Summative Skills Flashcards
1
Q
PDA
A
Persistence of the fetal connection between the aorta and pulmonary artery after birth –> left to right shunt
Presentation: failure to thrive, poor feeding, tachycardia, tachypnea
Diagnosis: harsh, continuous machinery-like murmur at left 2nd intercostal space; wide pulse pressure (low DBP)
***DIAGNOSED WITH ECHO
Labs: EKG (normal), CXR showing prominent pulmonary artery, aorta, and left atrium
Treatment: indomethacin in premature infants, surgical correction in term infants or older children
2
Q
Aortic Aneurysm
A
SMOKING BIG RISK FACTOR
Presentation: back/flank pain, pulsatile mass, hypotension
Diagnosis: US (3 cm+); CT, angiography gold standard
Treatment: no treatment if < 3cm, annual US if 3-4.4cm, US q 6 months if 4.5-5cm
*** >5.5cm needs surgical repair
3
Q
Aortic Stenosis
A
Presentation: exertional syncope, dyspnea, angina
Diagnosis: harsh systolic ejection crescendo-decrescendo at right upper sternal border with radiation to carotids
**best heard by leaning forward with expiration and squatting (split S2)
ECHO GOLD STANDARD
Labs: EKG (may show LVH), CXR showing cardiomegaly, calcified valve
**ELEVATED BNP
Treatment: valve replacement
4
Q
Dilated Cardiomyopathy
A
Weakened myocardium (alcoholism, hypertension, viral infections) –> dilation of all four chambers
Presentation: exertional dyspnea, edema, fatigue, loss of appetite, cough (systolic heart failure)
Diagnosis: ECHO (dilation and poor EF); EKG, CXR showing cardiomegaly and pulmonary congestion, S3 gallop
Treatment: beta blocker + ACE + lasix (just like HF)
5
Q
DVT
A
Presentation: edema, erythema, calf pain
Diagnosis: US, + Homan’s sign, dimer for low risk patients, venography gold standard
Treatment: IV heparin –> warfarin or other anticoag
6
Q
Hypercholesterolemia
A
Presentation: xanthomas, xanthelasma, corneal arcus, tissue ischemia
Diagnosis: lipid panel,
Treatment: 4 groups
- patients with any form of ASCVD
- patients with LDL > 190
- patients with T2DM and LDL 70-189
- patients with a 10 year ASCVD risk > 7.5%
7
Q
Hypertension
A
Normal: < 120/80 Elevated: 120-129/80 Stage I: 130-139/80-89 Stage II: 140+/90+ Hypertensive Crisis: 180/120
Treatment
- lifestyle changes (weight loss, DASH diet, sodium reduction, exercise, reduce etoh), reassess in 3-6 months
- ACE or ARB
- HCTZ
- beta blockers
- CCB
- spironolactone for refractory
8
Q
Venous Insufficiency
A
Risk Factors: prolonged standing, obesity, smoking, trauma, prior DVT, pregnancy
Presentation: lower extremity discomfort, edema, stasis dermatitis, ulcers
Diagnosis: US (rule out DVT)
Treatment: compression, wound care, leg elevation
9
Q
ACS
A
Presentation: retrosternal pain/pressure not relieved by rest or nitro, diaphoresis, nausea/vomiting, dizziness, jaw/arm pain
Diagnosis: EKG (ST elevations/depressions, t wave changes, q waves)
- STEMI: ST segment elevation with reciprocal depressions
- NSTEMI: ST depressions +/- t wave inversions
Labs: TROPONIN
Treatment:
- STEMI: heparin, cath lab for revascularization (best within 90 min), aspirin 325 mg chewed, beta blocker, ACE, nitro (MONA)
- NSTEMI: heparin, beta blockers, nitro
10
Q
Pericarditis
A
- Most commonly caused by a virus (enterovirus, coxsackie, echovirus)
Presentation: sharp pleuritic chest pain that is worse when laying supine, relieved by leaning forward
- Can radiate to back, shoulders, arms
- Fever usually present
Diagnosis: pericardial friction rub best heard at end expiration when leaning forward
- EKG: diffuse ST elevations in precordial leads with associated PR depressions
- Echo used to assess for effusion or tamponade
Labs: cardiac enzymes, inflammatory markers
Treatment: aspirin or NSAIDs for 7-14 days (ibuprofen 1200 mg QD)
11
Q
Stable Angina
A
- Caused by fixed plaque causing supply/demand mismatch during exertion
Presentation: substernal exertional chest pain that can radiate to arm, teeth, jaw), back, shoulders (lasting < 30 min) that is relieved by rest or nitro
- Associated symptoms: dyspnea, nausea, diaphoresis, numbness, fatigue
Diagnosis: EKG, stress testing, angiography gold standard
- EKG: ST depressions classic finding +/- t wave inversions and poor r wave progression; resting EKG often normal
Labs: cardiac enzymes, BNP, CBC, BMP
Treatment: stenting or CABG (left main coronary artery disease or 3 vessel disease) for definitive treatment
- Daily aspirin, beta blocker, and statin + nitro PRN
12
Q
Atrial Fibrillation
A
Presentation: majority of afib cases are asymptomatic; palpitations, fatigue, poor exercise tolerance, pre-syncope/syncope
Diagnosis
- EKG: irregularly irregular rhythm with no p waves, rate can be normal or fast
Labs: CBC, BMP, cardiac enzymes, inflammatory markers, TSH
Treatment
- Rate Control: beta blocker or calcium channel blocker; digoxin can be used in patients with hypotension or CHF
- Rhythm Control: synchronized cardioversion (anticoag + TEE), amiodarone, radiofrequency ablation for definitive treatment
- Anticoagulation need based on CHADS-VASC (Xarelto 20 mg QD)
13
Q
Heart Failure
A
- Most commonly caused by CAD
- Increased afterload, preload, or decreased contractility
Presentation
- Left Sided: increased pulmonary venous pressure from fluid backing up into the lungs causing dyspnea, orthopnea, cough, wheezing
- Right Sided: increase in systemic venous pressure leading to signs of fluid retention –> peripheral edema, JVD, and GI/hepatic congestion
Diagnosis: ECHO, chest x-ray, BNP
- S3 in systolic heart failure, S4 in diastolic heart failure
Treatment: ACE + Lasix + beta blocker +/- spironolactone
- Digoxin can be used in severe acute CHF
14
Q
Giant Cell Arteritis
A
- Vasculitis of the extracranial branches of the carotid artery
- Strong association with PMR
Presentation: new headache (usually temporal), jaw claudication, scalp tenderness, fever, acute vision disturbances, fatigue
Diagnosis: clinical diagnosis but can confirm with biopsy
Labs: inflammatory markers elevated
Treatment: high dose steroids (60 mg QD x 6 weeks, then taper) started immediately to prevent blindness
15
Q
Peripheral Artery Disease
A
Atherosclerotic disease of the lower extremities
Presentation: intermittent claudication, decreased or absent pulses, decreased cap refill, thin/shiny skin with hair loss, thickened nails, may have ulcers on malleoli
Diagnosis: ankle-brachial index < 0.9, arteriography gold standard (shows length/location of lesion)
Treatment: cilostazol mainstay of therapy (could also do aspirin, clopidogrel, or pentoxifylline)
- Angioplasty, fem-pop bypass, or endarterectomy for definitive treatment
- Supportive: foot care, exercise (fixed distance walking)
16
Q
Acne
A
Mild: topical retinoids, benzoyl peroxide, topical antibiotics (clindamycin), OCPs
Moderate: add oral antibiotics (doxycycline, minocycline) +/- spironolactone
Severe: isotretnoins
- highly teratogenic, must monitor triglycerides and LFTs
- S/E: dryness, psych issues, arthralgias
17
Q
Coxsackie
A
HAND FOOT AND MOUTH DISEASE
Presentation: small, tender, erythematous papules or vesicles on pharynx, mouth, hands, and feet
- Associated fever, sore throat, irritability, and lack of appetite
Treatment: supportive, usually clears within 10 days
18
Q
Impetigo
A
Presentation: non-painful, pruritic vesicles, pustules –> honey colored crust (most commonly staph or strep)
Treatment: topical mupirocin x10 days or keflex 50 mg/kg x10 days
19
Q
Molluscum
A
