Internal Medicine Outpatient Rotation Flashcards
1
Q
Sort Chronic Otitis Externa and Swimmer’s Ear from Malignant Otitis Externa
A
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
2
Q
Fluctuant soft tissue mass, often found in axilla, neck and perirectal regions, no erythema or warmth.
Rx?
A
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
3
Q
Sort Mild Persistant Asthma from Moderate Persistent and Severe
A
Moderate is Daily
Mild is more than 2X a week but not daily
Severe Persistant is continual and exacerbations limit activity
4
Q
What is Ideopathic Pulmonary Fibrosis and how is it treated?
A
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.
5
Q
Symmetric DESCENDING muscle weakness, think
A
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
6
Q
LisFranc Injury
A
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.
7
Q
Bones that form the ANKLE
A
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
8
Q
Most common Ankle Fracture involves which bone
A
Distal TIBIA
9
Q
What is the most common Ankle Sprain site?
A
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
10
Q
Mortise Ankle View on Xray, describe?
A
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.
11
Q
How to Dx and Rx an ankle sprain?
A
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
12
Q
RICE for sprains, explain:
A
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.
13
Q
High Ankle Sprain
A
Tear of the ligament that holds the proximal tibia and fibula together (aka the syndesmosis)
14
Q
Degrees of Frostbite, Dx + Rx?
A
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.
15
Q
Hypothermia, Dx + Rx
A
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
16
Q
Core Temp After Drop
A
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
17
Q
Whooping Cough Sx, Dx, Rx:
A
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.
18
Q
Hypertension Labs
A
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?….
19
Q
BMP
A
8 Tests:
Blood Glucose Ca++ Na+ K+ Cl- CO2/ HCO3-- BUN Cr
20
Q
CMP
A
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
21
Q
AST
A
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
22
Q
ALP
A
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.
23
Q
ALT
A
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
24
Q
Bilirubin
A
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.
25
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.
26
Ankle Brachial Index for
Peripheral Artery Disease (PAD)
Normal is 0.9-1.4;
Over 0.9 = PAD;
0.9- 1.4 = calcified PAD
27
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
28
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
29
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
30
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
31
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)
32
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.
33
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.
34
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.
35
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.
36
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
37
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
38
Amlodapine
CCB for primary hypertension
Start at
39
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.
40
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.
41
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
42
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
43
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
44
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
45
Ulcerative Colitis
Bloody Diarrhea
Ulcers in the COLON and RECTUM only.
Pseudopolyps are fingers of scar tissue from healing ulcers
Just stopped smoking
46
Crohns Dz
GREASY diarrhea
Fistulae
Fever
47
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)
48
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)
49
Zoldipem (Ambien)
Short acting benzo for trouble falling asleep
Addictive
Refocus Pt on sleep hygiene and only give short course.
50
Meloxycam
Prescription Strength NSAID for Inflammation, Pain and Fever
Use meloxycam instead of OTC NSAID as relief last
51
Indomethecin
Prescription NSAID classically used for relief of pain and swelling in GOUT
52
Toradol
Prescription IM/IV NSAID classically used for acute relief of Migraine Headache
53
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
54
Byetta / Exenatide
| Bydurian / Exentatide Extended
GLP-1 Agonist
Increases Pancreatic Secretion of Insulin
Slows stomach motility
Suppresses Glucagon release
55
Invokanna
SGLT2 Inhibitor.
Lowers sugar threshold in the neprhon, permitting loss of sugar through the renal system
56
Prandin
Repaglinide
57
Radial Nerve Radiculopathy
Extensor compartments of upper and lower arms. Pointer finger, thumb and half of middle finger on dorsal aspect of hand.
58
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.
59
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
60
Fenofibrate
PPAR activator lowers VLDL (and thereby LDL) and increases HDL
Side Effect: Myopathy + Rhabdo, just like statins
61
ZETIA/EZETIMBE
H
62
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.
63
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.
64
Donnatal
Intestinal Anticholinergic for cramping relief
Slows progress down there for serious cramping like that found in IBS
65
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)
66
Lesion of Pinta
r
67
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
68
Crackles are...
Bubbles
Heard both on inspiration or expiration or both, likely both
69
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.
70
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)
71
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
72
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
73
Centor Criteria
For whether or not to do Rapid Strep Test. 1 Point for each symptom:
1) Fever
1) Tonsillar Exudate
1) Cervical Adenopathy, Tender
1) No Cough
1 Point = No Strep Test
2 -3 Points = Rapid Strep, Culture any Negatives
4 Points= Don't Test just treat
Kill it with straight up Penn VK or Amoxycillin or....
74
RX for toxic Shock?
Clindamycin + Penicillin
Its usually staph or strep but DEEP penetration of the antibiotic is needed.
75
C Dif Sxs
Bloody diarrhea, fever, abd discomfort, Treated with Clindamycin, Ampicillin, Cephalosporins, Keflex or Fluoroquinalones in the past couple weeks
Stool Test for CDif toxins A+B or colonoscopy to look for the pseudomembranous colitis, that is diagnostic for C Dif.
Rx is Metronidazole and Oral Vanco. Only use for oral vanco, always IV otherwise.
Crohns and Ulcerative Colitis sufferers can end up with CDif even if they are not on ABX.
76
Psoriasis signs
Silvery Scale
Pitted Nails
Psoriatic Arthritis in fingers
Rx: UV B, narrow band
Topical Corticos:
Ca++ controlling drugs
Mod to Severe Plaque Psoriasis:
Methotrexate, Cyclosporin, M
77
Physiatrist
Physical Medicine Specialty
Stroke Rehab and Nerve Pain
Nerve Conduction Studies
In Ithaca: Dr. Melissa Thibault
78
Imitrex aka;
Sumatriptan
Take PO at first sign of migraine, can be SQ (more eft)
Risk of Coronary Artery Vasospasm. Prophylaxis is Nifedipine but MI risk is worth discussing and perhaps a different HA med if prinzmetals develops.
Its a Serotonin Agonist, causes VasoCONSTRICTION in the cerebral vessels. Recall that the migraine issue is DILATED vasculature pressing on nerves in the head.
79
"TaDINE!!!"
H2 Blockers
Famotadine (Pepsid)
Ranitidine (Zantac OTC)
Cimetidine (Tagamet OTC)
Histamine
Recall HISTAMINE 2 H2 is the paracrine that turns on Parietal Cells in the stomach lining and ultimately induces Gastric Acid Secretion from there.
H2 blockers stop the cycle at the Parietal H2 receptor.
Proton Pump Inhibiters (PPI) stop the cycle by preventing the proton pump on Parietal Cells
80
Crohns vs Ulcerative Colitis
BOTH usually start in teens/twenties
BOTH can have RA joint issues because
BOTH are autoimmune like RA
BOTH Rxed with Mesalazine (Aspirin Derivative)
CROHNS:
-Affects ENTIRE GI tract from Anus(fistulae) to Mouth (sores)
-PATCHY, some GI areas unaffected
-Failure to Thrive as children
-Uveitis and Episcleritis (red inflamed sclera)
-Rhumatoid Arthritis
-Erythema Nodosum (skin ulcers, Tibial)
-B12 deficiency as terminal ilium can get wrecked and
Intrinsic Factor may not be absorbed
-Possible IgE derangement - strangely parasitic infections help heal up Crohns ulcerations????
