IM Essentials Flashcards
What are the sx of serotonin syndrome? unique features?
high fever, muscle rigidity, cognitive changes
unique feat: shivering, hyperreflexia, myoclonus, ataxia
What are the sx of malignant hyperthermia?
severe muscle rigidity, masseter spasm, hyperthermia, tachyarrhythmia, rhabdomyolysis
What drugs cause malignant hyperthermia?
inhaled anesthetics (halothane) and depolarizing NM blockers (succinylcholine, decamethonium)
What are the sx of neuroleptic malignant syndrome?
muscle rigidity, hyperthermia, autonomic dysregulation, commonly delirium, extrapyramidal sx (tremors/parkinsonism/dystonia, high muscle enzyme [CK])
(vs 5HT s/o has hyperreflexia and myoclonus)
What are indications for starting abx in pt with URI/sinus infection?
- 3-4 days of severe sx: fever > 39, purulent drainage, facial pain
- worsening sx that were initially improving after typical URI
- sx that do not resolve in 10 days
What are the centor criteria?
- t > 38.1 (100.5)
- tonsil exudate
- tender cervical lymphadenopathy
- absence of cough
if 4 –> > 40% changce of strep pharyngitis
2-3 –> intermediate –> do RADT
may empirically treat 3/4 which wait for test results
What should you suspect/next test in someone w/ pharyngitis, persistent fever, neck pain, septic pulmonary emboli?
lemierre syndrome = septic thrombosis of jugular vein
do CT of neck w/ contrast
When do you need to cover for psuedomonal pneumonia? what is abx of choice?
- hx of smoking, hx COPD, broad spectrum abx use in previous month, recent hospitalization, malnutrition, neutropenia, steroid use
What is/are abx of choice for pseudomonas pna?
B lactam + aminoglycoside (ex. piperacillin tazobactam + amikacin)
What is curb-65?
confusion, BUN > 19.6, RR > 30, SBP 65
if 2 or more, admit to hospital
if 3-4 to ICU
What is the outpatient treatment for CAP?
azithromycin
What are risk factors for drug resistant strep pneumo?
- age > 65
- B lactam use in last 3 mo
- medical comorbidities
- immunocompromised
- alcoholism
- exposure to child in day care
What is the most appropriate test for pt who has received BCG vaccine to test for TB?
interferon-y-releasing assay
What is the next step if +PPD and negative CXR?
latent TB –> give INH for 9 mo
Who should receive abx prophylaxis to prevent infective endocarditis?
only pts w/ underlying heart conditions w/ high risk of adverse outcome from infective endocarditis –> prosthetic heart valve, hx of prior infective endocarditis, unrepaired cyanotic heart disease or repaired congesnital heart disease for 6 mo following repair, cardiac transplant recipieitns with cardiac valvulopathy
What are 2 abx treatments for endocarditis 2/2 MRSA?
IV vancomycin or daptomycin
What is the initial therapy for pericarditis?
NSAID or ASA
What are characteristics of pericarditis chest pain?
pleuritic, worse with lying down (better when sitting forward)
What is next step in dx GERD in pt with CP where cardiac etiology has been ruled out?
trial of PPI for 8-10 wks
if successful –> continue
if unsuccessful –> do endoscopy or manometry
When do you increase dose of B blocker vs add on CCB?
optimal B blockade = resting HR of 55-60
if HR is higher, you can increase dose
if HR in optimal range, add on CCB
What is next line medication if pt’s angina not controlled on BBlockers?
add CCB
What are contraindications to giving B Blockers in pts with ACS?
heart failure, systolic
What are contraindications to LMWH instead of regular heparin?
obese, CKD
What is preferred treatment for pts presenting with many hours of STEMI?
