Uworld Questions Flashcards
When is puberty considered delayed?
If there are no secondary sexual characteristics (testicle enlargement >4ml or breast development) in boys by 14 or in girls by 12
Treatment of uncomplicated cystitis in nonpregnant women
Fosfomycin single dose
Or
Tmp-smx (Bactrim) for 3 days (avoid if local resistance is >20%)
Or
Nitrofurantoin for 5 days (avoid if cr clearance is <60)
Treatment of complicated cystitis in nonpregnant women
Fluoroquinolones (ciprofloxacin or levofloxacin) for 5-14 days
Or
Ampicillin/gentamicin (for more severe cases)
Treatment of pyelonephritis in nonpregnant women
Outpatient management with fluoroquinolones (ciprofloxacin or levofloxacin)
Or
Inpatient with fluoroquinolones or aminoglycosides (with or without ampicillin)
What antibiotics can be used to treat a UTI in a pregnant women?
amoxicillin-clavulanate, cefalexin, or fosfomycin
Note: Do NOT give tetracyclines (e.g. doxycycline), fluoroquinolones (ciprofloxacin or levofloxacin), nitrofurantoin, or trimethoprim-sulfamethoxazole as these are teratogenic
Note: Nitrofurantoin can be used only in the second and early third trimesters
What is the most common complication of TURP (transurethral resection of the prostate)
Retrograde ejaculation
IgA nephropathy vs. Acute poststreptococcal glomerulonephritis
Both diseases often present with hematuria following a URI, however IgA nephropathy is more often associated with gross hematuria and flank pain. It may also progress to more severe renal disease, though there is no definitive therapy ACE inhibitors can be tried
Note: HTN and 24-hour urine with >1g protein are likely to progress rapidly
Diagnosis of vitamin d deficiency
Serum OH(25)-vitamin D level <20 ng/mL
Note: Pt has insufficiency if only <25 ng/mL
Treatment for vitamin D deficiency
50,000 units cholecalciferol (vit D3) once per week for 8 weeks, then 2,000 units daily for maintenance (or 5000 units daily for maintenance if absorption is thought to be decreased as in pts with gastric bypass)
Indications for starting a statin
Primary prevention if:
- LDL 190 or more
- Age 40 or more with diabetes mellitus
- 10 year ASCVD risk of 7.5% or more
Secondary prevention if:
- h/o Acute coronary syndrome
- h/o Stable angina
- h/o Revascularization (PCI or CABG)
- h/o Stroke, TIA, or PAD
When should you start someone on medium-intensity statin vs high intensity statin?
- age > 75
- ASCVD risk score < 20
What are the high intensity statins?
Atorvastatin 40-80mg
Rosouvastatin 20-40mg
Anti-TPO antibody positive
Associated with Hashimoto thyroiditis
Note: Anti-thyroid peroxidase antibodies lead to hypothyroidism
What is Subclinical hypothyroidism, and should you treat it?
Elevated TSH with a normal free T4 (with or without symptoms)
Note: Subclinical hypothyroidism is still treated if:
- TSH 10 or greater
- TSH 7 or greater AND age <70
- Pt is symptomatic (Note: If symptoms are nonspecific, then anti-TPO levels can’t be measured to see if treatment may be beneficial)
Common causes of hypercalcemia
PTH-dependent (high or high-normal PTH levels)
- primary or tertiary hyperparathyroidism
- familial hypocalciuric hypercalcemia
- lithium use
PTH-independent (low PTH levels)
- malignancy
- vit D toxicity
- granulomatous disease
- drug-induced (e.g. thiazide diuretics)
- milk-alkalai syndrome
- thyrotoxicosis
- vit A toxicity
- immobilization
Treatment of hypercalcemia of immobilization
If a pt will be immobilized for an extended period of time, as in quadriplegic accidents, bisphophonates can be used to prevent bone resorption
Treatment of diabetic neuropathy
-control of blood glucose levels
If pts sleep is affected by symptoms:
- duloxetine, pregabalin, or tricyclics (first line)
- gabapentim, lamotrigine, carbamazepine (second line)
- topical lidocaine or capsaicin (may be helpful)
Treatment for Graves’ disease
Symptom management with beta blockers and methimazole (or PTU if PT is pregnant in first trimester of pregnancy)
Definitive management with radioactive iodine ablation or thyroidectomy
How should treatment with methimazole or PTU be monitored?
Total T3 and free T4 levels
Note: TSH is not a good way to monitor anti-thyroid medications because it remains suppressed long after initiation of treatment
What should be monitored during the first few days of treatment for vitamin b12 deficiency?
Potassium levels
Note: monitor K levels for the first 48 hours of treatment for moderate-severe megaloblastic anemia because the newly produced red blood cells use up a lot of serum potassium
Elevated TSH, elevated T3 and T4, elevated alpha subunit…
Likely TSH-secreting pituitary adenoma
Note: This is treated with somatostatin analogues and transsphenoidal surgery
Central obesity, weight gain, plethoric face, violaceous striae, proximal limb weakness…
Cushing syndrome due to excess cortisol
How do you work up likely Cushings syndrome?
Rule out exogenous cushings by asking about glucocorticoid exposure
Confirm endogenous cushings by collecting late-night salivary cortisol, 24-hour urinary free cortisol excretion, and/or 1mg dexamethasone suppression test to differentiate (2/3 need to be unequivocally abnormal to confirm)
Identify etiology by measuring serum ACTH: if low ACTH, get CT of adrenal glands; if high ACTH, get pituitary MRI; if indeterminate ACTH, perform corticotropin-releasing hormone testing
What are likely outcomes of untreated primary hyperparathyroidism?
Osteoporosis, nephrolithiasis, and chronic kidney disease
Note: Labs will show elevated calcium and elevated parathyroid hormone in these cases
Low TSH, high free T4 in a pregnant woman at 10-weeks gestation…
Physiologic response to the thyroid-stimulating actions of beta-hcg
2-week old female with ambiguous genitalia, hyponatremia, hyperkalemia, and hypoglycemia…
Congenital adrenal hyperplasia (likely 21-hydroxylase deficiency)
Note: treat with hydrocortisone and fludrocortisone
What will aldosterone deficiency cause?
Hyponatremia and hyperkalemia
How can you confirm the diagnosis of 21-hydroxylase deficiency?
Measure levels of 17-hydroxyprogesterone (which builds up because there’s no 21-hydroxylase to convert it to cortisol)
Note: 21-hydroxylase also helps convert progesterone to aldosterone so progesterone and testosterone levels will be high and aldosterone and cortisol levels will be low
Should met for in be stopped prior to cardiac catheterization?
Met form in should be stopped on the day of any procedure that requires a large dose of IV contrast (including caths) and restarted two days later
Note: This is due to the concern for potentially fatal lactic acidosis
How should insulin be adjusted in a type 1 diabetic who anticipates running a race?
Doses of short-acting insulin that are due 1-3 hours prior to exercise should be reduced to decrease risk of hypoglycemia
Note: if exercise is expected to be prolonged (>60 minutes), then the previous nights basal insulin dose should also be reduced (if the exercise will occur before breakfast, just the basal dose should be lowered)
Which anti thyroid drug is best?
Methimazole, except during the first trimester when propylthiouracil/PTU should be used
Note: PTU is avoided when possible due to hepatotoxicity
What should the target be for anti thyroid medications during pregnancy?
To achieve a state of mild hyperthyroidism, as defined by trimester-specific ranges for TSH and T4
Note: Mild hyperthyroidism is targeted because overtreatment can lead to fetal hypothyroidism and goiter
Decreased T3, normal T4, and normal TSH in a pt with lobar PNA…
Euthyroid sick syndrome, due to decreased conversion of T4 to T3
Note: this does not require treatment unless thyroid dysfunction persists after pts acute illness has resolved
How does Amioka tone affect thyroid function?
Amiodarone has 3 effects on thyroid function, all of which can be managed without stopping Amiodarone:
Amiodarone decreases the peripheral conversion of T4 to T3 (elevated T4, reduced T3), which doesn’t have clinical effects and doesn’t need to be treated
Amiodarone has a high iodine content (this can produce primary hypothyroidism (elevated TSH, reduces T4) which can be managed with levothyroxine
Amiodarone can also produce amiodarone induced thyrotoxicosis by directly increasing thyroid hormone synthesis (AIT type 1, treated with anti thyroid drugs) or destructive thyroiditis (AIT type 2, treated with glucocorticoids)
How long does Amiodarone stay in the body after discontinuation?
Very, very long (half life of 100 days)
By what age should women have their first period?
Age 15
15-year-old girl with primary amenorrhea, normal breast development, and no axillary or pubic hair…
Likely androgen-insensitivity syndrome
Note: PT is genetically male but excess androgens are aromatized to estrogen and produce breast development
Diagnosis of DKA
Hyperglycemia, metabolic acidosis, and positive serum ketones
Initial treatment for DKA
Aggressive IV fluids with normal saline and continuous insulin infusion with Q1H fingersticks (potassium should be added to the fluids if serum K levels are <5.2 because the insulin will push K into cells)
Note: bicarbonate can also be added if serum pH is 6.9 or lower and serum phosphate and calcium levels should also be monitored
When can you deescalate insulin infusion in DKA?
You can switch from continuous IV to intermittent subQ insulin (as long as the pt is eating) when the glucose is <200 AND two of the following are present:
Anion gap <12
Bicarbonate 15 or greater
Venous pH >7.3
Note: insulin infusion should be continued for 1-2 hours after subQ insulin is given
When should D5 be added to normal saline when treating DKA?
When serum glucose is less than 200
When is puberty considered delayed in boys?
If no testicular enlargement by age 14
Initial work up for delayed puberty in boys
Bone age radiographs, FSH, LH, testosterone, TSH, and prolactin
Screening for diabetes in pregnant women
Screening for everyone at 24-28 weeks gestation with a 50g glucose challenge test and then a 100g glucose tolerance test if the screen is positive
Note: Gestational diabetes mellitus can be treated with insulin, metformin, and/or glyburide (none appear to be teratogenic)
1-week-old infant with high TSH and low T4…
Congenital hypothyroidism, levothyroxine should be started immediately to prevent developmental delay
Note: T4 and TSH will be normal at birth because they cross the placenta
Common triggers for iodine-induced thyrotoxicosis
Radiocontrast agents, Amiodarone, topical antiseptics, and kelp-based dietary supplements
Note: thyrotoxicosis most often occurs in people who were iodine deficient and often with preexisting nodular thyroid disease; treat with beta blockers (and methimazole if persistent) until resolution
How should you titrations levothyroxine in pts who had radioiodine ablation for thyroid cancer?
Target TSH level of 0.1-0.5 to reduce risk of cancer recurrence
Note: if low risk for recurrence you can target low normal range for TSH after ~1 year, and if high risk for recurrence you should target TSH level <0.1
Nelson’s syndrome
Pituitary enlargement and hyperpigmentation following bilateral adrenalectomy for Cushings disease
Note: this is why transsphenoid surgery is preferred over adrenalectomy now
How should levothyroxine doses be adjusted during pregnancy?
As soon as the pregnancy is detected, levothyroxine dose should be increased by 30%. Then, after 4 weeks check the TSH and make adjustments every 4 weeks based on the TSH
Serum glucose target in hospitalized patients
140-180
Other than electrolytes, what should be monitored for when treating severe DKA?
Cerebral edema
Note: get CT head for any pt with persistent AMS, lethargy, headache, vomiting
A pt with hypothyroidism wants to start OCPs…
Her TSH should be checked after starting OCPs and levothyroxine dose should be increased accordingly
Note: Elevated estrogen levels in pts on OCPs cause increased thyroglobulin. Pts with normal thyroid function just produce more T4 to achieve the same free level, but pts with hypothyroidism need to increase their levothyroxine to keep up with the increased binding globulin
Which adrenal incidentalomas should be surgically removed?
- functional masses
- malignant massed
- masses > 4cm
- mass that’s increasing in size on repeat imaging
Note: All adrenal incidentalomas should be worked up with dexamethasone suppression, 24-hour urine catecholamines, metenephrine, vanillylmandelic acid, and 17-ketosteroid (to see if the incidentaloma is functional)
Diagnostic criteria for diabetes mellitus
- hba1c > 6.5%
- fasting blood glucose > 126
- blood glucose > 200 after oral glucose tolerance test
- random blood glucose > 200 (with symptoms of hyperglycemia)
Hypertension and hypokalemia…
Think hyperaldosteronism (measure plasma renin:aldosterone ratio)
Preferred treatment for prolactinoma
Capergaline (or other dopaminergic medications)
Do pts with insulin-dependent gestational diabetes require insulin postpartum?
No, they generally do not require any insulin starting after the placenta is delivered; however, they should be screened for diabetes a few months postpartum and every 3 years
PT with hashimotos who years later develops rapidly expanding thyroid gland with obstructive symptoms…
Think thyroid lymphoma
Which diabetes medications have the highest risk of hypoglycemia?
- insulin
- sulfonylureas (glyburide, glimipride, glipizide)
- meglitinides (nateglinide, rapaglinide)
Glipizide…
A sulfonylurea (along with glyburide and glimepride) in the insulin-secretagogues family of diabetes medications. It increases insulin secretion by inhibiting beta cell potassium channels.
Note: watch out for hypoglycemia and weight gain
Nateglidide…
A diabetes medication in the meglitinide subsection (along with repaglinide) of insulin-secreagogues that increases endogenous insulin secretion by inhibiting beta cell K channels
Note: Biggest side effects are hypoglycemia and weight gain
Metformin…
A biguanide diabetic medication that increases peripheral uptake of glucose, decreases hepatic glucose production, and inhibits mitochondrial
Gluconeogenesis
Note: Look out for diarrhea and lactic acidosis
Pioglitazone…
A thiazolidinedione diabetic medication that decreases insulin resistance by activating a transcription regulator (PPAR-gamma)
Note: can make heart failure worse and cause weight gain
Sitagliptin…
A DPP4 inhibitor diabetic medication that increases endogenous GLP-1 and GIP levels
Note: Can cause nasopharyngitis
Acarbose…
An alpha-glucosidase inhibitor (along with miglitol) that can be used to treat diabetes by decreasing intestinal disaccharide absorption
Note: often causes diarrhea and flatulence
Dapagliflozin…
An SGLT2 inhibitor that can treat diabetes by increasing excretion of glucose in the urine
Note: can cause urinary tract infections and hypotension
How do you workup hyperthyroidism?
TSH, free T3, and T4
If TSH and thyroid hormones are high, then get MRI of pituitary
If TSH is low, then check for signs of Graves’ disease and order tests (if no goiter or opthalmopathy, perform radioactive iodine uptake and if that’s low order serum thyroglobulin levels)
Low TSH, high free T3, high T4, low radioactive iodine uptake, low serum thyroglobulin levels…
Exogenous hormone administration (ask about supplements)
Low TSH, high free T3, high T4, low radioactive iodine uptake, high serum thyroglobulin levels…
Think thyroiditis or iodide exposure
High radioactive iodine uptake with nodular pattern…
Think toxic adenoma or multinodular goiter
Hyperthyroidism after a URI with very tender thyroid gland…
Subacute (de Quervain) thyroiditis caused by release of stored thyroid hormone. Treat symptomatically with NSAIDs and propranolol.
What is the target for treatment of hypoparathyroidism?
Increase meds to reach a goal calcium level 8.5-9
Note: This requires high dose vitamin D and calcium (some pts will also need a thiazide diuretic to reduce urinary excretion of calcium)
What medications can decrease levothyroxine absorption?
Calcium supplements, aluminum hydroxide, iron supplements, PPIs, bile acid-binding agents (e.g. cholestyramine)
Definition of hypoglycemia
Plasma glucose less than 60
Should hormone replacement therapy be used to treat menopause?
Estrogen/progesterone menopausal hormone therapy (or estrogen alone in pts who have had a hysterectomy) can be used for a short period (3-5 years) in younger, low-risk women (nonsmokers, no history of breast cancer, no history of venous thromboembolism, no coronary artery disease)
Note: there is a significant increased risk of stroke
Treatment for lithium-induced hypothyroidism
Levothyroxine
Note: lithium does not have to be discontinued if it has been effective for the PT
When should you treat subclinical hypothyroidism (high TSH, but normal free T4)?
- symptomatic hypothyroidism
- TSH>10
- positive anti thyroid antibodies
- abnormal lipid profile
- ovulatory/menstrual dysfunction
Should you pretreat a toxic thyroid module prior to definitive therapy?
Older pts and those with significant cardiovascular risk factors (diabetes, CAD, etc) should receive pretreatment with methimazole to achieve euthyroidism prior to radioiodine ablation
All pts getting thyroid surgery should be pretreated
When is surgery preferred over radioiodine ablation for toxic thyroid nodule?
- pts with very large goiters
- pts with obstructive symptoms (e.g. dysphagia)
- suspected thyroid cancer
- contraindications to radioiodine (e.g. breastfeeding)
How should a thyroid nodule be evaluated initially?
TSH level and thyroid ultrasound
How should you evaluate a thyroid nodule in a pt with risk factors for thyroid cancer?
Fine needle aspiration
How should you evaluate a thyroid nodule in a pt with no suspicious findings on ultrasound?
Fine needle aspiration (if normal or high TSH)
Iodine 123 scintigraphy (if low TSH)
Treatment of hot nodule on iodine 123 scintigraphy
Propranolol, methimazole, and/or ablation
Note: A cold or intermediate nodule that doesn’t show increased iodine uptake should be biopsies with an FNA
Hypocalcemia and hyperphosphatemia
Think decreased effectiveness of parathyroid hormone (either due to decreased levels of parathyroid hormone in hypopararhyroidism or pseudohypoparathyroidism due to increased resistance to parathyroid hormone, which would be elevated)
Note: hyperphophatemia itself can also acutely decrease calcium, but this rarely causes chronic hypocalcemia
Bilateral cataracts and basal ganglia calcifications in a young patient…
Think chronic hypocalcemia (as in pseudohypoparathyroidism)
How should you evaluate for suspected adrenal insufficiency?
Baseline ACTH levels and ACTH stimulation test
If there is a subnormal cortisol response it’s either primary adrenal insufficiency (high ACTH level) or central adrenal insufficiency (low ACTH level)
Note: Even if cortisol response to ACTH storm test is normal, if you have high clinical suspicion you should pursue with a metyrapone or insulin hypoglycemia test
What are the benefits of tight glycemic control in diabetics?
Reduction in micro vascular complications (nephropathy, retinopathy, etc)
Note: macro vascular complications (MI, CVA) have not been shows to be affected yet
What should the target A1c level be for most diabetics?
Less than or equal to 7%
Definition of precocious puberty
Onset of secondary sex characteristics in boys younger than 9 or girls younger than 8
Acne and pubic hair in a 7 yo boy with testes that are normal in size for his age…
Think peripheral precocious puberty (due to excess androgens from the gonads, adrenals, or an exogenous source)
Note: central precocious puberty is caused by early maturation of the hypothalamic-pituitary-gonadal axis and would present with normal progression of puberty (enlargement of testes first)
Why do some women that exercise frequently develop amenorrhea?
Frequent high-intensity exercise can lead to low estrogen levels, which can cause amenorrhea
Note: These women are at high risk for osteoporosis
Which diabetic medication often triggered acute decompensated heart failure?
Thiazolidinediones (e.g. pioglitazone)
Note: These increase sodium retention
Treatment of glyburide overdose
IV dextrose and Octreotide
Note: glyburide is a sulfonylurea, which increases insulin secretion. Dextrose infusions alone won’t be enough to treat hypoglycemia in these pts because the added dextrose will cause extra insulin secretion and rebound hypoglycemia so octeotide is needed to stop additional insulin from being secreted
What should you look out for in a pt on canagliflozin who is having a major surgery?