ULCERATIVE COLITIS
-Often starts JUST after quitting smoking
-Tenesmus
-Limited to the Colon, no small intestine effect but
inflammation is CONTINUOUS
- ONLY affects colon endometrium, no trans-wall
ulcerations
81
Xaralto / Rivaroxaban
Factor Xa Inhibitor (X for Xaralto...)
No generic available until Feb 2021
No monitoring needed BUT... no antidote so if there is an
overdose, they'll have to transfuse FFP
82
Warfarin
Vitamin K Inhibitor
83
Crohns
```
Mucusy Diarrhea, Frequent - up to 20X/day
Entire GI
Patchy
Fistulae
Skin Eye Mouth Ulcers
Rheumatoid Arthritis-ish
```
Dx: Deep Ulceratiions on Colonoscopy. May need
Endoscopy as well.
Rx: Corticos, MABs, Methotrexate, Helminthic Therapy??
Suppress that overactive Immune system
84
Ulcerative Colitis
```
Bloody Diarrhea
Tenesmus
Colon Only, Cobblestoned colon epithelium
Continuous
Often starts after stopping smoking
```
Rx: Cobblestoning of enometrium on Colonoscopy. Trans-wall ulceration and/or fistula is Crohns. No need for endoscopy as UC only affects the colon.
85
Amyloidosis
Dz resulting from improperly folded proteins, often causing purport and petechiae
Kidney and Heart are the most commonly affected organs
Skin.
-Kidney: Hemodialysis doesn't filter certain protein chains
as well as does a functioning kidney so amyloid
chains glom up the kidneys.
-Heart: Causes Heart Failure
Seen in:
- Rheumatoid Arthritis
- Infectious TB
Dx requires biopsy and microscopic eval
86
Mesalazine (brand name LIALDA)
aka: Mesalanine
Rx for Crohns, Ulcerative Colitis,
Mild DMARD: Salicylic Acid Deriviative
Stays mostly in the gut
87
Sulfasalazine
Rx for Rheumatoid Arthritis Mild DMARD
Like Mesalazine, it is Salicylic Acid derivative but it is bound to a sulfa antibiotic
Can reverse scarring from chronic ETOH cirrhosis
88
DMARD
```
D-Disease
M-Modifying
A-Anti
R-Rheumatic
D-Drug
```
DMARDS are used to address AutoImmune Diseases.
Now Many DMARDS are MABs + TNF inhibitors
Old school DMARDS include chemotherapies like:
-Methotrexate
-Cyclosporin
-Sulfasalazine
-Mesalazine
-Minocycline
Of these Sulfasalazine and Mesalazine are only MILD DMARDS
89
Polymyalgia Rheumatica
BiLateral Shoulder Girdle and/or
Pelvic Girdle Pain
Autoimmune/ Inflammatory in nature
Rx is low dose prednisolone (10mg/day as 5mg BID)
90
Mobic / Meloxicam
NSAID collects more in synovial fluid than serum
Especially nice as a first attempt at relief of Rheumatoid Arthritis symptoms or with DMARDS and Corticos later on
91
RA treatment plan
Mild RA: NSAIDS (Meloxicam-Mobic)
Also consider Vit D and non inflammatory diet
RA Refractory to NSAID: Add Sulfasalazine to NSAID
RA Refractory to Sulfasalazine and Meloxicam:
Substitute Methotrexate for Sulfasalazine
RA Refractory to Methotrexate and Meloxicam:
Add Rituximab to Methotrexate and Meloxicam
Once RA is refractory to Rituximab, the newer biologicals
become options. Choose a newer MAB that
has a Mechanism of Action that differs from
Rituximab
Or... You might jump straight into DMARDS to prevent damage if your patient can tolerate the drugs
Don't forget the immune modulating abilities of D though, get that D up.
Or... you might just refer to rheumatology
92
What is the deal with Potassium?
Normal Serum K+ is 3.5-5.3. 90% is intracellular and 10% is
extracellular. Hence we are just measuring the 10%.
In tissue damage though, the 90% gets out and
throws the 90/10 ratio out of whack. The ratio is
also deranged by kidney damage and small
intestine absorption issues and by meds and
K+ supplementation.
INCREASED Extracellular K+ can cause BRADYCARDIA because it raises the extracellular (+) charge, increasing the threshold the cardiomyocyte has to overcome in order to initiate contraction.
Conversely, depolarization doesn't happen in a nice gradual bump of a T-wave. K+ rushes back in quickly. Recall that the T-Wave is K+ moving BACK INSIDE the cardiomyocyte after contraction. Increasing the amount of extracellular K+ makes creates an inward SURGE of K+ and you get PEAKY T-Waves instead of the nice rounded hump.
Eventually, your QRS widens so much that you essentially lose your r and end up with a SINE WAVE beginning with a tiny R a huge S and an equally huge and opposite and peaky T
Thus... HyPERkalemia is to be avoided. The heart slows down in hyperkalemia, blood pressure drops and the RAAS kicks in. Aldosterone gets busy reabsorbing Na+ in the distal tubule and to do that, it DUMPS K+ into the filtrate to be excreted as urine. This is obviously how ACE Inhibitors cause hyperkalemia, they inhibit RAAS, no Aldosterone, no Sodium retention and voila, K+ is not wasted in exchange for Na+ leading to lower blood pressure but higher K+
When serum K+ is HIGH, the electrical gradient in the small intestine by which K+ is absorbed is thrown off. Thus K+ is not absorbed from the gut and is excreted in feces. A nice protective measure but... When the gut is itself sick and absorption is not occurring, this is how we LOSE K+ in diarrhea. We are simply not absorbing anything and out it goes.
In the ER, Hyperkalemia is addressed both by trying to get it excreted at the kidney and also by trying to shift extracellular K+ to the inside with insulin.
CBigKDrop
C= Calcium. Give it. This will increase heart rate
counteracting K+ bradycardia
Calcium Gluconate 10ml IV over 10 min
B= Beta Agonist. Beta 2As shift K+ intracellular
Its why albuterol causes palpitations...
Give Albuterol Nebulization
ig= Insulin and glucose. Give them together. We're
not worried about Blood glucose here
Insulin shifts K+ intracellular and we
need to give dextrose to ensure it
doesn't take BG into hypoglycemia
in the process of shifting K+
10 Units IV Push Insulin + 1 Ampule D50W
over 5 minutes
K= KayEXalate. Rids K+ by blocking bowel reabsorp.
more for chronic conditions
You might give Kaexalate to someone
DROP= Dialysis Renal of Patient - last ditch...
