Internal Medicine Outpatient Rotation Flashcards
Sort Chronic Otitis Externa and Swimmer’s Ear from Malignant Otitis Externa
Chronic Otitis Externa:
When uncomplicated by otitis media or excessive edema, drainage or celluilits is usually itchy as it’s caused mostly by allergic rxn.
-Try OTC antihistamines and otic steroids.
Swimmer’s Ear
Usually Acute and presents with pain on moving pinna/auricle. Usually Pseudomonas. TM intact and usually visible if uncomplicated.
-Rx Wick in Cipro otic with Steroid.
- Prevention is Swimmer’s Ear otic drops
Home-made is 1/2 Rubbing ETOH + 1/2 Vinegar
The ETOH combines with water to dry and the
Vinegar creates a hostile envr. for pseudomonas
Malignant Otitis Externa/ Necrotizing - Is a rare complication of chronic otitis externa, thus also usually caused by Pseudomanas A.
Diabetics and Immunocompromised patients are more susceptible. DM more likely to have Candida (white fungus on canal debris) or Aspergillus (grey fungus on canal debris)
The external canal is usually so edematous you cannot see the TM, there is foul drainage, perhaps green, and "deep otalgia" or pain deep in the ear. Cranial Nerve Palsies may result and infection can spread to the base of the skull
- Life Threat
- Control Sugar or Correct Immune Compromise
- ESR, CBC, CULTURE the discharge/necrotic tissue
- Get CT and/or Radionuclide Scan if you can
Dx confirmed by osseous erosion shown on CT/scan
and you want to confirm if bone is involved.
- Start Cipro/Gentamycin PO/IV and Cipro/Steroid Otic
on a wick.
- You could start IV Zosin to start and back down
to Cipro if culture indicates sensitivity
-Debride canal ONLY if TM is visible and intact
Fluctuant soft tissue mass, often found in axilla, neck and perirectal regions, no erythema or warmth.
Rx?
Incision and Drainage perhaps with a wick for drainage but definitely left open to heal.
This is a SIMPLE CUTANEOUS ABSCESS
Often seen in IV/IM Drug abusers
Usually Staph or Strep Pyogenes
Sort Mild Persistant Asthma from Moderate Persistent and Severe
Moderate is Daily
Mild is more than 2X a week but not daily
Severe Persistant is continual and exacerbations limit activity
What is Ideopathic Pulmonary Fibrosis and how is it treated?
Scarring from repeated Alveoitis (think smokers so it’s not entirely idiopathic…)
Looks like Honey Comb on CT
Treatment is OXYGEN, PULMONARY REHAB + Supportive care
Neither albuterol nor steroids help fibrosis. DO get your pt VACCINATED to reduce risk of pneumonia as that will exacerbate the problem.
Symmetric DESCENDING muscle weakness, think
Botulism
Clostridium Botulinum
Upper Extremities more affected by the weakness than Lower Extremities.
No fever, No loss of consciousness and No Tachycardia
Most cases are in Infants from Honey and/or Corn Syrup
but Home Canning is also a source: Jams
LisFranc Injury
Tarsometatarsal Joint sprain or fracture
Pain @ dorsal mid-foot especially when heel is held and foot is rotated (forefoot rotation against a stabilized hind foot). Flexion + Extension of toes not painful
Metatarsals meet tarsal bones (3 cuneiform and the cuboid) right there at the dorsal mid-foot. Metatarsals can be fractured, the tarsal bones can be fractured and all can be dislocated - more typically laterally than medially and dorsally as opposed to ventrally.
Neither a tibiomalleolar sprain nor a fibulatalar sprain hurts on the mid dorsal aspect of the foot on stabilized rotation of forefoot.
Bones that form the ANKLE
Tibia, Fibula and Talus
The DISTAL TIBIA forms the Medial Malleolus
the DISTAL FIBULA forms the Lateral Malleolus
The SPACE between the distal Tibia and Fibula and the “dome” or superior aspect of the Talus is called the
JOINT SPACe
Ankle FRACTURES mostly involve the distal Tibia
Ankle SPRAINS most
Most common Ankle Fracture involves which bone
Distal TIBIA
What is the most common Ankle Sprain site?