1st = PCI = benefit up to 12 hrs from onset sx and possibly even longer
no benefit for thrombolytic therapy more than 12 hrs after sx onset = 2nd line
What are the sx of postinfarct VSD?
new holosystolic murmur at L sternal border, acute resp distress, thrill
–> leads to cardiogenic shock from acute volume overload to R ventricle
What are sx of LV free wall rupture postinfarct?
hemopericardium w/ electromechanical dissociation and death
What is first line tx for pt with ACS?
dual antiplatelet (ASA + tienopyridine [clopidogrel]), B Blocker, nitrates, heparin
morphine if active CP
if BBlocker CI –> CCB [not nifedipine]
What are sx of sixk sinus syndomre?
episodes of sinus bradycarida with dizziness
What do you see on KEG with LBBB?
absent Q waves in leads 1, aVL, V6
large wide positive R in leads 1, aVL, V6
prolonged QRS to > 0.12 s
What is the acute treatment for AFib if hemodynamically stable?
rate control = IV BBlocker (metoprolol, esmolol) or CB (diltiazem, verapamil)
When do you do cardioversion for AFib?
adverse hemodynamic status of acute coronary ischemia 2/2 afib
What do you see on EKG with atrial flutter?
saw tooth pattern, regularly irregular, 2:1 AV conduction = typical
Who is at risk for multifocal atrial tachycardia?
acutely ill pts in setitng of pulm dz (COPD, electrolyte abnormalities)
What is EKG in MAT?
presence of at least 3 different P wave morphologies with varying P-R intervals
What is EKG of AVNRT?
RP interval so short that P wave buried in QRS, narrow QRS
What is the treatment for atrial tachycardia?
B blocekrs and CCB (verapamil/diltiazem)
- adenosine/cardioversion not very effective
What is treatment for AVNRT?
IV adenosine
What is treatment for AVRT?
if narrow QRS –> adenosine
if wide complex –> 2/2 accessory path, don’t use AV node blocking drugs –> procainamide
What is treatment for MAT?
treat underlying pulm disease, discontinue B agonists
if doesnt resolve, give metoprolol or high dose MG
What is treatment for HCM if risk factors for sudden death?
implantable cardioverter-defibrillator
What is treatment for ventricular tachycardia?
if stable –> amiodarone [or procainamide or sotalol]
if unstable –> cardioversion
What is the treatment for suppression of premature ventricular complexes?
B blockers (metoprolol) if symptomatic
Who should get spironolactone in heart faulire?
class III-IV symptoms, serum K
What are some factors that increase and decrease BNP?
increase: ventricular wall stress, kidney failure, older age, F
decrease: obesity
What are some clinical situations in which BNP is elevated?
CHF exacerbation, PE, acute MI, acute tachycardia
When should you do coronary angiography to evaluate new HF?
angina or new onset LV dysfunction in the setting of risks for silent ischemia (ex. DM)
What meds should everyone wtih HF get?
B Blocker, ACEI
What meds should you give to patient with HF with preserved EF?
CCB or BBlocker AND
ARBs (candesartan) or ACEI
avoid nitrates and nondihydropyridine CCBs b/c decrease preload/filling even further
What is optimal medical therapy for severe systolic HF?
ACE inhibitor + BB + spironolactone
When is cardiac resynchronization indicated in pt with HF?
persisitnet moderate to severe sx despite optimal medical therapy and QRS > 120
What med should you give a patient with resistant htn and HF receiving optimal lisinopril/carvedilol/chlorthalidone?
add 2nd gen dihydropyridine CCB (amlodipine)
What does it mean if a murmur increases in intensity with inspiration?
R sided murmur
What type of murmur is seen with aortic regurg?
soft blowing diastolic murmur best at 3rd L or 2nd R intercostal space
does no radiate
best leaning fwd in end-expiration
When is echo indicated for a murmur?
- grade 3+
- diastolic or holosystolic or late systolic, or with ejection click
- radiation to back
What is treatment for patients with severe aortic stenosis?
surgical aortic valve replacement
What murmur is diastolic with opening snap, accentuated wtih atrial contraction. loud S1, variable S2?
mitral stenosis
What murmur is associated wtih wide pulse pressure?
aortic regurg
What systolic murmur presents with click? Where does it radiate? what happens with valsalva/standing?
mitral valve prolapse
radiates to axilla
click-murmur moves closer to S1 with valsalva/standing
What is the tx of choice for fibromuscular dysplasia?
revascularization with kidney angioplasty
What is goal for bridging/INR for DVT anticoagulation?
5 days LMWH until INR 2 for more than 24 hours
What is initial treatment for acute DVT in pt with kidney disease?