93
1 Ampule of D50 is
25g of Dextrose in 50mL of Water
94
HYPERKalemia arrhythmia
Bradycardia, Peaky Ts and QRS widens into a SINE WAVE
It takes a longer time to depolarize but a shorter time to re-polarize. QRS stretches out and T wave Peaks creating the classic hyperK sine wave. Even the faster depolarization can't balance the stretched out QRS time and the rate slows
95
HypOkalemia arrhythmia
Tachycardia, Flattened T Waves and U waves
K+ flies out of the cell as soon as the gates open, quickening depolaraiztion. It is slow though, to move back in. Its kind of a wash with the actual myocytes but...
Really the tachycardia of hypOkalemia is more to do with the pacemakers in the SA getting screwy and ectopic beats hopping in. RE-ENTRY TACHYCARDIA is especially common as is VTach. Junctional PVCs start popping off then re-entry passages open and BAM! Things are screwy.
96
Carbon Monoxide Poisoning
```
Physical Sxs:
Looks Like Flu (Pallor HA Dizzy Nausea) but...
-SOB
-Crushing Anterior Chest Pain
-Tachycardia
-Agitation
-Hallucination
-Incontinence
-Coma
```
On exam:
- Flame Shaped Retinal Hemorrhages
- Bright Red Retinal Veins (early sxs)
"Cherry Red Means Your Dead..." This is more a post mortem sort of sign known as Cherry Red Dependent
Lividity.
97
ECG Derangements
ECG leads Location of MI Coronary Artery
II, III, aVF Inferior MI Rt Coronary Art
V1-V4 Ant/Anteroseptal MI Left Anterior
Descending Artery
V5-V6, I,aVL Lateral MI Lft Circumflex Artery
ST depression in V1, V2 Posterior MI Left Circumflex Artery
or Rt Coronary Artery
98
T Waves are Upright in all leads but...
aVR and V1, Sometimes in aVF
In These T-Waves are inverted
99
QT Interval represents
Repolarization
Measure in V5 or V5
```
QT should not exceed 1/2 the previous RR.
If it does exceed 1/2 RR, think:
-Hyper K+
-Hyper Mg+
-Hyper Ca++
-Hypothermia
-Ischemia
- Drugs
-IICP Incr. Intracranial Pressure
```
100
Hyperacute T waves vs Peaky Ts...
Hyper-acutes are wider and asymmetrical.
Hyper-acutes can be thought
of as early ST Elevations as they often
shape up into an elevation especially if the
J-T segment is slope-y.
Peaky Ts of hyperkalemia are pretty skinny + symmetrical
101
Normal T-Wave Height
15mm (1 1/2 lg boxes) on precordial leads.
102
How does smoking damage vasculature?
Inhibits VasoDilation by Lowering Production of
Nitric Oxide Synthetase, such that NO can't be
made quickly and the endothelium can't
quickly dilate.
NO also regulates inflammation. Without it, Inflammation
can run amuck in the endothelium, attract immune
response and oxidants that can damage the
endothelium
Damaged endothelium attracts lipids that burrow in
and call out even more of an immune response. Soon
we have foam filled macrophages in there bloating
themselves on LDLs and voila, plaque.
Smoker Platelets are inherently STICKY. They aggregate
even in the absence of injury.
Smokers don't get rid of their clots well. Their
Fibrinolysis mechanisms are impaired. Thus they
clot up unnecessarily and then don't degrade their
clots. No good when a clot has stuck to
sclerotic plaque and is waving around in the blood
causing intermittent ischemia and or angina.
Overall, oxidative stress from free radicals in the smoke damage the endothelium and invite inflammation and immune response. Additionally, smoke toxins disable Nitric Oxide production, inhibiting protective vasodilation and leaving vasculature unable to quickly dilate in response to increased pressure. HTN goes hand and hand with smoking for this reason.
103
All patients with carotid stenosis of any degree on carotid duplex/doppler ultrasound get...
At LEAST Medication + Smoking Cessation:
- Aspirin
- Antihypertensisves
- Statins
- Smoking Cessation + Lifestyle mods
- Blood Glucose Control/ DM Management
104
Symptomatic vs Asymptomatic Carotid Stenosis
Symptomatic Carotid Stenosis would indicate TIAs from blocked flow to the brain but...
There is an argument that carotid atherosclerosis is a good marker of systemic atherosclerosis which suggests the risk of death by MI exceeds that of Stroke by the mere fact that the coronary arteries are tiny compared with the carotids.
105
Endarterectomy vs Carotid Angiogram and stenting and when to consider either?
Consider surgery when doppler ultrasound says carotid stenosis is over 90% OR,,, when its symptomatic (TIAs are occurring, Vascular Dementia is setting in..)
Endarterectomy = surgical removal of the plaque.
Stenting has a higher risk of post procedure stroke and
Endarterectomy has a higher risk of post procedure MI
Overall mortality is equal between the two
106
When to screen for prostate cancer with PSA (prostate specific antigen)
If you're going to test asymptomatic (no pee trouble) men, 50-70 is a reasonable window; HOWEVER....
In 2012, the U.S. Preventative Task Force recommended against the use of PSA screening for healthy men of all ages, stating that the harms of screening outweigh the benefits.
Certainly, there is no reason to screen anyone who is expected to live 10 years or less.
Young men with family histories of early onset prostate cancer or AFRICAN AMERICAN men in general are at increased risk and may want to start ten years earlier than their relative was when he was diagnosed.
PSA over 4.0 used to get biopsied but not so now. NOW the man would get a series of PSA tests with DREs to see if there is an upward trend before getting an invasive biopsy.
Prostatiasis and UTI can increase PSA as does BPH - Benign Prostatic Hyperplasia.
ONCE DIAGNOSED, PSA is a useful tool to track disease course and treatment efficacy.
107
Fibromyalgia aka Fibrositis
Technically Fibromyalgia is defined as Heightened Painful Response To Pressure
In reality, it seems this diagnosis is given to patients whose psychiatric condition manifests as physical pain, tingle, burn, parasthesia, in short the Somatic Disorder Patients. There is no somatic disorder code in ICD-10 though, so we call it fibromyalgia.
THAT'S why duloxatine/cymbalta and Lyrica (a GABApentin derivative) work so well.
Duloxatine is an SNRI, it addresses both the depression and meddles in the Nor Epi Pain Pathway. Gets them up and going and insensate to somatic manifestations.
108
Fibromyalgia Syndrome
Fibromyalgia (heightened painful response to pressure) with:
- -Fatigue
- -Insomnia
- -Joint Stiffness
- -Memory + Cognitive Difficulties
- -Difficulty Swallowing
- -Bowel/Bladder abnormalities
- -Numbness + Tingling
109
Headache.... What to do when Its not reduced by OTC NSAIDS and isn't DeHydration. It isn't a Migraine (not unilateral, no aura, no nausea, no photo/phonophobia). It isn't a stabbing/eye-tearing Cluster either.
What next?
CT and MRI... Need to rule out Tumor or Mass.
If there IS a tumor or Mass, deal with it or refer
If there ISN'T a tumor or mass, first, be relieved then start to worry about Autoimmune Headaches (Lupus + Temporal Arteritis) and Cancer....