Lateral Malleolus: the FibuloTalar ligaments stretch when the foot inverts or rolls under the leg.
Ligaments most commonly stretched in a Fibulotalar lateral malleolar sprain are:
- Anterior TaloFibular Ligament. Holds the top of the
Talus to the anterior distal fibular head
-Calcaneal Fibular Ligament. Holds the inferior fibular
head to the Lateral Calcaneous or heel bone
Mortise Ankle View on Xray, describe?
AP of ankle should show equal joint space all along the talar “dome” or the top of the talus. The talus sits atop the calcareous and communicates anteriorly with the tarsal bones (3 cuneiform and the cuboid) which in turn communicate with the 5 metatarsals.
How to Dx and Rx an ankle sprain?
XRay will show normal joint space and no distal tibial, fibular or talar fracture.
There will be pain, bruising and swelling on the lateral malleolus in an inversion sprain.
In a mild sprain, the pt can bear weight - No need to immobilize the joint. Crutches and an ace with RICE
RICE for sprains, explain:
REST : but only for a few days. Thereafter weight bearing
is good for recovery
ICE: Control that swelling but only 1st 24hrs, thereafter heat
COMPRESSION: Control that swelling. Compression keeps
Plasma in the vasculature
TYLENOL: Use NSAIDS to control pain. The ice
should handle inflammation immediately. Tylenol isn’t
good for inflammation, only pain.
High Ankle Sprain
Tear of the ligament that holds the proximal tibia and fibula together (aka the syndesmosis)
Degrees of Frostbite, Dx + Rx?
Digits, ears, nose, cheeks, extremities
1st degree frostbite: Anesthesia + Erythema, Shiny
2nd: Anesthesia, Erythema, Edema CLEAR BLISTERS
3rd degree: Hemorrhagic blood filled Blisters, possibly
Quite large and encompassing the digit.
But… Still soft when pressed upon (gently)
4th degree: Solid, waxy white, obviously frozen
RX:
FIRST: Assess for hypothermia and treat that
SECOND: Immerse damaged tissue in warm, gently circulating water (95F) slowly warm but not above 107F.
Hypothermia, Dx + Rx
Core Temp below 97F or 35C (rectal or esophageal for
Intubated patients.
95F - 90F Awake + Shivering stops at 90F
90F-82F Drowsy, not shivering
82F-68F Unconscious, not shivering
Below 68F/20C No Vitals, Profound Hypothermia
Coma and death
Think ETOH with hypothermia. Give Thiamine BEFORE Dextrose IV as alcoholics so profoundly affected may have Wernike’s Encephalopathy and need Thiamine. Glucose metabolism is thiamine dependent so give the thiamine first as giving dextrose first can worsen the Wernike’s symptoms.
Rewarming MODERATE (above 82F) Hypothermia:
- Dry warm blankets,
- Progressively warmer hot water bottles to the axilla and groin and around the neck.
- Warm IV fluids Thiamine then NS 5% dextrose
Core Temp After Drop
Decrease in BP after rewarming due to cardiac arrhythmia
Frozen cells leak K+ into the blood on rewarming. Hyperkalemia causes widening of the QRS, Peaky Ts as repolarization slows and bradycardia.
Brady causes low blood pressure
Whooping Cough Sx, Dx, Rx:
Three stages of Pertussis Bordatella:
CATARRHYL: Cold Sxs and cough 7-10 days.
PAROXSYSMAL: Coughing fits unto Post Tussive Emesis
possibly even apneic pds after a coughing
fit. This is where the
INSPIRATORY WHOOP appears
Rarely, SEIZURES occur from the
coughing
Rx NOW with MACROLIDE to reduce infectivity. The course for the patient is set though and will not be shortened by
the Macrolide.
CONVALESCENT: sometimes up to 3 months during which
Cough tapers and eventually ends.
Mainly incompletely vaccinated infants under 1 yr or adults who have not had boosters.
Hypertension Labs
Urinalysis: Protein and/or Sugar in the urine points to
Renal Malfunction
CMP - you want electrolytes, BUN, Cr, Glucose AND Liver
enzymes and Billirubin.
CBC - Sick?? Anemic???
