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Clinical Objectives > Outpatient Internal Med > Flashcards

Outpatient Internal Med Flashcards

1
Q

Physical Findings with COPD Patient

A
  • General
    • Cough
    • Dyspnea
    • Dec FEV1/FVC ratio
  • Pink puffer (Emphysema, think destruction beyond primary bronchiole → decreased CO)
    • Pink, perfusion is fairly adequate
    • Body tissue wasting
    • Barrel chest, pulls air into pockets without alveoli for gas exchange and expulsion
    • Hyperventilation
    • Lung exam
      • Decreased breath sounds
      • Hyper-resonant percussion
      • Large lung volume
  • Blue bloater (Chronic bronchitis, think clogging of primary bronchioles → increased CO with VQ mismatch to compensate)
    • Blue, perfusion is inadequate
    • Excessive sputum prdcn
    • Lung exam
      • Clogged lung sounds, mucus present
        • Rhonchi
        • Wheezing
      • Normal lung volume
    • Peripheral edema, increased CO and cor pulminale
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2
Q

Most important lifestyle change for COPD pt survivial

A

Smoking cessation

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3
Q

Relationship between cigarette smoking and vascular disease

(4)

A
  1. Increased oxidative stress
  2. Endothelial dysfunction
  3. Low grade, permanent inflammation
  4. Increased thrombosis risk
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4
Q

Correlate carotid US findings with clinical reccomendations

A
  • > 50% = begin medical treatment
    • Anticoagulation
    • Lipid control
    • Close monitoring
  • > 70% = endarterectomy
  • > 95% = bruit disappears
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5
Q

Prostate cancer screening reccomendations

A
  • No risk factors
    • Timing = 50-75 yo
    • Incidence = q 1 year
  • Risk factors (African American, +FHx)
    • ​Timing = 40-75 yo
    • Incidence = q 1 year
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6
Q

Colorectal screening recommendations

A
  • Typical with negative results
    • Start = 50 yo
    • Incidence
      • Colonoscopy = q 10 years
      • Verbal screen @ 7 years
  • RF-specific screening
    • 1st degree relative
      • 40 yo or
      • 10 years before relative’s onset
    • Polyps found on colonoscopy
      • q 3-5 years
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7
Q

Explain why digoxin is used to treat heart failure

A
  1. Positive inotrope
    1. MOA - increased intracellular calicum flow, each myocyte contracts better
    2. Therapeutic result - stronger stroke volume
  2. Negative chronotrope
    1. MOA - decreases conduction through SA/AV nodes
    2. Therapeutic result - longer filling time
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8
Q

Medical management for septic arthritis (goncoccal and nongonococcal)

A
  • Nongonococcal
    • Initial
      • Hospitalization
      • Immobilization
    • Abx
      • If organism ID’d on gram stain = narrow spectrum
      • If organism not ID’d on gram stain = broad spectrum
        • Include vancomycin if considering MRSA
    • Joint effusion
      • Arthroscopic lavage
      • Drain placement
  • Gonococcal
    • Initial - hospital admission to
      • Confirm diagnosis
      • R/O endocarditis
      • Begin tx to monitor for resistance
    • Abx
      • Ceftriaxone 1 g IV q daily
    • Joint effusion
      • Only consider draining if tx not dramatically responding x 24 hrs
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9
Q

Medical management for 50 yo with newly diagnosed RA

A
  • Symptomatic
    • NSAIDs
      • Indomethacin (Indocin)
      • Celoxib (Celebrex)
    • Low dose CTS, only until DMARD is functioning
  • Disease modifying
    • Synthetic DMARD
      • Methotrexate (Rheumatrex)
      • Sulfasalazine (Azulfidine)
      • Leflunomide
      • Anti-malarials (Hydroxychloroquine sulfate)
      • Minocycline
    • Biologic DMARD
      • TNF-inhibitors
      • Abatacept
      • Rituximab
      • Toclizumab
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10
Q

Explian why NSAIDs should be used cautiously in a pt with HTN

A

Renotoxic

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11
Q

Explain why SLE pts treated with plaquenil are required to have opthalmologic exams annually