Test for ESR + CRP and ANA:
-Lupus: Anti Nuclear Antibody Tests (ANA). 98%
of Lupus Pts will test (+) for ANAs. So will
up to 10 % of people in general. Likewise
Rheumatoid Arthritis and Scleroderma also
create ANAs. Additionally, this has a
50% false (+) rate so... if its negative, likely no
Lupus (or scleroderm or RA...) If it's positive,
Though, TEST On...:
-ANA PANEL is the next test, to ID
which autoantibodies are present;
--Anti-double-stranded DNA- (+) in 30%
of Lupus only in 1% gen pop.
High in Lupus Kidney Involvement
--Anti-Smith - The Sm antibody is
really exclusive to Lupus Pts. It's
only present in 30% of them but it
isn't found in the general popular.
--ATnti-U1RNP-Not specific to lupus; they
do mean there is a rheumatic
conditions : RA, systemic sclerosis,
Sjogren’s syndrome, polymyositis.
--Anti-Ro/SSA- This one can be (+) in
15% of the general population but
most often in Cutaneous or
Neonatal Lupus and Sjogrens.
Neonatal Lupus causes congenital
heart block so pregnant Lupus Pts
get tested for these antibodies
--Anti-Histone - usually Drug Induced
Lupus but sometimes systemic
-Giant Cell Arteritis: (Get Biopsy of temporal artery and
start Prednisone 80mg/day ASAP if (+) to protect
retinal blood supply. Taper Pred slowly, over 2
years while increasing Methotrexate. Start
Methotrexate early so you can shorten the
Prednisone course and decrease chance of
serious side effects like osteoporosis, Cataracts
Glaucoma, Wt Gain and High Blood Glucose.
Maybe have your pt see ophthalmologist during
this long a course of high dose steroids to track
glaucoma and retinal health.
-Cancers may or may not elevate ESR and/or CRP. There are many TUMOR MARKERS but there isn't such thing as a TUMOR MARKER SCREEN - You have to follow the symptom trail and order tests for specific tumor markers. If the symptom is headache, do the MRI/CT scan and LOOK for a tumor. If Pt has GI sxs, do CT then Colonoscopy or Endoscopy based on symptoms then order Alpha Fetoprotein, the tumor marker for Liver Cancer or Ca19-19 for Pancreatic Cancer. Cancer does not have a blood test.
110
Prostatitis, what do you know about it??
Acute Prostatitis is Bacterial, usually EColi + UTI bugs
VERY PAINFUL, these guys can't sit still or pee/poo
Cipro, Bactrim + Doxy have the penetration needed
to treat that deep. Prostate has a blood barrier
which makes treatment difficult but in Acute infer-
tion, the barrier becomes porous. Choose Cipro
first X 2-3 weeks.
Chronic - Formerly Chronic NonBacterial Prostatitis
This covers 90-95% of Prostatiasis Diagnoses
Painful erection/ejaculation (Dysparunia),
Painful urination + defacation. Prostate enlarged
often no sign of infection: WBC normal.
This still seems to benefit from antibiotics, CIPRO in
in particular. 2 weeks then check back.
Chronic Bacterial Prostatitis is associated with chronic UTI
111
NSAID that accumulates in synovial fluid better than in serum, making it nice for Osteoarthritis
Meloxicam (Mobid)
112
What Standing Lab Orders do you place for patients starting METHOTREXATE therapy?
Methotrexate most commonly causes
-Liver Toxicity (so order Pre and during Rx LFTs)
-Stomatitis (no labs to order just note baseline of
oral mucosa in case it thereafter becomes
inflamed. Stomatitis is inflammation of the
oral mucosa with or withOUT ulcers)
-Low WBC (order pre and during CBC w/Dif)
Labs for Methotrexate pre + monthly: LFT & CBC w/dif
Oh, and don't forget to co-prescribe folic acid. You might bet a preRx level on that as well. Deficiency will show up on the CBC as oversized RBCs early on though.
113
How to explain why an increase in Mean Corpuscular Volume leads to an increase in Mean Corpuscular Hemoglobin but a decrease in RBC#?
Imagine a shoe box filled with ping-pong balls, each one full of sand. The balls represent RBCs and the sand represents hemoglobin. Now fill the same box with sand- filled tennis balls, which have a greater volume than ping-pong balls. You fit fewer balls in there but the amount of sand inside them is much greater than that which fit into the pingpong balls.
Thus, larger RBCs (Increased MCV) means fewer RBCs in the bloodstream (the RBC count goes down) but the Mean Corpuscular Hemoglobin (MCH) rises as the larger RBCs can hold more Hb than normal RBCs. The OVERALL Hb however, could be essentially normal.
114
Class of drugs ending in "-- dipine" ?
Dihydropyridine CCBs
think Nife-dipine.
Use them for peripheral arterial dilation in Reynauds or to lower Bp from the periphery, without impacting the heart.
This sounds like a good idea but over-dilating peripheral vessels can lead to foot/ankle/leg swelling.
Further, if Bp gets too low, these drugs can also cause rebound tachycardia precisely because they are NOT acting on the heart. So when the system notices Bp dropping, the heart is called upon to address it. This can exacerbate ischemia and cause hypoxia if there is CAD.
I think you'd use this for HTN in someone who is slender, has cold hands and feet, mildly high Bp, a decent lipid profile and no history of cardiac dysfunction.
115
reflex rating scale
```
0 = nothing
5= sustained clonus
2= normal
1= diminshed
```
Rate the reflex with the following scale:
5+ Sustained clonus
4+ Very brisk, hyperreflexive, with clonus
3+ Brisker or more reflexive than normally.
2+ Normal
1+ Low normal, diminished
0.5+ A reflex that is only elicited with reinforcement
0 No response
Reinforcement is accomplished by asking the patient to clench their teeth, or if testing lower extremity reflexes, have the patient hook to
Increased reflexes indicate reflex is in charge with little dampening from higher function.
116
Myasthenia Gravis, what do you know?
Antibody to either the AcH Receptor or the the MuSK Protein. MuSK protein is a signal protein necessary for AcH Receptor up regulation at the neuromuscular junction. Antibodies to either the receptor or the protein effectively prevent neurotransmitter (AcH) docking @ neuromuscular junction so message to move gets stalled.
Blood Test for AcH Esterase Antibody
CXR for Thymoma (d/t hyperplasia, is seen in 10% of MG
cases. Source of the rogue Antibody)
Sxs:
Ptosis, worse when tired
Facial Weakness - Hanging Jaw Sign, uneven smile
Muscle weakness, legs turn to lead on sustained walking
Difficulty Breathing - Intercostals get tired, may need
ventilation
Difficulty Swallowing - muscles get tired
If sxs are one-sided, it can still be MG but you have to rule out a stroke with CT
Rx: Acetylcholine Esterase Inhibitors slow the de-assembly of AcH and increase the likelihood that AcH will hit a receptor.
Atropine, an anticholinergic (?) also helps.
-
117
Vitiligo
Autoimmune attack on Melanocytes
118
Prolia
Denosumab
MAB attacks
119
VonWillibrand
Gums bleed when you brush? Think Von Willibrand Dz
More common bleeding disorder than Hemophelia but less severe.