ECG - What’s going on in the heart?….
BMP
8 Tests:
Blood Glucose Ca++ Na+ K+ Cl- CO2/ HCO3-- BUN Cr
CMP
CMP = BMP + Proteins and Liver Enzymes
Albumin- high when glomerulus has holes in it or when
blood pressure just pushes stuff through
Total Protein- same as above, albumin + Hb
AST
ALP- All four elevate in cirrhosis and hepatic
ALT
Bilirubin
AST
Aspartate Amino Transferase,
Normal is 6-40, males higher
Found in Liver, Brain, Heart, Muscle and RBCs. AST is not specific to any one of them and only indicates liver dz when it rises WITH ALT, which IS Liver-Specific
Elevated alone AST could indicate toxicity of:
A: Alcohol
S: Statins
T: Tylenol
Elevated with ALT and ALP you’re looking at liver dz
ALP
Alkaline Phosphatase
Normal is 20-140mg/dL higher in kids and pregn females
Elevated alone think GROWTH
- If a child/adolescent, think normal growth ongoing
- If adult think bone cancer, growth of tumors that increase phosphate in the blood.
Elevated with ALT and AST, Liver Dz. Hepatocytes are dying and dumping their enzymes into the blood.
ALT
Alanine Amino Transferase
The MOST sensitive liver health marker. Only found in hepatocytes. Increases when hepatocytes rupture and spill cellular contents into the portal blood.
Females Under 34
Males under 52
Bilirubin
Total Bilirubin : 0.3 - 1.9ml/dL
Direct Bilirubin (conjugated): 0 - 0 .3 ml/dL
Indirect (unconjugated) Bilirubin = Total minus direct
Bilirubin over 2.5mg/dL causes JAUNDICE
Bilirubin crosses the BBB and causes ICP - Increased IntraCranial Pressure
High UNconjugated (indirect) Bilirubin is common in infants who got a lot of blood back from the umbilical cord which RBCs are breaking down and whose little livers are just not quite online yet’
BUT… in adults, High Unconjugated Bilirubin could
be causes by heart failure, the pump not being strong
enough to push the blood effectively through the liver
especially if the liver is also damaged and/or fibrosed.
High Conjugated (direct) Bilirubin indicates the liver is doing its job but billirubin conjugated for excretion in feces, urine and bile just isn’t getting out. Think bile duct blockage, Gallstones, Hepatitis. Could also be sepsis where RBCs are just getting shredded and the liver can’t keep up with recycling the Heme.
Rifampin (TB regimen) and Probenecid (Gout prophylaxis) can both cause Jaundice by decreasing hepatic uptake of unconjugated billirubin.
Probenecid
Prevents reabsorption of Uric Acid in the distal tubule. Urine then is more acidic and Uric Acid XLs are less concentrated in the blood and less likely to settle out in gouty toes
Probenecid also concentrates the blood as water has to follow the uric acid out into the urine. It was and still is uses to concentrate penicillin in the blood. In WWII, they did this as their penicillin supply was low- so they maintained MIC with less antibiotic by challenging renal function with Probenecid.
Ankle Brachial Index for
Peripheral Artery Disease (PAD)
Normal is 0.9-1.4;
Over 0.9 = PAD;
0.9- 1.4 = calcified PAD
Rx of choice for HTN in Pregnancy?
Methyl Dopa
Beta Blockers may exacerbate Asthma, which often appears in pregnancy
Nifedepine is also acceptable
Hydralazine, an H1 blocker/antihistamine is often added to Methyl Dopa in MD Refractory gestational HTN.
Diuretics, Alpha Blockers, ACEs and ARBs are teratogenic
Gestatl HTN vs PreEcclampsia vs Ecclampsia vs HELLP
Gestational HTN is elevation in BP detected after week 20
with no sxs of end organ damage
Rx is Methyl Dopa
PreEclampsia is Gestational HTN with proteinuria or
other end organ damage (retinal hemorrhages..