Euglycemic diabetic ketoacidosis (treated the same way as DKA, but with less insulin requirements)
Note: All SGLT2 inhibitors can cause euglycemic diabetic acidosis(where you have ketoacidosis with a blood glucose <250), especially during prolonged periods of fasting because the insulin to glucagon ratio is reduced in these patients
Treatment of primary ovarian insufficiency
Hormone replacement therapy with estrogen and progesterone (or estrogen alone if PT doesn’t not have a uterus and therefore not at risk for uterine cancer). Treatment should continue until average age of menopause (~age 50)
Note: POI is often caused by chemotherapy/radiation
Next step in management of a pt with a 1.9 cm thyroid nodule with normal TSH/T3/T4 and thyroid ultrasound with reassuring features…
Fine needle biopsy
Note: All nodules associated with normal or elevated TSH should be biopsied
MEN type 1
Primary hyperparathyroidism
Enteropancreatic tumors
Pituitary tumors
MEN type 2A
Medullary thyroid cancer
Pheochromocytoma
Parathyroid hyperplasia
MEN type 2B
Medullary thyroid cancer
Pheochromocytoma
Mucosal and intestinal neuromas
Mariano is habitus
Common clinical manifestations of prolactinomas
Oligo/amenorrhea Infertility Galactorrhea Hot flashes Osteoporosis Bitemporal hemianopsia Decreases libido Gynecomastia
Treatment for prolactinoma
Cabergoline (dopamine agonist)
Note: Trans-sphenoid all surgery may be needed if medications aren’t effective
Treatment for central precocious puberty
Gonadotropin releasing hormone agonist (to suppress LH and FSH levels)
When should you screen for osteoporosis?
Get DEX scan for women age 65 and older and any postmenopausal woman with risk factors for osteoporosis (low body weight, smoker, family history of hip fracture, glucocorticoids, etc.)
Note: Repeat DEX scan every 3-5 years in women with osteopenia
Indications to start bisphosphonates
- T score -2.5 or less on DEX scan
- T score -1 or less AND 10-year FRAX score of 20% or greater for major osteoporotic fracture OR 3% or greater for hip fracture
- low bone mass with history of fragility fracture
Long term sequelae of untreated hyperthyroidism
Arrhythmia, dilated cardiomyopathy, osteoporosis
When should you treat primary hyperparathyroidism with parathyroidectomy?
- age < 50
- PT has symptomatic hypercalcemia (bone pain, abdominal pain, psych symptoms)
- Pt has complications (osteoporosis, nephrolithiasis, kidney disease)
- increased risk of complications (moderate-severe hypercalcemia)
Positive anti thyroid peroxidase antibody
Chronic lymphocytic (hashimoto) thyroiditis
Note: These pts develop hypothyroidism and should be treated with levothyroxine
What are pts with impaired fasting blood glucose levels (100-126) at increased risk for?
Coronary artery disease (even if lipid panel is normal)
Enlarged liver, elevated alk phos, elevated ggt, normal transaminases, normal bilirubins, hypercalcemia
Think about infiltration liver diseases (such as hepatic sarcoidosis)
Diagnosis of acute pancreatitis
2/3 of the following:
- characteristic epigastric pain
- serum amylase or lipase > 3 times normal
- imaging findings consistent with pancreatitis
When should pts start eating again in acute pancreatitis
Pts should be NPO until their pain resolves
Note: nasojejunal feeds should be started if the PT is still not tolerating food after 3 days
Common causes of acute pancreatitis
Gallstones and alcohol use
Note: hypercalcemia and hypertriglyceridemia are less common causes
Cherry red lesions in the colon of a PT with iron deficiency anemia
Think angiodysplasia (vascular ectasias or AV malformations)
Note: most of the time these don’t bleed, but pts with bleeding diathesis (ESRD platelet dysfunction, von willebrand disease, aortic stenosis leading to von willebrand dysfunction, anticoagulation, etc)
Diagnostic evaluation for suspected chronic pancreatitis
MRCP (or CT abdomen)
Note: Amylase and lipase may not be elevated in chronic pancreatitis, so MRCP is a better diagnostic test
Treatment of chronic pancreatitis
- lifestyle modifications (small low-fat meals, avoiding alcohol and tobacco)
- fat-soluble vitamin supplementation (if steatorrhea indicating malabsorption is present)
- pancreatic enzyme supplementation (if fecal elastase-1 levels are low)
- pain control if persistent with:
- amitriptyline or other tricyclics
- NSAIDs
- pregabalin
- opioids (if refractory)
- celiac nerve blocks, Ducati decompression therapy, extracorporeal shock wave lithotripsy, and surgical resection
Common causes of gastroparesis
- Diabetes (due to autonomic neuropathy)
- medications (opioids, anticholinergics)
- Vagus nerve injury (e.g. surgery)
- Neurologic (multiple sclerosis, spinal cord injury, etc)
- idiopathic/postviral
Treatment for gastroparesis
- lifestyle modifications (small frequent meals with low fat and no insoluble fiber)
- promotility drugs (erythromycin, metoclopramide)
- gastric electrical stimulation or jujunal feeding (for refractory cases)
Workup for delayed gastric emptying
- Upper GI endoscopy or barium swallow (to r/o mechanical obstruction)
- Abdominal CT (if extrinsic compression from mass/vessel is suspected)
- nuclear gastric emptying study (to assess for motility disorders)
Diagnostic criteria for acute cholangitis
- signs of infection (fever, leukocytosis, elevated CRP)
- Labs suggesting biliary obstruction (jaundice, elevated bilirubin, abnormal liver chemistries)
- biliary dilation or evidence of etiology of obstruction on imaging
Note: Pts with acute cholangitis require urgent ERCP to drain the infected bile
Clinical manifestations of GERD
- Regurgitation of acidic material in mouth
- heartburn (postprandial, retrosternal burning sensation)
- odynophagia (usually indicates reflux esophagitis)
- extraesophageal manifestations (cough, hoarseness, wheezing)
Alarm features in GERD
- New onset dyspepsia
- hematemesis/melena/hematochezia
- anorexia
- unexplained weight loss
- dysphagia
- odynophagia
- persistent vomiting
- GI cancer in a first degree relative
Workup for GERD
8-week trial of low dose (once daily) PPI, followed by 8-week trial of high dose (BID) PPI
Note: Pts with alarm symptoms or who failed high-dose PPI should get an upper endoscopy
How often should newborns defecate?
Exclusively breastfed: More liquid stool 6-10 times per day at first then decreasing to once every 1-2 days
Formula-fed: More solid stool 1-2 times per day
Note: Normal varies a lot and if there are no signs of pathology (abdominal distension, emesis, poor feeding, failure to thrive), reassurance is appropriate
Pts admitted to the hospital for variceal bleeding are at increased risk of…
1 infections such as SBP, UTI, respiratory infections, aspiration PNA (these pts should be placed on prophylactic antibiotics, usually ciprofloxacin for 7-10 days)
- hepatic encephalopathy
- renal failure
When should a HIDA scan be ordered?
To confirm suspected acute cholecystitis
E.g. RUQ abdominal pain, normal LFTs, gallstones on RUQ u/s, negative sonographic Murphy sign
Positive antimitochondrial antibody
Think primary biliary cholangitis
Treatment for primary biliary cholangitis
- Ursodeoxycholic avid to slow progression
- liver transplant for cure
Note: These pts should also be given calcium and vitamin D supplements to help prevent osteopenia
Palpable mass in abdomen of 2-year-old with acute abdominal pain and current jelly stools…
Think intussuaception
Note: Treat with an air enema
Best test to confirm suspected intussusception (if not clear)
Abdominal ultrasound showing a target sign
Note: Abdominal radiographs should also be obtained to rule out abdominal free air
When can a minor provide their own consent?
Medical emancipation (emergency care, STIs, mental health and substance abuse treatment, pregnancy care, and contraception)
Legal emancipation (financial independence, minor has a child, minor is married, minor is in active military service, minor is a high school graduate)
Treatment for pediatric constipation
Increase fiber and water in diet
Osmotic laxatives (if dietary changes are insufficient)
Corkscrew pattern on esophogram
Diffuse esophageal spasm
Note: Treat with calcium channel blockers (nitrates or tricyclics can also be used)
How do you confirm H. Pylori was fully treated with antibiotics?
Fecal antigen testing or urea breath testing 4 weeks after the completion of therapy
Triple therapy for H. pylori
Omeprazole, clarithromycin, and amoxicillin
Common precipitating factors for hepatic encephalopathy
Drugs (sedatives, narcotics) Hypovolemia (diarrhea, diuretics) Electrolyte changes (hypokalemia) Increased nitrogen load (GI bleed) Infections Portosystemic shunts (TIPS)
Treatment for hepatic encephalopathy
Correct precipitating causes (fluids, antibiotics, etc)
Decrease blood ammonia concentration with lactulose or rifaxamin
Rapid onset of periumbilical pain with pain out of proportion to physical exam findings of usually mild abdominal tenderness…
Think acute mesenteric ischemia
Indirect hyperbilirubinemia in a newborn at 2-weeks old…
Breast milk jaundice, thought to be due to high beta-glucuronidase activity in breast milk that deconjugates intestinal bilirubin
Note: This is benign and pts can continue exclusively breastfeeding
Dyspepsia
Epigastric pain/fullness (possibly with nausea)
Workup for dyspepsia
H. Pylori testing (in pts younger than 60 with no alarm symptoms)
Upper endoscopy (in pts 60 or older or with alarm symptoms)
Clinical manifestations that suggest boerhaave over Mallory Weiss syndrome
Fever, chest pain, mediastinitis, left pleural effusion, and hemodynamic instability point towards esophageal perforation (Boerhaave)
Diagnostic test for suspected boerhaave syndrome
Esophagography or CT scan with water-soluble contrast
Note: If you’re suspecting Mallory Weiss syndrome instead, you should get an upper endoscopy
Treatment of boerhaave syndrome
Emergency surgical consultation
Acid suppression, antibiotics, and make pt NPO
Treatment for Mallory Weiss tear
Acid suppression
Note: Most heal spontaneously
Next step in management if pt has a CT scan showing a loculated cystic lesion in the pancreas with some wall calcifications…
Endoscopic ultrasound and aspiration
Note: This cyst is not categorizable by CT as pseudocyst, non-neoplastic, or neoplastic. Therefore, biopsy is needed.
Next step in management of pt with no history who presents with periumbilica abdominal pain, bloating, flatulence, and watery diarrhea after eating
Trial of lactose-restricted diet (can also do a lactose breath hydrogen test)
Show should you evaluate the etiology if ascites
Paracentesis with fluid analysis to calculate SAAG
SAAG of 1.1 or greater indicated portal hypertension
Common etiologies of ascites with SAAG > 1.1
CHF
Cirrhosis
Alcoholic hepatitis
Note: These all cause portal hypertension
Common etiologies of ascites with SAAG < 1.1
Peritoneal carcinomatosis Peritoneal tuberculosis Nephrotic syndrome Pancreatitis Serositis
Hematemesis in the setting of prior pancreatitis with gastric varices on EGD, but no esophageal varices…
Think about splenic vein thrombosis (causing isolated gastric varices that are now bleeding)
Note: SVT most often occurs when a thrombus forms just inferior to the pancreas due to compression during a pancreatitis episode
Diagnostic test for splenic vein thrombosis
CT abdomen with contrast, Doppler ultrasound of splenic vein, MRI abdomen
Upper endoscopy showing isolated gastric varices is also confirmatory
Long term treatment for splenic vein thrombosis and GI hemorrhage
Splenectomy
Indications for stress ulcer prophylaxis
- Coagulopathy (platelets < 50,000; INR > 1.5; PTT >2x normal)
- mechanical ventilation >48 hours
- GI bleeding pretty ulceration in last 12 months
- head trauma, spinal cord injury, or major burn
-any 2 of: glucocorticoid therapy, >1 week ICU stay, occult bleeding >6 days, sepsis
Punctuate or curvilinear calcifications within the wall of the gallbladder…
Think porcelain gallbladder due to chronic cholelithiasis
Note: Pts with symptoms or punctuate calcifications should have a cholecystectomy due to increased risk of gallbladder cancer (asymptomatic pts with curvilinear calcifications do not require cholecystectomy)
Screening guidelines for colon cancer in average risk pts
Start screening at age 50 with one of the following:
- colonoscopy every 10 years
- yearly FOBT
- FIT-DNA every 1-3 years
- CT colonography every 5 years
- Flexible sigmoidoscopy every 5 years (or every 10 years when combined with annual FIT testing)
Who is considered at high risk for colon cancer and how should they be screened?
1st degree relative with colon cancer or adenomatous polyp when younger than 60
2 or more 1st degree relatives with colon cancer or adenomatous polyps at any age
Note: These pts should be screened with colonoscopy every 3-5 years starting at age 40 OR 10 years younger than the age of cancer diagnosis in family
How can you reduce risk of colon cancer
Increase intake of fruits and vegetables
Decrease red meat consumption
Avoid tobacco and alcohol
Exercise regularly
What are the two major types of dysphagia?
Oropharyngeal dysphagia (characterized by difficulty initiating a swallow, often with coughing/drooling/aspiration)
Esophageal dysphagia (characterized by delayed sensations of food sticking in the upper or lower chest)
Diagnostic test for progressive dysphagia
Barium esophogram (not barium swallow)
Nasopharyngeal laryngoscopy (if pt has oropharyngeal dysphagia)
EGD (if pt has esophageal dysphagia)
What are the major types of severe malnutrition?
Marasmus (characterized by wasting)
Kwashiorkor (characterized by edematous malnutrition, protuberant abdomen, pitting edema)
Treatment of severe malnutrition
- rewarming for hypothermia
- oral rehydration using an NG if needed (IV fluids only if in shock and even then a smaller, slower bolus due to the risk of fluid overload and heart failure)
- cautious refeeding
Note: Look out for heart failure and refeeding syndrome during treatment
Who should be screened for Barrett esophagus?
- pts with chronic GERD (>5 years)
- pts with frequent symptoms and 2 of the following
- make sex
- age>50
- Caucasian
- hiatal hernia
- obesity
- current or former tobacco use
- first degree relative with Barrett’s or esophageal adenocarcinoma
Note: These pts should have a one time screen with an EGD, with surveillance screening if positive
Treatment for Barrett’s esophagus with no dysplasia
PPI and surveillance EGDs every 3-5 years
Treatment for Barrett’s esophagus with low-grade dysplasia
PPI and surveillance endoscopy in 6-12 mont
OR
Endoscopic eradication
Treatment for Barrett’s esophagus with high-grade dysplasia
Endoscopic eradication therapy
Diagnostic criteria for SBP
Diagnostic paracentesis with 250 or more neutrophils OR positive peritoneal fluid culture
Treatment for SBP
Empiric antibiotic coverage with a 3rd generation cephalosporin (eg cefotaxime)
IV albumin (to reduce risk of renal failure)
Note: Id creatinine levels worsen while on IV albumin, you should consider treating for hepatorenal syndrome
Treatment for hepatorenal syndrome
Octreotide, midodrine, and albumin (or norepinephrine and albumin if in the ICU)
Note: TIPS can be considered if pt failed medical management
What is the best way to predict mortality in pts with liver disease
MELD score (which includes bilirubin, INR, creatinine, and sodium levels)
Note: This predicts 90-day mortality (pts with higher MELD scores are prioritized on transplant lists)
Hepatic adenoma
A benign epithelial tumor of the liver primarily seen in young women on oral contraception
Note: Most cases are asymptomatic and managed conservatively by discontinuation if the OCP (unless otherwise is symptomatic or rumor is > 5cm, in which case surgical resection is the management)
32 yo female with CT scan showing a well demarcated lesion in the right lobe of the liver with early phase peripheral contrast enhancement…
Think hepatic adenoma
Note: Discontinue oral contraceptive if PT is taking
Management of hepatic adenoma
If 5cm or less, conservative management by discontinuing oral contraceptive
If > 5cm or PT is symptomatic, then surgical resection
Note: PT should be followed with serial imaging and alpha-fetoprotein levels (there is a 10% chance of malignant transformation). They can also rupture or hemorrhage.
Management for hematochezia with orthostatic hypotension and tachycardia…
Fluid resuscitation followed by EGD to look for possible upper GI bleed
Note: If EGD is negative, then pursue colonoscopy to look for source (if PT presents with signs suggesting lower GI bleed such as passage of large clots or a known recent diverticula bleed, then the colonoscopy should happen first)
Management of hematochezia with hemodynamic instability and failure of volume resuscitation to stabilize
IR angiography to identify bleed with embolization
Pt with history of ulcerative colitis presents with abdominal pain, bloody bowel movements, tachycardia, leukocytosis to 19,000, and dilated colon with air fluid levels on abdominal radiographs…
Toxic megacolon (characterized by nonobstructive colonic dilation and signs of systemic toxicity)
Management of toxic megacolon
- Immediate surgical consultation (though surgery can often be avoided with aggressive medical management)
- Fluid resuscitation, NG tube placement, bowel rest, and admission to ICU
- glucocorticoids (if due to IBD)
- avoid medications that slow peristalsis (e.g. opioids, anticholinergics, etc)
Note: C. diff should be ruled out and glucocorticoids avoided if positive
Intervals for follow up colonoscopy after finding small rectal hyper plastic polyps
No change (every 10 years)
Interval for follow up colonoscopy after finding 1-2 tubular adenomas (0.6 and 0.9 cm)
Every 5 years
Note: this applies if 1-2 small (< 1cm) tubular adenoma s are found
Interval for follow up colonoscopies if a single villous adenoma is found
Repeat colonoscopy in 3 years if:
- 3-10 adenoma
- any adenoma >1cm
- adenoma with villous features or high grade dysplasia
Note: If nothing is found on repeat the pt can have screening colonoscopies every 5 years
Interval for colonoscopy follow up if 12 tubular adenoma are found
Less than 3 years if more than 10 adenomas
Note: These pts should also be worked up for an underlying familial syndrome
Interval for follow up colonoscopy if a 2.5 CM sessile polyp is removed but piecemeal excision
Repeat colonoscopy in 2-6 months
Follow up interval for colonoscopy if adenocarcinoma with minimal invasion is excused with a wide margin (> 2mm)
2-3 months
Management of ingested button battery
Endoscopic removal if battery is stuck in esophagus
Close monitoring with serial xrays if battery is in the stomach or beyond
Note: Endoscopic or surgical removal is required if the battery stops progressing or the PT becomes symptomatic
Management of pt who swallowed a fishbone and initially had sharp pain, but now only mild odynophagia
Urgent endoscopy for removal of foreign body is indicated it pt is symptomatic (e.g. odynophagia) or history of sharp object ingested (e.g. fish/chicken bone, toothpick, etc)
Note: These objects are often not seen on radiographs (small bones and wood often appear radiolucent)
Common causes of drug-induced pancreatitis
Sulfonamide medications
Thiazide diuretics (HCTZ, chlorthalidone)
Loop diuretics (furosemide)
Antibiotics (tetracycline, TMP-SMX)
Antiepileptics (valproate)
Immunosuppressants (azathioprine, corticosteroids)
Note: DIP is common in pts with heart failure, HTN, autoimmune diseases, chronic pain, seizure disorders, or HIV due to the medications they are commonly on
5-week old boy with no bloody nonbilious projectile vomiting immediately after feeding with an olive shaped mass in the abdomen…
Pyloric stenosis
Note: Diagnosis should be confirmed with abdominal ultrasound and treated with volume resuscitation and electrolyte repletion followed by surgical pyloromyotomy
What kind of acid base disturbance is most common after prolonged episodes of vomiting
Hypokalemia hypochloremic metabolic alkalosis from volume contraction and loss of stomach acid
Risk factors for development of pyloric stenosis
- first born boy
- erythromycin exposure (e.g. pt receives pertussis prophylaxis)
- bottle feeding
Why is octreotide used for variceal bleeding?