VonWillie is necessary for clotting and Factor VIII
Lack of it is genetic or caused by drug effect
NSAIDs, esp Aspirin but even Ibuprofen, should be avoided as they may impair clotting.
120
Ehlers-Danlos syndrome
defect in the structure, production, or processing of collagen or proteins that interact with collagen, such as mutations in the COL5A or COL3A genes.
121
Linzess
Linaclotide
GC2c Receptor Agonist. The Guanalate Cycles 2c Receptor is expressed on the luminal endothelium of the intestine and also in the brain.
It is specific to enterotoxins like E.Coli and Cholera, both toxins that cause severe DIARRHEA.
Activating these intestinal receptors stimulates colonic movement and impedes water reabsorption (hence the diarrhea). It also somehow blocks PAIN transmission.
Its expensive but its a once a day Rx for chronic refractory constipation, especially for the 1/3 of IBS sufferers who have constipation instead of diarrhea. It gives relieve in +/-50% of patients suffering constipation pain within the first week.
122
Hypermobile Joints think....
Connective tissue Genetic Syndromes:
Ehlers-Danlose = Collagen Problems. Easy dislocations,
Early (20s) onset osteoarthritis
Fragile skin
Easy bleed/Bruise as vessel collagen
is mutated. Can cause serious
life threat vascular conditions
Loeys-Deitz = Aortic Aneurysm Risk, tortuous vessels
Cleft Palate, Wide set eyes, Blue Sclera
Overbite and high arched soft palate
TGF Beta Receptor Mutation
Split Uvula or very wide uvula
Marfan Syndrome = Mis-folded Fibrillin in Connective Tissue
leads to weak heart valves, vasculature
and joints. High risk of AAA, spinal deform.
Tall, Arms too long, Thumbs stick out of
closed fist. Misshapen Lens is notable
on retinal exam, off center creates dark
half moons. Spider like fingers and toes
123
Split Uvula
Loeys-Deitz. AAA risk. Blue Sclera. WIDE set eyes
| connective tissue genetic disorder
124
Intensive Statin Therapy Needed If:
- Known Atherosclerosis or CVD
- LDL over 190
- Diabetic with LDL over 70
Intensive Statin Therapy is 20-40 mg of Atorvastatin or Simvastatin (usually). Choose 20 and see if you can't use Pravastatin if the pt isn't yet diabetic.
I would try to start with 5mg or 10 and see if that impacts the LDL. CoPrescribe 100 mg of CoQ10 and intensive Pre-Diabetes diet counseling with interval aerobic training and weight training consultation. Avocados and beans...
125
1st line for Osteoporosis in males
Testosterone
Vit D up into 40-60 + 500mg Ca++
2nd Line: Bisphosphenates
My fav after steroids would be the MAB but you have to (Denosumab/Prolia)
126
Vitamin D Target
40-60 ng/ml normally
50-70 normally per Dr. Mercola/Dr. Heaney (grassroots health)
Somewhere above 70 and below 100 for cancer and heart disease
Too much, for now, is over 100 ng/ml
127
B12 range
180-900
If B12 is down in the 200s and there are any emotional or tingle/burn go ahead and supplement.
128
Sjogren's
Chronically enlarged & tender submandibulars and dry mouth.
Often dry mouth facilitates mouth sores (stomatitis)
129
Lumbago
Low Back Pain
if with sciatica, there is ICD-10 for that specify side.
130
TENS unit
transcutaneous electrical nerve stimulation
for sciatica
implanted and/or transcutaneous
131
DuToprol
Metopropolol + HCTZ
Toprol is straight up metroprolol
HCTZ is K+ wasting and can cause elevated uric acid + lipids and decreased blood glucose.
132
Relationship between Anemia and the Kidney?
Erythropoietan EPO
HYPOXIA stimulates release of EPO by endothelial cells of renal cortex and outer medulla.
EPO travels to bone marrow where it binds its receptor on the COLONY FORMING UNIT (CFU), CFUs are essentially erythroid line stem cells. EPO stimulation of one CFU produces between 8 and 64 pro-erythroblasts.
Normal EPO is low, around 10 but in hypoxic conditions can soar to 10,000. EPO can be exogenously raised, common med is DARBOPOETIN. Also used in sports doping, and tested for.
Chronic Kidney Dz often presents with Anemia d/t low EPO production by diseased cortex/medulla cells.
133
What is Anemia?
Too Few RBCs
could be small d/t low Fe++ or ...
could be big d/t increased time to gather DNA in folate or B12 deficiency
Big RBCs have more Hb per RBC but total Hb may be normal.
134
Moxifloxacin/Avalox/Vigamox
4th generation Fluoroquinelone
has broader (+) coverage than cipro and Levo as well as anaerobes
135
Ichtheosis
Scaly Skin
Genetic Skin Disorder
Rx: Ammonium Lactate, Emollients and Retinoids
136
Alternatives to colonoscopy for colorectal screening
Fecal Occult Blood Test + Fecal Immunochemical test
or FOBT + FIT
Used together, annually, about $600 per test, these are effective colorectal cancer screens with no prep and are noninvasive. Medicare does cover these tests
CT Colonography: CT of the colon DOES require special diet to clear the colon AND bloating the colon with gas to distend the rugae. Medicare doesn't cover CT Colonography.
All alternative tests require colonoscopy to actually address and remove any nodules that are identified thus you will need the test and the procedure if the test is + whereas colonoscopy is the test AND the resolution. Medicare covers colonoscopy screening (usually)
137
Scromboid Poisoning
Spoiled Ocean Fish
Histamine develops as fish decays. Cooking does not destroy the Histamine but proper icing and precooking handling does prevent its development
Sxs are allergic: Onset 10 minutes resolved +/- 14 hrs
Flushing, hot throat, NVD, HA, dizzy, Rash not real wheals though. Can cause anaphylaxis especially in asthmatics.
138
Cyclobenzeprine / Flexeril
For Muscle Spasm
Only good for 2 weeks max, use right after trauma PO or IV
Side Effects: Dry Mouth + Dizziness
Centrally acting, MOA unknown, seems to both enhance and interrupt in the spinal cord.
NorEpi
139
Lymphedema
Stretched out/Scarred lymph vasculature does not move lymph and it pools in the legs, calves and ankles and often the feet. Often Unilateral.
Axillary nodes after Mastectomy. Any nodes after Radiation can be scarred. Sometimes develops years after the procedure, infection or trauma.
Infection of nodes, any nodes can cause it. Inguinal nodes are suspect in leg swelling, axillary in arm swelling
Lymphedema is often unilateral whereas Chronic Venous Statis, also giving rise to extremity swelling, is usually bilateral.
Dx: Lymphoscintigraphy
Diuretics?
140
Lymphedema vs Lipedema
LYMPHEDEMA is stasis of the lymphatic system. Often unilateral and often affects the foot.
LIPEDEMA is an inflammatory genetic pattern of laying down excess fat from the waist to the ankles. The FEET are SPARED in LIPEDEMA; in fact, there is often an adipose CUFF at the ankle in stage 3 Lipedema. Can also target the arms. BILATERAL
Women more than men. Women can be slender atop. The extreme PEAR shaped woman.