RX is Methyl Dopa + Hydralazine
MgSO4 as seizure preventative
HELLP Syndrome is Liver Damage from Preeclampsia
H - Hemolysis
EL- Elevated Liver Enzymes
LP-Low Platelet Count
Sxs: are NV after eating
RUQ pain from distended liver
Rt Shoulder Pain on Inspiration
Headache
Vision Changes
Rx:
Eclampsia is gest. HTN with seizures
Rx is MgSO4 and C-Section
Portal HTN with Ascites, RX?
NaCl RESTRICTION to 2g/day first - the problem is that the RAAS has gone nuts and is conserving Na+
Next step is SPIRONOLACTONE to stop Na+ reabsorption in the distal tubule. Start at 100mg/day and go up to 400mg/day
If that isn’t sufficient, ADD FUROSAMIDE
Constipated or Hemorrhoids? Consider….
Docusate/Colace - Stool Softener
Prescription
2 Capsules @ bedtime
In opiate users you might co-prescribe it or you might just prescribe the Oxycodone/Naloxone combo TARGIN
SOB?
ABCs then…
Lung exam - Reduced Lung Sounds?
Pneumothorax?…XRay
Pneumonia? (Fever? Cough?… XRay
Albuterol Help? (order PFTs)
-Need to rule out Pulmonary Embolism is really sick people
with spiral CT
-Need to rule out
-CHF (cough, bilateral rales lower lobes)
-AFIB (EKG)
-Internal Bleeding (Guiac)
- ANEMIA (CBC w/Iron Studies)
A1C Diabetic Range
Over 6.5 is Diabetes
5.7-6.4 is PreDiabetes
Sugar is sticky, so much so that it doesn’t unstick from proteins. HbA1C measures the percentage of Hb that is stuck to sugar and we deem this as representative as a reflection of the sugar level in the blood for the life of the RBC (120 days/3 months).
A1C IS A STARTING PLACE ONLY. BEFORE DIAGNOSING NEW ONSET DM IN ANYONE NOT PRESENTING IN DKA OR HHS AND WITH A1C UNDER 7.5, GET GLUCOSE TOLERANCE TEST TO TEST POSTPRANDIAL GLUCOSE.
(This is not the guideline. Guidelines say you can call it at 6.5A1C)
An emerging problem with reliance on A1C for DM Dx is the possibility that RBCs may live longer than 120 days at normal blood sugars, this gives them time to collect more sugar and the A1C is higher, making it seem like they’re diabetic. Conversely, at high diabetic blood sugars, RBCs may have shorter life spans, less than 90 days and have less time to gather sugar making the Diabetic A1C appear lower when in reality, the average daily blood sugar is higher.
Anemia also impacts the A1C. In anemia there is altogether LESS Hb, so less sugar can be collected. Likewise, the cells live shorter lives. A1C readings in anemia are not entirely reliable.
Oral Glucose Tolerance Test (OGTT) is the most reliable test to Dx Diabetes. Blood glucose is measured 2 Hrs after ingesting a certain amount of sugar. Normal range is less than 140. 140-199 is PreDiabetes and over 200 is Diabetes.
To solidly Dx new onset Diabetes OGTT & Fasting BG as well as A1C are needed. When OGTT doesn’t agree with A1C, some detective work will need to be done.
Oral Glucose Tolerance Test
What is it?
What are normal, pre diabetic and diabetic ranges?
Oral Glucose Tolerance Test (OGTT) is the most reliable test to Dx Diabetes. Blood glucose is measured 2 Hrs after ingesting a certain amount of sugar.
- Normal range is less than 140.
- 140-199 is PreDiabetes and
- Over 200 is Diabetes.
Targin
Oxycodon/Naloxone combo pill
The naloxone knocks the opiate off the Mu receptors all along the large intestine, preventing coleostasis from getting underway in the first place. The naloxone is too bic to get through the intestine so it does not act systemically whereas the opiate does pass through the intestine and carries out it’s pain relief mission systemically.
Meniscal Tear Tests
McMurry & Apley
McMurry ROTATIONAL TEST for Meniscal Tear: Pt is SUPINE, leg raised and knee flexed. Lower leg is parallel the table. Dominant hand is on patella, MEDIAL side first. This places a VARUS force on the patella. Nondominant hand grasps sole of foot and rotates lower leg, extending and reflexing throughout rotation. Crepitus in joint as felt by dominant hand indicates MEDIAL meniscal tear
If no medial crepitus is felt, place dominant hand on lateral knee at the joint (applying VALGUS force to the knee) and rotate lower leg with non dominant hand. Lateral crepitus indicates LATERAL meniscal tear.