It decreases splanchnic blood flow which reduces the pressure within esophageal varices
Long term management of pt with esophageal variceal bleeding who has been stabilized
- Surveillance endoscopies
- non selective beta blocker (propranolol or nadolol)
- oral nitrate (optional)
Management of acute viral gastroenteritis
Oral rehydration if possible
Early return to normal diet
Note: PT should be hospitalized for IV fluids if they cannot tolerate oral rehydration
Why are colonic diverticula predisposed to bleed?
Diverticula occur when the mucosa and submucosa herniate through the muscular layer at points where an artery pierces the muscular layer, creating a point of weakness. Once the diverticula are formed, that artery is exposed and at high risk for bleeding
Rectal discomfort, rectal bleeding, protruding rectal mucosal mass with bluish discoloration, concentric rings, and friability…
Rectal prolapse with strangulation and possible gangrene, get a surgical consult
Management of rectal prolapse
Medical management for partial thickness prolapse:
- increased fiber and fluid intake
- pelvic floor muscle exercises
- biofeedback (if fecal incontinence)
Surgical management via intraabdominal or perineal approach for full thickness prolapse or symptomatic pts (fecal incontinence, constipation, sensation of mass)
Abdominal pain, weight loss, fatigue, and fever in a PT with poorly controlled celiac disease
Think enteropathy-associated T-cell lymphoma (EATL)
Note: This is an aggressive malignancy that can develop in the proximal jejunum of untreated celiac pts and can lead to bowe obstruction, perforation, and GI bleeding. Prognosis is poor with median survival of 10 months
Common causes of chronic diarrhea in high-income countries
Irritable bowel syndrome
Inflammatory bowel disease
Chronic infection
Malabsorption syndromes (e.g. celiac disease, lactose intolerance, chronic pancreatitis, small intestinal bacterial overgrowth)
Initial evaluation of chronic diarrhea
Stool studies:
- stool O and P
- FOBT
- stool pH
- stool fat content
- stool electrolytes (to calculate osmotic gap)
Diarrhea with stool osmotic gap of 150
A stool osmotic gap > 125 is consistent with osmotic diarrhea
Note: A stool osmotic gap < 50 suggests secretory diarrhea
How do you calculate stool osmotic gap?
290 - (2 x (stool Na + stool K))
Chronic diarrhea with macrocyctic anemia…
Think small intestinal bacterial overgrowth (macrocytic anemia due to vitamin B12 deficiency)
Workup for suspected celiac disease
Immunoglobulin A anti-tissue treansglutaminase and anti-endomysial antibody
Upper endoscopy with small bowel biopsy (shows villous atrophy, intraepithelial lymphocytic infiltrates, and crypt hyperplasia in celiac patients)
Management of celiac disease
- gluten free diet
- vitamin supplementation as needed (iron, calcium, vitamin D, folic acid)
- screening for osteopenia with DXA scan
- administer pneumococcal vaccine (due to associated hyposplenism)
Abdominal pain, diarrhea, nausea, dizziness, sweating, and SOB in a pt who recently has a partial gastrectomy due to ulcers…
Dumping syndrome (can happen in pts with gastrectomies due to faster transit of food through the stomach. The high similar load of food being dumped into the small bowel leads to the dumping of water from plasma into the small bowel causing diarrhea and hypotension)
Note: Treatment is dietary modification with smaller more frequent meals low in simple carbohydrates, high in fiber and protein. Separating solids from liquids by at least 30 min can help too.
Management of small bowel obstruction
Surgery if complete small bowel obstruction
Close observation and monitoring for partial small bowel obstructions (early surgical intervention if PT does not improve in 12-24 hours)
Mild abdominal pain and tenderness 6 weeks after an episode of acute pancreatitis
Think pancreatic pseudocyst
Note: Treatment is supportive unless pt has mod-severe symptoms, which then warrants surgical or endoscopic drainage)
What are common inflammatory fluid collections that occur after an episode of acute pancreatitis?
Pancreatic pseudocyst (a late, walled-off colllection of pancreatic fluid)
Walled-off necrosis (a late, walled collection of necrotic tissue)
Acute necrotic collection (early collections without a wall that occur within one month of acute episode and cause more complications)
Peripancreatic fluid collection (early collection of fluid without a wall)
What complications should you look out for in pts with suspected inflammatory fluid collections (e.g. pseudocyst or acute necrotic collections)
- biliary or pancreatic duct obstruction
- fistulization into adjacent organs
- erosion of blood vessels
- infection/abscess
What types of post-pancreatitis inflammatory fluid collections should be surgically or endoscopically drained?
Only ones that cause moderate-severe symptoms should be drained
Serological for scleroderma
ANA
Anti-topoisomerase I (anti-Scl-70)
Anticentromere
What are common complications of scleroderma with systemic sclerosis?
- interstitial lung disease
- pulmonary arterial hypertension
- hypertension
- scleroderma renal crisis (oliguria, thrombocytopenia, MAHA)
- myocardial fibrosis and pericarditis
What are the two major types of systemic sclerosis?
CREST syndrome (Calcinosis, raynaud, esophageal dysmotility, sclerodactyly, and telangiectasias)
Diffuse cutaneous systemic scleroderma (often involves the lungs, kidneys, and/or GI tract)
Note: Limited cutaneous sclerosis is a non-systemic form of scleroderma that only affects the skin
Common causes of acute mesenteric ischemia
- Superior mesenteric artery occlusion due to thromboembolism (often in the setting of a fib)
- superior mesenteric vein occlusion (often in the setting of portal hypertension, hypercoagulable states, and abdominal infections)
- nonocclusive ischemia (in the setting of low cardiac output)
2-year-old with painless bright red blood per rectum
Think Meckel diverticulum (AV malformations are another possibility)
Note: Get a technetium-99m pertechnetate scan to confirm the diagnosis by identifying ectopic gastric tissue in the diverticulum and treat with surgical resection
When is a hgb goal of 8 or greater appropriate?
- stable coronary artery disease
- pts being prepared for major surgery
Note: Pts with acute coronary syndrome, severe thrombocytopenia, or cancer with high bleeding risk may require a transfusion goal >8
PT with GERD develops dysphagia requiring him to take very small bites and chew very thoroughly
Think about esophageal stricture
3-year-old boy with crampy abdominal pain, fever, and bloody diarrhea…
Suspect bacterial enteritis
Note: obtain stool culture for diagnosis and treat with fluid repletion (avoid using empiric antibiotics unless PT is septic or immunocompromised)
Antibiotic choice for acute bloody diarrhea
Do not start empiric antibiotics unless the pt is septic or immunocompromised
Note: Antimicrobials can prolong symptoms and predispose children with E. coli O157:H7 to develop hemolytic uremic syndrome (wait until cultures grow something to start targeted antibiotics when possible)
What is the most common cause of fecal incontinence in elderly patients?
Fecal impaction
Note: Diagnose with a digital rectal exam and treat with manual disimpaction followed by an enema or suppository to empty the colon
Epigastric pain with radiation to the back and right shoulder following a meal with nontender abdomen…
Think biliary colic if intermittent, get RUQ ultrasound to confirm
Note: In pancreatitis you would expect abdominal tenderness on exam and right shoulder pain would be unusual
When would you order a cholecystokinin-stimulates cholescintigraphy?
To evaluate for a functional gallbladder disorder in a pt with typical symptoms of biliary colic, but no gallstones on imaging
Note: Pts with a low gallbladder ejection should get a cholecystectomy
Management of asymptomatic gallstones
No specific treatment unless pt has episodes of biliary colic (in which case treatment is elective cholecystectomy or ursodecholic acid if not a surgical candidate)
Fever, jaundice, RUQ pain, hypotension, confusion…
Acute cholangitis, start emergent antibiotics and plan for ERCP
When should an ERCP be ordered?
Any of the following:
- visualized choledocholithiasis
- evidence of acute cholangitis
- high risk features (dilated CBD on imaging, elevated serum bilirubin)
Note: Pts with suspected choledocholithiasis but none of the above features should get an MRCP
If you suspect diverticulitis, what test should you order?
CT abdomen with oral and IV contrast
Management of confirmed diverticulitis
Bowel rest
Antibiotics (ciprofloxacin and metronidazole)
Management of colonic diverticulitis complicated by abscess formation
Percutaneous drainage and IV antibiotics, followed by elective partial collecting several weeks later
healthy pt with acute watery diarrhea with visible blood through the stool and many fecal leukocytes
Likely acute dysentery, get stool studies (stool culture, shiga toxin, fecal leukocytes)
Note: Get a CT abdomen if concerned about ischemic colitis or an endoscopy if concerned about inflammatory bowel disease
How can you differentiate viral from bacterial gastroenteritis by history
More likely to be bacterial if:
- Diarrhea with visible blood or mucous
- significant abdominal pain
- systemic symptoms (fever, malaise)
Common causes of acute dysentery
Bacterial infection (EHEC, shigella, campylobacter, salmonella)
Intestinal amebiasis (rare in developed countries)
Inflammatory bowel disease
Ischemic colitis
Acute dysentery (bloody/mucousy diarrhea) and low fecal leukocytes
Consider invasive amebiasis (especially if pt was recently in a developing country)
Management of acute dysentery suspected bacterial etiology
Rehydration (preferably oral)
Oral empiric antibiotics, usually ciprofloxacin (unless EHEC is suspected)
Management of pt with chronic hepatitis C infection
- sofosbuvir-velpatasvir
- hepatitis A and hepatitis B vaccination (if not already immune)
- screening for complications of HCV (liver fibrosis, renal disease, cryoglobulinemia)
Hepatic hydrothorax
A type of pleural effusion that can develop in pts with cirrhosis and ascites because the ascitic fluid passes through the diaphragm to enter the pleural space. It is usually right-sided and transudative by lights criteria.
Note: treatment is with furosemide, spironolactone, and sodium restriction to prevent ascites buildup (initial management includes paracentesis to remove excess ascitic fluid)
Woman with history of cervical cancer (in remission) who presents with a painful urge to have a bowel movement but only passing mucous and some bright red blood. Rectosigmoidoscopy shows pale rectal mucosa, telangiectasias, and small areas of mucosal hemorrhage…
Think about radiation proctitis if pts cervical cancer was treated with radiation
Note: Treat with fluids and antidiarrheals in the acute setting (can use sucralfate or glucocorticoid enemas if chronic)
What characteristics best predict more severe pancreatitis?
Older age Obesity Elevated hematocrit Elevated CRP BUN of 20 or more
Note: BUN is the best value to track disease progression
Treatment for post-cholecystectomy diarrhea
- Dietary modification
- bile salt-binding resins (cholestyramine) for refractory cases
Note: Post cholecystectomy or port ileal resection diarrhea is most often due to excess secondary bile acids reaching the colon
When should a newborn have their first bowel movement?
They should pass meconium within 48 hours of delivery
Failure to pass meconium within 48 hours of birth and a contrast enema showing dilated descending colon with normal caliber rectosigmoid…
Think hirschsprung disease
Note: get rectal mucosal suction biopsy to confirm absence of ganglion cells and treat with surgical resection of the aganglionic portion of bowel
Clinical manifestations of thrush
White plaques on the buccal mucosa that can typically be scrapped off, which might reveal inflamed tissue beneath.
Usually asymptomatic, but might give pt a strange cottony taste in their mouth.
Note: if pt has odynophagia, they may have esophageal candidiasis and should get systemic therapy
GER vs GERD in infants
Gastroesophageal reflux (“happy spitters”) is natural in infants because their esophagus is shorter and stomachs smaller. This is not dangerous and can be managed with upright positioning after feeds, smaller more frequent feeds, and burping during feeds.
If the infant is experiencing weight loss, feeding refusal, aspiration, or significant pain and irritability during feeds then it is called gastroesophageal reflux disease.
16 year old with intermittent periumbilical pain that prevents them from eating, normal physical exam, negative FOBT…
Think about functional abdominal pain (abdominal pain with no identifiable organic pathology) and ask the pt to record a symptom diary to try to identify triggers/patterns
Note: An FOBT should be obtained to evaluate for GI bleeding, but other tests should not be ordered unless suspicious of a particular disease
Treatment for reducible inguinal hernia
The treatment for all types of hernias, whether they are reducible or not is surgical repair to avoid possible incarceration or strangulation
When does colonic adenocarcinoma not require surgical resection of colon segments?
Only if all of the following are true:
- adenocarcinoma is only in the head of the polyp
- tumor was removed during endoscopy with at least a 2mm margin
- no lymphovascular invasion
- tumor is well differentiated
Note: These pts are candidates for avoiding surgery with surveillance colonoscopies with the first in 2-3 months, then at 1, 4, and 9 years after polyp removal (the area the tumor was removed from should be tattooed so it can be found and monitored again)
Treatment for H pylori
- Triple therapy (PPI, amoxicillin, and clarithromycin for 10-14 days)
- quadruple therapy (PPI, bismuth, metronidazole, and tetracycline for 10-14 days)
Note: If pt has a penicillin allergy you can use metronidazole instead of amoxicillin in triple therapy. Quadruple therapy should be used in areas with clarithromycin resistance of 15% or more.
Who should be tested for eradication after treatment for H. Pylori?
Pts with any of the following:
- persistent symptoms
- H pylori-associated ulcer on endoscopy
- evidence of H pylori-associated malignancy (MALT)
Note: Test for cure with urea breath test or fecal antigen testing 4 or more weeks after treatment is completed
Isolated anti-HBc antibody positive with anti-HBs negative…
Only 3 possible situations:
- during the window period of acute hep B infection
- years after recovery from acute HBV after HBs antibodies have declines
- after many years of chronic HBV infection
Note: You should get IgM anti-HBc antibodies and liver enzyme levels to further evaluate. If IgM is negative but liver enzymes are abnormal, you should get HBV DNA to test for chronic infection
Treatment of infant born to a mother who developed a hep B infection during birth
- hep B immunoglobulin and hep B vaccine within 12 hours of birth
- completion of hep B vaccine series (at age 0, 2, and 6 months)
- hep B serology at the 9 month well-child visit
What tests should be performed to evaluate for possible osteomyelitis?
- Probe to bone (if diabetic ulcer probe to bone is positive, no need for imaging, probe to bone is most specific)
- MRI (most sensitive)
- bone scan (if you can’t get MRI)
26-year-old male who went into ventricular tachycardia and was found to have a dyskinetic and thin left ventricular apex…
Chagas disease (ask if pt spent time in central or South America years ago)
Note: Cardiac apical aneurysm is virtually pathognomonic for chagas
Evaluation for suspected tuberculosis
- CXR (look for upper lobe cavitation lesions, hilar lymphadenopathy, or pleural effusions)
- Three sputum samples spaced by 8-24 hours with at least one early morning sample (if CXR is suspicious)
- tuberculin skin testing or interferon-gamma release assay (to prove exposure, can not show active disease)
Epidemic of vomiting-predominant gastroenteritis with a negative stool culture…
Norivirus
Can a pt refuse testing for HIV if there has been a needle stick injury to a healthcare worker?
Yes, and the healthcare worker should be given post-exposure prophylaxis as quickly as possible regardless of whether the pt agrees or not (prophylaxis can be stopped if a negative test result is obtained)
Note: Some states do allow testing for HIV without consent in these cases, but not all
Is it ok to prescribe antibiotics for a pt who tells you over the phone they are having a UTI?
Yes, UTI can be diagnosed over the phone with history alone. However, if the pt is likely to be pregnant (no contraception, no recent menstrual period) or likely to have pyelonephritis (fever, chills, flank pain) then a physical exam and urine culture are required
Note: You should prescribe Bactrim for 3 days or nitrofurantoin for 5 days
Pt who had a wood splinter recently who presents with fever, hypotension, leg swelling, slight erythema around wound, and significant tenderness to palpation…
Think about necrotizing fasciitis and treat with immediate hemodynamic support (IV fluids and pressers as needed) IV antibiotics and surgical debridement of necrotic tissue
What are the most common organisms found in necrotizing fasciitis?
-Streptococcus pyogenes (group A strep) is the most common
- Staph aureus
- Clostridium perfringens (if crepitus on exam)
- polymicrobial (common in diabetics)
Empiric antibiotics for necrotizing fasciitis
- Zosyn or a carbapenem (to cover Group A steep and anaerobes)
- vancomycin (to cover staph and MRSA)
- clindamycin (to inhibit toxin formation by strep and staph species)
How does constipation predispose to UTIs?
Rectal distension due to constipation can cause a mass effect on the urethra, leading to obstruction of bladder emptying and urine stagnation
Can you treat a child with pyelonephritis with oral antibiotics?
Yes, but only if none of these are present:
- hemodynamic instability
- unable to tolerate oral meds (e.g. persistent vomiting)
- pt is less than 2 months old
- failure of improvement on oral antibiotics
Risk factors for pediatric constipation
- initiation of solid foods
- initiation of cows milk
- toilet training
- school entry
Treatment of pediatric constipation
- increased dietary fiber and water
- limit cows milk intake to <24 oz
- laxatives
- suppositories/enemas
50 year old pt who received the BCG vaccine in childhood is found to have a tuburculin skin test with 16mm induration and upper lobe fibrosis on CXR…
Latent tuberculosis, which should be treated with a 9-month course of isoniazid
Note: Induration > 15mm is not likely due to BCG vaccine (in cases of smaller induration a gamma release assay can be used to distinguish between TB exposure and BCG vaccine)
Diagnosis of Lyme disease
Enzyme linked immunosorbent assay to screen and western blot confirmation if positive
Clinical manifestations of early disseminated Lyme disease
Erythema migrans
Fatigue, headache
Myalgias, arthralgias
Clinical manifestations of early disseminated Lyme disease
Unilateral/bilateral Bell’s palsy Multiple erythema migrans rashes Meningitis Carditis (AV block) Migratory arthralgias
Clinical manifestations of late Lyme disease
- Lyme arthritis (usually a mono articulate arthritis not as bad as septic arthritis)
- echephalitis
- peripheral neuropathy
Treatment for Lyme disease
Doxycycline or amoxicillin (if under the age of 8, though children with late Lyme complications should still get doxycycline)
Meningitis in a pt with HIV and lumbar puncture with CSF showing high opening pressure, low glucose, high protein, and 40 leukocytes (96%lymphocytes)…
Think about cryptococcus neoformans infection causing cryptococcal meningoencephalitis. Confirm with India ink preparation or cryptococcal antigen test and treat with amphotericin B and flucytosine for two weeks, followed by high dose oral fluconazole for 8 weeks, followed by low dose fluconazole for at least a year
Pt with cryptococcal meningoencephalitis who develops nausea, vomiting, lethargy, with no focal neuro deficits…
Think about elevated intracranial pressure
Note: This should be treated with serial lumbar punctures to avoid brain herniation
Treatment for salmonella gastroenteritis
Oral rehydration therapy
Note: Antibiotics are reserved for children less than 12 months and immunocompromised adults (use ciprofloxacin, TMP-SMX, or ceftriaxone)
HIV-associated lipodystrophy
The tendency of HIV pts on antiretrovirals to develop central adiposity and buffalo humps whil also having peripheral atrophy of adipose tissue (pts have thin arms/legs and large midsections)
Note: This often is associated with increased insulin resistance, dyslipidemia, and an increased risk of cardiovascular disease, so these pts are often started on a statin (definitely if 10-year ASCVD risk is over 7.5%)
Management of delivery of an infant with an HIV positive mother with a viral load > 1,000
Cesarean delivery with antiretroviral drugs including zidovudine given to the mother during deliver and multi drug antiretroviral therapy given to the infant after birth
Note: If the mother’s viral load is <1000, they can deliver vaginally and only need regular antiretroviral therapy during delivery (zidovudine does not need to be given to the mother); however, the infant should receive zidovudine after birth
Can HIV positive mothers breastfeed?