A

Plaquenil

MOA - suppress antigens for hypersensitivity rxns

S/E - permanent progressive retinopathy

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12
Q

Describe tx for lateral epicondylitis

A
  • Lifestyle modifications
    • D/C aggrevating activity
    • Lift in supination
  • Forearm braces
  • Stretch/strengthening exercises (+/- PT)
    • Wrist extension +/- small weight
    • Extend wrist c arm abducted 90 deg and thumb facing down
  • Pain relief
    • Mild case (< 2 weeks s/sx) = NSAID
    • Mod case =
      • Quicker result - triamcinolone + lidocaine injection
        • Risk of ulnar nerve injury
      • Longer result - physiotherapy
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13
Q

Treatment, rotator cuff tendonitis

A
  • Rest/decrease aggrevating activity
  • Conservative tx
    • NSAID
    • Moist heat
  • Moderate tx
    • Triamcinoone + lidocaine injection
  • PT, prevent frozen shoulder
    • Spider walk up walls
    • Circles
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14
Q

Tx, Otitis Externa

A
  • Otic abx for pseudomonas +/- corticosteroid, +/- wick
    • Fluroquinolone
      • Levofloxacin
    • Aminoglycoside
      • Neomycin
  • Analgesic PO
    • OTC
    • Hydrocodone
  • Behavior modification
    • Keep head dry in shower
    • No swimming
  • Tx concurrent cellulitis PO
    • Cephalosporins
    • Augmentin
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15
Q

Pathogen responsible for hot tub folliculitis

A

Pseudomonas

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16
Q

Common side effects of phosphodiasterase inhibitors (PDE-5)

A
  • Indication - erectile dysfunction*
  • Sildenafil, tadalafil, vardenafil*
  • Hypotension, esp in combination
    • Nitrates
    • Alpha blockers
  • HA
  • Vision changes, esp blue/green color descrimination
    • Sildenafil
  • Flushing
  • Dyspepsia
  • Nasal congestion
  • Reduced effectiveness with
    • Ritonavir
    • Protease inhibitors
      • Clarithromycin
      • Erythromycin
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17
Q

Treatment goal for LDL in obese DM II

A

< 100

< 70 if comorbid CVD

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18
Q

ADA treatment guidelines for DM II

A
  • Glycemic targets
    • A1C < 7.0%
      • reduces microvascular complications
      • reduces macrovascular dz
    • ​Glucose
      • preprandial = 80-130
      • postprandial (1-2 hrs) = < 180
  • Management protocol
    • Step 1 = lifestyle changes
      • ADA diets
        • ​DASH
        • Low CHO
        • Low fat
        • Mediterranean
        • Vegan
        • Vegetarian
      • Exercise
        • > 150 min/week moderate intensity over 3+ days/week
          • No more than 2 consecutive days s exercise
        • Resistance training > 2x/week
        • No more than 90 min consecutive sedentary time
      • Weight loss
        • Bariatric surgery consideration at BMI > 35
      • Smoking cessation
    • Step 2 = pharmacology
        1. Metformin - preferred initial therapy
        1. Consider insulin therapy +/- other agent addition
          * markedly symptomatic newly diagnosed pt
          * highly elevated BGL/A1C
      • ​3. Add 2nd oral agent, GLP-1 receptor agonist, or insulin
        • maximal dose does not achieve/maintain A1C x 3 mo
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19
Q

MOA - Biguanides

A

Drugs - Metformin

MOA

  1. Increase #/affinity of insulin receptors on peripheral tissue
  2. Decrease hepatic glucose output
  3. Decrease glucose absorption fromt he gut
  4. Increase glucose uptake/utilization in skeletal/adipose tissue

The liver gets big in MARCH

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20
Q

MOA - Thiazolidinediones (TZD)

A

Drugs - Pioglitazone (Actos), Rosiglitazone (Avandia)

MOA

  1. Decrease insulin resistance
  2. Decrease hepatic glucose production
  3. Increase peripheral insulin sensitivity

Rosie and actos are glitzy and have cannot have heart disease due to their medditeranean diets

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21
Q

MOA - Sulfonylureas

A

Drugs - Glyburide (Micronaise), Glipizide (Glucotrol), etc.

