Medicine 6 Flashcards
Pt with clinically stable with unstable angina OR pt with non-ST elevated MI are low risk. After starting recommended therapies at hospital what is recommended for tx?
What if Intermediate or high risk?
Cardiac stress test
Early coronary angiography
MCC of sudden death in MVC when blunt trauma with steering wheel.
aortic rupture
Procedures that require antiBx PPx if patient has prosthetic valve
Dental surgery
GI or GU procedure in setting of active infection
Surgery on infected skin or muscle
Surgical replacement of prosthetic cardiac material
Superficial skin infection of the dermis; infected lymph nodes surrounding infection, very sharply demarcated borders, rapid onset and spread of infection
Pt has fevers and chills
Erysipelas
Most often Strep Pyogenes
Infection involved skin; deep dermis and subQ fat, ill defined and flat borders that develops over days
Cellulitis
S. pyogenes and MSSA
Infertility; or not being able to conceive >12 mo of appropriately time intercourse require which step in initial eval?
Semen analysis
IF hx of irregular menses; then confirm ovulation
Seen in pt with other autoimmune dx; can have loss of or changed sensation like numbness/tingling in the lower extremities; may have loss of reflexes.
Pt with macrocytic anemia on smear
pernicious anemia resulting in Vit B12 deficiency
Hx of two prior second trimester losses that were painless. Hx of cervical conization
What may prevent a subsequent loss
Cerclage placement for cervical insufficiency
Pt with scant hematemesis, EGD showing gastric varices, no esophageal. Hx of pancreatitis and EtOH abuse
Splenic vein thromobsis; leads to left sided portal HTN and congestive splenomegaly w/ congestive splenomegaly
Significant predictor of adverse cardiovascular outcomes especially women
Diabetes
Even more so than smoking
Treatment of choice for keloids
intralesional gulcocorticoids
can use slilcone gel sheeting to reduce symptoms
What eye drops should we prescribe for typical bacterial conjuctivitis?
What about contact wearers?
Erythromycin (macrolide) or Bactrim
If contact; rx fluoroquinolone drops or cipro/oxofloxacin (more common to have pseudomonal involvement)
Complication of bacterial conjuctivitis in contact lens wearers?
Keratitis from PSA; must urgently see optho; can lead to scrring and blindess; will likely do slit lamp with florosceie
Tx option for bone pain 2/2 to mets in pt with metastatic prostate cancer not responding to hormone therapy
radiation
PT with fever, jaundice and leukocytosis with biliary dilation on US
Criteria for acute cholangitis
Perform urgent ERCP to confirm and tx
Gout flare;
1st line is NSAIDS and colchicine (avoid if renal fail)
2nd line if monoarticular use systemic (better in pt w/ diabetes or hx of bleeds bc no systemic steroids)
3rd line is oral steroids if multiple joints
PT with dysphagia to solids and liquids; occational. Has chest pain when this happens. No wt loss or hx of smoking. Normal barium study, manometry shows premature and simultaneous contractions of the distal esophagus, lower esophagus is normal
Dx?
Tx?
Diffuse esophageal spasm; see corkscrew pattern on esophogram
Calcium channel blockers; may try nitrates or tricyclics
Immunocompromised pt, hemoptysis, peluritic chest pain and cough. They have been on steroids for past several months. CT shows nodular disease w/ ground glass opaciites and cavitation
Aspergillosis
Pt immunocompromosed, not on ppx meds. cough and fever, CT with diffuse interstitial pulmonary infiltrates and resp failure
Pneumocystisis
should be on Bactrim
Pt presents with cough, c/p and hemoptysis. Nodular or interstitial infiltrate on CXR. Has high fever, diarrhea/vomitting
Legionella, levofloxicin
Acute presynaptic neuromuscular jnx disorder; inhibits releasease of acetylcholine to cleft in autonomic and somatic NS.
What is this
How do patients present?
Botulism
Present acute bulbar and descending limb weakness; absent reflexes and autonimc dysnfx; preserved sensation.