Highly contagious viral infection (poxviridae family)
Presentation: single or multiple dome shaped, flesh colored, waxy papules with central umbilication
Treatment: none, spontaneous resolution in 3-6 months
20
Q
Actinic Keratosis
A
PROLONGED SUN EXPOSURE
- Premalignant condition to SCC
Presentation: dry, rough, scaly “sandpaper” skin lesion or erythematous, hyperkeratotic plaque (horn)
Diagnosis: biopsy
Treatment: observation, cryotherapy, Effudex, Imiquimod
21
Q
Alopecia
A
Non-scarring immune mediated hair loss targeting the hair follicles
Presentation: smooth, discrete circular patches of complete hair loss that develops over a period of weeks
- Exclamation point hairs: short, broken hairs with tapering near the proximal hair shaft
- Nail abnormalities
Treatment: intralesional or topical corticosteroids
22
Q
Contact Dermatitis
A
Irritants, chemicals, detergents, cleansers, acids, metals
Presentation: burning, itching, and erythema to the affected area
- Dry skin, eczematous eruption
Treatment: avoid irritants, topical corticosteroids
23
Q
Eczema
A
Atopic association –> eczema, allergic rhinitis, asthma
VERY ITCHY
Presentation: erythematous, ill-defined blisters/papules/plaques –> dries and crusts over/scaly
- Most common in flexor creases
Treatment: topical corticosteroids, antihistamines for itching + daily heavy moisturizing
24
Q
Melanoma
A
Presentation: asymmetry, irregular borders, color variation, diameter > 6mm, evolution
- Thickness most important prognostic factor for METs
Diagnosis: full thickness excisional biopsy + lymph node biopsy
Treatment: surgical excision +/- adjuvent immune or radiation therapy
25
Onychomycosis
Presentation: opaque, thickened, discolored nails with subungual hyperkeratinization
Treatment: itraconazole and terbinafine topically
- If topicals fail, can do oral course of terbinafine (monitor LFTs)
26
Psoriasis
Presentation: raised, dark purple/red plaques or papules with thick silver/white scales that are usually pruritic (most common on bilateral extensor surfaces)
- May have nail pitting, discoloration
Treatment: high potency topical steroids, topical retinoids
- Severe: phototherapy, methotrexate 10 mg weekly, cyclosporine, Humira 40mg weekly
27
Allergic Drug Eruption
Presentation: generalized distribution of bright red macules/papules that coalesce to form plaques
- Typically begins 2-14 days after medication initiation
Treatment: most reactions are self-limited if the drug is discontinued, can use oral antihistamines for itch relief
28
Cellulitis
Acute, spreading superficial infection of dermal and subcutaneous tissue (most common staph aureus, strep)
Presentation: macular erythema (not sharply demarcated), swelling, warmth, and tenderness
- Rarely may have fever, chills, lymphadenopathy, lymphangitis, myalgias, ect
Treatment: Keflex x 10 days
- Bactrim if worried about MRSA
- Augmentin for bites
29
Tinea Corporis
Presentation: erythematous plaques, scaling, cracking, and vesicles (circular rash with clear center and defined borders)
Diagnosis: KOH smear
Treatment: topical antifungal (econazole 1% cream)
30
Varicella Zoster
VZV reactivation along one dermatome (virus lays dormant for years in the spinal root and cranial nerve ganglia)
Presentation: painful vesicular/maculopapular rash along one dermatome, burning electrical pain in same area prior to rash
Diagnosis: mostly clinical but can be confirmed with Tzanck smear showing giant multinucleated cells
Treatment: Valtrex 1g x 7 days started within 72 hours to prevent postherpetic neuralgia
* Shingles vaccine recommended for all immunocompetent adults over age 50
* If it involves the nose --> urgent ophthalmology evaluation
31
Conjunctivitis
Bacterial, viral, or allergic
Presentation: discharge, lid crusting, usually no visual changes, red eye
Treatment: topical erythromycin x7 days)
- Must cover pseudomonas if contact lens wearer (moxifloxacin x7 days)
32
Dacryocystitis
Infection of the lacrimal sac, most commonly staph aureus
Presentation: tearing, tenderness, edema, and redness to the medial canthal of lower lid (may be purulent)
Treatment: probing first line treatment in children > 1 yr
- Antibiotics if infected (clindamycin 10 mg/kg x7 days)
33
Otitis Externa
SWIMMERS EAR
Presentation: ear pain, pruritus, auricular discharge, pain on traction of the tragus
Treatment: Cortisporin drops x 7 days
- Protect the ear against moisture (no swimming) for 7 days
34
Otitis Media
- Commonly preceded by viral URIs
- Strep pneumo, H. flu, M. cat
Presentation: fever, otalgia, tugging on ear, hearing loss
Diagnosis: bulging TM, loss of landmarks, decreased TM mobility
Treatment: Amoxicillin 80-90 mg/kg x10 days
- Augmentin 80-90 mg/kg second choice
- Can do Bactrim or clindamycin if allergic
35
Benign Positional Vertigo
Caused by displaced otoliths
Presentation: sudden, episodic peripheral vertigo provoked with changes in head positioning (usually lasts 10-60 seconds)
Diagnosis: patient placed in supine position with head 30 degrees lower than body, head quickly turned 90 degrees to one side --> delayed fatiguable horizontal nystagmus (Dix-Hallpike Maneuver)
Treatment: Epley Maneuever
36
Corneal Ulcer
Most commonly caused by bacteria
Presentation: pain, photophobia, reduced vision, tearing, conjunctival erythema
Diagnosis: defect seen on slit lamp exam --> hazy cornea
Treatment: Moxifloxacin eye drops
37
Hordeolum
Local abscess of eyelid margin (most commonly staph aureus)
Presentation: painful, warm, swollen red lump on eyelid
Treatment: warm compresses +/- erythromycin ointment if actively draining
- Can I&D if no spontaneous drainage after 48 hours
38
Macular Degeneration
- Most common cause of legal blindness and visual loss in the elderly
- Dry vs. Wet
DRY: gradual breakdown of the macula --> gradual blurring of central vision
- Drusen spots (small, round, yellow-white spots on outer retina)
WET: new abnormal vessels grow under the central retina, which leak/bleed --> retinal scarring (more aggressive)
- Diagnosed by fluorescein angiography
Presentation: bilateral blurred or loss of central vision with scotomas, metamorphopsia, and/or micropsia
Diagnosis: fundoscopy
Treatment
- Dry: Amsler grid at home to monitor stability
- Wet: intravitreal anti-angiogenics, laser photocoagulation
39
Peritonsilar Abscess
Most commonly caused by GABHS, staph aureus
Presentation: dysphagia, pharyngitis, hot potato voice, difficulty handling oral secretions, trismus, uvula deviation
Diagnosis: CT scan first line
Treatment: I&D + antibiotics (Clindamycin 300 mg TID or Unasyn 3 g QID)
40
Retinal Detachment
Retinal tear --> retinal inner sensory layer detaches from choroid plexus
- Predisposing factors are myopia and cataracts
Presentation: photopsia (flashing lights), floaters, progressive unilateral vision loss --> loss of central visual field (curtain coming down)
Diagnosis: fundoscopy --> visual actual retinal tear (flapping tissue), Shafer's sign (tobacco dust)
Treatment: urgent evaluation by ophthalmology (ophtho emergency) --> laser, cryotherapy, ocular surgery
* Differential includes amaurosis fugax
- Temporary "curtain" that lifts up usually within one hour
41
Sinusitis
- Acute = 1-4 weeks
- Most commonly caused by strep pneumo, H. flu, GABHS
- Often follows viral URI or dental infection
Presentation: sinus pain/pressure worse with bending down and leaning forward