IV unfractionated heparin (don’t use LMWH)
What is the next diagnostic step in patient with low probability of DVT?
D Dimer to exclude DVT
What is wells score?
1 point each for: cancer, paralysis, immobilization or surgery, tenderness along deep veins, sweelnig of leg, calf circumference differential of 3, pitting edema, collateral superficial veins, -2 pts for clinical suspicion that another dx is likely
What happens to lung volumes, PFTs in respiratory muscle weakness?
restrictive pattern –> decreased TLC, but with increased RV b/c unable to exhale fully
decreased FEV1 and FVC, but preserved ratio
What etiology of chronic dyspnea in setting of hx of multiple intubations? What is next diagnostic step?
at risk for tracheolmalacia or tracheal stenosis
dx by PFTs = see flattening of curve on insp/exp
What does it mean if jugular vein distends/fills during inspiration?
kussmaul sign = suspicious for constrictive pericarditis
What do you see on echo in constrictive pericarditis?
restrictive filling and ventricular itnerdependence (diastolic filling of one V impedes the other = to and fro diastolic motion of ventricular septum)
What are characteristics of pleural effusions associated w/ malignancies?
exudative, predominantly lymphocytes, unilateral
When do you tap a parapneumonic effusion?
only if complicated (empyema)–> do chest tube
What kind of pleural effusion in PE?
exudative, small and unilateral
How do you distinguish lobar consolidation vs pleural effusion on physical exam?
both have decreased breath sounds, only decreased tactile fremitus with effusion, consolidation will have increased fremitus
When should you order a1 antitrypsin levels in pt with COPD?
- dx younger than 45
- non-smoker
- predominantly basilar lung disease
- concurrent liver disease
When is O2 therapy indicated in COPD?
- arterial PO2
What are indications for admission in COPD exacerbation?
- severe disease
- advanced age
- significant comorbidities
- marked increase in intesnity of sx
- newly occuring arrhythmias
- diagnositc uncertainty
- insufficient home support
- onsent new physical sx
- poor response to inital medical management
When should you give noninvasive positive pressure ventilation in COPD (BIPAP/CPAP)? when intubate?
acute hypercapnic resp failure, acidosis, RR> 25
intubate if RR> 35
How do you dx OSA?
polysomnography
What is first line treatment for OSA?
CPAP
What diagnosis should you think of when pt presents with CAP sx but does not improve with treatment?
cryptogenic organiziaing pneumonitis
What 3 ILDs are known to be in basal lobes?
IPF
asbestos
NSIP
What 3 ILDs are known to go to upper lobes?
hypersensitivity pneumonitis
sarcoid
silicosis
When do you do ventilation perfusion scan vs CTA for pulm embolism?
ventilation perfusion in kidney failure or other contraindication to contrast CTA
What is next step if you suspect diverticulitis? What tests should you avoid?
if uncomplicated –> start PO abx if can tolerate oral intake (cipro + metronidazole for anaerobes + gram neg rods)
if complicated –> surgery
avoidcolonoscopy and barium enema 2/2 risk of perforation
What are the 3 classic findings in chronic pancreatitis?
abdominal pain (mid-epigastric), postprandial diarrhea, DM 2/2 pancreatic endocrine insufficiency
What is next step for confirming dx of GERD in pt that fails to respond to PPIs?
gold standard dx = 24 hr esophageal pH impedance monitoring
What is the next dx step if suspect HCC on US?
triple phase contrast enhanced CT or gadolinium enhanced MRI of abdomen
[no need for bx, radiologic criteria are specific]
What is DASH diet? What is effect of DASH diet on BP?
diet high in fruits + veggies, low is sat fat and total fat
SBP down by 8-14
What is effect of wt loss on BP?
5-20 SBP per 10kg loss
In order which are most effective at decreasing BP?
wt loss, alcohol, dietary Na, DASH, exercise
wt loss > DASH > exercise > dietary Na > alcohol
What are the most common tumors to met to liver?