Sluggish pupils
Autoimmune postsynaptic NMJ dxx; from antibodies in acetylcholine receptor; pt present with fatigue, fluctuating weakness (arms>legs) ptosis, dipolpia and dsyarthria as well as dysphagia
Myasthenia gravis
can have bulbar symptoms; ALWAYS spares pupils
Pt with illness then two weeks later has ascending muscle numbness/weakness–> later respiratory and bulbar involvement
Guillain barre
Acute autoimmune demyleniating polyradiculoneuropathy; often preseceded by respiratory or campylobacter illness
Newborn with macrocephaly, diffuse intracranial calcifications, juandice and hepatosplenomegaly
can have blueberry muffin rash and chorioretinitis with hearing impairement
Toxo
tx pyrimethamine, slfadiazine, folate
Congenital heart defect, cataracts and hearing impairement in newborn
congenital rubella
Consequences of untreated hyperthyroidism
arrythmia; a fib, dilated cardiomyopathy
Osteroporosis as TSH stims calcium and phosphate release from bone
Tx for Raynauds
Calcium channel blocker
Amplodipine, Nifedipine
Tx for patient with MDD, partial responder to the first line medication?
Add second agent; antidepressant w/ dif MOA, 2nd gen antipyschotic, lithium thyroid hormone
PT with PCOS have increased estrogen and testosterone levels, endometrial hyperplasia, androgen excess.
Best BC method for them?
Progestins for endometrial protection (thins and reverses hyperplasia), long acting IUD good option
weight loss and clomiphene citrate for ovulation induction if desire pregnancy
Pt with T2DM wiht BS >800s, hypoT, with afib and slightly elevated K, Na and AMS. ?How do we treat?
Do we rate/rhythm control?
Give insulin?
Fluid resuscitate
once partially resuscitated can start insulin
usually K depleted and if <5.3 start repleating
Can do RATE control over rhythm control
Pt with decreased ability of extension at the 3/4th digits, nodules along flexor tendons near distal palmar crease
Dx
Dx association
Tx
Dupuytren contracture; male, >50, tobacco/EtOH
associated with diabetes
Tx modification of hand tools, neele aponeurotomy, intralesional steroids or surgery if advanced
Tx of asymptomatic lead poisoning <5 5-14 15-44 45-69 >69
<5: No meds, anticipatory guidance, repeat 6mo-12mo
5-14: No meds, guidance, Ca/Ir supplementation; repeat 1-4 months
5-44: No meds, guidance, Ca/Fe supplementation; repeat 1-4 weeks
45-69: Chelation therapy; can use DMSA or succimer
>69: (or pt with symptoms) Dimercaprol PLUS calcium disodium edetate (EDTA)
Tx of pregnant women with syphillis
What about if PCN allergy?
Pen G
Penicillin desentiziation; dont’ do doxy; can mess up baby teeth and long bones
Rapid plt drop after patient has knee replacement. In hospital, on heparin for DVT ppx and ends up with PE. Tx option? Cause of issues?
type 2 heparin induced thrombocytopenia;
see drop of PLT >50% from initial, thrombosis, and anaphylactoid rx after heparing
confirm via serotonin release assay, STOP heparin
Start direct thrombin inhibitor; argatroban
–start Warfarin once PLT >150,000
CSF:
Elevated WBC >1,000
Glucose <40
Protein >250
bacterial meningitis
CSF analysis
WBC 0-5
Glucose 40-70
protein <40
NORMAL
CSF
WBC 100-500
Glucose <45
Protein 100-500
pt with 2-3 weeks malaise, low grade fever, HA
Now with nuchal rigidity, vomitting, confusion
Can have CN nerve palsies, Sz and choroidal tubercles on fundoscopic exam (yellow/white nodules in optic disc) and basilar meningeal enhancement
TB meningitis
See CSF with acid-fast bacilli
Pt with TB meningitis; what is treatment?
2 months of 4 month therapy; isoniazid, rifampin, pyrazinamide, fluoroquinolone
then by 9-12 months continuation with isoniazid + rifampin
**Give adjuvant steroids to reduce CNS inflammation and reduce morbidity and mortality
Tox:
Pt with vomiting, diarrhea, miosis, lacrimation, salivation, paralysis, fasciulations and complicated by bradycardia, resp fail, seizure and coma.
Dx and tx
organophosphate poisoning
Tx; Atropine and pralidoxime
resuscitation
____major cause of hypoxemia in pt with COPD and mismatch is worse during exacerbation. Supplemental O2 fixes this how?
V/Q mismatch in low V/Q regions of lung
O2 increases O2 exchange in these areas
RF for preeclampsia
How to prevent Preeclampsia
RF: prior PreE, CKD chronic HTN, DM, mulitiple gestation, autoimmune dx
Tx to prevent: low dose ASA starting at 12 weeks
When should you be able to visualize a pregnancy on US?