- Headache, malaise, purulent sputum or nasal discharge, fever, nasal congestion
Diagnosis: mostly clinical --> opacification with transillumination (symptoms must be present for 1 week)
Treatment: symptomatic therapy indicated if symptoms < 7 days
- If symptoms present for 10-14 days, give Augmentin 500 mg BID x10 days or doxycycline or Bactrim
42
Blowout Fracture
Orbital floor fracture --> may lead to trapping of eye structures
Presentation: decreased visual acuity, diplopia (especially with upward gaze), orbital emphyhsema (eyelid swelling)
- May have anesthesia to the anteromedial cheek due to stretching of the infraorbital nerve
Diagnosis: CT SCAN (teardrop sign)
Treatment: nasal decongestants, Clindamycin, corticosteroids to reduce edema
- Severe cases may need surgical repair
43
Cataract
- Lens opacification (usually bilateral)
- Risk factors: aging, cigarette smoking, corticosteroid use
Presentation: blurred/loss of vision over years
Diagnosis: absent red reflex, opaque lens on exam
Treatment: surgery
44
Glaucoma
- Increased intraocular pressure
- Acute open angle: decreased drainage of aqueous humor via trabecular meshwork in patients with preexisting narrow angle or large lens (ophthalmologic emergency)
Presentation: severe, sudden onset of unilateral ocular pain, nausea/vomiting, headache
- Visual disturbances: halo around light, peripheral vision loss (tunnel vision)
- Conjunctival erythema, steamy cornea, mid-dilated, fixed, nonreactive pupil, cupping of optic nerve on fundoscopy
Diagnosis: increased intraocular pressure by tonometry (>21 mm Hg) --> eye may feel hard
Treatment: Acetazolamide to lower IOP, Pilocarpine to open the angle
- Peripheral iridotomy definite treatment
Narrow angle - bilateral peripheral vision loss that occurs over years
- Treatment: Latanoprost first line, timolol, brimonidine
- Laser therapy if medical therapy fails
45
Meniere Disease
Hearing and balance disorder characterized by episodic vertigo, tinnitus, ear fullness, and fluctuating hearing loss
Presentation: episodic vertigo lasting 1-8 hours with horizontal nystagmus, nausea/vomiting
Diagnosis: transtympanic electrocochleography during active episode, audiometry shows loss of low tones
Treatment: meclizine, diazepam, scopolamine
- Preventative: hydrochlorothiazide, avoidance of salt/caffeine/chocolate/alcohol
46
Orbital Cellulitis
Usually secondary to sinus infections (staph aureus, strep pneumo, GABHS, H. flu)
Presentation: decreased vision, pain with ocular movement, proptosis, eyelid erythema and edema
Diagnosis: CT SCAN
Treatment: IV antibiotics (ceftriaxone infusion 1 g daily or clindamycin)
47
Vertigo
Peripheral Causes - horizontal nystagmus
- BPPV (most common)
- Meniere
- Vestibular neuritis (continuous vertigo without hearing loss)
- Labyrinthitis (continuous vertigo with hearing loss)
Central Causes - vertigal nystagmus
- cerebellopontine tumors, migraine, MS
Treatment - meclizine, metoclopramide, scopolamine, lorazepam
48
Type 1 Diabetes
Pancreatic beta cell destruction --> patient can no longer produce insulin at all
Presentation: polyuria, polydipsia, polyphagia, weight loss
Diagnosis
- Fasting plasma on 2 separate occasions of > 126
- A1C > 6.5%
- Random plasma > 200 in a symptomatic patient
Treatment: all type 1s need insulin
- .5 units/kg/day (half basal, half bolus)
- basal: insulin glargine
- bolus: insulin lispro
49
Adrenal Insufficiency
DECREASED CORTISOL
- Primary: problem with the adrenal gland
- Secondary: insufficient pituitary ACTH production
ADDISON'S DISEASE
- destruction of the adrenal cortex resulting in loss of cortisol production
- Presentation: hyperpigmentation, hypotension, fatigue, myalgias, GI complaints, weight loss
- Labs: BMP (low sodium, high potassium), low morning cortisol, elevated ACTH, low DHEA
- Diagnosis: high dose cosyntropin stimulation test --> little or no increase in cortisol levels after IM ACTH is given (< 20 mcg/dl)
- Treatment: daily hydrocortisone
Adrenal Crisis: emergent IV saline, glucose, steroids
50
Type 2 Diabetes
Diagnostic Criteria
- random glucose > 200
- fasting glucose > 126 twice
- A1C > 6.5%
Metformin - decreases hepatic glucose production and peripheral glucose utilization (can cause lactic acidosis and diarrhea)
- C/I if CrCl < 30)
- Add in other non-insulin agents if not controlled on metformin
- If still uncontrolle,d --> insulin
Annual eye exams, ACEI if microalbuminuria, annual foot exam
51
Hypothyroidism
- Thyroid gland does not produce enough thyroid hormone
- Most common is Hashimoto's thyroiditis (autoimmune)
Presentation: fatigue, weight gain, cold intolerance, constipation, heavy periods, delayed DTRs, bradycardia
Diagnosis: elevated TSH and low T4
- Hashimoto's confirmed by presence of TPO antibodies
Treatment: Levothyroxine (125 mcg)
52
Cushing's Syndrome
- Symptoms from increased cortisol secretion
- Increased cortisol, hypokalemia, hypertension
Presentation: central obesity, moon face, thin skin, hypertension, hirsutism, proximal muscle weakness, purple striae, acne, easy bruisability
Diagnosis: 24 hour urine cortisol test, low dose dexamethasone suppression test (failure to suppress cortisol levels = positive test)
Labs
- HYPOKALEMIA
- HIGH CORTISOL
- Decreased ACTH = adrenal tumor
- Normal/increased ACTH = ectopic ACTH producing tumor
Treatment - take out tumor, ketoconazole given in inoperable patients
- begin gradual steroid withdrawal to prevent Addisonian crisis
53
Hyperthyroidism
Presentation: weight loss, anxiety, tachycardida, proptosis, moist skin, palpitations, heat intolerance
- hyperreflexia, goiter, PVCs
Diagnosis: low TSH and high free T3/T4
- Radioactive iodine uptake to determine etiology
- Graves: anti-thyrotropin antibodies present
Treatment: methimazole 10 mg QD or PTU, radioactive iodine, or thyroidectomy
- Atenolol 25 mg for cardiac symptoms
54
Celiac Disease
Inflammation of the small bowel secondary to the ingestion of gluten-containing foods (autoimmune)
Presentation: diarrhea, steatorrhea, flatulence, weight loss, weakness, abdominal distention
- Infants/children may present with failure to thrive
Diagnosis: IgA antiendomysial and antitissue transglutaminase antibodies
- Confirm with endoscopic intestinal mucosal biopsy of the duodenal bulb and distal duodenum
Treatment: gluten free diet (may need iron, B12, folic acid, calcium, vitamin D supplementation)
55
Constipation
Causes - opioid use, DM, hypothyroidism, MS, dehydration
Presentation: straining, hard stool, sensation of incomplete evacuation, digital maneuvers, < 3 BMs per week
Diagnosis: rectal exam to assess for masses, anal fissures, hemorrhoids, sphincter tone
- Patients older than 50 with new onset constipation should be evaluated for colon cancer
Labs: CBC, CMP, TSH
Treatment: increase fiber, exercise, and water intake
- Metamucil, Miralax, Senna PRN, Colace
56
Pyloric Stenosis
Presentation: 3-4 week old infant with nonbilious projectile vomiting after feedings
Diagnosis: US or upper GI series (STRING SIGN)
- Palpable epigastric olive-shaped mass in right upper quadrant
Labs: hypokalemia, metabolic alkalosis
Treatment: pyloromyotomy
57
Intussusception
Generally occurs following a viral infection
Presentation: sudden onset of colicky abdominal pain that recurs every 15-20 minutes, often with vomiting (knees to stomach)
- CURRANT JELLY STOOL
Diagnosis: US (target sign), barium or air enema may be both diagnostic and therapeautic
