Step3 32 Flashcards
Psoriatic arthritis (5) and soft tissue and nails (4) characteristics
ARTHRITIS Asymmetric Olygoarthritis or Symmetric polyarthritis (similar to RA) Can include DIP joints Sacrilitis and spondilitis Arthritis multilans
NAILS AND SOFT TISSUE Dactylitis (sausage) Enthesitis Nail pitting/onycholysis Pitting edema of hand and feet
Serologic testing in Psoriatic arthritis
Negative rheumatoid factor and CCP
positive in 10%
Treatment of Psoriasis
Limited (10% skin involvement): topical steroids or vitamin D derivatives (calcipotriene)
Systemic treatment:
Methotrexate, cyclosporine, retinoids
Biologics
Management of nipple discharge
- Physical exam:
abnormal: imaging, biopsy, tests
normal: step 2 - US +/- mammogram (If >30yo)
abnormal: percutaneous biopsy
normal: Step 3 - Galactorrhea workup
abnormal: treat accordingly
normal: reassurance and observation
Patients super bothered by symptoms? consider duct extraction
X-ray findings of lead poisoning
Lead lines:
Opacification of metaphyseal plate
Treatment for lead poisoning
Chelation if lead >45
Succimer
Adetate calcium sodium (EDTA)
Manifestations of lead poisoning
Asymptomatic
Abdominal pain/constipation
Lead level as low as 10-20:
Cognitive impairment/behavioral problem (eg. ADHD)
Lead >70
Hemolytic anemia
Lead >100
Encephalopathy (AMS, seizures)
Diagnosis of multiple sclerosis
T2 MRI lesions disseminated in time and space: periventricular, juxtacortical, supratentorial, and spine
CSF:
oligoclonal IgG band
Usually reserved for patients with unclear diagnosis on MRI
Clinical features of MS
Onset 15-50 Optic neuritis Intranuclear ophthalmoplegia Motor symptoms (weakness) Sensory symptoms (paresthesias) Shooting pain down the spine Worsening symptoms in hot weather Bladder/bowel dysfuntion Fatigue Transverse myelitis (UMN symptoms)
Treatment of MS exacerbation
Steroids (oral equal to IV unless…)
IV prefered if patient has optic neuritis as oral medication can worsen the condition
Can taper to oral after IV
Plasmapheresis if no response to steroids
Treatment for MS
Exacerbation: steroids
Control: decrease frequency of exacerbations
B-interferon
Glatiramate acetate
MS and pregnancy
Clinical manifestations
Treatment
Delivery
Risk of child
Continue maintenance treatment unless the patient is being treated with teriflunomide and mitoxantrone are teratogenic
Usually less symptomatic during pregnancy and worse after postpartum
Increased risk of assisted delivery (vacuum. c-section)
Increased risk for child to have MS
Treatment for depression in MS
SSRI or SRNI
Treatment for urinary incontinence in MS
Schedule voiding
Fluid restriction
Anticholinergic medication:Doxybutinine, tolterodine (for urgency)
Treatment for spasticity in MS
Muscle stretching
Massage
Physical therapy
Muscle relaxants: Baclofen, tizanidine
Treatment for fatigue in MS
Sleep hygiene
Amantadine
Stimulants: methylphenidate, modafinil
Treatment for neuropathic pain MS
Gabapentin or duloxetine
Diagnosis of HCV infection
Antibody testing first:
Positive result:
Confirm with RNA test (NAT- nuclear acid test)
Positive result:
Treat with antiviral meds
Patients at risk for Influenza complications
> 65
Pregnant patient up to 2 weeks postpartum
Other comorbidities (diabetes, COPD, CAD)
Obesity
Immunocompromised
Nursing care facilities
Native Americans
CURB 65
Confusion Urea >30 Respiration >30 BUN: BP>90/60 >65
0-1: Outpatient
2: Ward
>3: ICU
Important clinical features of ADHD
> 6 months
In more than 2 settings (eg. school and home)
Symptoms appear before age 12
Treatment of ADHD
steps before medication and scalation
<6 years: parent-patient CBT
> 6 years or CBT failure:
Methylphenidate or amphetamine with prior cardiac exam and history. EKG if any hx or physical fidings
Atomoxetine
Alpha 2 adrenergic
If one stimulant fails (doesn’t work or too many side effects) after max dosing, switch to a different stimulant or a different medication
Titration of medication is done on a weekly basis. If no response after a couple of weeks.. switch
AV nodal blocker
Beta-blocker
CCB
Adenosine
Digoxin
Treatment of WPW
Acute setting: Procainamide, ibutilde, amiodarone
Radiofrequency catheter ablation
Medication to avoid in a patient with multifocal atrial tachycardia
Beta-blockers:
MAT is associated with COPD and B blocker can worsen their condition
Medical error that reaches the patient but causes no harm
Near miss
Treatment for narrow complex tachycardia
Adenosine (short live, helps uncover underlying rhythm)
DO NOT USE IN WPW
Hypercalcemia workup
- Confirm hypercalcemia
Recheck Ca
Correct for albumin/measure ionized Ca - Measure PTH
High: PTH related (1 or 3 hyperparathyroidisms, familial hypercalciuric hypercalcemia, lithium)
Low: step 3 - Measure PTHrP, 25-hydroxyvitamin D, 1,25 dihydroxyvitamin D, chest x-ray (granulomatous disease), urine protein electrophoresis for MM
PTH related hypercalcemia Dxx
1 or 3 hyperparathyroidisms
Familial hypercalciuric hypercalcemia
Lithium
non-PTH related hypercalcemia Dxx
Malignancy Vitamin D toxicity Granulomatous disease Drug-induced (thiazide) Milk alkali syndrome Thyrotoxicosis Immobilization Vitamin A toxicity
Cancer that produces PTHrP
SCC
renal and bladder
breast and ovary
Mechanism of Hypercalcemia in
Multiple myeloma
Lymphoma
Multiple myeloma:
Osteolytic lesions
Lymphoma:
Elevated 1,25-hydroxyvitamin D
They give you the sensitivity and specificity of a test and ask you to calculate the PPV or NPV.