No, in developed countries with access to clean water HIV mothers should formula feed their infants
Contraindications you’re breastfeeding
- active untreated tuberculosis
- HIV infection
- herpetic breast lesions
- active varicella infection
- chemotherapy or radiation therapy
- active substance abuse
- infant has galactosemia
Pt on active chemotherapy develops painless red macules that rapidly progress to pustules/bullae and then necrotic ulcers with an erythematous rim and yellow-green exudate…
Think ecthyma gangrenosum (an infection of perivascular structures that disrupts blood supply to the skin causing necrosis), most likely due to pseudomonas infection in this pt who likely has neutropenia with greenish exudate
Note: most commonly acquired via an implanted chemo port the bacteria seeds the blood and infects the walls of blood vessels
Empiric treatment for ecthyma gangrenosum
Zosyn and gentamicin is commonly used
Note: anti-pseudomonas cephalosporins, monobactams, fluoroquinolones, and carbapenems can also be substituted
Male presents a week after unprotected sex with burning with urination, no urethral discharge, and urethral fluid stain showing many neutrophils but no organisms…
Non-gonococcal urethritis, likely secondary to chlamydia, and should be treated with a single dose of Azithromycin (if pt fails therapy, then other organisms should be considered such as ureaplasma urealyticum, mycoplasma genitalium, or trichomonas vaginalis)
Note: If pt had purulent urethral discharge and stain showed intracellular gram-negative diplococci, then it would be gonococcal urethritis and he should be treated with ceftriaxone AND azithromycin
Treatment for mycoplasma genitalium
Moxifloxacin
Note: M. Genitalium is the second most common cause of nongonococcal urethritis after chlamydia
Pt with advanced untreated HIV with fever, dry cough, dyspnea on exertion, hypoxia, and interstitial infiltrates on CXR…
Pneumocystis jirovecii pneumonia (PCP), pt should give sputum sample for confirmation (though sensitivity is low for sputum samples) and treated empirically with trimethoprim-sulfamethoxazole in addition to standard PNA empiric antibiotics +/- steroids based on oxygenation
Note: Pneumocystis jirovecii is an atypical fungus that often causes pneumonia in HIV pts with CD4 counts < 200
When should you consider giving a pt with pneumocystis jirovecii pneumonia corticosteroids?
ABG showing alveolar-arterial oxygen gradient of 35 or more (or a PaO2 less than 70 in room air)
Note: HIV pts with PCP often have respiratory decompensation during the first 2-3 days of treatment due to the inflammation caused by lysis of the fungal cells
Empiric treatment of community acquired pneumonia for outpatients
- macrolide, such as azithromycin, or doxycycline (if healthy)
- azithromycin + fluoroquinolone, such as levofloxacin, or beta-lactam (if comorbidities)
Empiric treatment for pts with community acquired pneumonia requiring hospitalization
- IV fluoroquinolone, such as moxifloxacin
- IV azithromycin + IV beta-lactam, such as ceftriaxone
What are the respiratory fluoroquinolones often used to treat pneumonia
Levofloxacin or moxifloxacin
What are the most common causes of cellulitis in pts who have been bitten by a human?
- Eikenella corrodens
- viridans group streptococci (alpha-hemolytic)
- staph aureus
- other anaerobes (fusobacterium, prevotella, etc)
Note: Wound should be irrigated and left open (unless on the face then you can do primary closure) and pt should be given a tetanus booster if needed and empiric therapy with amoxicillin-clavulanate
Treatment of a human bite wound with warmth, erythema, and swelling
- Wound should be debriefed, irrigated, and left open to heal by secondary intention (unless on the face then you can do primary closure)
- tetanus booster, if wound is deep and pts hasn’t been vaccinated recently
- empiric therapy with amoxicillin-clavulanate (or ampicillin-sulbactam if IV therapy is needed)
STI screening for men who have sex with women
Fourth generation HIV test (p24 antigen and HIV antibodies)
Note: Everyone 13-65 should be offered this regardless of risk factors, and MSW don’t need any other STI screening unless they engage in high risk behaviors (such as sex with sex workers)
When should a healthcare worker get post exposure prophylaxis for HIV?
- percutaneous injury from a contaminated needle stick or sharp object such as a scalpel
- mucous membranes or nonintact skin contact with an infected bodily fluid (high risk: blood, any other fluid with visible blood, semen, vaginal secretions; possible risk: CSF, synovial fluid, pleural fluid, pericardial fluid, or amniotic fluid)
Note: Urine, feces, tears, and vomitus are considered non infectious as long as there is no visible blood present
Untreated HIV pt with widespread skin papules with central umbilication, some with central necrosis/hemorrhagic crusting…
Cutaneous cryptococcus, confirm diagnosis with biopsy of the lesion and treat with 2-weeks of IV amphotericin B followed by oral fluconazole for a year
In addition to normal vaccines, what vaccines should be given to HIV patients?
- HAV (if IV drug user, chronic liver disease, or gay)
- HBV
- HPV (if age 11-26)
- meningococcus
- pneumococcus (PCV13 initially, followed by PPSV23 at multiple time points after)
23 yo male with 2 week history of intermittent fever, dry cough, malaise, diarrhea, anorexia with weight loss, scaly facial rash, and excessive dandruff…
Think about acute HIV infection
Note: Mononucleosis-like illness with prolonged symptoms, mucocutaneous ulcers, or a generalized rash should raise suspicion for HIV
Serum sickness
An immune-complex mediated hypersensitivity reaction (type III) that occurs when circulating antibodies combine with an antigen and overwhelm normal clearance mechanisms. The compliment system becomes activated leading to systemic signs like fever, skin rash, and polyarthralgias. Treatment is mostly supportive (most important to remove the offending agent), but can include steroids or plasmapheresis if severe
Note: Some antibiotics and acute hepatitis B can also cause serum sickness-like reactions
Newborn with hydrocephalus, intracranial calcifications, and hepatomegaly…
Think of congenital toxoplasmosis acquired by transplacental transmission (mom may have had undercooked meat, unwashed fruits/vegetables, or been around cat feces) and treat with pyrimethamine and sulfadiazine along with supplemental folate for a year
Treatment of giardiasis
- metronidazole or tinidazole
- avoidance of recreational water venues and staying home if incontinent (to avoid spread)
When should a pt be prescribed antibiotics for UTI prophylaxis?
Recurrent UTIs (at least 2 UTIs within 6 months or at least 3 in one year) while adhering to behavioral modifications (postcoital voiding, oral hydration, avoiding spermicides)
Note: If the UTIs always happen after sex you can prescribe postcoital antibiotic prophylaxis but if the UTIs don’t seem to be related to sex they should get daily antibiotic prophylaxis
Post exposure prophylaxis for rabies
Rabies immunoglobulin and rabies vaccine on days 0, 3, 7, and 14
Note: If the pt has been vaccinated against rabies before they only need to get the rabies vaccine on days 0 and 3 (and do not need to get rabies immunoglobulin)
Pt with headache, malaise, nausea, and blurry vision tests positive for HIV, RPR positive with 1:128 titer, and positive fluorescent treponemal antibody absorption test. What should be the next step in management?
Lumbar puncture and CSF analysis for possible neurosyphilis
Clinical manifestations of syphilis
Primary (painless chancre)
Secondary (diffuse rash, condylomata lata)
Teriary (neurosyphilis, aortitis)
Latent infections are asymptomatic
Treatment for primary syphilis
Benzathine penicillin G (2.4 million units IM as a single dose)
Treatment for latent syphilis
Benzathine penicillin G (2.4 million units IM) single dose (if known to be less than 1 year infected) or weekly for 3 weeks (if unknown duration of infection)
Treatment for secondary syphilis
Benzathine penicillin G (2.4 million units IM as a single dose)
Treatment for neurosyphilis
Aqueous penicillin G (3-4 million units) given IV every 4 hours for 10-14 days
Treatment for congenital syphilis
Aqueous penicillin G (50000 units/kg/dose) given IV every 8-12 hours for 10 days
Several hours after getting penicillin G shot for syphilis, pt develops fever, headache, and achy sensation…
Jarisch-Herxheimer reaction (an acute febrile syndrome that occurs in some people after initiating treatment for a spirochete infection, such as syphilis, leptospirosis, and tick-borne diseases)
Note: There is no effective way to prevent this reaction to spirochete lysis and symptoms usually go away within 48 hours
Who should receive antimicrobial prophylaxis following possible Neisseria meningitidis exposure?
- all household members
- roommates or other intimate contacts
- child care center workers
- anyone directly exposed to respiratory secretions (kissing, mouth to mouth, intubation, suctioning)
- anyone seated next to pt for at least 8 hours (e.g. on a plane or bus)
Note: Prophylaxis can be with rifampin (unless pregnant or on oral contraceptives), ceftriaxone, or ciprofloxacin (not in children)
Should you treat asymptomatic bacteruria?
Rarely:
- pregnant women
- pts undergoing urologic procedures
- within 3 months of renal transplant
Diagnostic criteria for C. Diff colitis
At least 3 watery bowel movements within 24 hours and positive C. Diff stool antigen
Note: they may also have lower abdominal pain, low grade fever, and leukocytosis
Risk factors for C diff colitis
- gastric acid suppression
- recent antibiotic use (especially fluoroquinolones, clindamycin, and broad spectrum penicillins)
- hospitalization
- advanced age
Immune reconstitution inflammatory syndrome
A worsening of symptoms that can happen a few weeks after starting antiretrovirals for HIV infection that occurs because the immune system is getting better and causes more inflammation. It can be symptomatically managed with NSAIDs or a short course of corticosteroids
Note: Most common in pts being treated for tuberculosis when they start antiretrovirals
When should a healthy adult be vaccinated against pneumococcal pneumonia?
Starting at age 65 with the PCV13, then also with the PPSV23 at a later time
Note: the PPSV23 vaccine alone is recommended for adults younger than 65 with other chronic medical conditions, such as smoking/diabetes/heart disease/liver disease (only very high risk pts such as Sickle cell and HIV pts get both pneumococcal vaccines before age 65)
Treatment for UTI in a pregnant women
Cephalexin
Amoxicillin-clavulanate
Fosfomycin
Treatment for pyelonephritis in a pregnant woman
- hospitalization for IV fluids and IV broad spectrum beta-lactams (e.g. ceftriaxone, cefepime, etc)
- once afebrile for 48 hours they can be discharged on oral antibiotics for 10-14 days
- after treatment, they should receive daily suppressive therapy with low-dose nitrofurantoin or cephalexin until 6 weeks postpartum
Treatment for acute hep B infection?
Outpatient supportive care and close follow-up to monitor liver function
Note: Only pts with hemodynamic instability, impaired hepatic synthetic function (increased INR), or other signs of acute liver failure (such as encephalopathy) need to be hospitalized
What percentage of adults with acute hep B infection will go on to develop chronic hep B?
5% (infants born with acute hep B have a 90% chance of progressing to chronic disease)
Note: if hep B surface antigen isn’t cleared from the body after 6 months, then they have progressed to chronic hep B
Recurrent sinopulmonary infections in childhood, intestinal obstruction in infancy, and a sibling with the same problem…
Cystic fibrosis
confirm with sweat chloride level, nasal potential difference, or CFTR genetic testing
Treat with nutritional support, pancreatic enzymes as needed, airway clearance with chest PT, and antibiotic coverage for exacerbations
Treatment of cystic fibrosis lung disease acute exacerbation
Vancomycin PLUS 2 anti-pseudomonal antibiotics (e.g. cefepime and amikacin)
Anti-pseudomonal antibiotics
- Some cephalosporins (cefepime and ceftazidime)
- Some aminoglycosides (to rant in and amikacin)
- Some fluoroquinolones (ciprofloxacin and levofloxacin)
- carbapenems (except for ertapenem)
- Aztreonam
- Colistin
Unvaccinated child with cough, fever, sore throat, bilateral conjunctival erythema, maculopapular rash that started on the face and spread downward,and anterior lymphadenopathy…
Rubeola (measles)
Note: Treatment is supportive, but includes vitamin A for hospitalized patients
Periodic fevers, headaches, and thrombocytopenia in a world traveler…
Malaria
Mycotic aneurysm
An arterial aneurysm that forms due to a bloodstream infection, usually due to a septic embolism from infective endocarditis. The aneurysm can cause focal neurological deficits or rupture and cause a stroke or subarachnoid hemorrhage.
Confirm with CT angiogram
Treat with broad-spectrum antibiotics and surgical intervention (endovascular or open)
Cardiovascular complications of infective endocarditis
- Valvular insufficiency (a common cause of death)
- perivalvular abscess
- conduction abnormalities
- mycotic aneurysm
Pt with new kitten at home presents with a tender swollen lymph node in the R axilla and a erythematous painless papule on the R hand
Bartonella henselae (cat scratch disease)
Treat with azithromycin
Note: Pts often don’t remember being scratched or bitten
Management of healthcare worker who has a tuberculin skin test with 12mm induration and a negative CXR
Pt has latent tuberculosis with no pulmonary imaging findings and should be treated with isoniazid first 6-9 months (or rifampin for 4 months or isoniazid and rifapentine weekly for 3 months). Pts who do not work in high risk settings and are not at high risk of developing active TB (e.g. immunocompromised) do not require treatment for latent TB
Note: Latent tuberculosis is noninfectious and this pt can continue working with no restrictions
Empiric therapy for catheter-related bloodstream infections
Vancomycin plus cefepime (or gentamicin)
Do all pts with catheter-related bloodstream infections need to have the catheter removed?
No, catheter should definitely be removed if:
- severe sepsis
- hemodynamic instability
- evidence of metastatic infection (e.g. endocarditis)
- pus at the exit site of the catheter
- continued symptoms after 72 hours of empiric antibiotics
- blood culture evidence of Staph aureus, Pseudomonas, or fungi
Note: Pts who do not need to have the catheter removed should still have the catheter exchanged over a guidewire once afebrile (alternatively they can get antibiotic lock therapy after each access)
Abrupt onset fever, sore throat, malaise, and tender anterior cervical lymphadenopathy with no coughing, sneezing, or rhinorrhea…
Test for Strep pharyngitis (group A strep) with a rapid antigen testing and culture
Treat Strep pharyngitis with penicillin for 10 days (to prevent peritonsilar abscess, cervical lymphadenotis, and acute rheumatic fever)
Note: Post streptococcal glomerulonephritis is not avoided but antibiotic use
Treatment for strep pharyngitis in a pt with a penicillin allergy
Cephalosporin (if it was a mild reaction)
Azithromycin or clindamycin (if it was anaphylaxis)
Child with fever, malaise, painful vesicles/ulcers on buccal mucosa, papules and vesicles on both palms
Hand foot and mouth disease due to coxsackievirus
Treatment is supportive with hydration and pain control
Note: A similar appearance can happen in pts with herpes infection, but oral lesions are usually external on the lips/vermillion border and spread to the hands, if present, is usually only unilateral
Pt with fever, scattered pustules over distal extremities, right ankle pain, and left wrist pain with pain on passive extension of fingers…
Think about disseminated gonococcal infection in pts with dermatitis (pustules), tensynovitis (pain with passive flexion of joint), and polyarthalgia (especially if asymmetric and involving both large and small joints)
Confirm with nuclei acid amplification test if the urogenital tract along with blood cultures and synovial fluid sampling. They should also be tested for HIV and chlamydia.
Treatment of asymptomatic pt with positive N. Gonorrhoeae test
Single dose of intramuscular ceftriaxone and single dose of azithromycin
Child with fever, sore throat, odynophagia, and vesicles on the posterior soft palate and no cervical lymphadenopathy…
Think herpangina due to coxsackie A infection in pts with vesicles/ulcers on the posterior oropharynx
Treatment is supportive with saline gargles, analgesics, and antipyretics (non-acidic popsicles or cold fluids can help with the pain)
Aphthous stomatitis
“Canker sores,” which are recurrent ulcers on the anterior mucosa and do not cause systemic symptoms (e.g. fever)
Pt cut on cheek by falling tree limb developed ulcer with clear drainage near wound, now presenting with erythematous nodules in right anterior cervical area…
Think sporotrichosis due to infection with the fungus Sporothrix schenckii
Diagnosis is clinical, but collection of lesion fluid or biopsy cultures is common
Treat with 3-6 months of oral itraconazole
Flu like illness with severe myalgias, arthralgias, thrombocytopenia, and petechiae after sphygmomanometer cuff inflation for 5 min…
Think dengue fever (endemic to tropical/subtropical regions of south/Southeast Asia, pacific islands, Caribbean, and americas)
Treatment is mostly supportive (dengue virus causes increased vascular permeability, so look out for hemodynamic collapse due to extravasation of plasma and loss of intravascular volume)
Pt cut hand while cleaning a saltwater fish tank and developed rapidly progressive cellulitis with hemorrhagic bullae…
Infection with Vibrio vulnificus (a gram negative bacteria that lives in marine environments and infects through open wounds or ingesting oysters)
Collect blood and wound cultures
Treat with IV ceftriaxone and doxycycline (give empirically if suspected as V. Vulnificus is highly fatal in pts with liver disease, diabetes, or rheumatoid arthritis)
Most common side effect of isoniazid
Hepatotoxicity (usually asymptomatic transaminitis that does not require discontinuation unless aminotransferases are at least 5 times the upper limit of normal or if they develop symptoms with aminotransferases at least 3x ULN)
Note: INH is usually given with pyridoxine (vitamin B6) to prevent peripheral neuropathy, parenthesis, and ataxia
Diarrhea, positive FOBT, 8000 leukocytes (65% neutrophils, 13% eosinophils, 20% lymphocytes)…
Intestinal helminth infection (most coughs while in a developing country)
Treat with oral albendazole (mebendazole is better for Trichuris trichiura/whipworm)
Dry cough and dyspnea that resolves and is followed by abdominal discomfort and diarrhea in a world traveler…
Intestinal helminth infection (worm larvae enter through the skin and travel to the lungs where they cause a dry cough, then some are swallowed and attach to the GI tract walls, leaving eggs in the stool
Fever, breast pain, and focal inflammation in a breastfeeding mother…
Lactational mastitis (infection of the breast milk within clogged milk ducts)
Most common culprit is Staph aureus and diagnosis is clinical
Treatment is with oral dicloxacillin or cephalexin, frequent breastfeeding or pumping, and evaluation by a lactational consultant because poor latching is usually the cause
Pt bitten by insect and develops a bright red, well demarcated raised rash that is tender and tense along with ipsilateral lymphadenopathy…
Erysipelas, a common, rapidly spreading, superficial bacterial infection of the skin (most commonly due to Strep pyogenes, group A strep)
Note: cellulitis is a deeper infection and causes much less well demarcated erythema and is flat
Fever and malaise followed by fear of drinking water, drooling, agitation, and ataxia…
Rabies (Ask about possible exposure, especially caves, even if they don’t recall seeing bats that is a huge risk factor)
Note: Hydrophobia (fear of drinking water due to induction of pharyngeal spasm) is pathognomonic for rabies
Most common animal reservoir for rabies
Bats (in the United States)
Dogs (in the developing world)
Treatment for syphilis during pregnancy in a pt who had an anaphylaxic reaction to penicillin
Penicillin desensitization followed by intramuscular penicillin G benzathine (this treats the mother, prevents vertical transmission, and treats the fetus)
Note: Confirm successful treatment with repeat serologic titers (a 4-fold or greater decrease indicates treatment success)
Should pregnant women be screened for syphilis?