- SAUSAGE SHAPED MASS IN RIGHT UPPER QUADRANT
Treatment: air or barium enema tried first, surgery required if enema fails
58
Cholecystitis
Acute: RUQ/epigastric pain that is continuous in duration +/- nausea (may be precipitated by fatty food)
- fever, enlarged palpable gallbladder (Murphy's sign), may have shoulder pain
Diagnosis: US showing thickened gallbladder wall, distended gallbladder, sludge, gallstones, pericholecystic fluid, sonographic Murphy's sign
- Can also do CT
Labs: leukocytosis, elevated bilirubin, elevated alk phos, elevated LFTs
Treatment: cholecystectomy with ceftriaxone + metronidazole IV
Chronic: strawberry gallbladder --> porcelain gallbladder (pre-malignant condition)
- May result from repeated bouts of acute/subacute cholecystitis
59
Pancreatitis
Most commonly caused by gallstones or etoh
Presentation: constant epigastric pain that radiates to the back, worsened with eating, walking, and laying supine (relieved by leaning forward)
- Nausea/vomiting, fever, tachycardia, ecchymosis
Labs: elevated lipase/amylase, elevated ALT, hypocalcemia
Diagnosis: abdominal CT test of choice, US abdomen to rule out gallstones
Treatment: NPO, IV fluids (up to 10 L/day), pain control
Chronic: continual inflammation causing parenchymal destruction, fibrosis, and calcification resulting in loss of exocrine and sometimes endocrine function
- Triad: calcifications, steatorrhea, and diabetes
Diagnosis: calcified pancreas as seen on x-ray (amylase/lipase usually normal)
Treatment: oral pancreatic enzyme replacement, etoh abstinence, pain control
60
Appendicitis
Presentation: anorexia and periumbilical pain --> RLQ pain, nausea/vomiting
- Peritoneal signs: Rovsing, obturator, psoas, McBurney point tenderness
Diagnosis: CT scan, US
Labs: leukocytosis
Treatment: appendectomy (consult surgery)
61
Cirrhosis
- Irreversible liver fibrosis with nodular regeneration secondary to chronic liver disease, can cause portal hypertension and increases risk of HCC
- Etoh most common cause, but also HCV, nonalcoholic fatty liver disease, hemochromatosis, drug toxicity
Presentation: fatigue, weakness, weight loss, muscle cramps, anorexia, ascites, hepatosplenomegaly, gynecomastia, spider angiomas, caput medusa, pruritus
- Hepatic encephalopathy: confusion, lethargy, asterixis, fetor hepaticus (elevated ammonia levels)
- Spontaneous bacterial peritonitis
Diagnosis: US determines liver size and evaluates for HCC, liver biopsy
Treatment:
- Encephalopathy: lactulose +/- rifaximin
- Ascites: Lasix + spironolactone, sodium restriction, paracentesis
- Pruritus: cholestyramine
Liver transplant for definitive treatment
62
Diverticulitis
Inflamed diverticula secondary to obstruction/infection --> distention
Presentation: fever, LLQ pain, nausea/vomiting, diarrhea, constipation, flatulence, bloating
Diagnosis: CT SCAN
Labs: leukocytosis, + guaiac
Treatment: clear liquid diet and antibiotics (Cipro 750 mg BID + Metronidazole 500 mg QID)
63
GERD
Transient relaxtion of LES --> gastric acid reflux --> esophageal mucosal injury
Presentation: heartburn (often post prandial) that is worse when laying down, regurgitation, dysphagia, cough at night, hoarseness
Diagnosis: mostly clinical, but often get endoscopy if persistent symptoms (gold standard 24 hour pH testing)
Treatment: try antacids and OTC H2 receptor antagonists (Pepcid) first, then move on to PPI (omeprazole 20 mg QD)
- Lifestyle: elevate head of bed, avoid laying down after eating, avoid spicy food and caffeine, weight loss, ect
- Nissen fundoplication if refractory to all medical treatment
64
Ulcerative Colitis
LIMITED TO THE COLON (CONTIGUOUS SPREAD)
Presentation: colicky abdominal pain (LLQ most common), tenesmus/urgency, BLOODY DIARRHEA, hematochezia
Diagnosis: colonoscopy showing uniform inflammation +/- ulceration in rectum or colon
- Flex sigmoidoscopy in acute disease
Labs: + P-ANCA, inflammatory markers
Treatment: mesalamine, steroids for acute flares, methotrexate, Humira
- Surgery can cure
65
Crohn's Disease
ANY SEGMENT OF THE GI TRACT
Presentation: crampy abdominal pain (most commonly RLQ), weight loss, diarrhea with no blood usually, perianal disease
Diagnosis: colonoscopy showing skip lesions, cobblestone appearance
- Upper GI follow through in acute disease
Labs: + ASCA, inflammatory markers
Treatment: mesalamine, steroids for acute flares, methotrexate, Humira
66
Colon Cancer
Progression of adenamatous polyp into adenocarcinoma
Presentation: iron deficiency anemia, rectal bleeding, abdominal pain, change in bowel habits, ascites,
- Can cause large bowel obstruction
Diagnosis: colonoscopy with biopsy, barium enema showing apple core lesion
Labs: CBC, elevated CEA levels
Treatment: surgical resection if stage I-III, chemotherapy if stage IV
Screening every 10 years for everyone 50+ at average risk
- 1st degree relative start at 40
67
Hemorrhoids
- Engorgement of venous plexus
- Risk factors: chronic constipation, pregnancy, obesity, prolonged sitting, cirrhosis/portal hypertension
Internal: intermittent rectal bleeding (BRBPR), rectal itching and fullness, mucus discharge
External: perianal pain aggravated by defecation, tender palpable mass
Diagnosis: visual inspection, digital rectal exam, fecal occult blood testing
- Colonoscopy in patients with hematochezia to rule out proximal sigmoid disease
Treatment: sitz baths, topical corticosteroids
- If fail conservative management --> rubber band ligation, sclerotherapy
- Hemorrhoidectomy for all stage IV
68
Peptic Ulcer Disease
- MOST COMMONLY CAUSED BY H. PYLORI INFECTION
- NSAIDS also common cause
- Most common cause of GI bleeds
Presentation: dyspepsia, burning epigastric pain usually worse at night, nausea/vomiting
Diagnosis: ENDOSCOPY with biopsy to rule out malignancy if ulcer present, upper GI series
- H. pylori breath test
Treatment: PPI, H2 blocker, antacids, sucralfate
- H. pylori positive: Clarithromycin + Amoxicillin + PPI
69
Bowel Obstruction
Most commonly caused by adhesions
Presentation: cramping abdominal pain (progressive), abdominal distention, vomiting, obstipation/diarrhea
- Hyperactive bowel sounds in early obstruction, hypoactive in late obstruction
Diagnosis: KUB showing air fluid levels and dilated loops of bowel
Treatment: NPO, IV fluids, NG tube decompression
- If conservative management fails or strangulated --> surgery
70
Testicular Torsion
Spermatic cord twists and cuts off testicular blood supply
Presenation: abrupt onset of scrotal, inguinal, or lower abdominal pain +/- nausea/vomiting
- Swollen, tender, high-riding testicle (may look horizontal)
- Negative Prehn's sign
- ABSENT CREMASTERIC REFLEX
Diagnosis: US
Treatment: surgical detorsion and orchiopexy within 6 hrs
71
Vesicoureteral Reflux
Urine flows backwards from the bladder back up through ureters to kidneys
Presentation: recurrent cystitis/pyelonephritis
Diagnosis: voiding cystourethrography
Treatment: mild-moderate disease usually resolves spontaneously, but severe disease may need surgery
- Prophylactic antibiotics may be given (half dose --> nitrofurantoin 1 mg/kg nightly)
72
BPH
Prostate hyperplasia --> bladder outlet obstruction
Presentation: frequency, urgency, nocturia, hesistancy, weak stream, incomplete emptying
Diagnosis: uniformly enlarged, firm, rubbery prostate on digital rectal exam
Labs: elevated PSA > 4
Treatment: Finasteride 5 mg QD for longterm treatment, Flomax 0.4 mg QD for rapid relief of symptoms
