, hepatitis B, measles, mumps, rubella, and varicella viruses and should receive the appropriate vaccinations.
Outpatient treatment of pneumonia in healthy patients
Amoxicillin or doxycycline
(An alternative treatment option would be monotherapy with a macrolide if local pneumococcal resistance is less than 25%.)
Treatment of outpatient pneumonia in patients with comorbidities
Cefuroxime and doxycycline or levofloxacin monotherapy
Treatment of severe COPD with chronic bronchitis phenotype or frequent exacerbations.
Roflumilast, a selective phosphodiesterase-4 inhibitor, can reduce symptoms and exacerbations in patients with severe COPD who have a chronic bronchitis phenotype or frequent exacerbations.
Azithromycin, a macrolide antibiotic, can also be used for patients with COPD and persistent exacerbations, especially in those who are current nonsmokers.
When do you need to do more for melanoma?
Removal of a melanoma by biopsy alone is inadequate therapy; the excisional margins depend on melanoma depth.
For nonulcerated melanomas less than 0.8 mm in Breslow depth, neither sentinel node sampling nor regional lymph node dissection is indicated.
If the sentinel node is involved with metastatic melanoma, adjuvant systemic therapy (with either immunotherapy in all patients or with either immunotherapy or BRAF /MEK inhibitors in BRAF -mutated melanomas) would be considered, as data support an improvement in disease-free and overall survival. Completion axillary dissection in the presence of a positive sentinel node has not improved overall survival in randomized trials and is not necessary, although these patients do require ultrasound surveillance to detect nodal recurrence.
MGUS
Monoclonal gammopathy of underdetermined significance is characterized by an M protein level less than 3 g/dL (or less than 500 mg/24 h of urinary monoclonal free light chains), clonal plasma cells comprising less than 10% of the bone marrow cellularity, and the absence of related signs and symptoms of end-organ damage.
Patients with low-risk monoclonal gammopathy of undetermined significance can be clinically observed and do not require follow-up testing.
Management of thyroid nodules
Thyroid nodule evaluation begins with a thyroid-stimulating hormone (TSH) measurement; if it is normal or elevated, ultrasonography and FNAB are performed.
Repeat ultrasonography should be performed in 6 to 12 months for all high-suspicion thyroid nodules, 12 to 24 months for intermediate- and low-suspicion nodules, and 24 months or longer for very low-suspicion nodules.
Repeat fine-needle aspiration biopsy is indicated for all high-suspicion thyroid nodules, nodules with concerning new sonographic findings, and intermediate or low-suspicion nodules that increase significantly in size.
Management of acute limb ischemia
1) initiate intravenous anticoagulation with unfractionated heparin
2) perform angiography, and
3) establish a plan for reperfusion of the leg.
Alcoholic ketoacidosis
Alcoholic ketoacidosis results in an increased anion gap metabolic acidosis and minimal ketones on urine dipstick analysis.
Ethylene glycol, methanol, and isopropyl alcohol toxicities are associated with an increased osmolal gap.
(Alcoholic ketoacidosis occurs in patients following an episode of acute intoxication; however, by the time of clinical evaluation, the ingested ethanol may be extensively metabolized, leading to low or absent serum ethanol levels. )
Osmolal gap
Ethylene glycol, methanol, and isopropyl alcohol toxicities are associated with an increased osmolal gap.
The plasma osmolal gap is calculated as the difference between the measured osmolality and calculated osmolality, which is determined as follows:
2 × Serum Sodium (mEq/L) + Plasma Glucose (mg/dL)/18 + Blood Urea Nitrogen (mg/dL)/2.8
Treatment of hyperthyroidism in pregnancy
Treatment of hyperthyroidism during pregnancy is typically with medical management; propylthiouracil is the drug of choice during the first trimester.
Radioactive iodine is contraindicated during pregnancy because it may cause destruction of the fetal thyroid.
Treatment after TIA
-aspirin
-statin
-clopidogrel
In patients who have experienced a transient ischemic attack, adding clopidogrel to aspirin for 21 days has been shown to be effective in reducing the risk for subsequent stroke compared with monotherapy with either agent alone.
In patients treated with dual antiplatelet therapy following a transient ischemic attack or minor stroke, aspirin should be continued following discontinuation of clopidogrel at 21 days.
Treatment of myasthenia gravis
Myasthenia gravis is an autoimmune disease of the postsynaptic neuromuscular junction associated with antibodies to the postsynaptic acetylcholine receptors.
Indications for thymectomy in myasthenia gravis include the presence of thymoma and the need to minimize immunotherapy requirements in patients without thymoma who have active disease and positivity for acetylcholine receptor antibodies, are younger than 65 years, and are within 3 years of diagnosis.
DAPT in stroke?
Dual antiplatelet therapy is recommended if started within 24 hours in select patients with transient ischemic attack or mild noncardioembolic ischemic stroke and continued for 21 and up to 90 days.
Dual antiplatelet therapy for ischemic stroke should not be extended beyond 90 days given the lack of benefit and increased risk of bleeding.
(Following completion of DAPT, the selection of a single antiplatelet agent should be individualized on the basis of patient risk factor profiles, cost, and tolerance. Aspirin versus clopidogrel monotherapy has been studied for the secondary prevention of the combined outcomes of ischemic stroke, peripheral artery disease, and myocardial infarction, and clopidogrel was associated with a 0.9% per year absolute benefit; however, the results of this trial were driven by peripheral artery disease outcomes. In this patient with ischemic stroke and peripheral artery disease, stopping aspirin in favor of clopidogrel is reasonable.)