Yes, all pregnant women should be screened for syphilis at their first prenatal visit (high risk pts should get a second screening in the third trimester and at delivery)
Postcoital spotting in a pregnant woman with pelvic exam showing mucopurulent cervical discharge…
Think about chlamydia
Confirm with nuclei acid amplification test
Treat empirically with azithromycin and ceftriaxone (if confirmed chlamydia infection give only azithromycin, if confirmed gonorrhea infection give both ceftriaxone and azithromycin)
Common complications of chlamydia during pregnancy
Preterm premature rupture of membranes Preterm labor Postpartum endometriosis Neonatal conjunctivitis (most common cause of infectious blindness) Neonatal pneumonia
Yellow-green malodorous vaginal discharge
Think trichomoniasis
Confirm with wet mount microscopy
Treat with single dose 2g oral metronidazole (if pt is breastfeeding when they take the dose they should express and discard their milk for the 24 hours following the dose because it has high concentration of metronidazole during this time, then they can resume normal breastfeeding)
Fever, tonsillitis, pharyngitis, posterior cervical lymphadenopathy, hepatisplenomegaly, failure of treatment with amoxicillin which triggered a rash…
Infectious mononucleosis, most often due to EBV
Confirm with heterophile antibody test (Note: there is a 25% false negative rate during the first week)
Treatment is symptomatic with avoidance of contact sports for at least 4 weeks
When should corticosteroids be used to treat infectious mononucleosis?
If lymphadenopathy reaches the point of obstructing the airway, aplastic anemia, overwhelming infection, or thrombocytopenia
Child has been tugging on his ear lobe, has limited tympanic membrane motility on insufflation, and bulging of the tympanic membrane on otoscopy, and purulent conjunctivitis…
Otitis-conjunctivitis syndrome secondary to most often secondary to nontypeable H. Influenzae infection
Note: Strep pneumonia and moraxella catarrhalis are also common causes of otitis media but do not cause concurrent conjunctivitis
Treatment for acute otitis media
First-line: 10 days of amoxicillin
Second-line: amoxicillin-clavulanate (if pt failed therapy with amoxicillin within the past month)
Note: clindamycin or azithromycin can be used if the pt has a penicillin allergy
Complications of acute otitis media
Tympanic membrane perforation
Conductive gearing loss
Mastoiditis
Meningitis
Who should receive tetanus prophylaxis after a wound
- pts who have not had a booster in the past 10 years
- pts who have not had a booster in the last 5 years and have visibly dirty or deep wounds
- pts who have not completed the initial tetanus vaccination schedule or their vaccination status is unknown (these pts should also get tetanus immune globulin if their wound is visibly dirty)
Pt admitted for DKA develops a fever and black eschar on a nasal turbinate…
Think about rhino-orbital-cerebral mucormycosis due to infection with rhizopus oryzae
Confirm diagnosis with sinus endoscopy with biopsy and culture
Treat with sinus endoscopic surgical debridement and IV liposomal amphotericin B followed by an oral anti fungal such as posaconazole once stabilized
Note: Mucormycosis often spreads to the palate, orbit, and brain so prompt treatment is important
Risk factors for mucormycosis
- diabetes (especially ketoacidosis)
- hematologists malignancies
- solid organ or stem cell transplant
What is the window period for the 4th generation p24 antigen/HIV-antibody test?
1-4 weeks (Note: This means the test isn’t very sensitive for the first month after exposure and may miss some pts who have HIV that hasn’t built up in the body enough to be detected yet)
When should HIV post exposure prophylaxis be given?
Less than 72 hours after possible exposure (ideally within 1-2 hours after possible exposure)
What tests should be ordered for a pt newly diagnosed with HIV
- Staging tests (CD4 count, viral load)
- Drug resistance testing (HIV genotyping)
- Screening tests (hep B serologies, tuberculosis, hep C, syphilis, and N. Gonorrhea)
Note: Hep B is particularly important to screen for prior to initiation of antiretrovirals because some have dual activity against both HIV and hep B
Basilar meninges enhancement includes brain imaging and CSF analysis shows elevated protein, low glucose, and lymphocytic pleocytosis…
Think tuberculous meningitis (CSF also usually has elevated adenosine delaminates)
Confirm with serial lumbar punctures with SCF examination for acid fast bacteria via smear and culture
Treat with 2 months of 4-drug therapy (isoniazid, rifampin, pyrazinamide, and fluoroquinolone/aminoglycoside) followed by 9-12 months of continuation therapy (with isoniazid and rifampin). Adjuvant glucocorticoid therapy should be given for the initial 2 months to prevent CNS inflammation (glucocorticoids significantly reduces morbidity and mortality)
Child with renal transplant presents with low grade fever, nonproductive cough, dyspnea, diffuse tales throughout lungs, and hypoxia to 82% on room air…
Think pneumocystis jirovechii pneumonia (PCP) in this pt with hypoxia out of proportion to physical exam and renal transplant
Collect induced sputum culture
Treat with trimethoprim-sulfamethoxazole (pt should have been taking bactrim prophylactically)
Pt with nuchal rigidity, headache, altered mental status, and multiple excoriated insect bites…
Think viral meningoencephalitis likely due to the arbovirus West Nile virus (excoriated insect bites are likely from mosquitos)
Collect CSF samples and viral serologies
Treatment is mostly supportive
Most common causes of viral CNS infections in children
Enteroviruses (coxsackievirus, echovirus)
Herpesviruses
Arboviruses (west nile virus)
Pt presents 3 weeks after laparotomy for perforated appendix with swinging fever, dry cough, and R shoulder pain…
Right subphrenic abscess
Confirm with abdominal ultrasound
Treatment for Lyme disease during pregnancy
14-21 days of amoxicillin or cefurixime
Note: There does not appear to be any increased risk of fetal abnormalities if the mother is treated adequately
Cough, pleuritic chest pain, hem Optus is, and imaging with lung nodules surrounded by ground-glass opacities…
Pulmonary aspergillosis (imaging shows this halo sign or cavitations with air-fluid levels)
Confirm with serum fungal biomarkers (galactomannan and beta-D-glucan assay) and sputum sampling for fungal staining and culture (may require bronchoalveolar lavage if inconclusive)
Treat with voriconazole, reduction of any immunosuppression regimen, and surgery (if needed)
Risk factors for invasive pulmonary aspergillosis
- stem cell or solid organ transplant
- prolonged neutropenia
- chronic corticosteroid use
- immunosuppressive conditions (e.g. AIDS)
Most common complication of untreated diphtheria
Myocarditis (a toxin-mediated complication)
Diagnosis and treatment of diphtheria
Diagnose with toxin assay (to prove toxigenic strain)
Culture from respiratory secretions (C. Diphtheriae is a gram-positive bacillus)
Treatment of diphtheria
Erythromycin or penicillin G Diphtheria antitoxin (if severe disease)
Clinical manifestations of neurosyphilis
Early (not part of tertiary syphilis)
- meningitis
- posterior uveitis (most common)
- decreases visual acuity
- infectious CNS arteritis causing ischemia/infarction
Late:
- progressive dementia
- generalized paresis
- tabes dorsalis (uncommon)
Can vaccines be given while the pt is sick?
Yes, unless the pt has a severe illness they can get vaccinated against anything
Tuberculosis post exposure screening
Tuberculin skin test or interferon-gamma release assay immediately after exposure and repeat testing 8-10 weeks after exposure
Empiric antibiotics in pediatric sepsis
Ampicillin PLUS gentamicin or cefotaxime (if 28 days old or younger, when E. coli or Group B strep are the most common culprits)
Ceftriaxone or cefotaxime PLUS vancomycin only if meninges involvement is suspected (if older than 28 days, when Strep pneumoniae or Neisseria meningitidis are the most common culprits)
Workup for neonate (28 days old or less) with fever
CBC Blood culture Urinalysis Urine culture Lumbar puncture (with CSF cell count and CSF culture)
Who should receive oseltamivir for a confirmed influenza infection
- all pts who have been symptomatic for less than 48 hours
- all pts with severe disease requiring hospitalization (no matter how long ago their symptoms started)
- all pts at high risk of having severe complications (no matter how long ago their symptoms started)
Note: High risk pts include age 65 and up, women who are pregnant or within 2 weeks postpartum, pts with underlying chronic medical problems such as pulmonary/cardiac/renal/hepatic disease, immunosuppression, morbid obesity, native Americans, nursing home residents
Pt with nonspecific fever, headache, myalgias, arthralgias, macular/petechial rashes on wrists and ankles, and thrombocytopenia…
Rocky Mountain spotted fever caused by rickettsia rickettsii transmitted by tick bite
Clinical diagnosis (antibiotics should be started before confirmation as serologic tests remain negative early in the disease and delay can lead to encephalitis, pulmonary edema, and arrhythmia)
Treat with doxycycline (even in children and pregnant women)
3-month history of dysuria, pain with ejaculation, and evidence of bacteria and leukocytes on urinalysis that persists despite treatment for UTI…
Chronic bacterial prostatitis (mostly due to the same bacteria common in UTIs such as E. Coli)
Confirm diagnosis with urinalysis collected after prostate massage
Treat with 6-weeks of ciprofloxacin or bactrim
HIV positive IV drug user with CD4 count of 190 who presents with high fever, pleuritic chest pain, cough, and CXR showing nodular opacities in both lung fields including subpleural opacities…
Acute infective endocarditis
Confirm with blood cultures and a TTE (IE is usually right-sided in IV drug users, so TTE is good whereas left-sided IE is more common in the general population and usually requires TEE)
Note: Staph aureus is the most common culprit in IV drug users
Treatment for primary C. Diff colitis
- oral vancomycin OR oral fidaxomycin
- discontinuation of any high-risk antibiotics (e.g. fluoroquinolones, cephalosporins, clindamycin) and replacement with low-risk antibiotics
Note: Add IV metronidazole if pt has severe disease (hypotension, ileus, megacolon)
Treatment for C. Diff colitis with associated ileus
Intracolonic vancomycin PLUS IV metronidazole
Which antibiotics have a low risk of causing C. Diff colitis
Bactrim (TMP-SMX)
Macrolides
Tetracyclines
Aminoglycosides
Treatment for recurrent C. diff colitis
- PO vancomycin with prolonged 2-8 week pulse/taper course
- PO fidaxomycin (unless fidaxomycin was used for primary)
- PO vancomycin followed by rifaximin (if multiple recurrences)
- fecal microbiota transplant (if multiple recurrences)
Note: ANY episode associated with hypotension, ileus, or megacolon should be treated with PO/PR vancomycin AND IV metronidazole
When should a bite from a pet get prophylactic antibiotics?
Any of these high risk features:
- Crush injury
- bites in hands or feet
- wounds on body > 12h or on face > 24h
- cat bites (except on face)
- human bites (except on face)
- immunocompromised pt
Note: Prophylaxis is with amoxicillin-clavulanate (and these pts wounds should be left open to heal by second intention)
What is the most common cause of cellulitis?
Strep pyogenes (group A strep)
Note: Cephalexin is a good choice for cellulitis
Empiric therapy for young pt with fever, headache, AMS, and focal neurologic deficits
Acyclovir, vancomycin, and ceftriaxone (to treat for encephalitis)
Note: Collect lumbar puncture CSF culture prior to antibiotics if possible
Treatment of active tuberculosis in a pregnant woman
3-drug therapy (Isoniazid, rifampin and ethambutol) for 2 months followed by just isoniazid and rifampin for an additional 7 months. Pregnant women should also receive pyridoxine (vitamin B6) supplementation time help prevent isoniazid-induced neurotoxicity as in nonpregnant patients as well.
Note: None of these drugs are teratogenic, but pyrazinamide (a component of the normal 4-drug therapy) isn’t that important and has uncertain safety in pregnancy
Most common cause of community acquired PNA in HIV patients
Strep pneumoniae (an encapsulated bacterium that is particularly invasive in HIV pts who have deficits in opsonuzation, humoral immunity, and macrophage/neutrophil function)
Empiric treatment for PNA in preschool age children (or children with focal lung findings)
High-dose amoxicillin (usual culprit is Strep pneumoniae)
Empiric treatment for PNA in older children or any hemodynamicaly stable child with bilateral lung findings
Azithromycin (usual culprit is Mycoplasma pneumoniae)
Child with new onset emotional lability, decline in school performance, distal hand movements, facial grimacing, knee jerking, decreased strength, heart murmur, and migratory arthritis…
Acute rheumatic fever (clinical picture of Sydenham chorea and possible carditis)
Treat with long-acting intramuscular penicillin until adulthood for secondary prevention and to eradicate the bacteria. Corticosteroids can also be used in severe cases of Sydenham chorea.
Diagnostic criteria for acute rheumatic
2 major OR 1 major and 2 minor
Major criteria (JONES criteria): Joints (migratory arthritis) ❤️ carditis Nodules, subcutaneous Erythema marginatum Sydenham chorea
Minor criteria: Fever Arthralgias Elevated ESR/CRP Prolonged PR interval
Elderly woman with painful, unilateral, localized rash with fluid-filled blisters…
Localized herpes zoster infection (shingles)
Diagnosis is clinical
Treat with oral acyclovir if pt has had symptoms for less than 72 hours (this reduces risk of transmission, new lesion formation, and possible postherpetic neuralgia)
Treatment for disseminated herpes zoster (grouped vesicles affecting more than just one dermatome and surrounding area)
Hospitalization for IV acyclovir (to reduce risk of complications such as ocular infection)
What infection precautions should be used for pts hospitalized with herpes zoster infections?
Standard precautions and lesion covering (for localized infection)
Standard, contact, and airborne precautions (for disseminated infection)
Note: precautions are only needed until the lesions crust over (indicating they are no longer infectious)
Fever, chills, myalgias that quickly evolve into hypotension, diffuse macular rash, and shock with multiple organ failure in a pt with recent repair of a deviated nasal septum…
Think toxic shock syndrome due to nasal packing or tampons infected with Staph aureus that release a toxic shock syndrome toxin that acts as a superantigen to cause widespread T cell activation and massive cytokine release
Treat with removal of source (nasal packing, tampon, etc), IV fluids, clindamycin (to prevent toxin production), and vancomycin/nafcillin (to eradicate the bacteria)
Immigrant from Ghana with dysuria, terminal hematuria, and peripheral eosinophilia…
Urinary schistosomiasis (parasitic blood fluke)
Confirm with the identification of eggs of urine sediment microscopy
Treat with praziquantel
Pt rescued from burning building with headache, nausea, AMS, lactic acidosis of 10, pulse ox 98%, troponin 0.36…
Carbon monoxide poisoning due to smoke inhalation
Confirm diagnosis with an ABG for carboxyhemoblobin level (normal pulse oximetry can’t tell the difference between oxyhemoglobin and carboxyhemoglobin)
Treat with high-flow supplemental oxygen, mechanical ventilation if needed, and hyperbaric oxygen if severe
Mono-like syndrome with generalized macular rash on face, trunk, palms, and soles, as well as a painful mucocutaneous ulcer on the posterior pharynx…
Acute HIV infection
Confirm with HIV screen AND viral load (pt may not have seroconverted yet, so antibody screening alone may be negative)
Treat with combination antiretroviral therapy
Pt has symptoms of a viral URI and then develops 2 weeks of purulent yellow-green nasal discharge, headache, and facial pain…
Acute bacterial rhinosinusitis
Clinical diagnosis with any of the following:
- persistent symptoms for 10 days or more
- severe symptoms (fever over 39, purulent nasal discharge, facial pain for at least 3 days)
- “double sickening” (viral URI that resolves followed by clinical deterioration)
Treat with 5-7 day course of oral amoxicillin-clavulanate (second line is doxycycline or fluoroquinolones)
Infant with severe weakness, not feeding, and lives on a farm…
Infantile botulism (due to ingestion of C. Botulinum spores in farm soil/honey that produces a neurotoxin that inhibits presynaptic acetylcholine release)
Diagnosis is mostly clinical but can be confirmed with stool spore or toxin assays
Treatment is with IV botulism immunoglobulin and admission to ICU to monitor for sudden respiratory decompensation (may take months to recover, but full recovery is likely with treatment)
Underweight newborn with no red light reflex, failure of bilateral hearing test, and continuous murmur over the left infraclavicular region…
Congenital rubella syndrome (cataracts, hearing loss, and patent PDA)
Note: Mothers should be immunized with MMR vaccine prior to conception because they cannot receive the live-attenuated vaccine during pregnancy
Immigrant with maculopapular rash that spreads from the head downwards and is associated with arthralgias/arthritis…
Adult rubella
Confirm with serology
Pt with fever, cough productive of white sputum, pharyngeal erythema, tender anterior cervical lymphadenopathy, and tonsilar exudates…
Acute pharyngitis
This pt has 3 Centor criteria so a rapid strep test should be ordered to see if they have group A strep pyogenes
Treat with 10 days of penicillin V or amoxicillin (cephalexin can be used in pts with mild penicillin allergies and azithromycin can be used in pts with severe penicillin allergies)
Cantor criteria
3 or more centor criteria indicates someone should be tested for group A strep pyogenes with a rapid strep test:
- tonsilar exudate
- tender anterior cervical lymphadenopathy
- fever
- absence of cough
Absolute contraindications to the varicella zoster vaccine
- anaphylaxic to neomycin
- anaphylaxis to gelatin
- pregnancy
- immunodeficiency (long term immunosuppressive therapy, hematologists or solid tumors, severe HIV infection)
Note: Household contacts of immunodeficiency people (e.g. transplant recipients) should get the vaccine but be monitored closely for a rash, which occurs in some people with this live-attenuated vaccine and can be contagious
Treatment for asymptomatic lead toxicity
Levels <45 don’t require treatment (normal is <5)
Levels 45 and over should be treated with meso-2,3-dimercaptocuccinic acid (DMSA, succimer)
Levels 70 and over or any level associated with encephalopathy are medical emergencies requiring hospitalization and should be treated with dimercaprol AND calcium disodium edetate (EDTA)
Pt found with pinpoint pupils, diaphoresis, productive cough, SOB, vomiting, fecal/urinary incontinence…
Organophosphate poisoning, usually from agricultural pesticides (leading to inhibition of acetylcholinesterase at the neuromuscular junction)
Diagnosis is clinical (DUMBELS): Defecation Urination Mitosis Bronchospasm/bradycardia Emesis Lacrimation Salivation
Treatment includes resuscitation (oxygen, fluids, intubation if needed), decontamination (removal of clothes), atropine AND pralidoxime (Note: only pralidoxime affects nicotinic symptoms such as muscle weakness/paralysis), activated charcoal (if within 1 hour of exposure)
Ginkgo biloba
An herbal supplement used for memory enhancement that also increases bleeding risk
Ginseng
An herbal supplement that improves mental performance and also increases bleeding risk
Saw palmetto
An herbal supplement used for BPH that can cause mild stomach discomfort and increases bleeding risk
Black cohosh
An herbal supplement used for postmenopausal symptoms that can also cause hepatic injury
St. John’s wort
An herbal supplement used for depression and insomnia that can cause serotonin syndrome (if used with antidepressants), decreased INR (in pts on warfarin), decreased efficacy of OCPs, and can also cause hypertensive crisis
Kava
An herbal supplement used for anxiety and insomnia that can also cause severe liver damage
Licorice root
An herbal supplement used for stomach ulcers and viral infections that can also cause hypertension and hypokalemia (increases available cortisol)
Echinacea
An herbal supplement used to treat colds and the flu that can cause anaphylaxis (especially in asthmatics)
Ephedra
An herbal supplement used for the common cold, weight loss, and athletic performance that can cause hypertension, arrhythmias, strokes, and seizures
Who should be screened for lead toxicity?