What does an ectopic pregnancy look like?
visualize on US when bHCG >1500
US will show empty uterus, complex adnexal mass and thickened endometrium
RF: prior ectopic, prior pelvic/tubal surgery or PID
Tx for ectopic pregnancy?
MTX if HDS
otherwise surgical
Autoimmune process that causes sudden non-scarring hair loss in round patches (non-inflammatory), nail pitting. Areas don’t itch
alopecia areata
seen with other autoimmune conditions
Pt with sudden onsent unilateral pelvic pain, tender adnexal mass. Fever, cervix closed, no drainage, neg Upreg, not sexually active
Likely dx?
Imaging?
Ovarian torsion
Stat pelvic US with doppler; usually shows large, edematous ovary with decreased blood flow
tight glycemic control of DM can reduce risk of _____ type of disease but has not been shown to have control in preventing this type of disease
reduce risk of MICROvasulcar disease (nephropathy so CKD or proteinuria) and retinopathy
Not associated with reduced risk of preventing MACROvascular disease (MI, PAD)
What medications are typically started for atrial fibrillation?
Beta blocker: Atenolol or metoprolol for chronic management (IV esmolol, metoprolol, propranolol acute)
Ca Channel Blocker: Verapamil or diltiazam for acute (IV) and long term control
Medication that can increase risk for Digoxin toxicity? What would this look like in patient?
Verapamil, amiodarone and quinidine increases risk
Dig toxicity: nausea, vomiting, confusion, fatigue, vision changes
What are good prognostic signs for response to antipyschotics
Positive symptoms: delusions or hallucinations are better than negative ones (withdrawl or loss motivation) and for schizophrenia better if acute onset, occurs at later age
Characterized by low T3 levels, normal TSH and normal T4 in pt with illness
Tx?
Euthyroid sick syndrome
Just recheck in a few weeks; tx if abnormal labs persist after return to health
Presents with painful vaginal bleeding, fetal heart rate abnormalities like late decells and a tender, rigid uterus
placental abruption
How does placental previa present
Presents with painless vaginal bleeding
Pt delivered baby, has postpartum hemorrhage and cant remove the placenta
placenta accreta
from anterior placenta implanting over uterine scar
Pt with long standing CKD can develop anemia and may need to be started on EPO, but what do we check first
Fe stores; these become rapidly depleted once therapy started
First line treatment for patients with DVT/PE that do NOT have cancer
Oral factor Xa inhibitors (rivaroxaban)
Use LMWH if underlying malignancy
CANT use warfarin alone; get transient increase in hypercoaguable state and takes days to be fully effective
Preferred first line tx for patients that are HDS with new onset a.fib
Beta blocker or Ca channel blockers
be careful if the patient has DECOMPENSATED HEART FAILURE, hypoT or bradyarrythmias
Threshold for transfusion in stable patients with suspected upper GI bleed
HgB <7.0
If stable CV disease may benefit from goal HgB >8.0
Pt with ESRD have goal of transferrin saturation ____ and ferritin of _____
transferrin saturation <30%
Ferritin <500
*have higher iron demand
*if on EPO even higher demand; monitor FE closely even if
SGLT meds for DM work by inhibiting NA-Glucose cotransporters thus reducing glucose levels; get more glucose excreation in renal tubules… SE of this
incresaesd risk for vulvovaginal candidiasis
DDP4 inhibitors for glycemic control have what neg SE
risk of pancreatitis; if hx dont use
Patient’s with suspected ACS but unremarkable initial EKG and troponins should…
be observed with serial EKG and troponins to confirm or r/o diagnosis; done 3 times 6 hours apart
What two markers are helpful in monitoring the progression of active renal involvement in patients with SLE nephritis?
Complement and Anti-dS DNA
Pt with supsected HIV comes in with AMS, white plaques on tongue, outbreak looks like molluscum.