GI tract, lung, breast
What is the geo location of blastomycosis?
great lakes, Mississippi and ohio river basins
What are sx of systemic blastomycosis?
ulcerated skin lesions, lytic bone lesions, pulm/cxr findings similar to TB/histo
How do you dx blasto?
broad based budding yeast in sputum
What is treatment of systemic blasto?
itraconazole or amphotericin b
What are sx of systemic coccidioidomycosis?
fever, cough, night sweats, extrapulm manifestations –> skin,meninges, skeleton
What is location of coccidiomycosis?
southwestern US
What is best dx test for HCC?
triple phase contrast CT
What is the definition of hepatorenal syndrome?
development of kidney failure in patients with portal hypertension and normal renal tubular function
presents w/ AKI, increased renal Na avidity, normal urine sediment, and sometimes oliguria
What is the treatment for large esophageal varices (>5mm)?
use nonselective B Blocker
if CI, do endoscopic variceal band ligation
as PPX to prevent hemorrhage
What is the indication for TIPS?
recurrent or refractory variceal hemorrhage
What is the next step if you find asymptomatic gallstones?
observation
What is the next step if you suspect cholecystitis?
ultrasound
What do you see on US with cholecystitis?
pericholecystic fluid, thickened gallbladder wall 3-4 mm
What do you see in acute cholecystitis on HIDA scan?
non visualization of gallbladder
When is ERCP indicated?
- remove stones/help drainage in pts with cholangitis or with gallstone pancreatitis complicated by cholangitis
What are poor prognostic factors in acute pancreatitis?
hemo-concentration –> elevated BUN, cr, hematocrit
What is next step if find asymptomatic pancreatic pseudocyst after acute pancreatitis?
if asymptomatic, no further testing, will resolve on its own in ~ 4 wks
drain only if pain/fever/anorexia
What is the tx for severe or relapsed CDiff?
oral vanco OR oral vanco + IV metro
What is tx for CDiff with ileus or obstruction?
vancomycin per rectum combined with oral vancomycin and intravenous metro
What is a late complication of gastric bypass?
SIBO –> diarrhea, bloating, and features of malabsorption
What are alarm sx that should make you work up chronic diarrhea rather than just assuming its IBS?
weight loss, anemia, fever, chronic severe diarrhea, family history of gastrointestinal disease
What is treatment for IBS?
supportive, can give anti-spasmodic
What are recommendations for colonoscopy in UC?
disease extending beyond the rectum should undergo routine surveillance colonoscopy with biopsies every 1 to 2 years beginning 8 to 10 years after diagnosis.
What medical treatment should you give to patient w/ acute UGI bleed from ulcer?
proton pump inhibitors can decrease the potential need for intervention during upper endoscopy and can reduce the risk of recurrent hemorrhage (omeprazole, pantoprazole, etc)
What is the MCC obscure small intestine bleeding in elderly?
angiectasia
When should you work up rectal bleeding further that you suspect is from hemorrhoids?
- if > 40 with typical hemorrhoidal symptoms but at low risk for colon cancer, do colonoscopy or at least sigmoidoscopy
- if > 50 do colonoscopy
MCC severe hematochezia?
bleeding from colon –> diverticulosis
What are symptoms/ findings in exogenous glucocorticoid induced 2ndary adrenal insufficiency?
N/V/ab pain, hypotension, hypoNa, +/- hypoK
What should you do if pt with well controlled hypothyroid becomes pregnant?
increase levothyroxine by ~30% with goal TSH 0.1-2.5
What is next step if TSH greater than the reference range, with serum free thyroxine (T4) level in the reference range and only mild fatigue?
subclinical hypothyroid
repeat testing of thyroid function in 6 mo
unless: marked symptoms, goiter, pregnant, TSH > 10
What is acute treatment for hyperthyroid?
β-blocker and methimazole (or PTU)
What tests should you do when someone presents with adrenal incidentaloma?