MOA

  1. Close K channels
  2. Compensitory Ca channel opening
  3. Ca stimulates insulin release from beta cells

Guide the beta cells fondly

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22
Q

MOA, Alpha glucosidase inhibitors

A

Drugs - Acarbose (Precose), Miglitol (Glyset)

MOA

  1. Competitively bind intestinal enzyme that converts oligosacchardes → disacchardies → glucose in gut
  2. Prevent/delay glucose absorption from gut

Your glycemic index is set without (a) carbs

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23
Q

Explain clinical importance of proper fitting footwear in DM pts

A

Neuropathy may preclude pt from feeling feet. Consequences:

  • Trauma with impaired wound healing = ulcer, cellulitis, osteomyelitis
  • Altered gait = charcot foot
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24
Q

Diagnostic criteria, metabolic syndrome

A
  1. Truncal obesity
    1. M > 40”
    2. F > 35”
  2. Low HDL
    1. M < 35
    2. F < 50
  3. High trigs
  4. HTN
  5. Glucose resistance (fasting BGL 100-125)
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25
Q

MOA, CPAP for OSA

A
  • Maintains airway patency
  • Ensure adequate alveolar ventilation
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26
Q

Explain why exposure to sun can precipitate an outbreak of oral HSV

A

HSV outbreaks are d/t stress on the body. UV rays provide stress on the body.

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27
Q

Common oral medications used for HSV outbreaks

A

Start all treatments within 48 hours of prodrome

  • Acyclovir (Zovirax) 400 mg PO TID x 7 - 10 days
  • Famciclovir (Famvir) 250 mg PO TID x 7 - 10 days
  • Valacyclovir (Valtrex) 1 g PO BID x 7 - 10 days

10 days at first outbreak, 7 days subsequently

28
Q

Diagnostic study of choice for pt c suspected polycystic kidney disease

A

Ultrasound

29
Q

Diagnostic study of choice for acute pancreatitis

A

Serum lipase

  • Increase = 4-8 hours
  • Normalize = 8-14 days

Imaging modalities are not good, although CT is probably best option to eval streaking and ducts

30
Q

Rational for therapeutic phlebotomy in pts with polycythemia vera

A
  • Maintain hct
    • Male < 45%
    • Female < 42%
  • Decrease sequelae of too much blood
    • Thrombosis
    • Bleeding
    • Myelofibrosis
    • Acute leukemia
    • Other malignancies
  • Thwart disease process
    • Induce relative iron deficiency, preventing ability to produce more blood

Some polycythemia vera facts:

  • Elevated hematopoesis in all 3 hematopoietic cell lines (but mostly RBC)
  • Elevated Hct
    • ​> 54% in males
    • > 51% in females
  • ​BM disordder characterized by autonomous overproduction of normal erythroid cells (independent of erythropoeitin)
  • JAK2 mutation present 95%
  • S/Sx = generalized pruritis following warm shower, HA, dizziness, fatigue, epistaxis, visual changes from engorged retinal veins, thrombosis and increased bleeding
31
Q

S/Sx, Aortic Stenosis

A
  • Auscilitory findings
    • Timing: SEM
    • Quality
      • Crescendo-decrescendo
      • Harsh
      • Decreased S2, severe
    • Location
      • 2nd R ICS
      • Radiation to carotids
  • Symptoms
    • Exertional syncope (inc. LV pressure → baroreceptor stim → vasodilation)
    • Dyspnea/weakness/fatigue
    • Palpitations
    • Angina
    • Pulmonary edema → CHF
32
Q

Clinical significance of ST depression on EKG

A
  1. Myocardial ischemia causes change in electrical conduction
  2. Change in depolarization currents travel oppositely/around ischemic tissue
  3. EKG monitors detect electrical conductivity at different angles
  4. Atypical pattern (ST depression) shows on EKG
33
Q