Hes gets a tap;
elevated OP, low glucose, elevated protein and cell count of 40 with lymphocytic predominance
Likely dx
Cytococcal meningitis; tx with amphotericin B and flucytosine
May need serial LPs bc of high fungal burdern
Tx of cyrptococcal meningitis in HIV pt
- Induction: amphoB + flucytosine for >2 weeks til sx gone
- Consolidation: high dose oral fluconazole x 8 weeks
- Maint: lower dose of oral fluconazole >1 year
Pt comes in with suspected OD: mydriasis, tachycardia, resp despression, dry mouth and vision change, urinary retention, flushing. EKG with prolongued QRS or QT OD? Tx? Why?
OD on TCA;s
Sodium bicarb to prevent arrhythmia
Supportive cares
can do charcoal if present w/i 2 hrs ingestion if awake
First line tx for tinea capitus
on scalp; need oral griseofulvin or oral terbinafine
topicals don’t penetrate the hair follicles
Pt with multivessel CAD and diabetes what is preferred treatment
CABG is superior to PCI
First line tx in patients with toxic megacolon that have IBD
Glucocorticoids! Bowel rest
may need antiBx, do not give 5-ASA or opiods
Three meds that increase dig toxicity (nausea, vision changes, vomiting, anorexia, confusion and EKG changes)
Verapamil, quinidine, amiodarone
First line tx for MS attack
Tx for long term management and prevention of relapse
IV steroids (or oral steriods)... plasmapheresis if not responding Long term is beta interferon
Pt with chronic abdominal pain, fat loose stools and EtOH hx raises concern for…
Dx?
Diagnostic approach
chronic pancreatitis
get MRCP; A/L may not be elevated 2/2 to chronic pancreatic fibrosis
MCC of secondary polycythemia
Chronic hypoxemia
- -will see elevated epo levels (this excludes polycythemia vera) adn you should get carboxyhemoglobin levels to assess for CO poisoning
- test for sleep apnea
Best initial diagnostic test in patient with iron deficiency anemia and FOBT + if >50
stable.. do colonoscopy. Likely colon cancer
Started on antipyschotics.. develop gradual onset tremor and rigidity.
Cause?
Tx
Parkinsonism
Tx with benztropine or amantidine
Started on antipyschotics.. subjective restlessness and inability to sit still
Cause?
Tx?
Akathisia
Tx: Beta blocker (propranolol), Benzos (lorazepam) or benztropine
Started on antipyschotics.. gradually develop dyskinesia of mouth, face and trunk
Cause?
Tx
Tardive dyskinesia
Tx Valbenzine or Deutetrabenzine
First line therapy for dementia related impairment
Acetycholinsterase inhibitors: donepezil, rivastigmine, galantamine
Can do Memantine: NMDA for moderate to severe
Pt with new onset seizure, he’s 15. Had GTC that self aborted after 2 mins. Noticed he has been having weird AM arm jerking movements for past three months.
EEG with bilateral poylspike and slow wave activity
Juvenile myoclonic epilepsy
Tx: Valproic Acid
Tx for patient with catatonia
Benzos!
Giving antipyschotics can worsen catotonia
Recommended tx for cancers of head and neck that are locally advanced?
Radiation + chemo
most are non-operable but often see high survival rates
Increased suspicion for this diagnosis in patients with recent joint injury with burning pain and swelling with sweating and edema in the area then worsening edema and swelling followed by limited ROM and bone deminerilzations
Complex regional pain syndrome
Post cholecystectomy diarrhea; bile salt induced diarrhea seen in 10% pt after cholestectomy is treated with…
Cholestyramine
First line treatment for bacterial conjunctivitis in patient?
Erythromycin (macrolide) or POlymyxin-trimethoprim
Contacts; then use fluoroquinolone for increased PSA risk and increased risk of keratitis
Sjogrens is associated with which type of malignancy?
non-hodkins B cell lymphoma
Pain, redness, variable visual loss and constricted irregular pupil. See leukocytes in anterior segment
Anterior uveitis or Iritis
_____ antibody is seen in primary biliary cholangitis
Treatment is ____
antimitochondiral antibody
Ursodeoxycholic acid
Pt with fatigue, elevated alk phos, slight elevation in other LFTS. Xanthelasmata and xanthomata with itching and arthritis. Associated with bone loss; osteopenia and osteoprorsis
Primary biliary cholangitis
+antimitochondrial antiB
tx ursodeoxycholic acid
Delivery is indicated in mom with preeclampsia wihtout severe features when > ____GA
Delivery indicated for preeclampsia with severe features when >____GA
> 37 weeks
>34 weeks