Lipoedematous adipose tissue has a "beans in a bag" feel on palpation and is often painful whereas lymphedema is not painful to palpation.
LipoLymphEdema: LYMPHedema secondary to a primary LIPedema
Rx: antiinflammatory diet. Bariatric surgery will usually only result in pts losing fat from waist up
141
Dercum's Disease
"Adiposis Dolorosa"
Inflammatory, possibly Rheumatic painful lipomas usually located on belly, hips, behind, posterior and lateral thighs.
These folks tend to be lumpy, not just regularly obese or even lipedematous.
142
Carisoprodol
Muscle Relaxer w/dependance risk
DON'T CHOOSE THIS, ESPECIALLY NOT WITH OPIATES..
It acts centrally to prevent muscle spasm like Cyclbenzaprine (Flexoril) but has greater risk for abuse. These are GABA-ergics, it's GABA dock is via the barbiturate port on the GABA receptor.
Potentiates opiate effect, which can be useful but is usually more dangerous. Overdose where the two are coprescribed is an issue.
Overdose presents as barbiturate and Airway & Breathing Mgt, possibly a respirator, with URINE ALKINIZATION (as with barbiturates) is needed. If mixed with opiate, naloxone will treat the opiate but not the carisoprodol. Flumanazil will not work. As always with coma try DONT: Dextrose, Oxygen, Naloxone and Thiamine but only oxygen will really help in Carisoprodol.
143
Digoxin, how does it work and what is it good for?
Two MOAs...
(1) Its a Na/K Atpase pump blocker in the heart. By preventing Na+ shift extracellularly, it draws in Ca++ and thereby INCREASES LEFT VENTRICULAR contractility
(2) It's a VAGUS enhancer, SLOWING rate at the SA node and SLOWING transmission through the AV node.
For its LV Contractility effect, Digoxin was/is used in Heart Failure, especially in extreme heart failure. It isn't first line anymore for heart failure as it's level has to be watched carefully.
For its VAGAL ENHANCEMENT effect, it is used in AFIB and AFLUTTER though newer chronotropes are preferred like Beta Blockers and CCBs.
144
1st line for Heart Failure:
Beta Blockers , Ace Inhibitors + Diuretics
Metoprolol, Atenolol and Carvedilol
145
Gonococcal Arthritis (GC Arthritis)
Presentation and Rx?
GC Arthritis usually presents with polyarthralgia: multiple joints swelling and pain in younger sexually active people.
Elbows, wrists and knees are commonly affected
Rx: Cephtriaxone 1g IM daily for 7 day + a one time 1gram Axithromycin dose for chalmydia as its often comorbid. You can switch from IM to oral doses of Ceftazadine after significant clinical improvement but don't shorten the 7 days.
If there is substantial fluid effusion in the joint, it can be aspirated during abx treatment.
If the pt has a rash or petechiae, the GC is likely systemic.
146
Rx for newly diagnosed RA in 50 yr old
NSAIDS for arthralgia and DMARDS to prevent progression
Meloxicam is a 1X/day NSAID that accumulates in the joints moreso than in the serum.
+
Methotrexate is the 1st Line DMARD for RA.
Co-Prescribe Folic Acid. Then Sulfasalazine. 3rd line is Cyclosporine and then we get to move to the MABS like Infliximab and rituximab - which are probably the best anyway but you have to fail on the old standbys before insurance will pay for the best.
147
NSAIDS cause HTN?? How
NSAIDS even aspirin, block COX1, COX2 or both
COX1 and COX2 are both expressed in the neprhon. COX1 causes dilation and increases filtration. COX2 prevents Na+ retention in the distal tubule, flushing Na+ and lowering Bp thereby.
Blocking COX 1 or COX2 will likely decrease renal filtration to some degree causing fluid retention. This may just be puffy feet and bags under the eyes for some, but in people already retaining fluid, with CHF or Lymphedema or Hypertensives, that little bit of reduction can really wreak some havoc.
Caution with NSAIDS where EDEMA is of CONCERN
148
Blood Pressure Meds don't seem to be working, don't forget to ask about...
NSAID use. They could make the difference between controlled HTN on a med and uncontrolled.
If using NSAID for pain, switch to Tylenol, not to exceed 4000 mg/day
If for joint pain, try a topical NSAID instead. They tend to give relief without systemic effect. DiCloFenac Gel (Voltaren)
In general, Non NSAID anti-inflammatories include herbals like Tumeric and Capsacin as well as anti-inflammatory diets without wheat and/or dairy.
149
Voltaren gel 1%
Topical NSAID gel: Diclofenac 1% Script required
Not to exceed 32 grams of gel per day. Gel grams are measured on a plastic card prior to application to skin to ensure max is not exceeded.
Diclofenac is also available as tablets and Ampules
150
DMARDS
```
Methotrexate
Hydroxychloroquine (Plaquinel)
Cyclosporine
Sulfasalazine
Minocycline
```
These suppress the immune rxn that fuels autoimmune disorders like:
```
RA
Type I Diabetes
Systemic Lupus Erythmatosis
MS
Polymyalgia Rheumatica
Sjogren's
Celiac Dz
Crohns
Ulcerative Colitis
```
151
Most common Autoimmune disorders
```
RA
Type I Diabetes
Systemic Lupus Erythmatosis
MS
Polymyalgia Rheumatica
Sjogren's
Celiac Dz
Crohns
Ulcerative Colitis
```
152
Hydroxychloroquine
What is it
What does it treat?
Risks?
Well... Its a DMARD but it also is a quinine. So it treats autoimmune disorders and Malaria
Risk of high dose or long term treatment is "Chloroquine Retinopathy" or damage to the retina (macula really) and also damage to the cornea.
Must see ophthalmologist annually if pt is going on it at high dose or long term (as in Lupus)
153
Lateral Epicondylitis
AKA?
Rx?
aka Tennis Elbow
Test is resisted pronation/supination causes pain
Etiology is radial nerve entrapment by inflamed tendons @ the elbow
RX:
RICE, short term NSAIDS (PO or topical) and PT if that doesn't work
Complete Immobilization is not good but do stop the receptive action that lead to the pain. Corticosteroid injections may help short term but show worse outcome over the long run
154
Rotator Cuff Tendonitis
How?
Rx?
A repetitive use injury (usually) swimming, golf baseball, weight-lifting, tennis...
Stop the activity but do NOT immobilize the joint!!!
RICE, NSAIDS (PO or Topical) and PT if that doesn't work
Keep the joint from FREEZING by practicing the PENDULUM STRETCH: bracing uninjured arm against a wall then dangling affected arm forward + down and making loose circles with the arm.
Xray, Ultrasound and/or MRI can Dx the exact problem if necessary.
155
Pradaxa and Xaralto vs Warfarin
Pradaxa/Dabigatran = Thrombin inhibitor. No Antidote
Need to give Fresh Frozen Plasma
Works for 36 hrs
PPIs/Omeprazole reduces absorption
-NEEDS acid, don't take with Tums...