S/Sx, Parkinson’s Disease

A
  • Shuffling gait
  • Cog wheel rigidity
  • Resting tremor, pill rolling
  • Dementia
  • Depression
  • Postural instability
  • Bradykinesia
  • Mask-like expression
34
Q

MC laboratory diagnostic study to confirm temporal arteritis

A
  • ESR > 50
  • CBC = anemia of chronic disease
  • CRP = elevated

Confirmation is via temporal artery bx

35
Q

Weber findings in pt c ear wax occluding L ear canal

A

Lateralization to left ear (same)

36
Q

Sarcoidosis RF, S/Sx

A
  • Risk Factors
    • Race:
      • North American blacks (M > F)
      • Northern European whites
    • Age: 30-40 yo
    • Genetics: +FHx increases risk x5
  • S/Sx; may be asymptomatic, depends on granuloma location
    • Common
      • Erythema nodosum (or other rash)
      • DOE
      • Cough
      • Mild CP
      • Perihilar adenopathy
    • Less common
      • Fatigue
      • Arthralgia (wrist, ankle, elbow)
      • HA
      • Fever
      • Iritis (uveitis in blau syndrome)
      • Peirpheral neuropathy
      • Cardiomyopathy
      • Seizures

Buzzwords:

  • ACE levels
  • Bilateral hilar adenopathy
  • Widened mediastinum
  • Non-caseating granulomas
37
Q

IBS Reccomendations

A
  • Reassurance
  • Lifestyle changes
    • Stress management
    • Exercise
  • Bulking agents, gravity helps move stool
    • Psyllium (Metamucil)
    • Methylcellulose (Citrucel)
    • Calcium polycarbophil (FiberCon)
  • Antispasmotics
    • Dicyclomine HCl (Bentyl)
    • Hyoscyamine sulfate (Levsin), controlled
    • Combo meds (Donnatol), controlled
  • ​Anti-diarrheal
    • Opioids
      • Loperamide (Immodium), OTC
      • Diphenoxylate (Lomotil), script
    • Anti-depressant anti-diarrheals, females only, 5HT3 receptor agonist
      • Alosteron (Lotonex)
  • Prokinetic
    • Metochlopramide (Reglan)
38
Q

Treatment Reccomendations, H. Pylori gastritis

A
  • Triple therapy x 10-14 days
    • Abx (1 and 2)
      • Standard - Clarithromycin (Biaxin) 500 mg PO BID
      • Choose 1
        • Metronidazole 500 mg PO BID
        • Amoxicillin 1 go PO BID
    • PPI BID (3)
  • Quadruple therapy x 10-14 days
    • Abx
      • Tetracycline 500 mg PO QID
      • Metronidazole 500 mg PO TID
    • PPI BID
    • Bismuth subsalicylate (Pepto-bismol) 500 mg PO QID
39
Q

RF, esophageal carcinoma

(8)

A
  1. Persistant GERD, esp with complications
    1. Barrett’s esophagus
    2. Esophageal stenosis
    3. Esophageal stricture
  2. Smoking
  3. EtOH
  4. Achalasia
  5. Lye ingestion (corrosive-induced esophageal stricture)
  6. Other cancers
  7. Poor diet
  8. Obesity
40
Q

Treatment reccomendations, repeated gout attacks

A
  • Preventitive meds
    • Allupurionl (Xylopri) 100 mg PO daily
      • Xanthine oxidase inhibitor that reduces serum uric acid
      • Can reduce tophi by may precipitate gouty attack
    • ​Colchecine 0.6 mg PO 1-2x daily
    • Probenacid 500 mg PO BID
      • Block tubular reabsorption of uric acid
  • ​​Lifestlye changes
    • Weight loss
    • Avoid dietary triggers
      • Purines
      • EtOH
41
Q

S/Sx, osteoarthritis

A
  • Decreased ROM
  • Morning stiffness < 30 min
  • Joint pain
    • Worse c weight bearing
    • Relieved with rest
  • Typical joints
    • Hands (**spares MCP’s)
      • DIP - Herberden’s nodes
      • PIP - Bouchard’s nodes
      • Carpometacarpal
    • Hip
    • Knee (medial compartment → valgus/varus deformities)
    • Back (spondylosis)
  • ​Palpation
    • Crepitus
    • Hard/boney joint
  • Antalgic/trandelenberg gait
42
Q

Classic rash associated with Lyme Disease?