- TURP procedure removes excess prostate tissue, relieving the obstruction
73
Testicular Cancer
- Very good prognosis (curable)
- Risk factors: cryptorchidism
Presentation: painless testicular nodule, solid mass, or enlargement unable to be separated from the testicle
- May have dull pain or testicular heaviness
Diagnosis: scrotal US
Labs: alpha-fetoprotein and b-hCG (elevated in nonseminomatous), LDH
Treatment
- Low grade nonseminoma: orchiectomy with retroperitoneal lymph node dissection
- Low grade seminoma: ochiectomy --> radiation
- High grade seminoma: chemo --> ochiectomy --> radiation
74
Urethritis
Presentation: urethral discharge or pruritus, dysuria
- Gonococcal: abrupt onset of symptoms, opaque yellow thick dishcarge
- Nongonococcal: purulent or mucopurulent discharge, pruritus, hematuria, pain with intercourse (MC chlamydia)
Diagnosis: blood test or swab --> nucleic acid amplification
Treatment: treat for both chlamydia and gonorrhea
- Gonococcal: ceftriaxone 250 mg IM x 1 dose
- Nongonococcal: azithromycin 1 g PO x 1 dose
75
Incontinence
- Stress: urine leakage due to increased intra-abdominal pressure (sneezing, coughing, laughing)
- Urge: urine leakage accompanied/preceded by urge, usually with frequency, small volume voids, and nocturia
- Overflow: urinary retention (incomplete bladder emptying --> dribbling)
Treatment
- Pelvic floor exercises
- Stress: midodrine (alpha agonist)
- Urge: anticholinergics (oxybutynin 5 mg BID) first line, then TCAs, Botox, mirabegron (bladder relaxant)
- Retention: intermittent or indwelling catheterization first line, then Bethanacol (cholinergic)
76
Prostate Cancer
Presentation: often asymptomatic until invasion of bladder, urethral obstruction, or bone involvement
- Urethral obstruction: urinary frequency, urgency, urinary retention, decreased stream
- Mets to bone --> back/bone pain, weight loss
Diagnosis: hard, nodular asymmetrical prostate on DRE
- US with needle biopsy if PSA is elevated
Labs: PSA elevated > 4
Treatment
- Local disease: observation if low grade --> radical prostatectomy
- Advanced disease: radiation, chemo, orchiectomy and GnRH agonists for androgen deprivation
77
Pyelonephritis
Presentation: fever, tachycardia, back/flank pain, nausea/vomiting, dysuria, frequency, urgency, hematuria
- CVA TENDERNESS
Diagnosis: UA showing pyuria, + leukesterase/nitrites --> urine culture for definitive diagnosis
- WBC CASTS
Treatment: Cipro 500 mg BID x 7 days and increased fluid intake
78
UTI
Presentation: dysuria, frequency, urgency, hematuria, suprapubic discomfort
Diagnosis: UA showing pyuria, + leukesterase/nitrites --> urine culture for definitive diagnosis
Treatment: nitrofurantoin 100 mg BID x 7 days (can use during pregnancy as well)
- Increase fluid intake, void after intercourse
Complicated UTI: underlying condition with risk of therapeutic failure
- Symptoms > 7 days, pregnancy, diabetics, immunosuppression, indwelling catheter, elderly
79
Sickle Cell Disease
- Autosomal recessive genetic disorder
- RBC sickling --> micro thrombosis
- Sickled cells destroyed by spleen --> hemolytic anemia
Presentation
- Earliest sign is dactylitis
- Infections (osteomyelitis), jaundice, gallstones
- Microthrombosis: H-shaped vertebrae, necrosis of bone, splenic infarction, skin ulcers
-Painful occlusive crises triggered by cold weather, hypoxia, infection, dehydration, etoh, pregnancy (acute chest, back, abdominal, bone pain)
Diagnosis: CBC with peripheral smear (low hemoglobin/hematocrit, elevated reticulocytes, target cells, sickled cells, HOWELL-JOLLY BODIES), hemoglobin electrophoresis (HgbS, no HgbA)
Treatment
- Pain control: IV fluids and oxygen for acute pain crisis
- Hydroxyurea decreases frequency of occlusive crises
- Folic acid
- RBC transfusion for severe sickle cell crisis
- Stem cell transplant only curative treatment
80
AML
Most common acute form of leukemia in adults (most patients > 50 years old)
Presentation: pancytopenia, splenomegaly, gingival hyperplasia, bone pain
- Leukostasis (WBC > 100,000): headaches, confusion, TIA, CVA, respiratory distress, dyspnea
Diagnosis: bone marrow biopsy showing AUER RODS and > 20% blasts
Treatment: combination chemotherapy, bone marrow transplant after remission
81
CML
PHILADELPHIA CHROMOSOME
Presentation: most asymptomatic until they develop a blastic crisis (>30% blasts), splenomegaly
Diagnosis: FISH --> Philadelphia Chromosome, very high WBC counts (100,000), elevated LDH
Treatment: chemotherapy (Imatinib), stem cell transplant
82
Hemochromatosis
Excess iron deposition in parenchymal cells of the heart, liver, pancreas, and endocrine organs
Presentation: may be asymptomatic in early stage
- Liver dysfunction: abdominal pain, cirrhosis, fatigue, weakness, hepatosplenomegaly, arthralgias
- Heart failure: cardiomyopathy, arrhythmias, heart block
- Hypogonadism: testicular atrophy, impotence
- Pancreatic insufficiency: beta cell damage --> diabetes (bronze skin)
Diagnosis: serum iron > 200, serum transferrin > 70%, increased ferritin, elevated LFTs
- Liver biopsy gold standard: increased liver parenchyma hemosiderin (iron storage)
Treatment: weekly phlebotomy until depletion of iron, then maintenance with 3-4x a year for life
83
Multiple Myeloma
Cancer associated with proliferation of a single close of plasma cells --> increased monoclonal antibodies (interrupt bone marrow's normal cell production)
Presentation
- Bone pain: most common in spine and ribs due to osteolytic lesions and fractures, spinal cord compression
- Recurrent infections from leukopenia
- HYPERCALCEMIA
- Anemia: fatigue, pallor, weakness, weight loss, hepatosplenomegaly, soft tissue masses
- Kidney failure: antibody light chain protein deposition in the kidney
Diagnosis
- Serum protein electrophoresis: M PROTEIN SPIKE
- Urine protein electrophoresis: BENCE-JONES PROTEINS
- CBC: ROULEAUX FORMATION (RBCs stick together)
- Elevated ESR
- Bone marrow biopsy showing plasmacytosis >10%
- Imaging: punched out lytic lesions on skull radiograph
Treatment: chemo, stem cell transplant definitive treatment
- Bisphosphonates for bony destruction
84
Lyme Disease
Presentation
- Early localized: erythema migrans (red rash with central clearance) usually within a month of tick bite, expands over days to weeks +/- headaches, fever, malaise, LAD
- Early disseminated: 1-12 weeks --> arthritis, headache, weakness, facial nerve palsy, AV block, pericarditis, multiple erythema migrans lesions
- Late disease: persistent synovitis, neurological symptoms, subacute encephalitis
Diagnosis: clinical early on, then serologic testing (ELISA followed by western blot if positive)
Treatment: Doxycycline 100 mg BID x21 days
- Amoxicillin in children/pregnancy
Can do one prophylactic dose of doxycycline 200 mg within 72 hours of tick removal if tick is present for >36 hrs
85
Pinworms
Enterobius vermicularis --> transmitted fecal-orally
Presentation: perianal itching especially at night
Diagnosis: scotch tape test in the morning to look for eggs under microscope
Treatment: Albendazole 200-400 mg x1 dose, repeat in 2 weeks (no treatment in children < 2 years old)
86
Roseola
SIXTH DISEASE
Presentation: prodrome of high fever for 3-5 days --> fever resolves --> onset of rose/pink maculopapular, blanchable rash on the trunk/back that later spreads to face
Treatment: supportive
- Anti-inflammatories, anti-pyretics