- o/n dexamethasone suppression
- 24 hr urine metanephrines
- measure plasma renin and aldosterone [if hypertension or hypokalemia]
What signs of hyper and hypo cortisol do you look for to decide if you need to change dose of steroids in person w/ adrenal insufficiency?
increase dose if hypo = N/V, malaise, hypotension, wt loss, hypo Na, hypoglycemia
decrease dose if hyper = cushing = wt gain, hyperglycemia, htn, striae, ab fat
What clinical characteristics distinguish cushing disease from other causes of cushing syndrome?
hyperpigmentation = in cushing disease b/c of high ACTH
vs no hyperpigmentation if primary hypercortisolism
What are symptoms of carcinoid syndrome?
episodes of flushing lasting up to 30 min, accompanies by fall in BP and rise in HR
What are screening recommendations for DM1?
fasting lipid panel after puberty or at dx if dx is after puberty
- nephropathy screening > 5 yrs after dx
- dilated fundoscopic exam > 3-5 years after dx
When do you need to repeat testing in DM diagnosis?
dx must be confirmed on subsequent day by repeating the same test suggestive of DM
if results of 2 different dx tests available and both diagnostic for DM, additional testing is not needed
What electrolyte abnormalities in DKA?
- hyperosmolar
- hyponatremia
- hyperkalemia (although total body K is low, as give insulin shifts into cells –> hypokalemia)
is hyperK associated with acidosis or alkalosis?
acidosis
What type of insulin should you give in pt with hyperglycemic emergency?
regular insulin by IV infusion [b/c immediate onset of action]
What is the most appropriate tx for pt with osteoporisis and GERD?
IV bisphosphonate (zoledronic acid) [vs oral = alendronate, risedronate] b/c of risk of esophagitis
What are screening recommendations for lung cancer?
low-dose spiral chest CT scans for 55 to 79 yo with >30-pack-year history as current smokers or quit in past 15 years.
What is the treatment for ER+ DCIS?
breast-conserving treatment (lumpectomy plus radiation therapy) or mastectomy followed by tamoxifen therapy for 5 years.
What is next step if pt has 1/6 FOBT test positive?
colonoscopy now
What are colonoscopy recs for patients with a relative with colorectal carcinoma?
if fam member w/ ca
What is f/u treatment for completely resected colorectal ca?
adjuvant chemo (not radiation)
If ascus with positive HPV dna what is next step?
colposcopy
What is next step if find nodule/asymmetry on transrectal prostate exam?
do biopsy even if normal PSA
What is the treatment for metastatic prostate cancer?
androgen deprivation therapy [GnRH agonists or bilateral orchiectomy]
What is follow up for pts in remission from prostate cancer?
serial digital rectal examinations and serum PSA measurement every 6 to 12 months.
What is treatment for early stage diffuse large B cell NHL?
chemotherapy and rituximab followed by radiation
What is the next step when a pt presents with SVC syndrome?
mediastinoscopy and biopsy to confirm what type of cancer before treating
What is pathogenesis/tx of warm autoimmune hemolytic anemia?
IgG antibodies against RBCs, at warm temps
- facilitate destruction by splenic macrophages.
- dx by direct antiglobulin (Coombs) test
- see Spherocytes are seen on the peripheral blood smear
tx: Glucocorticoids
What are sx of ITP? how do you dx?
sx: asx OR petechiae/echymoses
dx: platelets often
What are diagnostic criteria of MGUS?
IgG spike
What are the two lab tests necessary for diagnosing multiple myeloma?
- serum protein electrophoresis
- urine protein electrophoresis
combined with immunofixation for whichever is positive for a monoclonal protein to confirm what it is
What should you work up if pt presents with first unprovoked DVT?
make sure patient’s age- and sex-appropriate cancer screening is up to date.
When should you work up a pt for inherited thrombophilia with VTE?
- avoid during acute phase of VTE or while on anticoagulation
- do it 2 wks after stop anticoagulation
What are recommendations for anticoagulation w/ antiphospholipid syndrome?
life long anticoagulation to prevent DVT
what special type of blood products for pt with IgA deficiency to prevent anaphylaxis?
washed RBCs and platelets
WHat is the universal donor blood?
O negative
What is presentation of adult onset stills disease?
daily fever, evanescent salmon-colored rash, arthritis, and markedly elevated serum ferritin
What is presentation of patellofemoral pain syndrome?
anterior knee pain that is made worse with prolonged sitting and with going up and down stairs
What findings suggest meniscal tear on exam?