A

Erythema migrans bullseye rash

43
Q

Describe the rash associated with rosacea

A
  • Primary
    • Flushing, transient or non-transient erythema
    • Papules/pustules without comedones
    • Talangiectasias
  • Secondary
    • Burning/stinging
    • Plaques
    • Dried skin
    • Edema
      • Soft
      • Solid
    • Occular manifestation
    • Peripheral location
    • Phymatous changes
  • Specific types
    • Vascular rosasea (eryteamtotelantiectatic)
    • Inflammatory (papulopustular)
    • Phymatous (sepaceous hyperplasia)
    • Occular
    • Granulomatous (rosacea varient)
    • Perioral/periofacial
44
Q

Describe the rash associated with secondary syphillis

A
  • Description
    • “Any form except vesicular lesions” (vesicular is primary)
    • Pustule
    • Macule
    • Papule
    • Scales
  • Color
    • Copper
    • Red
    • Redish-brown
    • White on mucus membranes
  • Size
    • 0.5 - 2 cm
  • Distribution
    • Trunk
    • Ventral hands/feet

Spirochete progression:

  1. Pathogen infiltration
  2. Rash +/- mild constitutional illness
  3. Latent phase (often not detectable in serum)
  4. Fulmonent phase
    1. ​Neuro inflammation (meningitis, encephalitis)
    2. Joint pain
    3. Blood/renal dysfunction (thrombocytopenia)
45
Q

Tx, wrist ganglion cyst

A
  • Observation (spontaneous regression possible)
  • Aspiration + cortisone injection if painful
  • Surgical cyst excision
46
Q

S/E of oral steroids

(12)

A

Cushingoid

  • Buffalo hump
  • Thinned skin
  • Acne
  • Claucoma/cataracts
  • Hyperglycemia → DM
  • Trunchal obesity
  • Moon facies
  • Decreased immunity
    • Inc infections
    • Poor wound healing
    • Low stress resistance
  • HTN
  • Striae
  • Extremity atrophy
  • Hirsutism
  • +/- Edema
47
Q

S/Sx, blepharitis

A
  • Dandruff-like deposits on eyelashes
  • Rim/lash adherence
  • Conjunctiva clear → erythematous
  • Thick, cloudy discharge (with associated meibomian gland obstruction)
  • Usually bilateral
48
Q

Treatment Reccomendations, Chronic rhinitis

A
  1. Avoid irritant, if possible
  2. Antihistamines
    1. Oral, OTC or Rx
    2. Intranasal, Rx only
  3. ​Intranasal CTS
    1. Fluticasone propionate nasal (Flonaise)
    2. Triamcinolone nasal (Nasocort)
    3. Mometasone nasal (Nasonex)
  4. ​Antileukotriene mediators
    1. Monteleukast (Singulair)
  5. ​Intranasal anticholinergic (Ipratropium)
  6. Desensitization, if allergic
49
Q

Management, ACS

A
  • Prehospital
    • EKG, quick note
    • Morphine
    • Oxygen
    • Nitroglycerin x 3 max
      • monitor BP
      • ask about phosphodiesterase inhibitors
    • ASA 324 mg chewed and left in mouth
    • (Heparin, if present)
  • In hospital
    • EKG/telemetry
    • Cardiac enzymes
      • CK MB
      • Troponin I
    • CXR
    • Other diagnostics to consider
      • Myoglobin
      • Echo
      • Lytes
        • Mg
        • K
        • Ca
    • ACS-level dependent reaction
      • STEMI = cath lab within 90 min
      • NSTEMI = cath lab within 24 hours
      • Unstable angina = further workup required
  • Post acute
    • Stress test
    • Echo (if not done already)
    • CT cardiac angio
50
Q