APLEY GRIND TEST FOR Meniscal Tear: Pt lies PRONE with knee flexed. Lower leg is parallel the table. Evaluator presses tibia down into the flexed knee joint and twists back and forth (applies varus and valgus forces). Pain indicates tear. Alternately, the evaluator may place her own flexed knee up and upon the posterior thigh of prone Pt, then LIFT the knee off the table and twist it. Likewise pain indicates meniscal tear.
New Bp Guidelines
140/90 for patients up to 60
150/90 for patients over 60
All ages if DM or Kidney Dz present target is 140/90
Do not give ACE/ARB to African Americans. All others get either:
-Thiazides Diuretics (HCTZ 12.5mg to start)
-ACE Inhibitor (Liprinosil 5mg up to 10mg)
All Diabetics get ACE until
or unless intolerance is established. Even if
Bp is within target range.
-Switch to ARB (Losartan 50mg to start or
Olmesartan 20 mg to start) if ACE
causes cough or angioedema
-CCB (Amlodapine) is 3rd line
Primary HTN Rx?
Do not give ACE/ARB to African Americans. All others get either:
-Thiazides Diuretics (HCTZ 12.5mg to start)
-ACE Inhibitor (Liprinosil 5mg up to 10mg)
All Diabetics get ACE until
or unless intolerance is established. Even if
Bp is within target range.
-Switch to ARB (Losartan 50mg to start or
Olmesartan 20 mg to start) if ACE
causes cough or angioedema
-CCB (Amlodapine) is 3rd line
SBp Targets are 140 under 60 + DM/CKD/CAD
150 over 60
DBp under 90
Amlodapine
CCB for primary hypertension
Start at
Vascular Dementia Vs Small Vessel Disease
What are they?
How to Dx?
Causes?
Rx?
Small Vessel Dz:
Tiny BRAIN infarctions that cause cognitive loss and eventually collectively cause VASCULAR DEMENTIA
Stroke can also cause VASCULAR DEMENTIA
Vascular Dementia is cognitive loss due to impaired blood circulation to the brain, usually the frontal lobe. It may present like ALZHEIMERS Dementia.
- Altered Speech Pattern - Diminished Problem Solving skills - Deranged social judgment (peeing in the potted plant)
Dx Test is CT of Head w/o contrast
Rx:
Once it has occurred the horse is really out of the barn. Small Vessel Dz and Stroke are known to be long term risks of uncontrolled HTN, DM and Hyperlipidemia /Atherosclerosis. Control those preventatively
Aricept PO 5-10mg/day or the Exelon patch may stall progression.
Vascular Dementia vs Alzhemier’s Dementia vs Frontal Lobe Dementia…
Vascular Dementia: Follows Stroke or Small Vessel Dz.
Altered speech patterns, decreased problem
solving and deranged social judgment
(The man peeing in the potted plant with no
idea it’s inappropriate).
Alzheimers Dementia: may look like Vascular Dementia but
no stroke and gradual short term memory loss
is the red flag.
Frontal Lobe Dementia: Often has motor components and
significant behavioral changes. Often caused
by a mass compressing the frontal lobe or TBI
Get a CT to rule out brain mass/damage.
Do a doppler scan of carotids to rule out atherosclerosis there
In either case, document basic cognitive testing results at Dx and repeat regularly to document decline.
Exelon Patch
Rivastigmine Transdermal Daily patch
Acetyl Cholinesterase Inhibitor. We NEED ACh to transmit
neural signals in the brain - in short - to think…
Rivastigmine has a greater effect on aggressive alzheimers behaviors and alzheimers-related hallucination.
Oral Rivastigmine (Aricept) has significant N/V side effect but the patch does not.
A 9.5mg Patch gives the same relief a 12.5mg of the same Rivastigmine orally, without NV
Typhoid
Bug
Sxs
Rx
aka Typhoid Fever
Salmonella Typhi, Fecal Oral Route
Onset 1 week to 1 month after exposure
Gradually Rising Fever (over days and in afternoons), Constipation, Abd Discomfort. If diarrhea, green + foul.