What other data do you need, why?
Practice an example
You need the prevalence of the disease because predictive values are modified by prevalence
Use a hypothetical sample of 1000
The prevalence will be the total of people with the disease (out of 1000)
Multiply total people with the disease by the sensitivity and you will have the True positives
Work from there
Blurry vision in a diabetic patient
Swelling of the optical nerve:
- Secondary to osmotic changes (uncontrolled hyperglycemia, more acute)
- Treat hyperglycemia
Diabetic retinopathy: TAKES YEARS TO DEVELOP
- Vitreous hemorrhage, retinal detachment, macular edema
- Treat with angiography, laser coagulation
Central retinal vein vs. artery occlusion main differences
Arterial:
Cherry spot on the fovea
Retinal swelling
Venous: (looks more dramatic)
Vein dilation
Swallen Disc
Hemorrhages
Diagnosis and Treatment for mucormycosis
Sinus endoscopy with biopsy and culture
Amphotericin B
Treatment for onychomycosis
Oral terbinafine or itraconazole
B12 deficiency manifestations
Subacute combined degeneration:
Dorsal column symptom
Lateral corticospinal tract: UMN symptoms
Spinocerebellar: ataxic gait
Dementia
Why is there elevated bilirubin in B12 deficiency
Ineffective erythropoiesis
Cells die in the bone marrow,
This is not intravascular hemolysis
Factors that increase risk of malignancy in solitary nodules (7)
>2cm Advanced age Smocking history Family history of lung cancer Female Upper lobe location Spiculated
Definition of solitary nodule (lung)
< 3cm (>3 is a mass)
Surround by parenchyma
No associated lymphadenopathy
Rounded opacity
Approach to a solitary nodule
- Review previous Xrays:
No change >2-3 years: follow up
Change or no previous studies available: CT - CT
High risk: Surgical resection
Intermittent risk: biopsy if possible
Low risk: Serial CT scans
High risk: >2cm Advanced age Smocking history Family history of lung cancer Female Upper lobe location Spiculated
Cervical insufficiency vs. threatened abortion vs. preterm labor
Threatened Abortion: vaginal bleeding, close cervix, <20 weeks, fetal heartbeat
Cervical insufficiency: painless cervical dilatation, < 24 weeks
Preterm labor: <37 weeks with painful contractions
Prognosis of cerclage
If prophylactic: (base on history and placed at 12-14 weeks)
Somewhat good
If place at diagnosis: poor prognosis
If membranes are prolapsing: worse prognosis. Membranes prolapsing is a relative contraindiction
Order of effective anticontraception
Implant: >99% (even more effective than IUD and surgery) IUD: >99% Surgery (male/female): >99% Injection: 94% Combine hormonal contraception: 91% Condom: 82% Withdrawal: 78%
papillary thyroid cancer management
Depends on size and involvement
<1cm with no adenopathies or anything else.. lobectomy. If not…
total thyroidectomy
adjuvant treatment with radioactive iodine
Manifestations of anterior uveitis
Erythema at the limbus (junction of the cornea and the sclera)
Constricted pupils
Moderate aye pain
Blurred vision
Approach to suspected Ectopic pregnancy
Unstable: surgery
Stable:
Algorithm
B-hCG value cut off is 3500
Approach to elevated AFP in pregnancy
- Repeat AFP
- Perform obstetric ultrasound
- Amniocentesis with AFP +acethylcholinesterase
If both are elevated: high positive predictive value for neural tube defects and ventral wall
Transfusion reactions that occur within mins-1hr
Acute hemolytic reaction
Abdominal pain/flank pain
Gross hematuria
Dark urine
Stop transfusion, give IV fluids
Transfusion reactions that occur within 1hr to 6 hrs
Febrile hemolytic
TACO: circulatory overload
TRALI: lung injury
TTBI: transmitted bacterial infection
Urticarial
Prevent with leukoreduction
Transfusion reaction that occurs sec/min within transfusion
Anaphylactic
Usually in patients with IgA deficiency
Give epinephrine
Patients that need radiated RBC transfusion
The donor is a family member
Congenital or acquired immunodeficiencies
Bone marrow transplant recipients
Patients that need leukoreduced RBC transfusion
Previous hx of reaction
CMV seronegative at risk infection (eg, aids)
Potential transplant recipient
Chronically trasfused
Patients that need washed RBC transfusion
IgA deficiency
Complement dependant autoimmune hemolytic anemia
Continued allergic reaction after antihistamine treatment
Stress ulcer prophylaxis
Any 1 factor: Spinal, head injury, or major burn Mechanical ventilation >48hrs PLT <50k, INR >1,5, PTT x2 normal limit GI bleed or ulcer in the past 12 months
Any >2 factors Corticosteroid therapy Occult GI bleed >6 days Sepsis ICU >1 week