Treatment Reccomendations, Recurrent Migraine

A
  • Abortive Tx
    • Mild
      • NSAIDs PO
      • Combination OTCs
        • Caffeine
        • Naproxen
        • ASA
    • Mod → severe
      • NSAIDs
        • IM (Toradol)
        • Combo
          • APAP - acetaminophen, caffeine, phenobarb
          • ASA + caffeine
      • Triptans - serotonin 5HT1 agonists
        • Imitrex 100 mg
      • Narcotis (last resort, can give with anti-emetic)
        • ​Narcotics
          • Morphine
          • Hydromorphone (Dilaudid)
          • Mepridine (Demerol)
        • Anti-emetics
          • Metochlopramide (Reglan) - best used with triptan
          • Odansetron (Zofran)
          • Prochloroperazine (Compazine)
          • Hydroxyzine (Vistaril) - antihistamine
  • Preventitive tx
    • Indication: > 4 episodes/mo
    • Interventions
      • Lifestyle changes: avoid triggers
        • Low tyramine diet
        • Caffeine moderation
      • Change hormonal therapy
      • Pharmacology
        • Anti-convulsants
          • Topiramate (Topomax)
          • Valproate (Depakote)
        • Beta blockers - Propranolol
        • TCA - Amitriptyline (Elavil)
        • CCB - Verapamil
      • Alternative med
        • Acupuncture
        • Relaxation therapy
        • CBT
        • Chriopractic
        • Botox
51
Q

Treatment Reccommendations, DVT

A
  • Arms/Distal to popliteal
    • Heat
    • Rest
    • Compression
    • Monitoring
  • Thigh
    • Conservative tx (see above)
    • Anticoagulation dependent on Well’s criteria
      • 3 mo = reversible cause
      • 6 mo = no know RF
      • Indefinitely
        • Irreversible RF
        • Multiple
    • Recurrent = consider IVC filter
52
Q

Asthma

(RF, Reversible sxs, Complications, Dx, Tx)

A
  • RF
    • Atopy, personal or FHx
      • ​Polyps
      • Eczema
    • Smoking
    • Occupational exposure
    • Home heating systems (wood burning)
  • Reversible Sxs
    • Typical
      • Episodic dyspnea
      • Wheeze/squeak
      • Tightness
      • Persistant cough, esp at night
    • Complications
      • Exhaustion
      • Dehydration
      • Airway infection
      • Tussive syndrome, neural vasopressor bradycardia in response to cough
      • Impending respiratory failure
      • Pulsus paradoxus
  • Dx
    • Spirometry
    • PFTs
      • Dec FEV1
      • Nml FVC
      • Dec FEV1/FVC ratio
    • Metacholine challenge (> 5 yo)
    • ABG
    • CXR, flattened diaphragms, eventually
    • Allergy testing
  • Tx
    • SABA
    • Systemic CTS
    • Mast cell stabilizers (Cromolyn)
    • OTC decongestants
      • Ephedrine
      • Guanfacine
    • Long acting beta 2
    • Biologics
    • Lekotriene inhibitor (Monteleukast/Singulair)
    • Oxygen
    • Education on when to use what
53
Q

URI

(Dx, Tx)

A
  • Diagnosis - usually clinical
    • ​Upper respiratory congestion
    • Sick contacts
    • +/- Mucus prdcn
    • Cough
    • Low grade fever, if any
    • Consider specific testing, usually reserved for peds
      • Rapid strep
      • Flu
      • RSV
  • Tx - supportive
    • Fluids
    • Rest
    • Humidifier
    • OTC antihistamines
    • Intranasal CTS
    • Expectorants, Guaifenesin (Mucinex)
54
Q

Allergic Rhinitis

(S/Sx, Tx)