All at risk children:
- history of pics
- foreign-born children
- homes built prior to 1978
- low socioeconomic status
- use of painted toys made before 1978 or made outside of the US
Clinical manifestations and treatments of hypothermia
Mild 32-35 C: tachycardia, tachypnea, ataxia, dysarthria, shivering (treat with passive external warming by removing wet clothes and covering with blankets)
Moderate 28-32 C: bradycardia, lethargy, hypoventilation, atrial arrhythmias (treat with active external warming by using warm blankets, heating pads, and warm baths)
Severe <28 C: coma, cardiovascular collapse, ventricular arrhythmias (treat with active internal rewarming with warmed pleural or peritoneal irrigation, and warm humidified oxygen)
Note: Warmed IV fluids can be used for anyone with hypotension
Treatment for heat stroke
Maximizing evaporative cooling by removing clothes from pt to maximally expose skin, spray pt with a tepid water mist or cover with wet sheet while using large fans to circulate air
Note: Ice water gastric/rectal lavages can also be used as adjunctives, but only after augmenting evaporative cooling
suicide attempt with tachycardia, hyperthermia, dizziness, vomiting, tachypnea, bicarbonate of 14…
Salicylate poisoning
Treat with alkalinization of the plasma and urine with IV sodium bicarbonate (this deactivates the toxic effects of salicylic acid by making it a charged molecule that can not pass the blood brain barrier). Supplemental glucose and activated charcoal (if within 2 hours of ingestion) can also be used.
Note: Dialysis is indicated if the pt has pulmonary edema, fluid overload limiting how much sodium bicarbonate can be infused, AMS, renal failure, cerebral edema, severe acidosis, or very high salicylate levels
Treatment for ethylene glycol poisoning
Fomepizole (a competitive inhibitor of alcohol dehydrogenase)
Treatment for methanol poisoning
Fomepizole (a competitive inhibitor of alcohol dehydrogenase)
What is the most common cause of chronic (>2 weeks) unilateral lymphadenitis in children
Cat scratch disease due to bartonella henselae
Treat with azithromycin (to speed recovery and avoid suppuration of lymph nodes)
Acute onset flushing, throbbing headache, palpitations, and abdominal cramps in a group of people after eating the same fish…
Scombroid poisoning due to ingestion of improperly stored seafood (due to accumulated histamine because histidine can be decarboxylated to histamine at temperatures over 15C)
Treatment for pediatric obstructive sleep apnea
Tonsillectomy and adenoidectomy
Treatment for panic disorder
SSRI/SNRI and/or cognitive behavioral therapy
Note: Benzodiazepines can be used for acute distress
Stages of change model
Precontemplation (not ready to consider change)
Contemplation (considering change)
Preparation (decision to change)
Action (making the change)
Maintenance (changes have been integrated, focus is on preventing relapse)
Identification (changes are incorporated into sense of self, changes are automatic)
Pt with schizophrenia has been off medications for months and now won’t respond to questions, won’t move on his own, and when you passively raise his hand over his head and let go it remains there…
Catatonia (a syndrome of psychomotor disturbance that can happen in severely ill pts with psychotic disorders)
Clinical diagnosis:
- immobility or purposeless activity
- mutism or decreased response to stimuli
- negativism (resistance to instruction/movement)
- posturing (maintaining positions against gravity when passively placed in them)
- waxy flexibility (initial resistant of movement then maintenance of new posture)
- echolalia, echopraxia (mimicking speech and movements)
Can confirm diagnosis with lorazepam challenge test (1-2mg IV lorazepam often partially relieves symptoms, but not always)
Treatment is with benzodiazepines or electroconvulsive therapy
Major differential for chronic psychosis
- substance-induced psychotic disorder
- psychosis due to another medical condition
- schizophreniform
- schizophrenia
How long do SSRIs need to be stopped before placing a pt on an MAO inhibitor such as phenelzine?
At least 14 days, but fluoxetine has such a long half like it needs to be stopped for at least 5 weeks before starting an MAOi (this is to prevent serotonin syndrome)
Anxiety, agitation, diaphoresis, hypertension, tachycardia, hyperthermia, tremor, myoclonus, and hyperreflexia…
Serotonin syndrome (due to excess SSRI, MAOi, linezolid, MDMA)
Diagnosis is clinical: mental excitability, autonomic dysrefulation, and neuromuscular excitability (hyperreflexia, tremors)
Treat by discontinuing all seritonergic medications, supportive care, sedation with benzodiazepines, and the serotonin antagonist cyproheptadine (if supportive measures fail)
Suicide assessment
- Ideation (wishing you die or wishing to not wake up are passive ideations, thinking about killing oneself is an active ideation)
- plan (have you thought about how you would kill yourself)
- Intent (how close have you come to acting on a plan)
Treatment for sleep terrors
Usually none necessary, will stop in 1-2 years
Note: low-dose benzodiazepines can be used if episodes are frequent, distressing, and persistent
Treatment for bipolar disorder
Usually either lithium or valproate (plus an antipsychotic if there are severe manic symptoms like aggression, psychosis, or high-risk behaviors)
Note: lithium is preferred over valproate if pt is pregnant or suicidal
AMS, high fever, autonomic instability, muscle rigidity, decreased reflexes…
Neuroleptic malignant syndrome
Treat with dantrolene
A few hours after getting IM haloperidol pt develops sudden, sustained contraction of neck muscles and sustained elevation of the eyes in an upward position…
Acute dystonia (an extrapyramidal effect, in this case with torticollis and an oculogyric crisis)
Treat with diphenhydramine or benztropine
Subjective restlessness and inability to sit still after getting haloperidol
Akathisia (an extrapyramidal symptom)
Treat with propranolol
Treat refractory cases with lorazepam or benztropine
After being on haloperidol for one year or develops twitching movements of the face and mouth…
Tardive dyskinesia
Treat with valbenazine or deutetrabenazine
A few months after starting haloperidol, pt develops gradual onset tremor, rigidity, and bradykinesia…
Drug-induced Parkinsonism
Treat with benztropine or amantadine
Diagnostic criteria for a major depressive episode
Depressed mood or anhedonia PLUS 5/9 SIGECAPS symptoms for at least 2-weeks duration:
Sleep disturbance Interest loss Guilt Energy low Concentration impaired Appetite changes Psychomotor retardation Suicidal thoughts Depressed mood
Treatment for postpartum depression
SSRI (Sertraline and paroxetine can be used safely even when breastfeeding)
How long should a pt be kept on an SSRI after having a single episode of major depression?
At least 6 months, then you can try tapering off
Schizoaffective disorder bipolar type vs bipolar disorder with psychotic features
In order to be termed schizoaffective disorder the pt much have at least 2 weeks where they have psychotic features with no mood symptoms
In mood disorder with psychotic features, the psychotic features only happen when the pt is experiencing mood symptoms
What are the most common characteristics associated with a request for euthanasia?
- loss of autonomy/control in the dying process
- loss of dignity
- loss of ability to engage in pleasurable activities
Risk factors for lithium toxicity
- low GFR (renal failure, elderly pts)
- volume depletion
- drug interactions (thiazide diuretics like chlorthalidone, ACE inhibitors, NSAIDs, etc)
Manifestations of lithium toxicity
Acute:
-nausea, vomiting, diarrhea
Chronic:
-ataxia, confusion, agitation, tremor
Treatment for lithium toxicity
-IV hydration
-lithium levels every 2-4 hours
Hemodialysis (if level > 4 or level > 2.5 with signs of renal failure or increasing levels despite IV fluids)
Note: Bowel irrigation can be used for pts with an asymptomatic acute overdose
Somatic symptom disorder vs illness anxiety disorder
In somatic symptoms disorder pts have excessive anxiety and preoccupation with one or more specific symptoms, even if there have been many negative tests
In illness anxiety disorder pts have a fear of having a serious illness despite few or no symptoms, even if there have been many negative tests
Treatment for somatic symptom disorder
-regularly scheduled visits with a single provider (reduces healthcare use compared to symptom based appointments)
-avoiding unnecessary testing and specialist referrals
-legitimizing symptoms but making functional improvement the goal
-focus on stress reduction
Mental health referral once good relationship if pt will accept
PTSD vs acute stress disorder
Acute stress disorder has the same symptoms but happens within 1 month of the traumatic event (but symptoms must last at least 3 days)
PTSD is diagnosed when these symptoms last more than 1 month
Treatment for acute stress disorder
- Trauma-focused cognitive behavioral therapy
- medication (in insomnia or intense anxiety)
- follow up to see if it has progressed to PTSD
Treatments for smoking cessation
- nicotine replacement therapy (patch or short acting or both)
- bupropion (contraindicated in pts with seizures or eating disorders)
- varenicline (most effective, but may increase risk of cardiovascular events)
Treatment for insomnia
- cognitive behavioral therapy including sleep hygiene (first-line)
- hypnotic medications (second line, with particular care in the elderly)
Treatment of delirium
- reassurance, reorientation, safety watch
- low dose haloperidol (if pt presents a danger to themself or staff)
Indications for electroconvulsive therapy
To treat depression, bipolar depression or mania, or catatonia in the following circumstances:
- refractory to medications
- psychotic features present
- refusal to eat/drink
- imminent risk of suicide
- pharmacotherapy is not an option (poor tolerance, comorbidities, pregnancy)
- history of ECT response
Contraindications to electroconvulsive therapy
No absolute contraindications (relatively safe in pregnancy)
NOTE: Pts with severe cardiac disease, recent MI, space occupying brain lesion, recent stroke, or unstable aneurysm are at increased risk for complications
Treatment for borderline personality disorder
- Dialectical behavior therapy
- adjunctive mood stabilizers and antipsychotics as needed
- antidepressants if comirbid mood or anxiety disorder
Anorexic pt who is hospitalized develops pulmonary edema and lower extremity pitting edema…
Refeeding syndrome (due to increased insulin from refeeding causing cells to take up phosphorus, potassium, magnesium, and thiamine and depletion’s intravascularly; pts can also have CHF symptoms due to weak strophic hearts)
Monitor closely with frequent chem 8 and replete electrolytes and thiamine aggressively (phosphorus is especially important to replete as it is needed for ATP, oral supplementation is preferred to IV)
Treatment for OCD
- SSRI
- exposure and response prevention therapy (a type of cognitive behavioral therapy where they are exposed to obsessive stimuli but prevented from carrying out compulsive behaviors)
First line treatment for agitation that risks self harm in the setting of PCP overdose
- Benzodiazepines (e.g. lorazepam)
- Antipsychotics (e.g. haldol) can be used if benzodiazepines alone are not sufficient
- physical restraints (if needed)
Note: If pt has only mild symptoms of PCP overdose (detachment, withdrawal, dissociation) the first treatment should be providing a low stimulation environment
Good prognostic indicators in schizophrenia suggesting more treatable disease
- later onset (peak onset is usually early 20s in med and late 20s in women)
- female sex
- acute onset with precipitation
- predominantly positive symptoms (antipsychotics are more effective at treating positive symptoms)
- no family history
- short duration of active symptoms
Diagnostic criteria for Tourette syndrome
Multiple motor and at least 1 vocal tic that persist for at least 1 year with an onset before age 18 (tics do not have to appear concurrently)
Note: vocal tics include grunting, snorting, throat clearing, barking, yelling, and coprolalia
Note: If the pt only has motor OR vocal tics but not both it’s considered chronic tic disorder. If the tics have not persisted for more than 1 year it’s considered provisional tic disorder.
Treatment for Tourette syndrome
- behavioral therapy (habit reversal training)
- antidopaminergic agents (such as the dopamine depleting agent tetrabenazine or antipsychotics such as risperidone or aripiprazole)
- alpha 2 adrenergic receptor antagonists (such as clonidine or guanfacine)
Are tics in Tourette syndrome voluntary?
They can be suppressed voluntarily for brief periods of time but usually are preceded by irresistible urges that are only relieved by the tic
Treatment of psychosis in a patient being treated for Parkinson’s
- reduce dose or number of antiparkinsonian medications to minimum necessary (reduce/discontinue the least potent medications first: anticholinergics, amantadine, MAO-B inhibitors, COMT inhibitors, dopamine agonists, then finally reducing carvidopa/levodopa only if possible)
- second generation antipsychotic with few movement side effects such as quetiapine or clozapine (these can be added if the pt is still having psychotic symptoms while on the minimum treatments necessary to treat Parkinson’s symptoms)
- pimavanserin is a serotonin 5HT-2A receptor reverse agonist that can also be used to treat psychotic symptoms in Parkinson’s patients
Joint aspiration with rhomboid crystals with positive birefringence under polarized light…
Calcium pyrophosphate dihydrate crystals seen in pseudogout and hereditary hemochromatosis
Most common cause of a colles’ fracture
Distal radius fractures are usually caused by a fall on an outstretched hand (FOOSH) in a pt with osteoporosis
Note: this fracture can usually be managed conservatively with sugar tong splinting +/- closed reduction, but may need surgical intervention (if severe displacement or angulation)
4 yo boy with a 6-day history of fevers, severe diaper rash, conjunctivitis, blanching macular rash on extremities, and erythema of the tongue and oral mucosa…
Kawasaki disease, a febrile vasculitis
Workup includes CRP, ESR, and echocardiogram (at time of diagnosis and at 2 and 6 weeks after diagnosis to evaluate for the most concerning complication: coronary artery aneurysm)
Treat with aspirin and IVIG
How does IVIG interact with vaccines
Live vaccines (e.g. MMR and varicella) should not be given for 11 months after receiving IVIG because it interferes with producing a robust immune response
How can you differentiate septic arthritis from post-viral transient synovitis in a child with unilateral hip pain?
The following make septic arthritis more likely:
- unable to bear weight
- leukocytosis
- fever of 38.5 or more
- ESR > 40 or CRP > 2
Note: Pts with 3 or more of these are very likely to have septic arthritis and should have immediate joint aspiration to confirm and decompress the joint and be initiated on IV vancomycin
Treatment for pediatric septic arthritis
- immediate joint aspiration for diagnosis confirmation and decompression
- IV vancomycin (plus cefotaxime if < 3 months old due to risk for group B strep agalactiae and gram-negative bacilli)
- surgical drainage and debridement of joint
What WBC count on joint aspiration is highly suggestive of septic arthritis?
> 50,000 with > 90% neutrophils
Anti-Ro/SSA and Anti-La/SSB antibodies
Associated with Sjögren’s syndrome (not very sensitive, only 50% of cases test positive for one of these antibodies)
Focal submandibular mass in a pt with Sjögren’s syndrome
Think about B-cell non-Hodgkin lymphoma (Sjögren’s causes polyclonal B cell activation and infiltration of salivary glands which causes lymphoma in about 5% of patients)
Physiologic genu valgum
A normal curvature of the legs that occurs between the ages of 2 and 5 where the knees are closer together than the feet when standing up (looks like “knock knees”), but is normal during development and resolves by age 7
Note: Radiographs should be taken if severe, progressive, persistent past age 7, unilateral, cause of medial thrust of knees while walking, or associated with short stature
Child suddenly refuses to move arm immediately after being lifted by forearm and now holding arm extended and pronated
Radial head subluxation (nursemaids elbow)
Clinical diagnosis (radiographs not required)
Treat with hyperpronation of forearm or supination of forearm with flexion of elbow
Wrist pain in 25 yo M after falling into outstretched hand with severe tenderness on palpating of the radial dorsal aspect of the wrist and minimally decreased range of motion…
Scaphoid fracture due to forceful wrist dorsiflexion
tenderness at the anatomic snuffbox is suggestive, but radiographs should be taken at time of injury and also repeat imaging 1-2 weeks later as xrays are often initially negative (if high suspicion can also do MRI at time of injury or bone scan 3-5 days post injury)
Treat with a short arm thumb spica cast with serial xrays every 2 weeks to monitor healing (surgical management may be necessary if there is an associated tilt of the lunate, fracture displacement > 1mm, nonunion during follow up, osteonecrosis, or scapholunate dissociation)
How should severed body parts be preserved during transportation?
Wrapped in gauze moistened with sterile saline and placed in a sealed sterile plastic bag
The bag should be placed in an insulated cooling container filled with a 50/50 mix of ice and sterile saline or water
Asymmetric peripheral oligoartheritis in a pt with recent gastroenteritis…
Reactive arthritis
Synovial fluid aspiration will be inflammatory (elevated WBCs) but culture negative
Treat with NSAIDs or intraarticular glucocorticoids (systemic glucocorticoids or DMARDs can be used for refractory cases)
Note: Antibiotics should also be given in the case of chlamydia infection or non-self-limiting gastrointestinal infection)
Circinate balanitis
Painless, shallow ulcers that appear on the glans of the penis as an extraarticular manifestation of reactive arthritis and may persist for months (unlike the painless ulcers of syphilis, which resolve in 3-6 weeks, and lymphogranuloma venereum, which resolve within days)
Treatment is with topical steroids
Extraarticular manifestations of reactive arthritis
- Ocular (uveitis, conjunctivitis)
- Genital (urethritis, cervicitis, prostatitis)
- Dermal (circinate balanitis, keratoderma blennorrhagicum)
- Oral ulcers
Diagnostic criteria for osteoporosis
DEXA scan showing T score of -2.5 or less
OR
History of a fragility fracture (any fracture occurring from a fall from standing height or less)
Note: T score between -1 and -2.5 indicates osteopenia
Who should be started on pharmacological therapy for osteoporosis?
- T score of -2.5 or less
- History of low-trauma hip or vertebral fractures (regardless of T-score)
- FRAX score showing 10-year probability of major osteoporotic fracture >20% or of hip fracture >3%
Note: Bisphosphonates (e.g. alendronate) are first line treatments along with calcium and vitamin D supplementation
Unilateral numbness and parasthesias affecting the 1st, 2nd, and 3rd digits that is worse at night and better with “shaking it out”…
Carpal tunnel syndrome (caused by compression of median nerve as it passes under the transverse carpal ligament)
Confirm diagnosis with a positive phalen test (reproduction of symptoms within 1 min of hyperflexion of the wrist) or tinel sign (tingling sensation elicited by tapping the median nerve in the carpal tunnel)
Initial treatment is to use wrist splints, especially at night, to prevent excessive wrist flexion/extension. Surgery can be considered for pts with mod-sev symptoms that persist for more than 6 months or if there are associated neurological deficits (as determined by nerve conduction studies showing demyelination)
Negatively birefringent needle-shaped crystals on arthrocentesis…
Monosodium urate crystals seen in gout
Treat acute gout with NSAIDs, oral glucocorticoids, colchicine, or intraarticular glucocorticoids
Use allopurinol or probenecid for prophylaxis against future attacks. Febuxostat can also be used unless there is high risk for cardiovascular disease
Risk factors for gout
- Medications (diuretics, low-dose aspirin, immune suppressants)
- recent surgery/trauma
- CKD
- volume depletion
- obesity, high protein/high fat diet, excess alcohol
26 yo M with slowly progressive lower back pain that is worse in the morning and better with exercise…
Ankylosis spondylitis
Confirm diagnosis with xrays of the sacroiliac joint
Monitor disease progression with serial xrays of the pelvis, lumbar spine, and cervical spine. These patients should also be monitored for restrictive lung disease due to limited costovertebral joint motion.
Treatment with lifestyle modification (regular aerobic exercise, immediate smoking cessation) and NSAIDs for pain
Note: These pts do not have decreased life expectancy
Who should be treated for scoliosis?