“Rose Spots” on abd and chest.
Delirium Possible, also called “nervous fever”
Rx: Handwashing and water boiling are preventative
Vaccination good for up to 7 yrs
Macrolides, Fluoroquinolones + 3rd gen Cephalos
Typhus
Parasite: a Rikettsia from fleas, lice + ticks
Sudden Onset Fever/Chills/Flu-Like
Rash starts on trunk and spreads to entire body, soles and palms
1-3 weeks from exposure, prisons, armies
If photophobia and delirium develops, meningeal encephalitis is the likely cause. This is potentially fatal
Vaccine available, Control rats, Avoid lice
Rx is Doxy or Chlormaphenicol
Chloramphenicol
Cholera
Typhus
Meningitis: Neisseria Meningiditus, Hemophilus Influenza
and Strep Pneumo are all susceptible
Risks: Aplastic Anemia (often fatal) Leukemia, Bone Marrow Suppression, Grey Baby Syndrome
Maybe not use this unless you have to
Ulcerative Colitis
Bloody Diarrhea
Ulcers in the COLON and RECTUM only.
Pseudopolyps are fingers of scar tissue from healing ulcers
Just stopped smoking
Crohns Dz
GREASY diarrhea
Fistulae
Fever
New Antidepressant has fast anti-anxiety effect and doesn’t cause sexual side effects or weight gain. Results notable within a week.
Vilazodone / Viibryd
Start 1/2 15mg pill/day in am 1st week
Increase to 15mg/day 2nd week
Very expensive, have to fail a few SSRIs before insurance will pay for this.
Serotonin Reuptake Inhibitor (SRI) and Partial 5HT3 1A agonist. Its kind of like a mix of an SSRI with Buspar (a partial serotonin agonist)
Harvoni / Ledipasvir-Sofosbuvir
Hep C Medication
Viral Inhibitor Combo says it has cure rates over 94% for the most common Hep C virus
Fatigue, GI and Cardiac side effects:
Fatigue severe enough to stop rx is not uncommon
Cardiac (brady - potentially severe) don’t take with
antiarrythmics
GI side effects (NVD potentially severe)
Zoldipem (Ambien)
Short acting benzo for trouble falling asleep
Addictive
Refocus Pt on sleep hygiene and only give short course.
Meloxycam
Prescription Strength NSAID for Inflammation, Pain and Fever
Use meloxycam instead of OTC NSAID as relief last
Indomethecin
Prescription NSAID classically used for relief of pain and swelling in GOUT
Toradol
Prescription IM/IV NSAID classically used for acute relief of Migraine Headache
Male genital tests that are part of the annual physical:
16-40 Testicular and Hernia exams
40-45 No genital exams unless warranted for GI/Gu reasons
Over 45, Prostate exam
Byetta / Exenatide
Bydurian / Exentatide Extended
GLP-1 Agonist
Increases Pancreatic Secretion of Insulin
Slows stomach motility
Suppresses Glucagon release
Invokanna
SGLT2 Inhibitor.
Lowers sugar threshold in the neprhon, permitting loss of sugar through the renal system
Prandin
Repaglinide
Radial Nerve Radiculopathy
Extensor compartments of upper and lower arms. Pointer finger, thumb and half of middle finger on dorsal aspect of hand.
Fuch’s Dystrophy
Fuch’s Corneal Endothelial Dystrophy
Corneal Dystrophies in general are caused by progressive genetic inclinatios to develop deposits (often lipids/cholesterol) in the cornea that cloud and reshape the cornea.
In Fusch’s Dystrophy, focal outcroppings (gut tae) grow on the cornea causing corneal edema and gradually reducing vision
Rx is Corneal Transplant: new endothelial cells (grafts) are grown in place.
Bipolar Drugs
Lithium #1 for BP1 Monotherapy or with an antipsychotic.