A
  • S/Sx
    • Bilateral eye irritation/tearing
    • Mucosal changes (especially in nose)
      • ​Pale/blue/gray
      • Boggy
    • ​Rhinorrhea, often clear
    • +/- Polyps
  • Tx
    • Antihistamines
      • Oral (may be OTC)
      • Intranasal (Rx only)
    • ​Intranasal CTS
    • Leukotriene inhibitors - Monteleukast (Singulair)
    • Mast cell stabilizer - Cromolyn sodium
    • Desensitization
55
Q

Influenza

(S/Sx, Tx)

A
  • S/Sx
    • Rapid onset
    • Severe constitutional sxs
      • High fever
      • Chills
      • Body aches
      • Fatigue
      • HA
    • Respiratory discomfort
  • Tx
    • < 48 hrs: neuraminidase inhibitors to shorten course, especially in at risk populations
      • Oseltamivir (Tamiflu)
      • Zanamivir (Relenza)
    • > 48 hrs: supportive
56
Q

Tx, N/V/D

A
  • Stable/viral source
    • Clear liquids → BRAT
    • Avoid medications
    • Electrolyte hydration
  • Untable/certain bacterial sources
    • NPO
    • IVF
    • Anti-emetics
      • Zofran
      • Opioid antagonists
        • Loperimide (Immodium) - otc
        • Diphenoxylate (Lomotil) - rx
    • Reversible causes (not all inclusive)
      • Abx - C. Diff, diverticulitis
      • Steroids/Sulfasalazine - IBD
      • Surgery - appendicitis
57
Q

UTI

(Pathogens, Dx Tests, Tx)

A
  • Pathogens
    • Complicated = E. coli
    • Uncompliated = Enterobacter
  • Dx tests
    • Dipstick
      • Blood
      • Nitrates
      • Leukocytes
      • Alkaline
    • Abx
      • Uncomplicated
        • Trimethoprim 160 mg/sulfamethazole 800 mg (Bactrim) x 3d
        • Cipro 250 - 500 mg po BID x 3d
        • Nitrofurantoin/Macrodantin (Macrobid) 100 mg po BID x 5-7 d
      • Complicated
        • Same meds with higher doses/durations
        • Refer to urology
        • Monitor for sepsis
      • Prophylaxis - 3+ postcoital infections within 1 year
        • ​Nitrofurantoin (Macrodantin) 100 mg PO prn coitus
        • Bactrim 80-400 mg PO prn coitus
      • Symptomatic
        • Phenazopyridine (Pyridium, Urostat) 200 mg PO tid prn
58
Q

Bacterial Vaginosis

(buzz)

A
  • Non-std
  • Garnerella vaginalis
  • Discharge
    • ​White → gray
    • Fishy/malodorous
  • ​Dx
    • pH = alkaline, 5 - 5.5
    • NS wet prep = clue cells
  • Tx
    • Metronidazole
      • PO = 500 mg bid x 7-10 d, no EtOH
      • PV = 1 applicator hs x 5 d
    • Clindamycin,
      • PO = 300 mg po bid x 7 d, no EtOH
      • PV = 1 applicator hs x 3 or 7 d
59
Q

Vulvovaginal Candidiasis

(buzz)

A
  • Non STD
  • Pathogen = candida albicans
  • Exam
    • Fire engine red satellite regions
    • Thick, white cottage cheese discharge
  • Dx
    • Wet mount = hyphae and buds
    • pH = nml (3.8-4.5)
    • “Gold standard” = cx triple screen
      • yeast
      • bv
      • trichomonas
  • Tx
    • Diflucan 150 mg x 2 pills, repeat x 3 days
    • Creams/suppositories for burning (Monistat)
60
Q

Chlamydial/Gonorrheal Vaginitis

(buzz)

A
  • STD
  • Exam
    • Odor = none
    • Texture = mucoid, variable
  • Dx
    • Gram stain/cx, will only show gonorrhea = gram neg intracellular diplococci
  • Tx - always tx for both and tx the partner
    • Ceftriaxone 250 mg IM
    • Choose 1
      • Azythromycin 1 gm po x 1
      • Doxycycline 100 mg po bid x 7d
61
Q

Trichomonas Vaginitis

(buzz)