Renal Dz increases [serum],
Don't use in renal or liver failure
Xaralto/Rivaroxaban= Factor Xa inhibitor. Antidote pending
Works for 24 Hrs.
Uses CYP 3A4 as do Lipitor + Crestor
(pravastatin/rosuvastatin not 3A4)
Renal Dz increases [serum]
Don't use in renal or liver failure
Warfarin = Vit K inhibitor, Monthly testing INR 2-3 range
works for up to 96 hrs but is reversible with Vit K. -You CAN use Warfarin in renal failure, its ALL liver.
-You CANT use it in liver failure, but you can't use the others either.
156
Outpatient PRE-OP Exam
Regular exam with an eye out for infection or anything
that might complicate the intended surgery
Inquire about previous rxns to Anesthesia
Inquire about rxns to opiates
Inquire about smoking and encourage stopping as far in
advance of surgery as possible. Even stopping a few
days beforehand will help though. Encourage pt to
use hospital stay to quit, offer Wellbutrin or Chantix to
assist.
Document Heart & Lung Status
Primary care doesn't "CLEAR" pts for surgery so much as
ensure the surgeon has ALL the facts to make a
safe for surgery call.
Document Drugs, D/C blood thinners
-Warfarin 4 days before
-Pradaxa 2 days before
- Xaralto 2 days before (could do 1... if full 24 hrs)
Document Vaccines. Give boosters if they won't
interfere with surgery timing.
157
Thyroid Nodule, if palpable,,,,
Get Ultrasound
If over 1cm get biopsy
If + for _______________ on biopsy... then...
functional nodule: Do TSH and ultra should
If nodule and TSH suppressed worry about HOT nodule.
158
Pharmacological baby step for mood swings without causing full on mania with an SSRI
Lamotragine
" for BiPolar Light"
159
Diagnose Ovarian Cyst? Always test for...
CA-125 serum level (Cancer Antigen-125)
Less than 35 is normal
85%of advanced ovarian cancers are + for elevated CA125
Only 50% of early cancers are + for it
OVASURE is a panel of lab tests for ovarian cancer which includes: leptin, prolactin, osteopontin, insulinlike growth factor, macrophage inhibitory factor, and CA125
160
Gabitril
Gaba Agonist/Anti-Convulsant
Mostly for epilepsy but also approved for BiPolar and Anxiety. Can cause seizure in non-epileptics. Must be tapered if taken regularly.
2mg dose CAN be given PRN for Panic Attacks to non-epileptics
Not sure what BiPolar dose is. The patient who requested it prn was bipolar II with panic disorder and she said this was the one drug that worked great for her and didn't make her unable to manage her day. She described having taken it 1X/week for a while but thereafter only for the rare panic attack that did not respond to breathing and self-calming techniques.
161
Carvedilol/ Coreg
Beta 1 Beta 2 and Alpha 1 blocker
162
Safe for UTI in Pregnancy up to Week 38 but colors urine brown
Nitrofurantoin/ Macrodantin
Risk is allergic rxn which can take the form of pulmonary irritation even unto edema. This usually presents 3-5 days into treatment. DC treatment
There is a pulmonary fibrosis long term adverse effect, very rare and related to lifetime dose. Usually 6+ yrs into treatment.
163
Intestinal Angioextasia
little telactangias in the bowel, may bleed. seen on colonoscopy reg or capsule photo.
90% self heal. Sometimes responsible for mysterious anemias.
164
Somatostatin
Pancreatic peptide hormone secreted when pH in duodenum drops too low...
Turns off Parietal Cell Gastric Acid Production in stomach
Turns off both Alpha and Beta Cell secretions in the
Pancreas
Also inhibits growth hormone. Is a treatment for acromegaly that way.
165
Lyme Testing
Elisa and if (+) confirm with Western Blot
166
EMBEDA
Morphine Sulfate with Naltrexone embedded into the capsule.
Opiate pain relief without constipation...ln a single dose. I suppose you could just co-prescribe tiny doses of naltrexone with your morphine sulfate tabs.
167
Sarcoidosis, what do you know about it?
Granulomas in the lungs and thoracic lymph nodes. Sometimes has cutaneous manifestations.
It's Autoimmune. T-Cells run amuck, particularly CD4 cells which causes an imbalance between CD4s and CD8s that you can catch by looking at their ratio.
-CD4/CD8 Ration over 3.5 is often seen
- Serum ACE levels are often high if lungs are affected
-TNF is usually high
-IL2 is usually high
-Serum Amyloid A is also up, but it's up in RA, Obesity
and Atherosclerosis as well since it's a general
acute inflammation marker like CRP
-CRP ought to be up
CXR is a MUST. Thereafter confirmation is by Biopsy
Broncoscopy Biopsy is great for this
Don't forget to test for TB. If you have granulomas and are (+) for TB, well then, it isn't going to be Sarcoidosis
```
DDX: if CXR shows granumomas
TB
Sarcoidosis
Lymphoma
Lung Cancer
```
168
Irritable Bowel Syndrome
Bowel change: to diarrhea or to constipation
PostPrandial Bowel Urgency
Abdominal cramping is relieved by defecation
Tenesmus is common
NO Bleeding and NO steatorrhea
Mucusy stool not uncommon
IBS is what you are left with if you cannot find any organic etiology for GI sxs. Therefore, you need to work up everything else first, before diagnosing IBS...
Rx Aim is to RELIEVE SXS
--SLOW THE HYPERACTIVE GUT with Bentyl an anticholinergic. Obviously DON'T do this if the Pt's IBS presents more with constipation...
-- Stop diarrhea if that's the bowel issue or relieve
constipation if that's the issue. Use bulking agents and
even immodium
--TriCyclic Antidepressants are helpful, Amitriptyline
Could try SSRI if that doesn't work.
169
H. Pylori...
Looks like an ulcer, GERD, Heartburn or Gastritis that won't go away. Epigastric pain, boring. May have halitosis.
First... check CBC to ensure no internal leaks causing anemia.
While you're at it, get the serum h. Pylori test. Its 90%
Its good for someone who has never been Dxed with h.Pylori before but you can't use it to gauge treatment effectiveness as it will remain (+) after treatment
You could use the fecal test for h. Pylori. Its pricy but very accurate.
You could also do the Urea Breath Test. Also pricy and you have to ensure no H2 blockers, PPIs, Peptobismol or Antibiotics for at least 4 days prior.
Or... you could send them to ENT for a biopsy.
TRIPLE THERAPY for a full 10-14 DAYS, 14 is better...:
--10 Day Rx is OAC: Omeprazole/Amox/Clarithromycin
--14 Day Rx is BMT: peptoBISmol/Metronid/Tetracycline
You can add Omeprazole to this treatment and get
Quadruple Therapy, which is considered the very
best. It isn't standard though for 1st line.
--10 or 14 Rx is LAC: Lansoprazole/Amox/Clarithromycin
170
Esophageal Cancer
Dysphagia of solids progressing to liquids is the MOST common presenting sign. Dysphagia in an adult ALWAYS gets a referral to GI for Endoscopy. Can also do a Barium Swallow, but Endoscopy is Gold Std.