- pain along the joint line is 76% sensitive
- audible pop/snap on McMurray test is 97% specific (Maximally flexing the hip and knee and applying abduction (valgus) force to the knee while externally rotating the foot and passively extending the knee)
what kind of knee injury presents w/
- pain along anteromedial proximal tibia distal to the joint line of the knee
- worse w/ climbing stairs
- worse at night
pes anserine bursitis
path: pt w/ osteoarthritis or from overuse
What is presentation of rotator cuff impingement? specific test?
pain w/ abduction, no decrease ROM
- Hawkins test: quickly internally rotate pt’s arm, assess for pain
What is next step if suspect rotator cuff tear?
- get MRI
if complete –> surgery
if incomplete –> physical therapy
What is next step for pt w/ OA who has pain in one or a few joints that is disproportionately painful to other joints?
- intra-articular glucocorticoid injection to decrease pain and improve function
What are criteria for OA?
meet 3 of the following:
- age greater than 50 years
- stiffness lasting less than 30 minutes
- crepitus
- bone tenderness
- bone enlargement
- no palpable warmth
What is likely dx if xray shows joint space narrowing w/ osteophytes and cartilaginous calcification, negative RF?
Calcium pyrophosphate dihydrate deposition disease = osteoarthritis-like arthritis in atypical joints, such as the metacarpophalangeal joints, along with the presence of chondrocalcinosis.
What is mnemonic for the 11 characteristics of SLE (4 required to make dx)?
MD SOAP BRAIN
- Malar
- Discoid
- Serositis
- Orla ulcer
- Arthritis
- Photosensitivity
- Blood –> los Plt, anemia
- Renal failure
- ANA
- immuno
- Neuro
What is next step if pt’s RA is not well controlled on methotrexate?
add a TNFa inhibitor [etanercept, infliximab, adalimumab]
What is tx for pt with SLE and early lupus nephritis?
high dose steroid
What are earliest imaging findings in ankylosing spondylitis?
MRI changes in sacroiliac joints before XR changes
What is tx for raynaud?
dihydropyridine calcium channel blocker [amlodipine, nifedipine]
What is tx for fibromyalgia?
1st = lifestyle: regular aerobic exercise, CBT
SNRI (duloxetine and milnacipran), TCA, pregabalin
What is next step if pt w/ isolated proteinuria?
split urine collection –> split urine collection during day vs night, if orthostatic proteinuria will have high protein during day not night
What is the tx for rhabdo?
IV NS
What are presenting sx of rhabdo?
serum creatine kinase level above 5000 U/L
blood on urine dipstick in absence significant hematuria.
What are complications of rhabdo?
hypocalcemia, hyperphosphatemia, hyperuricemia, metabolic acidosis, acute muscle compartment syndrome, and limb ischemia
What lab values in refeeding syndrome?
intracellular shift of phosphorus –> cells previously starved now stimulated to grow, consume phosphorous for ATP
What type of RTA characterized by normal AG, low K, urine pH > 6.0?
RTA type 1 (distal)
What are some etiologies of RTA type 1?
Sjögren syndrome, systemic lupus erythematosus, or rheumatoid arthritis; drugs such as lithium or amphotericin B; hypercalciuria; and hyperglobulinemia.
What lab abnormality in gitelman?
inactivating mutations in the gene for the thiazide-sensitive sodium chloride cotransporter
hypokalemic metabolic alkalosis
What lab values in RTA type 2?
normal AG met acidosis, low K, glucose in urine in setting of a normal BG, low-molecular-weight proteinuria, phosphate wasting, Uph
What is next step if pt w/ metabolic alkalosis?
get urine chloride
if volume responsive 2/2 dehydration/emesis
if > 10 –> volume non-responsive –> then if htn think hyperaldo
What is next step if someone w/ recurent Ca oxalate stones and hyperoxaluria
- decrease foods w/ oxalate –> low protein
- increased Calcium intake
When do you use hctz for ca oxalate stones?
if hypercalciuria
What is the corresponding increase in disease probability with a +LR of 2, 5, or 10?
15%, 30%, and 45%, respectively
What is the corresponding decrease in disease probability w/ a -LR of 0.5, 0.2, 0.1?
15%, 30%, and 45%, respectively
What are hypertension drugs of choice in pergnancy?
labetolol, hydralazine
What is definition of metabolic syndrome?