87
HIV
Presentation
- Acute seroconversion: flu-like illness (fever, malaise, rash)
- AIDS: CD4 count < 200 or the development of an AIDS defining illness
Diagnosis: ELISA antibody testing confirmed by western blot, rapid testing (blood or saliva), viral load
Treatment: Biktarvy, Genvoya
OPPORTUNISTIC INFECTIONS
- TB, Kaposi sarcoma, thrush, pneumocystitis, histoplasmosis, toxoplasmosis, CMV retinitis
88
Herpes Simplex
Presentation: prodromal symptoms 24 hours prior (burning, paresthesias, tingling) --> painful, grouped vesicles on an erythematous base
- HSV 1 usually oral (Herpes Labialis)
- HSV 2 usually genital
Diagnosis: clinical diagnosis, confirmed by PCR or Tzanck smear showing multinucleated giant cells
Management: Valacyclovir 1 g BID x10 days
89
Sepsis
Infective organisms activate the immune system --> host produces systemic inflammatory response --> vasodilation --> decreased SVR
Presentation: hypotension with wide pulse pressure, bounding arterial pulses, warm/flushed extremities
- Fever > 100.4
- Pulse > 90
- Respiratory rate > 20
- WBC > 12000
Labs: CBC, CMP, lactate > 4
Treatment
- Broad spectrum IV antibiotics (Zosyn + ceftriaxone)
- IV fluid resuscitation with NS or LR
- Vasopressors if no response to 2-3 L of IV fluids (goal MAP > 60) +/- IV hydrocortisone
90
TB
- Inhalation of airborne droplets --> mycobacterium reaches the alveoli and are ingested by alveolar macrophages
- Primary, latent (+ PPD with no evidence of active infection on imaging; not contagious), or secondary (reactivation) infection
Presentation: chronic productive cough, chest pain (pleuritic), hemoptysis, night sweats, fever/chills, fatigue, weight loss, anorexia
- Extrapulmonary symptoms: TB meningitis, pericarditis, peritonitis, joints, kidney, adrenal, or cutaneous
Diagnosis: acid-fast smear and sputum culture, interferon gamma release assay (blood test not affected by prior BCG vaccine)
Imaging: CXR
- Reactivation: upper lobe fibrocavitary disease
- Primary TB: middle/lower lobe consolidation
- Miliary TB: small millet-seed like nodular lesions
- TB pleurisy: pleural effusion caused by TB infection
- Granuloma: residual evidence of healed primary TB
Treatment
- Active: Rifampin + INH + Pyrazinamide + Ethambutol (RIPE) x 6 months (no longer infectious after 2 weeks of therapy)
Latent: INH + Pyridoxine x 9 months
PPD FOR TB SCREENING
91
Influenza
Presentation: usually abrupt onset of a wide range of symptoms --> headache, fever, chills, malaise, URI symptoms, pharyngitis, pneumonia, MYALGIAS
Diagnosis: rapid flu test (flu swab)
Treatment: supportive mainstay of treatment
- Tamiflu (antiviral) best if initiated within 48 hours of symptom onset
92
MRSA
Common in hospitals, prisons, nursing homes, diabetics, and IVDA (weakened immune systems
```
Presentation: pustules on an erythematous base (boils/pimples)
Diagnosis: culture
Treatment: I&D + antibiotics
- Bactrim DS for outpatient treatment
- Vanco for inpatient
```
93
Concussion
Mild traumatic brain injury --> alteration in mental status with or without loss of consciousness
Presentation: confusion, amnesia, headache, dizziness, visual disturbances, emotional instability, vomiting
Diagnosis: CT scan (normal), MRI if symptoms > 2 weeks
Treatment: cognitive and physical rest
94
Carpal Tunnel
Median nerve entrapment/compression at the carpal tunnel
Presentation: paresthesias and pain of palmar digits 1-3 especially at night, may radiate to the neck, shoulder, chest
- Thenar muscle wasting if advanced
Diagnosis: Tinel and Phalen sign
- EMG
Treatment: volar splint + NSAIDs, steroid injections, surgery
95
Complex Regional Pain
Autonomic dysfunction following bone or soft tissue injury (most commonly affects upper extremity)
Presentation
- Stage I: pain out of proportion to injury, swelling, extremity color changes, increased nail/hair growth
- Stage II: waxy/pale skin, brittle nails, loss of hair
- Stage III: joint atrophy and contractures
Treatment: NSAIDs, PT, corticosteroids, TCAs, gabapentin
96
Epilepsy
Focal Seizures: simple (no impaired consciousness) or complex (impaired consciousness --> automatisms and postictal state)
- Treat with phenytoin or carbamazepine
Generalized Seizures: absence, tonic-clonic, atonic, clonic, tonic, myoclonic
Diagnosis: BMP, glucose, EKG, EEG
- Adults with first seizures need a CT/MRI
Treatment: phenytoin, valproate, lamotrigine 200 mg QD
97
Migraine
Presentation: lateralized, pulsatile/throbbing headache +/-aura associated with nausea/vomiting, photophobia, and phonophobia that can last from 4-72 hours
- Worse with physical activity, stress, lack of sleep, etoh
Diagnosis: clinical (imaging only indicated if red flag symptoms are present --> age 50+, worst/changing headache, prolonged or bizarre aura, unremitting)
Treatment: NSAIDS/acetaminophen first line for mild symptoms, then sumatriptan and metoclopramide + Benadryl (abortive)
- Good sleep hygiene, regular exercise, healthy diet
-Prophylactic: propranolol, topiramate, valproate, amitriptyline
98
Meningitis
Presentation: fever/chills, headache, nuchal rigidity, photosensitivity, nausea/vomiting, AMS, seizures
- Kernig/Brudzinski sign
Diagnosis: LP showing elevated neutrophils, decreased glucose, elevated protein, and increased opening pressure
Treatment: Ceftriaxone 1 g IV + vanco 1 g IV daily
99
Subarachnoid Hemorrhage
Presentation: sudden onset "worst headache of my life", brief LOC, nausea/vomiting, meningeal irritation, photophobia
- No focal neurologic symptoms
Diagnosis: non-contrast CT, can do LP if CT is negative but still suspicious to look for xanthrochromia
Treatment: rest, surgical repair of bleeding aneurysm if present, anticonvulsants for seizure prophylaxis
100
Cluster Headache
Predominantly young-middle aged males
Presentation: severe unilateral periorbital/temporal sharp pain lasting < 2 hours with spontaneous remission
- Bouts occur several times a day over 6-8 weeks (clusters)
- Triggers: worse at night, etoh, stress, certain foods
Diagnosis: ipsilateral Horner's syndrome (ptosis, miosis, anhydrosis), nasal congestion, rhinorrhea, lacrimation
Treatment: 100% O2 first line (6-10L), sumatriptan during acute attack
- Prophylaxis: verapamil, corticosteroids, valproate, lithium
101
Parkinson Disease
Idiopathic dopamine depletion --> failure to inhibit acetylcholine in the basal ganglia
Presentation: resting tremor (pill rolling) that is worse with stress, better with voluntary activity and intentional movement (can be confined to one limb in early disease)
- Bradykinesia, shuffling gait, rigidity (cogwheel), fixed facial expression, postural instability
Diagnosis: clinical
Treatment: Sinemet most effective treatment, but should be reserved for age > 65
- Bromocriptine (dopamine agonist), Benztropine (anticholinergic), Amantadine, Selegiline, ect
102
Stroke
Risk factors: hypertension, hypercholesterolemia, diabetes, afib, carotid artery disease, and cigarette smoking
Presentation: symptoms contralateral to the side of stroke --> slurred speech, facial asymmetry, ataxia, confusion, ect
- Anterior: aphasia, hemiparesis, visual field defects
- Posterior: coma, drop attacks, vertigo, nausea/vomiting
Diagnosis: non-con head CT
- ASK TO RAISE EYEBROWS (strokes only involve lower half of face)
Treatment: if ischemic, treat with IV tPA within 3 hours of symptom onset (be mindful of exclusion criteria --> SAH, prior stroke or MI within 3 months, GI ulcer, recent surgery, patient taking anticoagulant, hx of intracranial hemorrhage)