Back braces are helpful in preventing progression of scoliosis in patients who have not completed skeletal maturity (puberty is less than tanner stage 5)
Surgical evaluation is indicated for pts with severe scoliosis (Cobb angle of 40 degrees or more)
Note: No treatment for follow-up is necessary for pts who have completed puberty and have a Cobb angle less than 40 degrees
Knee swelling after MVA where his knee hit the front dashboard…
Posterior cruciate ligament injury (dashboard injury) due to forced posterior movement of the tibia in relation to the femur
Note: Anterior cruciate ligament injuries usually occur after hyperextension of the knee and are often associated with a popping sound
60 yo male with subacute onset of diffuse proximal muscle pain and stiffness with no muscle or joint tenderness and stiffness on active range of motion but not on passive range of motion…
Polymyalgia rheumatica
Note: often associated with giant cell arteritis so look out for new headaches
Diagnostic criteria for giant cell arteritis
3/5 of the following (94% sensitive and 91% specific):
- age 50 or greater (greatest risk factor)
- new onset localized headache with fever and visual disturbances
- ESR > 50
- tenderness or decreased pulse of temporal artery
- temporal artery biopsy showing necrotizing arteritis with mainly mononuclear cells
Next step for 52 yo female with new localized temporal headache and ESR of 58
High-dose glucocorticoids (e.g. prednisone 40mg daily or more) while waiting for temporal artery biopsy
75 yo M with lower back pain that radiates to the gluteal region and is exacerbated by lumbar extension and relieved by sitting down or bending over his knees…
Lumbar spinal stenosis
Confirm diagnosis with MRI of the lumbar spine
Treatment is with physical therapy and oral pain medications. Surgical intervention (such as decompressive lamonectomy) can be considered for pts with severe refractory symptoms
How should you test for a complete Achilles’ tendon rupture?
Thompson test (have pt lie prone/belly down with feet hanging over table and squeeze the pts calf muscles; if there is no plantar flexion of the foot this indicated complete tear of the Achilles’ tendon)
Note: If Thompson test is negative you can get an MRI, which is more sensitive and can also diagnose partial tendon tears
Treatment for MCL tear
- RICE (rest, ice, compression, elevation)
- oral analgesics
- progressive return to activity as tolerated
- surgical intervention (if severe or complete tear)
Knee injury with locking sensation with extension of the knee and joint line tenderness…
Meniscal tear
Traumatic accident followed by R groin pain, inability to extend the knee against resistance, loss of knee jerk reflex, and sensory loss over anterior/medial thigh/medial shin/arch of foot…
Femoral nerve injury
24 yo F with subacute onset of poorly localized pain at the anterior knee that worsens with squatting and going up/down stairs…
Patellofemoral pain syndrome (most common cause of knee pain in young adults)
Confirm diagnosis with the patellofemoral compression test (pain elicited by extending the knee while compressing the patella against the knee joint)
Treat with exercises to stretch and strengthen the thigh muscles and avoidance of activities that aggravate the pain (may take weeks to months to resolve, NSAIDs usually aren’t very effective)
Adolescent with anterior knee pain that is worsened by physical activity and relieved with rest and exam showing tenderness and swelling at the tibial tuberosity…
Osgood-schlatter disease (pain at the insertion site of the patellar tendon, often happening after a growth spurt)
Anterior knee pain and swelling in a pt who works extensively on their knees…
Prepatellar bursitis
Note: Look out for secondary infection causing septic bursitis with staph aureus
Episodic anterior knee pain localized just inferior to the patella in a basketball player…
Patellar tendonitis
Lateral shoulder pain that is exacerbated by lifting the arm over the head with weakness of shoulder abduction…
Rotator cuff tear
Note: if there was no weakness it would likely be simply rotator cuff tendonitis, and if there was stiffness and reduced range of motion it would likely be a frozen shoulder
60 yo M with subacute pain in the shoulder and hip girdles, morning stiffness that lasts 2 hours, weight loss, elevated ESR, normal CRP, and benign physical exam…
Polymyalgia rheumatica
Diagnosis is clinical with elevated ESR adding weight
Treat with low-dose glucocorticoids (prednisone 10-20 mg daily), which usually cause rapid relief of symptoms
Note: These patients should also be asked about symptoms of giant cell arteritis (headache, jaw claudication, scalp tenderness, visual changes) as these are often comorbid
Treatment for acute gout attack
- Indomethacin (unless history of GO bleed/ulcers or renal failure)
- colchicine (unless advanced renal failure)
- intraarticular corticosteroids (if contraindications to NSAIDs/colchicine and only one joint is involved; septic arthritis MUST be ruled out prior to injection)
- oral prednisone (if contraindications to NSAIDs/colchicine and multiple joints are involved)
40 yo M who frequently travels to tropical regions of central/South America, Africa, and Asia develops a transient febrile illness followed by the development of severe, bilateral, symmetric, persistent polyarthralgias of the hands, wrists, and ankles…
Chikungunya fever (caused by a mosquito-borne virus)
Confirm diagnosis with PCR
Treat with fluids, pain relief, and acetaminophen (most cases resolve within 2 weeks, but some progress to chronic joint pain)
Anti-dsDNA antibodies
More specific for SLE than anti-nuclear antibodies, but still fairly sensitive (66-95% sensitivity)
Note: Anti-dsDNA antibodies can also be used as an indicator of disease activity while monitoring and are especially associated with the development of lupus nephritis
Anti-centromere antibodies
Sensitive for detection of CREST scleroderma
Anti-mitochondrial antibodies
Sensitive to detect primary biliary cirrhosis
Anti-smith antibodies
Highly specific for SLE, but not very sensitive (25% sensitivity)
Treatment for a patient with SLE presenting with fatigue, arthralgias, chest pain, positive anti-dsDNA, and mild unilateral pleural effusion…
This pt is having a lupus exacerbation with lupus arthritis and pleurisy causing a pleural effusion
Treatment should be with hydroxychloroquine (effective at treating the arthralgias and serositis) and temporary low-dose prednisone (5-15 mg prednisone daily) until the hydroxychloroquin takes effect
Note: If the kidneys or CNS were significantly involved, high-dose prednisone would be needed
Lower leg pain and tibial tenderness in a young female training for a marathon…
Tibial stress fracture (due to repetitive tension/compression of the bone without adequate rest between)
Clinical diagnosis (pain localized to a specific area of the tibia that increases with jumping/running and is associated with local swelling and point tenderness); initial xrays are usually negative and may take 4 weeks to show signs of fracture (sclerosis, cortical thickening, periostial elevation, visible fracture line). MRI should be used if confirmation of diagnosis is needed
Treatment is with pneumatic splinting, reduced weight bearing (e.g. crutches), and a graduated exercise program over 8-12 weeks
Saddle anesthesia
Loss of sensation over the inner buttocks, perineum, and inner thighs that is often associated with causes equine syndrome
Signs of cause equine syndrome
- saddle anesthesia (loss of sensation over buttocks/perineum/inner thigh)
- acute urinary retention
- motor deficits
Red flag features of lower back pain that warrant imaging studies
- constitutional symptoms (fever, weight loss, etc)
- age over 50
- higher risk for infections (IV drug use, immunosuppression, recent bacterial infection)
- nocturnal pain
- higher risk for malignancy (history of malignancy, smoker)
When should you get X-rays to evaluate lower back pain?
- suspicion for osteoporosis/compression fracture
- suspicion for malignancy
- suspicion for ankylosis spondylitis (insidious onset, nocturnal pain, better with movement)
When should you get an MRI to evaluate lower back pain?
- sensory/motor deficits
- cause equine syndrome
- suspected epidural abscess/infection or vertebral osteomyelitis
- known malignancy
Note: If pt has a contraindication to MRI they should get a bone scan instead
First line treatment of hypertension in patients with gout
losartan (has a mild uricosuric effect)
Note: Most diuretics decreased the fractional excretion of urate and should be avoided when possible
When should you get X-rays to confirm adolescent idiopathic scoliosis?
If there is spinal rotation of 7 degrees or more (or 5 degrees or more in children with obesity) in the forward bend test using a scoliometer or if there is an obvious deformity
Note: If the Cobb angle on radiographs is 10 degrees or more the diagnosis of scoliosis is confirmed and a back brace can be considered if grown hasn’t completed (a Cobb angle of 40 degrees or more requires surgical evaluation)
DMARDs
Disease-modifying antirheumatic drugs:
- methotrexate (common initial therapy when combined with temporary oral prednisone)
- TNF inhibitors (more effective, but increased risk of opportunistic infections, must be screened for TB prior to treatment)
- leflunomide
- hydroxychloroquin
- sulfasalazine
CT head showing a thickened calvarium with an inhomogenous bone density with “cotton wool” appearance…
Pagets disease of the bone (a disease characterized by increased bone turnover common in older pts, usually asymptomatic)
Confirm diagnosis with calcium (usually normal) and alkaline phosphatase (usually elevated) levels and a radionuclide bone scan to identify other affected areas
Treatment is with bisphosphonates to reduce bone turnover (pts with bone pain or high risk areas such as the skull affected should be started on treatment)
Note: Hearing loss is common in these pts but can be slowed with bisphosphonates and calcitonin
Painless proximal muscle weakness, elevated creatine kinase, transaminitis, elevated ESR/CRP…
Polymyositis (an inflammatory myopathy often triggered by a viral infection or underlying malignancy)
Confirm diagnosis with ANA, anti-Jo-1 antibodies, and a muscle biopsy
Treat with systemic glucocorticoids +/- methotrexate or azarhioprine
Note: Monitor for respiratory weakness vs interstitial lung disease with PFTs
Chronic, symmetric polyarthritis in the hands and wrists associated with prolonged morning stiffness and elevated ESR/CRP…
Rheumatoid arthritis (ESR/CRP levels tend to correlate with disease activity)
Confirm diagnosis with anti-citrullinated peptide antibodies (more specific specific) and rheumatoid factor (more sensitive)
Treatment is with NSAIDs and DMARDs (initially methotrexate then biologics like the TNF inhibitor infliximab or etanercept if refractory)
Side effects of methotrexate
- hepatotoxicity
- stomatitis
- bone marrow suppression
Note: Folic acid supplementation should be given to pts on methotrexate to reduce these side effects
Shoulder pain with decreased range of motion on both active and passive range of motion with normal radiographs…
Adhesive capsulitis (“frozen shoulder syndrome” due to joint capsule contraction due to chronic inflammation of the joint from underlying conditions like rotator cuff tendinopathy)
Treat by resting the shoulder and doing range of motion exercises. Glucocorticoid injections can be used in refractory cases
11 yo F with scoliosis and dull/gnawing back pain that wakes her up in the night…
Concern for spinal cord tumor
Get MRI spine
Respiratory insufficiency, neurological impairment, and petechial rash in a MVA pt who has multiple fractures…
Fat embolism
Can confirm with a VQ scan
Treatment is mostly supportive
Prevent from happening with early immobilization and operative fixation of fractures
When should bone density screening begin?
Age 65 for women without risk factors
Any postmenopausal women with risk factors (weight < 127lbs, chronic steroid use, smoking, malabsorption disorders, hip fracture or fragility fracture)
Note: All postmenopausal women should be counseled in the importance of adequate calcium and Vit D intake
Recommended intake of calcium and vitamin D for postmenopausal women
1200mg calcium daily
600-800mg vitamin D daily (sunlight for ~15 minutes twice a week)
Difficulty rising from a chair and going up steps, violaceous papules and plaques on the dorsum of both hands, and reddish purple rash on and around eyelids…
Dermatomyositis (with grottons papules on the hands and a heliotrope rash on the eyes)
Screen with ESR/CRP/CPK, an ANA titer, and other antibodies (anti-Ro, anti-La, anti-RNP, anti-Jo-1) and a muscle biopsy to confirm. Get a CXR to screen for interstitial lung diseases. If signs of pulmonary dysfunction, get PFTs and CT chest
Treat with high dose glucocorticoids plus methotrexate or azothiaprine. Screen for underlying malignancy.
Dupuytren contracture
A progressive fibrosis of the palmar fascia with discrete nodules along the flexor tendons that prevent full extension of the digits
Commonly seen in men over 50 with history of smoking, alcohol use, and/or diabetes
Treat with occupational therapy adjustments (cushion tape, padded gloves), needle aponeurotomy, intralesional glucocorticoid injections, or surgical repair
22 yo F presents with knee pain and swelling after feeling a popping sensation while playing soccer, arthrocentesis yields grossly bloody joint fluid…
ACL tear
Confirm with anterior drawer test/Lachlan test (tibia is able to be pulled anteriorly relative to femur) and evaluate with MRI to determine the severity of the tear
Treat with RICE (rest, ice, compression, elevation) and surgery (if needed)
Spondyliarthropathies
- sacroiliitis
- peripheral asymmetric oligoarthritis
- dactylitis
- enthesitis
- reactive arthritis
Note: These are more common in pts with HLA-B27
What are the first signs of acute compartment syndrome?
- Tightness in the area
- Muscle weakness
- Muscle pain with passive stretching
- Paresthesias
Note: paralysis, sensory deficits, loss of deep tendon reflexes, infection, diminished pulses, and necrosis occur later
Management of acute compartment syndrome
Monitor compartment pressures
If compartment pressure exceeds 20-30 mmHg, perform fasciotomy
Obese adolescent with progressive dull hip pain, altered gait with impaired ability to bear weight, externally rotated hip on exam, and radiographic abnormality of the femoral head…
Unstable slipped capital femoral epiphysis (SCFE)
Xrays show displaced femoral head that looks like “ice cream slipping off a cone”
Treatment of unstable (unable to bear weight) SCFE is with immediate surgical pinning (delay in treatment can lead to a vascular necrosis and femoroacetabular impingement with a greatly increased risk of degenerative arthritis)
57 yo F with chronic pain and tightness in the neck, posterior shoulders, and buttocks associated with fatigue, difficulty concentrating, tenderness on exam at specific points, normal ESR/CRP…
Fibromyalgia
Clinical diagnosis, but should get CBC and TFTs to screen for anemia and hypothyroidism, which can present similarly
Treat with a progressive exercise regimen +/- pharmacotherapy (tricyclics antidepressants, SNRIs, cyclic skeletal muscle relaxants)
Pt with SLE on chronic high dose steroids develops spontaneous left groin pain that’s getting progressively worse and associated with an antalgic gait…
Avascular necrosis of the femoral head (osteochondritis dissecans)
Early diagnosis with MRI is important to avoid bone collapse
Treatment involves conservative management with avoidance of weight bearing, core decompression, osteotomy, and then joint replacement (if progression to stage 4: characterized by flattening of the femoral head with joint space narrowing)
16 yo F who presents with joint pain involving the proximal interphalangeal and metacarpophalangeal joins of both hands, mildly pruritic reticular rash on the face/arms/legs, and a history of recent flu-like illness…
Parvovirus infection
Diagnosis is mostly clinical but can get parvovirus B19 serology
Treatment is supportive with NSAIDs
29 yo F with 3 month history of exertion always dyspnea, cough, hypercalcemia, elevated ESR, reduces FEV1, reduces diffusion capacity for carbon monoxide, and CXR with hilar fullness…
Pulmonary sarcoidosis (a systemic inflammatory disorder characterized by the formation of noncaseating granulomas against an unknown antigen)
CXR often has bilateral hilar lymphadenopathy, but biopsy is needed for definitive diagnosis
Symptomatic patients should be treated with 12-24 months of oral glucocorticoids (most cases resolve over time and do not recur)
Traumatic injury followed by knee pain, swelling, decreased range of motion, unilateral sweating of the left leg, and intermittent mottled bluish discoloration of left leg…
Complex regional pain syndrome (likely due to an injury causing increased sensitivity to sympathetic nerves)
Confirm diagnosis with autonomic testing and/or MRI to look for edema/skin thickening/muscle wasting/bone demineralization
Treat with a regional sympathetic nerve block or IV regional anesthesia
Contraindications to NSAIDs for the treatment of acute gout
- AKI or CKD
- CHF
- Peptic ulcer disease
- NSAID sensitivity
- Currently on anticoagulation
Treatment of hypertensive emergency in the setting of scleroderma renal crisis
PO captopril should be used to gradually lower the BP back to baseline over 72 hours (Note: ACE inhibitors should be used in scleroderma renal crisis to reverse angiotensin-induced vasoconstriction, even in the setting of renal failure ACE inhibitors will alleviate renal failure in the long run, though creatinine should be monitored as it may increase at first)
Note: In the setting of hypertensive emergency a single dose of IV nitroprusside should be given to immediately bring down the BP while the captopril takes effect. Caution is needed to avoid compromising renal perfusion and causing acute tubular necrosis.
Workup for sicca syndrome (xerostomia plus keratoconjunctivitis sicca)
- confirmation of salivary dysfunction (e.g. Schirmer test)
- Autoantibody screen (Anti-Ro, anti-la, RD, ANA)
At what age is genu varum considered physiologic?
From birth to age 2 years (still considered pathological if associated with unilateral bowing, short stature, progressive, or associated with a lateral thrust during ambulation)
Note: Genu varum is when the legs bow laterally so that the knees are more separated than the feet
Straight leg raise test
Have the pt lie supine with legs straight and lifting one leg over 60 degrees upward; if this elicits a shooting or burning pain that radiates to the calf and foot it is suggestive of a herniated disc
Acute low back pain, paraspinal tenderness on exam, reduced lumbar lordosis, negative straight leg test…
Lumbosacral sprain
No diagnostic imaging is needed
Treatment escalation with conservative management (manning moderate activity, heat packs, massage, spinal manipulation), NSAIDs such as naproxen or acetaminophen if contraindication, muscle relaxants (cyclobenzaprine, tizanadine)
Note: Opioids are not more effective than NSAIDs and should not be used
When should an elderly pt with a hip fracture get surgical correction?
Any elderly person who was stable and ambulatory prior to hip fracture should have surgical correction within 48 hours (associated with lower mortality)
12 yo M fell into outstretched arm now has severe elbow pain and swelling, limited range of motion, radiographs show a posterior fat pad but no fracture line or displacement…
Occult supracondylar fracture (the posterior fat pad is an abnormal radiolucency posterior to the humerus that represents displaced fat due to traumatic elbow effusion)
Treatment includes splinting for immobilization (displaced fractures on the other hand require open or closed reduction with percutaneous pinning)
Complications of supracondylar fractures of the humerus
- neurovascular compromise (brachial artery and median nerves are very easily injured by displaced supracondylar fractures)
- compartment syndrome
Note: Any possible elbow fractures check for distal pulses/perfusion/weakness
16 yo male presents after generalized tonic clinic seizure and notes a history of brief jerking movements shortly after waking lately, eeg finds bilateral polyspike and slow wave activity…
Juvenile myoclonic epilepsy
Confirm with EEG showing bilateral polyspike and slow wave activity (if no classical findings on EEG, should get MRI to rule out mass lesions)
Treat with valproic acid and avoidance of triggers (sleep deprivation, alcohol, etc)
Major adverse effects of valproic acid
- dose related thrombocytopenia (leukopenia and anemia can also be seen)
- hepatotoxicity
- pancreatitis
- neural tube defects if pregnant
Note: Monitor with CBC, LFTs
Late-life depression is a risk factor for the development of what other disorder?
Major neurocognitive disorder (dementia)
Note: Pseudodementia is treatable with SSRIs but pt should still be monitored for signs of full dementia
Treatment for dementia with Lewy bodies
- cholinesterase inhibitors such as donepezil (for cognitive impairment)
- carbidopa-levodopa (for Parkinsonism)
- melatonin (for REM behavior disorder)
Note: Antipsychotics can be used to treat functionally impairing visual hallucinations or delusions, but care should be taken as these pts are very sensitive and antipsychotics increase mortality in elderly pts with dementia (look out for worsening confusion, worsening Parkinsonism, and autonomic dysfunction such as orthostatic hypotension)
Pt presents in a coma and irrigation of the right external auditory canal with cold water reveals a transient, conjugate, slow deviation of gaze to the right followed by saccadic correction to the midline…
Psychogenic coma (caloric stimulation during oculivestibular testing cannot be voluntarily suppressed, so this pts normal response indicates that they are not in an actual coma)
Ptosis
Dropping eyelid
Anisocoria
Unequally sizes pupils
CNIII palsy
- ptosis (levator palpebae superioris)
- anisocoria (pupillary sphincter)
- diplopia (4 of the extrinsic eye muscles)
Woman with recent history of diplopia presents with sudden onset severe headache and now has unilateral ptosis, anisocoria, and Michael rigidity…
Subarachnoid hemorrhage due to rupture of a posterior communicating artery aneurysm
Which reflexes can be tested to confirm brain death?