A
  • Protozoan
  • STD, MC non-viral worldwide
  • Enhances HIV transmission
  • Exam = strawberries and cream
    • Discharge
      • Color = yellow → green
      • Texture = frothy
      • Odor = +/-
    • Punctate hemorrhages
    • Labial edema
  • Dx
    • pH = aklaline, > 5.0
    • NS wet mount = visualize protozoa
  • Tx = Metronidazole
    • 2 gm po x 1
    • 500 mg po bid x 7d
62
Q

Chemical Vaginitis

(buzz)

A
  • Irritants, commonly soaps/douches
  • Contact dermatitis
  • Clincal dx
  • Tx
    • Remove offending agent
    • Antihistamine
    • Sitz path, tepid water
    • Steroids
      • Low dose topical (sensitive skin, avoid thinning)
      • Oral
    • Ice pack
    • NSAIDS
63
Q

Conjunctivitis

(Etiologies, S/Sx, Dx, Tx)

A
  • Etiologies
    • Bacterial
      • Staph
      • Haemophilus
      • S. pneumo
      • Pseudomonas
      • Moraxella
      • Chlamydia(MC infectious cause of blindness worldwide)
      • Gonorrhea
    • Viral - advenovirus
    • Allergic
  • S/Sx
    • Bacterial
      • Purulent exudate
      • Pathogen-specific
        • Gonococcal = keratitis
        • Chlamydial
          • Inner lid follicular response
          • Nontender preauridcular adenopathy
    • Viral
      • Watery exudate
      • Systemic illness (URI)
      • FB sensation
      • Acute onset
      • Bilateral
      • Periaruicular adenopathy
    • Allergic
      • Conjunctival cobblestoning
  • Dx
    • Clinical
    • GS&C if suspecting STD
  • Tx (usually will tx regardless of bacterial/viral etiology suspicion, despite the fac that both are self limiting x ~ 2 weeks)
    • Bacterioviral
      • Uncomplicated = drops x 5-7 days
        • 10% Sodium sulfonamide opth soln tid
        • Erythromycin opth oint
        • Gentamycin opth oint (aminoglycoside)
        • Fluoroquinolone opth soln (limited use)
        • Polymyxin B/Trimethoprim sulfate
      • Complicated (STD)
        • Gonococcal
          • Ceftriaxone 1 g IM
          • Oral fluoroquinolone
        • Chlamydial
          • Azythromycin 20 mg PO x 1
          • Topical arythromycin x 3 weeks
    • Allergic = antihistamines
64
Q

Syncope Workup

(4 things to consider)

A
  • Hx leading up to event
  • Hydration status
  • Neuro status - full neuro exam + imaging
  • Cardiac status - carotid US + EKG
65
Q

Sprains/Strains Considerations

(3)

A
  • Get X-ray to r/o fx. Other than that, avoid imaging unless tx failure
  • PRICE
  • Consider PT
66
Q

HTN Tx

A
  • Goals
    • 140/80
    • > 60 yo, 150/80
  • Methods
    • 1st line = lifestyle changes
    • 2nd line = pharm
      • Initial meds
        • Thiazide diuretics, all but renal dz
        • CCB, African american/>75 yo
        • ACE/ARB, CKD and DM
      • ​Others
        • Bb, comorbid heart dz
          • ​Carvedilol (Coreg) for HTN, CHF, and renal dz
        • Alpha blockers, comorbid BPH
67
Q

CHF

(Dx tests, Tx)

A
  • Dx tests
    • BNP
    • CBC - anemia of chronic dz
    • CMP - hyponatremia, K changes
    • Echo
    • EKG
    • CXR - bat winging (alveolar edema), Kerley B, prominant upper vasculature, cardiomegaly, pleural effusion, pulm edema
  • ​Tx
    • Diuretics - loop +/- K sparing
    • RAAS inihbitors - first line for LV systolic dysfunction, asymptomatic low EF
    • Bb - only in chronic, decrease in acute
    • Vasodilators - resistant, use nitro/hydralazine
    • Anticoagulants - comorbid A-fib

Clinical Objectives (1 decks)

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