- If after 3 hours --> ASA 325 mg QD, clopidogrel
- Serial neuro exams
- Maintain blood pressure < 185/105
- If cardiogenic emboli, anticoagulate (Xarelto 20 mg QD)
103
TIA
- Transient episode of neurologic deficits caused by focal brain, spinal cord, or retinal ischemia without acute infarction, most commonly due to embolus or transient hypotension (most resolve in 30-60 minutes)
- PUTS PATIENT AT HIGH RISK OF CVA IN NEAR FUTURE
Presentation
- Internal carotid: amaurosis fugax (lampshade down over one eye), weakness in contralateral hand, sudden headache, speech changes, confusion
- Vertebrobasilar: gait and propioception problems, dizziness, vertigo (cerebellar symptoms)
Diagnosis: CT head, carotid doppler if carotid artery stenosis, CT angiography to look for occlusion, echo/ekg
Labs: blood glucose, electrolytes, coagulation studies
Treatment: ASA + Plavix (NO THROMBOLYTICS)
- Place in supine position to increase cerebral perfusion
- Control diabetes, blood pressure, and afib (warfarin)
104
Breast Cancer
Most common type infiltrating ductal carcinoma
Presentation: lump in breast that is firm, fixed, non-tender usually
- May have nipple discharge, retraction, inversion
- Late findings: pain, edema of arm, dimpling of skin (peau d'orange)
Diagnosis: breast exam, mammography, ultrasound, BIOPSY
Treatment: lumpectomy, radiation, chemo, mastectomy (refer to onc)
- Tamoxifen if estrogen receptor positive
DDX
- Fibrocystic disease
- Fibroadenoma
- Abscess
SCREENING: every 2 years from age 50-75, starting at 40 if risk is increased
105
Ectopic Pregnancy
Presentation: severe lower abdominal pain, amenorrhea, vaginal bleeding
- Hypotension, tachycardia, free fluid in pelvis, adnexal mass
Diagnosis: serial HCG TESTS, transvaginal US
- Ring of fire sign seen on doppler
Treatment
- Unruptured/Stable: medical management with one dose of IM methotrexate
- Ruptured: laparoscopic salpingostomy
DDX
- Spontaneous abortion
- Acute PID
- Acute appendicitis
106
Endometriosis
Presentation: dyspareunia, difficulty defecating (dyschezia), and dysmenorrhea
- May have history of infertility
- Pain worse with menstruation (starts 1-2 before period)
Physical exam: uterosacral nodularity, may have a retroverted uterus
Diagnosis: laparascopy, confirmed by biopsy
Treatment: OCPs first line, NSAIDs, Danazol, Leuprolide
- Severe or refractory disease may require laparoscopic tissue removal or hysterectomy
107
Fibroids
- AKA leiomyoma
- Benign smooth muscle cell tumors
Presentation: polymenorrhera, menorrhagia, intermenstrual bleeding, metororrhagia, uterine mass, pelvic pain/pressure, dyspareunia, constipation, urinary frequency
Diagnosis: US
- Can be detected on bimanual exam --> enlarged, mobile, irregular uterus
Treatment: NSAIDs, OCPs, levonorgetrel IUD
- Myomectomy definitive treatment for moderate sized fibroids in young women who wish to remain fertile
- Hysterectomy common
108
Gestational Diabetes
- Glucose tolerance test between 24 and 28 weeks gestation (positive if blood glucose > 130 in 1 hour)
- If positive --> 3 hour glucose tolerance test
Treatment: dietary modification and insulin
Most common complication = macrosomia
109
Gestational Hypertension
Preeclampsia: hypertension (BP > 140/90 on two occasions) + proteinuria +/- edema after 20 weeks
- Presentation: headache, visual symptoms, fetal growth restriction, HELLP syndrome
- Management: delivery if >37 weeks, bedrest < 34 weeks and steroids to mature lungs --> elective delivery
- Severe: prompt delivery, magnesium sulfate to prevent seizures, hydralazine or labetalol to lower blood pressure
Ecclampsia: addition of seizures or coma
- Management: ABCDs, magnesium sulfate for seizures, delivery of fetus once patient is stabilized, hydralazine or labetalol to lower blood pressure
If patient with chronic hypertension needs medication while pregnant --> methyldopa treatment of choice, then labetalol (NO ACEI OR DIURETICS)
110
Ovarian Cyst
Presentation: most are asymptomatic until they rupture, undergo torsion, or become hemorrhagic --> unilateral lower abdominal pain, menstrual changes, dyspareunia
Diagnosis: pelvic US, bimanual exam to feel for adnexal masses
Treatment: most cysts < 8 cm spontaneously resolve (monitor with serial ultrasounds), OCPs may prevent recurrences
- Persistent cysts laparascopic cystectomy
111
Vaginitis
BV: vaginal odor worse after sex +/- pruritus, thin grey-white discharge with fishy smell
- Diagnosis: CLUE CELLS on wet mount
- Treatment: metronidazole 750 mg QD x7 days
Candida: vaginal/vulvar erythema, swelling, burning (especially when peeing), pruritus, dyspareunia, thick curd-like discharge
- Diagnosis: HYPHAE seen on KOH prep
- Treatment: Fluconazole 150 mg x1 dose
Trichomoniasis: sexually transmitted --> vulvar pruritus, erythema, dysuria, dyspareunia, frothy yellow-green discharge, strawberry cervix
- MOBILE PROTOZOA on wet mount
Treatment: Metronidazole 500 mg BID x7 days (MUST TREAT PARTNER)
112
Buckle Fracture
AKA Torus Fracture
- Incomplete fracture with wrinkling or bump on the metaphyseal-diaphyseal junction
- Usually after a FOOSH
- Treatment: splint (dorsal more common), refer to ortho
113
Osgood Schlatter
Repetitive traction on patellar tendon where it inserts on tibial tuberosity
Presentation: tenderness over the tibial tubercle after a rapid growth spurt and/or sports that involve running
- Pain with resisted knee extension with lump below the knee and prominent tibial tuberosity
Diagnosis: lateral x-ray showing irregularity and fragmentation of tibial tubercle
Treatment: self-limiting --> rest, analgesics, ice, PT
114
SCFE
Slipped Capital Femoral Epiphysis - disorder common in adolescents in which the head of the femur slips off the neck of the femur, often due to mechanical overload (obesity)
Presentation: pain int the groin, hip, thigh, or ipsilateral knee without inciting trauma
- Antalgic gait with externally rotated leg (painful limp)
Diagnosis: AP and frog-leg lateral of hips
Treatment: surgical fixation with screws
115
Scoliosis
- Lateral spinal curvature
- COBB ANGLE > 10
Presentation: asymmetric scapula height when bending forward (Adam's test), usually asymptomatic
Diagnosis: PA and lateral x-rays of spine
- Cobb angle > 10
Treatment: based on the degree of curvature
- Curves 15-20 degrees: serial x-rays every 4-6 months
- Curves > 20 degrees: refer to ortho
- Curves 20-40 degrees: bracing, PT
- Curves > 40: surgery
116
Gout
- Accumulation of uric acid in soft tissues of joints & bone
- Risk factors: etoh, red meat, thiazide diuretics, men
Presentation: joint erythema, swelling, stiffness
- Tophi deposition: collection of solid uric acid in soft tissue (helix of ear, eyelids, and achilles tendon)
- Uric acid nephrolithiasis
Diagnosis: arthrocentesis and evaluation of joint fluid
- Negatively birefringent needle shaped crystals
- Rat bite erosions of bone on x-ray
Labs: increased uric acid, elevated ESR and WBC during acute attacks
Treatment: NSAIDs first line, then colchicine or steroids
- Allopurinol for chronic management (reduces uric acid production)
117
Osteosarcoma
Presentation: progressively worsening bone pain at night and joint swelling (most commonly distal femur and proximal tibia)
Diagnosis: sun burst or "hair on end" appearance on x-ray
- Need to get bone scan and chest CT to look for metastasis