Lamotragine - Anticonvulsant, good for BP Depression
Olanzapine (Zyprexa)- Atypical Antipsychotic, usually used WITH Lithium in BiPolar 1, alone in BP2
Quetiapine (Seroquel)- Newer Atypcial Antipsychotic. Monotherapy in BP2, with Li in BP1
Fenofibrate
PPAR activator lowers VLDL (and thereby LDL) and increases HDL
Side Effect: Myopathy + Rhabdo, just like statins
ZETIA/EZETIMBE
H
Carotid Endarterectomy Vs Carotid Stenting
ENDARTERECTOMY= Removal of the Plaque that builds up at the Carotid Bifurcation. Closure of the artery with a patch.
Increased Risk of MI in the 30 days after surgery
CAROTID STENTING = wire mesh inserted over plaque and expanded. Mesh can be impregnated with clopidrogel.
Increased Risk of STROKE in the 30 days after stunting
EITHER option can also be used with a filter to “catch” any clots before they get up into the smaller arteries
Essentially you choose by the patient’s surgical risk. Stenting is lower risk if there are comorbidities. Cost is about the same.
In either case, the 30 days following whichever procedure is elected are critical. You can for sure start anticoagulation after the stent but may have to wait after the endarterectomy.
Lymphocytic Colitis
Collagenous Colitis
Inflammation of the colon, as evidenced by increased white blood cells, that is only visible on microscopic inspection of the epithelium of the colon.
Lymphocytic Type: The increased white blood cells are largely Lymphocytes (B&T cells) but the layers of the lining of the colon are otherwise normal.
Collagenous Type : The collagen layer beneath the epithelium (the basement membrane) swells and there are increased WBC in the epithelium.
Theorists suspect Collagenous Type may be the next stage after Lymphocytic Type.
Donnatal
Intestinal Anticholinergic for cramping relief
Slows progress down there for serious cramping like that found in IBS
Anticholinergic Side Effects
Blind as a Bat (Mydriasis )
Red as a Beet (Vasodilation - Flushing)
Hot as a Hare (Hyperthermia)
Dry as a Bone (Dehydration)
Mad as a Hatter (delirium/Hallucination)
Bloated as a Toad (Ilius - Donatal for slowing gut activity)
(Urinary Retent - Incontinence Meds)
And the Heart Runs Alone (Tachycardia - think Atropine
use in Bradycardia)
Lesion of Pinta
r
Hamstring group made up of
Biceps Femoris
Semi Membranous
Semi Tendinous
Biceps Femoris: Long Head originates on posterior ischial ramus; Short Head originates on medial femur. Both insert on lateral fibular head at knee capsule
Semi Tendinous: Originates on posterior ischial rami, inserts on medial knee capsule
Semi Membranous: Originates on posterior ischial rami inserts on medial knee capsule
Crackles are…
Bubbles
Heard both on inspiration or expiration or both, likely both
Inspiratory vs Expiratory Wheeze
Asthma is usually an expiratory wheeze
Pneumonia/Bronchitis often have inspiratory wheezes with crackles. Bronchial crackles are close to the sternum and may clear on coughing.
Stridor
Inspiratory Squeak, very alarming
Foreign Body (esp on Rt)
or
Croup (Inflammation in the upper airway, around the cricoid
cartilage creates stridor, lower airways are usually
fine in croup. Cold mist nebulizations with
racemic epi)
Epiglottitis (Strep, HIB, Moraxella… Usually under 2,
Sniffing Dog position, Thumbprint X-Ray sign,
Intubate (do NOT attempt to visualize throat
w/depressor), racemic epi nebulization,
IV steroids and antibiotics, go right for ceph
triaxone or vanco)
Pneumonia Tests
Whisper Pectoriloquay - Whispered 99. Voice is heard
Most clearly over consolidation
Bronchophony - Spoken 99, heard more clearly over
consolidation
Increased Breath Sounds - The patient doesn’t really HAVE
to whisper or speak, even normal
breath sounds will echo more loudly
over consolidation.
Tactile Fremitus - Say 99 each time I move my hands…
Fremitus - a vibration transmitted
through the body
Tactile Fremitus - The vibration is felt
more intensely over
consolidation in the lung
Solid vs Liquid Lung Consolidation
Solid = Tumor
Liquid = Pneumonia
Congestive Heart failure is liquify ronchi at both lung bases, not actually consolidation. It should not set off the pneumonia tests