Weight Loss, Epigastric and/or Substernal Pain, Persistent Cough are also common presenting symptoms.
#1 Risk Factor is Smoking. Male is a 4:1 Risk. Over 65 is a risk.
- GERD sets up for Adenocarcinoma (Barrett's Esophagus)
- - Alcoholism wears down the esophagus
Staging:
- -Ultrasound determines depth of the tumor
- -Abd & Chest CT and Full Body PET scans look for metastases. PET can catch even distant lymph mets.
Chemo-Radiation is the gold std treatment for esophageal carcinoma In Situ, meaning no mets. This resolves 30% of cases entirely. Surgery, usually via endoscopy, is meant to remove any remaining malignant cells.
Surgical Fix either for In Situ or even for advanced disease for management of dysphagia includes esophageal resection: cutting out the bad bit and attaching the resected esophagus directly to the stomach or even to the duodenum if disease already took the stomach.
Metastases mean chemo and targeted radiation and much worse prognosis.
171
Bird's Beak on Barium Swallow
Achalasia
Also can do esophageal manometry
Rx is esophageal pneumatic dilation or surgical myotomy
Can also use Botox
172
Rosacea
Facial flushing exacerbated by heat, hot drinks, emotion, alcohol.
First sign may be Ocular Rosacea: Injected sclera, red puffy upper and lower lids, dry eye + Blepharitis. Its actually ocular lymphadenopathy and the under-eye bags can be dramatic.
"High Color" "Ruddy" eventually becomes permanent telangiectasia, esp on cheeks and nose.
Papules and pustules may develop on forehead, nose and cheeks
Rhynophyma is disfiguring papule/pustule/telangiextasia of the nose
Low Dose Extended Release Doxy is the long term RX:
Each capsule of anti-inflammatory--dose Doxy contains a total of 40 mg of anhydrous doxycycline as 30 mg of immediate-release and 10 mg of delayed-release beads
Topical Metronidazole gel works and is often first line
For eyes: tears drops and blepharitis hygine
173
Syphilis
PAINLESS CHANCRE lasting 3-6 weeks at infection site.
These are not like apthous ulcers. This marks
Stage 1
NON-ITCHY rash of rough, reddish-brown spots on palms and soles progress to cover the trunk and other body areas. There may be white/grey lesions on mucus membranes and general FLU-EY SYMPTOMS. These mark STAGE 2. They will go away w/o treatment.
Latency. No stage. Can last 20-30 yrs. No Sxs unless infections moves into the nervous system becoming neurosyphilis.
STAGE 3: Tertiary syphilis. Infection of the brain and nerves leads to loss of coordination, progressive loss of eyesight, numbness, paralysis, dementia and death.
--GUMMA appear. They are the body's attempt to
encapsulate the spirochete. A hard necrotic center
is surrounded by edematous wet tissue.
--Usually found on the liver and organs but can
occur on the face or anywhere
-If they occur in bone, as in the nose, the structure
Collapses
-Very disfiguring and usually a component of
Tertiary Syphilis
Rx for Syphilis is a single IM dose of Penicillin G for
Primary, Secondary and Early Latent Syphilis
For Late Latent syphilis or latency of an unknown
duration, a three injection series is recommended.
This will halt progression but won't repair damage.
The damage of Tertiary Syphilis is systemic and
usually beyond repair. The disease can be halted
even at this stage but the damage may already be
fatal.
174
Cyst on dorsal wrist...
Ganglion Cyst, typically arises at the scaphoid-lunate joint.
Can also be found on the volar aspect of the hand at the Radial Head-Scaphoid joint. Volar presentation may compress the medial nerve or the carpal tunnel.
Early on, while its small, you can smash it and the contents will be reabsorbed. Hit it with a book, so to speak.
Later, you really need to either aspirate it or have it surgically removed.
175
Carisoprodol / Soma
Partial - Agonist for the BARBITUATE dock at GABA
A CENTRALLY ACTING Muscle relaxant, controlled d/t abuse potential
The Carbamate Class of Muscle Relaxants, also includes Methocarbamol/Robaxin
176
Ramipril vs Lisinopril
Ramipril:
Lisinopril:
177
Arthritis Sxs in a young person, think.......
1st, thing GCC: obtain urine sample and have it tested for
GC C and what the heck, add in UA and pregnancy
If urine test is (-).... consider lyme, mono and other infectious diseases. Or... think autoimmunes. Test blood for lyme, tick borne illness panel,
178
MITRAL VALVE
Stenosis
Regurge
Prolapse
Mitral Stenosis is a DIASTOLIC whoosh, during filling
Mitral Regurge is a HOLOSYSTOLIC rumble that radiates to
the AXILLA
Mitral Prolaps has a Mid SYSTOLIC click and RUMBLE
179
PULMONIC VALVE
Stenoisis
Pulmonic Stenosis is Diastolic, Holosystolic and typically gets louder during INSPIRATON
It has to do with the LUNG and pressure increases in the lung during inspiration offering blood in the pulmonary artery greater resistance.
Pulmonary Hypertension begins here....
RX for Pulmonary Hypertension is Viagara - Sildenafil
180
Early Zika Sxs
7-10 days
Fever, Itchy Rash on upper body and face and
conjunctivitis (presumably viral red-sclera kind)
Headache, Myalgia, Malaise and Arthralgia
But for the Arm/Torso/Face Rash and Conjunctivitis, it sounds like Malaria
There really does appear to be a 7 day incubation pd from the Medscape Male to Male transmission in Dallas data: Recall Patient A went to Venezuela for 1 week, had sex with pt B on day 8, developed viral sxs on day 8. Pt B did NOT go to Venezuela but developed fever, arm/torso itchy rash and conjunctivitis on day 15.
RT-PCR (reverse transcription polymerase chain rxn assay) for Zika did not detect Zika on day 11 or day 24 - did not seem effective but...
The sera of both patients demonstrated a positive immunoglobulin M response in a "capture" enzyme-linked immunosorbent assay for the Zika virus and dengue virus, but not for chikungunya virus. According to plaque-reduction neutralization tests, patient A had been infected with the Zika virus, dengue virus serotype 1, or both, whereas patient B had been infected only with the Zika virus.
Symptoms resolved in both males in 1 week but virus was detected in the semen ONLY of Pt A, who traveled, not of Pt B. No virus in urine or saliva of either patient.
There are NO genitourinary Sxs of ZIKA
ZIKA persists in semen for at least 2 weeks post onset of sxs. It is NOT found in urine or saliva. It IS found in serum.
ZIKA does increase risk of Guillain-Barre.
It does cause Microcephaly in pregnant women
ZIKA is associated with an ENCEPHALITIS (an autoimmune syndrome called acute disseminated encephalomyelitis) Resembling multiple sclerosis and found mostly in children, acute disseminated encephalomyelitis attacks nerve fibers in the brain and spinal cord.
Anopheles AEGYPTI and ALBOPICTUS