Treatment: limb-sparing resection or radical amputation
118
Septic Arthritis
Presentation: single, swollen, warm, painful joint that is tender to palpation + fever, sweats, myalgias, and malaise (most commonly knee or hip)
Diagnosis: arthrocentesis
- WBC > 50,000 (WBC > 1100 is positive in patients with prosthetic joint) + organisms present
Treatment: arthrotomy with joint drainage + antibiotics
- Staph aureus: vanc/nafcillin
- Gonococcal: ceftriaxone
- IVDA: Cipro (cover for pseudomonas)
119
Adhesive Capsulitis
AKA FROZEN SHOULDER (due to inflammation)
Presentation: shoulder pain/stiffness lasting 18-24 months, decreased ROM (especially external rotation),
- Stiff-pain cycle
- Pain usually worse at night
Diagnosis: resistance on passive ROM only on the affected side
Treatment: PT, heat, anti-inflammatories, steroid injections
120
Ankylosing Spondylitis
INFLAMMATORY CONDITION
Presentation: chronic low back pain with decreased ROM and morning stiffness
- Pain decreases with exercise
- Associated with uveitis, psoriasis, IBD, aortic regurg
Diagnosis: BAMBOO SPINE on x-ray (squaring of vertebra)
- Elevated ESR/CRP
- HLA-B27 positive
Treatment: NSAIDs and PT
121
Hip Fracture
- Femoral head/neck fractures: high incidence of avascular necrosis, high incidence of DVT and PE
Presentation: hip pain with leg shortened, externally rotated, abducted
Diagnosis: x-ray (AP, lateral)
Treatment: refer to ortho for surgery (ORIF)
- May observe if high surgical risk, minimal pain, or non-ambulatory
122
Knee Joint Arthritis
- Articular cartilage damage and degeneration
- Narrowed joint space, sclerosis and osteophyte formation
Presentation: evening joint stiffness, pain decreases with rest and increases throughout the day and with changes in weather
- Decreased ROM, crepitus
- Hard, bony joint with no inflammatory signs
Diagnosis: x-ray showing joint space loss +/- osteophytes -- - AP, lateral, and sunrise view
Treatment: Tylenol preferred in the elderly, but NSAIDs more effective
- Refer to ortho for corticosteroid injections, ect
- Knee replacement definitive treatment
123
Polymyalgia Rheumatica
- Idiopathic inflammatory condition causing synovitis and bursitis --> pain/stiffness of the proximal joints
- Highly associated with giant cell arteritis
Presentation: bilateral proximal joint aching/stiffness worse in the morning
Labs: ESR/CRP elevated, CBC may show anemia +/- elevated platelets (acute phase reactant)
Treatment: low dose prednisone (10-20 mg/day) for 1-2 years, NSAIDs
124
Reactive Arthritis
Autoimmune response to an infection in another part of the body, most commonly caused by chlamydia/gonorrhea
Presentation: arthritis (especially lower extremities, swollen toes/fingers), conjunctivitis, and urethritis
Diagnosis: joint aspiration showing high WBCs but bacterial culture negative
Labs: + HLA-B27, CBC showing leukocytosis +/- normochromic anemia, elevated inflammatory markers, elevated IgG
Treatment: NSAIDS mainstay of therapy
- Second line: methotrexate, sulfasalazine, steroids, biologics
125
Spinal Stenosis
Narrowing of the spinal canal due to degenerative joint disease with impingement of the nerve roots, usually seen in patients >60 years old
Presentation: back pain with paresthesias in one or both extremities, pain may radiate to the thighs
- Worsened with extension and prolonged standing/walking
- Relieved with flexion (increases canal volume), sitting, walking uphill
Diagnosis: MRI
- Neuro exam including reflexes and sensation, straight leg raise test (usually negative)
Treatment: NSAIDs, PT, weight loss
- Steroid injections, surgery (laminectomy or fusion)
126
Anorexia Nervosa
- Refusal to maintain a minimally normal body weight by fueling a relentless desire for thinness with a morbid fear of fatness or gaining weight
- Restrictive type: reduced calorie intake, dieting, fasting, excessive exercise, diet pills
- Purging type: primarily engages in self-induced vomiting, diuretic/laxative abuse
Diagnosis: BMI < 17.5 or BW < 85% ideal body weight
- Emaciation, hypotension, bradycardia, skin/hair changes (lanugo), dry skin, amenorrhea, arrhythmias, osteoporosis
Labs: leukocytosis/leukopenia, anemia, hypokalemia, high BUN due to dehydration, hypothyroidism
Treatment: hospitalization for < 75% IBW or medical complications (electrolyte imbalances --> cardiac stuff)
- Psychotherapy: CBT, supervised meals, weight monitoring
- SSRIs, atypical antipsychotics may help gain weight
127
Bulimia Nervosa
Major difference from anorexia is patients have NORMAL WEIGHT or are overweight
Presentation
- Binge eating: recurrent episodes characterized by eating within a 2 hour period more than usual (lack of control), occurring at least weekly for 3 months
- Compensatory behavior: purging or restrictive
Diagnosis: teeth pitting or enamel erosion from vomiting, calluses on the dorsum of hand hand from induced vomiting (Russell's sign), parotid gland hypertrophy
Labs: hypokalemia, hypomagnesemia, metabolic alkalosis
- Electrolyte imbalances may lead to cardiac arrhythmias
Treatment: CBT
- Fluoxetine may reduce the binge-purge cycle
128
Pediatric Fever
COMMONLY CAUSED BY UTI
- Toxic appearing: CBC, blood cultures, UA/culture, LP, chest x-ray --> antbiotics
- Nontoxic appearing and < 30 days: same as toxic
- 30-90 days: just CBC, blood cultures, and UA/culture
- 3 months and up: CBC and UA/culture if high risk, optional if low risk
Treatment
- 30 days and less: ceftriaxone and ampicillin
- 30-90 days: ceftriaxone 50 mg/kg
- 3 months and up: 50 mg/kg (add vanco if needed)
129
Bipolar Disorder
Bipolar 1: >1 manic or mixed episode which often cycles with occasional depressive episodes
Bipolar 2: >1 hypomanic + >1 major depressive episode (NO MANIA)
- Hypomania: symptoms similar to mania (period of elevated, expansive, or irritable mood) but DOES NOT CAUSE MARKED IMPAIRMENT
Treatment: mood stabilizers
- Lithium first line, valproic acid, carbamazepine
- Haldol or benzos may be added for psychosis or agitation
- Be cautious with SSRIs --> may precipitate mania
- Therapy: CBT, good sleep hygiene
130
Borderline Personality Disorder
- Unstoppable, unpredictable mood and affect
- Unstable self image and relationships
Presentation
- Extreme pattern of instability in relationships but cannot tolerate "being alone", often have mood swings and fear of abandonment
- Black and white thinking --> all good or all bad
- Impulsivity in self-damaging behaviors --> suicide threats, self mutilation, substance abuse, reckless driving/spending
Treatment: psychotherapy mainstay of treatment
- May need short term doses of antipsychotics, antidepressants, or benzos
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PTSD
Presentation: >1 of the following intrusion symptoms after the event that may lead to significant distress/impairment
- Reexperiencing: >1 month as repetitive recollections (dreams, flashbacks, ect) leading to psychological distress
- Avoidance of stimuli associated with the event
- Negative alterations in cognition and mood --> inability to remember an important aspect of the event, horror, guilt, anger, shame (may included disinterest in activities)
- Arousal and reactivity: angry outbursts, irritable behavior, reckless or self-destructive behavior, hypervigilance, ect
Treatment: SSRIs first line treatment (Sertraline 100 mg), trazodone may be helpful for insomnia
- CBT