3 of the following 5:
(1) waist circumference >40 in M and >35 in F
(2) SBP≥130 DBP ≥85
(3) HDL
What test if you suspect vertebral fracture?
plain XR film
What initial imaging test to diagnose ankylosing spondylitis?
AP xray of the pelvis to view sacroiliac joints and the hips.
What is the tx for upper airway cough syndrome?
first gen antihistamine (like diphenhydramine) and a decongestant
What are sx of upper airway cough syndrome?
cough, nasal discharge, sesnation of postnasal drip, frequent throat clearing, cobblestoning of posterior pharyngeal mucosa
What is next step in pt w/ hemoptysis and hx of smoking?
get CXR –> then chest CT and fiberoptic bronchoscopy even if radiograph is negative
Which pts w/ influenza should get oseltamavir/zanamivir?
- within first 2 days of sx
- hospitalized pts w/ influenza
- severe complicated illness
- CKD, cardiovascular risk, active cacner, liver dz, hemoglobinopathies, immune compromise
What meds can you give w/ pt trying to quit smoking to prevent weight gain?
burpoprion
What is next step if pt w/ depression on SSRI for 8 wks and no response?
- switch to different antidepressant in same or different class
- add a second agent [usually do this after has 2 failed trials of medication monotherapy]
- do psychotherapy
What is tx for cocaine associated chest pain?
CCB and benzo
What is tx for pt w/ menorrhagia 2/2 fibroids?
- medroxyprogesterone acetate for 10-21 days
- or can use monophasic oral contraception 4x day for 5-7 days then daily for 3 wks
What is next step if pt with syncope w/ no diagnosis after using 30 day loop recorder?
implantable loop recorder –> lasts ~ 3 yrs
What is the biggest risk factor for pt w/ lymphadenopathy to be pathologic?
age > 40
What are risks for pathologic etiology of lymphadenopathy?
age > 40
sustained over > 2wks
size > 2cm
What is presentation of open angle glaucoma?
painless, gradual loss of peripheral vision in both eyes,
often asymmetric
clinical: increased optic cup to disc ratio (>0.5), disc hemorrhages, and vertical extension of the central cup
What is presentation of dry macular degeneration?
soft drusen (deposits of extracellular material) form in the area of the macula gradual loss of central vision
What is presentation of wet macular degeneration?
neovascularization of the macula with subsequent bleeding or scar formation. Visual loss may be more sudden (over a period of weeks) and is often more severe.
How do cataracts present? risk factors?
risks: older age, ultraviolet B radiation exposure, smoking, diabetes mellitus, a family history of cataracts, and systemic corticosteroid use.
present: difficulty with night vision.
What is the tx for acute urticaria?
H1 antihistamines (ceterizine)
What is preferred therapy for episodic tension HA?
NSAIDS
What is preferred imaging for dx subacute or chronic HA?
MRI (vs CT)
What is tx for carpal tunnel?
wrist splinting
What is tx of drug induced dystonia?
benzo, anticholonergic (diphenhydramine), or botulinum toxin shot
What is tx for essential tremor
lifestyl mod: getting enough sleep and reduction of caffeine
if that doesnt work start propanolol
What is next step in dx if pt w/ suspected MS but neuroimaging inconclusive?
LP –> oligoclonal bands or elevation of the IgG index
When should you do valve replacement in infective endocarditis?
heart failure; abscess or fistula formation; severe left-sided valvular regurgitation; refractory infection despite appropriate antibiotic therapy; or recurrent embolic events, especially with residual vegetation larger than 1.0 cm
WHat is presentation? mcc? tx? of acute epidydimitis?
unilateral pain and tenderness in the epididymis and testis, spermatic cord is enlarged and tender on palpation
mcc = chlamydia, can also be 2/2 gonorrhea
tx: ceftriaxone and doxycycline (or azithromycin)
How do you differentiate reactive arthritis from gonococcal arthritis?
reactive; symmetric, HLA B27, rash on palms and soles, conjunctivitis, urethritis, oral ulcers, balantitis
goococcal: asymmetric, migratory, tenosynovitis, skin lesions = vesico/pustules