- cold caloric testing (oculovestibular reflex)
- pupillary light reflex
- oculocephalic reflex (dolls eyes)
- corneal reflex
- gag reflex (e.g. on suctioning)
Apnea test is performed after neurological exam confirms brain death
Note: If pt is paralyzed or reflexes are difficult to interpret ancillary testing with EEG or brain angiography (CT/MRI/ultrasound) should be obtained
27 yo M with progressive headache, loss of pupillary light reflex bilaterally, ataxia, and impaired upward gaze…
Parinauds syndrome due to a tumor of the pineal gland (headache is caused by obstructive hydrocephalus)
Optokinetic nystagmus
Nystagmus (a combination of fast-phase and slow-phase eye movements) in response to a visual stimulus
Note: this allows us to track objects while keeping the head still (e.g. observing individual telephone poles on the side of the road while traveling in a car past them)
How is Parkinson’s diagnosed?
Clinical diagnosis based on the presence of essential features (bradykinesia, tremor, and rigidity on physical exam)
Note: If there is suspicion for Parkinson’s but physical exam is not confirmatory, you can get a striatal dopamine transporter scan (DaTSCAN), which used the radiotracer ioflupane-123 to light up dopamine transporters in the striatum (low uptake of the radiotracer has the same diagnostic accuracy as physical exam)
Initial treatment for Parkinson’s
- Dopamine agonists (e.g. bromicriptine, pramipexole, etc)
- Levodopa (if pt is over 65 with severe symptoms)
62 yo F with progressive memory loss, impaired vibration sense, positive Romberg sign, spastic paresis, and hyperreflexia…
Subacute combined degeneration due to B12 deficiency
12 yo M who recently went on a hiking trip in Washington State who develops tingling in fingers and fatigue followed by rapidly progressive ascending paralysis that develops over hours to a few days with no history of recent GI or respiratory illness, physical exam shows lower extremity weakness but no loss of sensation…
Tick paralysis (due to neurotoxins in the saliva of the tick)
Perform a meticulous skin exam to try to find the tick. Symptoms should recover within hours of removing the tick
Note: Guillain barre syndrome usually affects sensation and progresses more slowly over days and is preceded by a GI or respiratory illness
Major side effect of carbamazepine
Bone marrow suppression (neutropenia, anemia, thrombocytopenia)
Common causes of papilledema
Elevated intracranial pressure due to:
- mass lesions
- increased CSF production
- decreased CSF fluid outflow (e.g. venous sinus thrombosis)
- idiopathic intracranial hypertension (psudotumor cerebri)
66 yo M with fever, severe lower back pain, physical exam with tenderness on palpating on of the lumbar spine, absent deep tendon reflexes in b/l lower extremities, and decreased rectal sphincter tone…
Spinal epidural abscess (usually due to Staph aureus)
Evaluate with urgent MRI with contrast, ESR/CRP, and blood cultures
Treat with emergent surgical decompression to avoid complications of cord compression and perform CT-guided aspiration and culture to direct antibiotic selection followed by empiric antibiotics
Note: IV steroid are indicated for cord compression caused by malignant or traumatic injury but NOT for possible epidural abscess
24 yo F with recent URI presents with 2-day history of leg weakness and paresthesias and now urinary retention, physical exam shows decreased pain sensation up to the level of the umbilicus…
Acute myelopathy, likely secondary to transverse myelitis (caused by cord compression from a tumor, trauma, herniated disc, epidural abscess)
Get MRI spine with contrast
Treat with 3-5 days high-dose corticosteroids once transverse myelitis is confirmed (can give empirically in the setting of high chance of malignant tumor)
Note: Bladder dysfunction and well defined sensory level are not common in guillain barre syndrome
Initial workup of suspected cognitive impairment in elderly pt
- MMSE (scow <24 suggestive of MCI/dementia)
- lab work (CBC/Chem8/LFTs, B12/folate, TSH, vitamin D level, RPR for syphilis)
- imaging (CT or MRI brain)
- EEG (if atypical presentation)
- lumbar puncture with CSF studies (if early onset)
Treatment for dementia
- acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine, galantamine)
- memantine, an NMDA receptor antagonist (can be used for moderate to severe cases)
Note: All of these are likely only symptomatic treatments
Sudden onset severe occipital headache that is different from pts normal headaches…
Subarachnoid hemorrhage
Get noncontrast CT head, but if negative may need lumbar puncture to completely rule out (Look for CSF with xanthochromia: a pink/yellow tint due to hemoglobin degradation products, elevated opening pressure, or persistently elevated RBCs in all tubes).
Cerebral angiography can be used to identify the source of bleeding so that it can be stopped
Which cancers commonly metastasize to the spinal column?
- prostate
- breast
- lung
- non-hodgkins lymphoma
- renal cell carcinoma
55 yo F with non-hodgkins lymphoma presents with progressive back pain that is band-like around the mid thorax associated with b/l lower extremity weakness/numbness/tingling…
Epidural spinal cord compression due to mass effect from tumor
Immediately give dexamethasone to decrease edema and swelling around tumor and get an MRI spine to confirm diagnosis
Note: If MRI reveals an unstable spine or tumor is found to be radioresistant, then urgent surgical evaluation is warranted for surgical decompression, otherwise radiotherapy alone may be sufficient
What is the earliest sign of toxicity for the anticonvulsant phenytoin?
Nystagmus on far lateral gaze
Note: If this happens get plasma drug levels and decrease dose of elevated or on the higher range of normal
Clinical manifestation of cluster headaches
Severe unilateral headaches localized to orbital, Supra orbital, or temporal area that last less than 3 hours each but occur 1-8 times per day for a period of weeks and are associated with autonomic symptoms (ptosis, miosis, lacrimation, conjunctival injection, rhinorrhea, and nasal congestion)
Treatment for cluster headaches
Acute treatment with:
- 100% oxygen via nonrebreather for at least 15 minutes
- intranasal sumatriptan given contralateral to the side of the headache (second-line)
preventative therapy given at the beginning of a cluster:
-verapamil starting at 240mg and uptitrating (first-line)
When should a pt be treated for status epilepticus?
- 5 min or more of continuous generalized convulsive seizure activity
- two or more generalized convulsive seizures without recovery of consciousness between episodes
Treatment for status epilepticus
- Stabilize ABCs (intubate if needed)
- IV benzodiazepine (lorazepam, diazepam, or midazolam)
- Adjuvant IV agent (fosphenytoin, phenytoin, or valproic acid)
- continuous IV infusion with midazolam, pentobarbital, or propofol
Note: If IV access is taking too long, midazolam can be given intramuscularly or diazepam can be administered rectally
50 yo F with periodic involuntary closure of right eye in response to bright light or cigarette smoke with normal exam other than prolonged right eye closure on pupillary light reflex testing…
Blepharospasm (a form of focal dystonia provoked by external stimuli such as bright lights or irritants)
Diagnosis is clinical
Treatment is with botulinum toxin injections
22 y/o F with remote history of tingling/numbness in R hand associated with unsteady gait now presenting with intermittent dizziness, weakness, unsteady gait, and loss of visual acuity in R eye…
This young female with neurological deficits disseminated in time and space likely has multiple sclerosis (optic neuritis cause of monocular vision loss is particularly common)
Confirm diagnosis with an MRI of the brain and spinal cord (should show T2 hyperintense ovoid periventricular white matter lesions). Lumbar puncture with CSF analysis can can also be done to demonstrate oligoclonal IgG bands.
Acute treatment with oral or IV corticosteroids (IV should be used if optic neuritis and plasmapheresis can be used in refractory cases).
Disease modifying drugs (beta-interferon, glatiramer acetate) should be used for patients with the relapsing-remitting pattern of disease
Treatment of muscle spasticity in multiple sclerosis
- physical therapy and stretching
- massage therapy
- muscle relaxants (baclofen, tizanidine, etc)
Treatment of disabling fatigue in multiple sclerosis
- sleep hygiene and regular exercise
- amantadine
- stimulants (methylphenidate, modafanil, etc)
Treatment of urge urinary incontinence in multiple sclerosis
- timed voiding
- fluid restriction
- anticholinergics (oxybutynin, tolterodine, etc)
Risk factors for obstructive sleep apnea
STOPBANG:
- Snoring
- Tiredness, excessive daytime
- Observed apnea’s/choking/gasping
- Pressure elevated (hypertension)
- BMI > 35 (obesity)
- Age > 50
- Neck size increased (men > 17, women > 16)
- Gender male
Note: 0-2 points low risk, 3-4 points intermediate risk, 5 or more points high risk
Pt with diabetes, CAD, and active smoking presents with recurrent episodes of vertigo, diplopia, dysarthria, and numbness…
Vertibrobasilar insufficiency (reduces blood flow to the base of the brain often affecting the brainstem and labyrinth)
16 yo with multiple subcutaneous nodules, decreased hearing, and two hypopigmented spots on his back…
Neurofibromatosis with likely an acoustic scwannoma
9 month old M who was born at 35 weeks gestation presents with delayed motor milestones and found to have increased tone in b/l lower extremities, hyperreflexia, and sustained clonus in ankles…
Cerebral palsy
Diagnosis is predominantly clinical but should be confirmed with an MRI brain (usually showing periventricular leukomalacia and basal ganglia lesions)
Treatment is supportive with physical/occupational/speech therapy, nutritional support with G tube if needed, and antispastic medications (baclofen, botulinum, etc) as needed
Inability to copy a simple image such as a matchstick
Construction apraxia (usually due to a lesion in the nondominant/right parietal lobe)
Febrile seizure
A seizure that can occur during a high fever in children from age 6 months to 5 years with no signs of CNS infection
This is benign and does not require treatment other than antipyretics, but does predispose to further febrile seizures and increases risk of epilepsy
Clinical features of a concussion
- Transient post-trauma neurological disturbance (dizziness, disorientation, amnesia, etc)
- No structural intracranial injury on imaging
Management of concussion
- remove from same day physical activity
- rest for at least 24 hours
- gradual return to normal activity if symptoms do not worsen (light aerobic exercise to no contact sports to contact sports, limited screen time, school accommodations with frequent breaks and shortened days)
32 yo M with right sided facial weakness, months of fatigue, hepatomegaly, and firm nontender cervical/axillary/inguinal lymph nodes…
Sarcoidosis (extrapulmonary manifestations)
Get a CXR to look for bilateral hilar or mediastinal adenopathy followed by biopsy of the most accessible affected site for confirmation (usually a lymph node showing noncaseating granulomas)
71 yo m presents with slurred speech and right upper extremity weakness that lasted approximately 1 hour, Auscultation of upper anterior cervical triangle on the left side reveals a bruit…
TIA due to symptomatic carotid artery disease (note right sided weakness is usually due to decreased flow to the left middle cerebral artery, a branch of the internal carotid)
Get MR angiogram to confirm diagnosis and determine degree of stenosis
Treat with carotid endarterectomy (if 70-99% stenosis and life expectancy greater than 5 years. Medical management for all patients includes aspirin and statin.
Homeless male presents in a confused state and found to have decreased extraoccular motion on leftward gaze and significant ataxia…
Wernickes encephalopathy due to thiamine deficiency
Clinical diagnosis (MRI brain may show degeneration of mammillary bodies of pt also has korsakoff syndrome: amnesia and confabulation)
Treat with IV thiamine (occulomotor dysfunction usually resolves quickly but confusion/ataxia take longer and may never fully resolve; once Korsakoff syndrome develops it rarely resolves)
Treatment for large prolactinoma abutting but not elevating the optic chiasm causing an impairing right upper temporal quadrantic field defect
Oral dopaminergic receptor antagonist (bromicriptine, capergoline, etc)
Note: Transsphenoidal resection is rarely needed to treat prolactinomas as they are usually responsive to oral medications
Sudden onset, transient loss of vision in one eye…
Amaurosis fugax (retinal ischemia due to reduced retinal artery flow), usually due to carotid artery atherosclerosis
When is an acute stroke treatable with tPA?
When presenting within 3-4.5 hours of last known normal as long as pt has no contraindications to fibrinolysis (active internal bleeding, bleeding diathesis such as platelets < 100000, CT showing intracranial hemorrhage, CT showing hypodensity in >33% of an arterial territory, intracranial surgery within past 3 months, blood pressure > 185/110)
General workup for acute stroke
- Carotid imaging (CT/MR angiography or duplex ultrasound)
- ECG for arrhythmias or infarction
- echocardiogram to evaluate for intracardiac thrombus
What CSF findings suggest a traumatic tap?
- RBCs > 6000 (decreasing in subsequent tubes with no xanthochromia)
- elevated WBCs to approximately 1 WBC for every 1000 RBC
- elevated proteins
- elevated glucose
Treatment for severe opioid withdrawal
- clonidine
- benzodiazepines
- antiemetic
- antidiarrheals
- methadone (if pt will have good follow up in a detox program)
Note: Buprenorphine can make withdrawal worse but if good for long term management of opioid use disorder
Diagnostic criteria for narcolepsy
Any 1 of the following:
- REM sleep latency of 15 min or less on polysomnographic multiple sleep latency testing
- cataplexy (sudden transient loss of muscle tone associated with strong emotions or spontaneous abnormal facial movements without identifiable trigger)
- CSF analysis showing hypocretin-1 deficiency
Treatment of narcolepsy
- lifestyle modifications (scheduled naps, good sleep hygiene)
- modafanil (preferred over methylphenidate)
- SNRI or SSRI, especially venlafaxine (to treat cataplexy)
Note: Sodium oxybate can be used to improve nocturnal sleep and treat cataplexy but is rarely used due to abuse potential and restrictive regulations
34 yo obese M who works in a job requiring lots of squatting presents with numbness/burning over the right anterolateral thigh…
Meralgia paresthetica due to entrapment of the lateral femoral cutaneous nerve as it courses from the lumbar plexus under the inguinal ligament and into the thigh
Diagnosis is clinical
Treatment involves weight loss and avoidance of tight fitting clothes
If you suspect a concussion, what imaging should you order?
None, unless there are high risk features for intracranial structural injuries (AMS, LOC, severe headache/vomiting, severe mechanism of injury, signs of basilar skull fracture)
Pain and numbness in the right wrist and palmar surface of first three fingers in a pt who works at a bakery requiring a lot of dough rolling requiring hyperextension of the wrist and pronation of the forearm…
Carpal tunnel syndrome
Treat with splint (surgery for refractory cases)
65 yo M with severe left sided headache associated with transient left vision impairment with left pupil smaller than right on exam…
Carotid artery dissection (unilateral headache and associated Horner syndrome with transient loss of vision)
Confirm diagnosis with CT angiography (Note: TIA or acute stroke are common complications)
Treat with thrombolysis (if within 4.5 hours of last known normal) and antiplatelet therapy +/- anticoagulation
Note: Theombolysis is used if possible because carotid artery dissections are associated with intramural thrombus formation causing luminal obstruction
19 yo M on treatment for severe acne presents with headaches and found to have visual field deficits and fundoscopy with flame hemorrhages, venous engorgement, and hard exudates…
Pseudotumor cerebri/idiopathic intracranial hypertension (due to chronically elevated intracranial pressures which usually occurs in obese females but can also happen in other cases such as with the use of isotretinoin for severe acne)
Note: Headaches + papilledema think about pseudotumor cerebri
Infant born with red sac with an overlying membrane over the infants lumbar spine…
Myelomeningocele subtype of spina bifida due to maternal folate deficiency during pregnancy
Elevated alpha-fetoprotein during pregnancy is suspicious and diagnosis is confirmed with prenatal ultrasound
Treatment is with urgent surgical repair often complicated by hydrocephalus requiring ventriculoperitoneal shunt placement
Note: Even with appropriate treatment, motor/sensory/autonomic function below the level of the lesion is usually impaired (neurogenic bladder with urinary retention/incontinence and frequent UTIs is nearly universal requiring intermittent catheterization and neurogenic bowel requiring laxatives/enemas is also common)
Common complications of parathyroidectomy for symptomatic parathyroid adenoma
- hypocalcemia (perioral numbness, muscle cramps/spasms, Chvostek/Trousseau’s signs
- severe hypocalcemia (AMS, seizures)
Note: Hypocalcemia results from either relative hypoparathyroidism (due to chronic suppression of normal parathyroid tissue) or due to hungry bone syndrome (due to rapid influx of calcium to bone stores in states of higher bone turnover with post surgical decrease in parathyroid hormone, this happens 2-4 days post operation)
Leftward tongue deviation after carotid endarterectomy…
Injury to left hypoglossal nerve during surgery
Cranial nerve deficits associated with impaired sensation over ipsilateral face and contralateral body…
Brainstem lesion
Vertigo, nystagmus, ipsilateral limb ataxia, loss of pain/temperature sensation on ipsilateral face and contralateral legs, dysphagia/aspiration, hoarseness, decreased gag reflex, intractable hiccups, ipsilateral hornets syndrome (miosis/ptosis/anhidrosis)…
Wallenberg syndrome due to a lateral medullary infarction (often due to an occluded intracranial vertebral artery)
Confirm diagnosis with MRI
Treat with tPA (if within 4.5 hours)
Clinical manifestations of lateral medullary infarction
Dysphagia, hoarseness, diminished gag reflex (due to CN IX and X involvement)
Clinical manifestations of lateral mid-pontine infarction
Weakness in the muscles of mastication, diminished jaw jerk reflex
Clinical manifestations of medial medullary infarction
Tongue deviation toward the side of the lesion
Clinical manifestations of medial mid-pontine infarction
Contralateral ataxia and hemiparesis of the face, trunk, and limbs
45 yo M with difficulty walking, reduced sensation to pain/temperature/vibration/proprioception in the lower extremities, and pupils that react to accommodation but not to light…
Tabes dorsalis due to degeneration of posterior spinal columns in late neurosyphilis (Argyll Robertson pupils are characteristic)
Confirm diagnosis with tests for treponema pallidum
56 yo M with personality changes, disinhibited behavior, and apathy…
Behavioral variant frontitemporal dementia
Neuroimaging usually shows frontotemporal atrophy, often associated with autosomal dominant inheritance pattern
Usually fatal within 8 years
Note: Primary progressive aphasia is another type of frontotemporal dementia characterized by dementia that initially presents with isolated language impairment
62 yo M with progressive weight loss and right lower extremity weakness for the past two months associated with early morning cramping and a physical exam significant for R leg atrophy and fasciculations, hyperactive knee jerk, and tongue fasciculations with normal sensory exam…
Amyotrophic lateral sclerosis (progressive motor neuron disease that affects both lower and upper motor neurons, though usually starts with lower motor neuron defects)
Treatment with riluzole (a glutamate inhibitor) can slow progression of the disease and prolong survival
Note: Ocular motility, sensory, bowel, bladder, and cognitive functions are preserved (even in advanced disease)
15 month old M with hypopigmented skin lesion, developmental delay, and new onset seizure…
Tuberous sclerosis complex (autosomal dominant mutation in hamartin or tuberin proteins that leads to the development of many benign tumors throughout the body)
Confirm diagnosis with genetic testing
Management is with frequent screenings: skin exams, eye exams, MRIs brain (screening for gioneuromal hamartomas), MRI kidneys (screening for angiomyolipomas), baseline echocardiogram with serial ECGs (screening for rhabdomyomas), baseline EEG, and neuropsychiatric screening
Note: Antiepileptics should be started if EEG is abnormal as uncontrollable seizures are the most common cause of death)
Clinical manifestations of guillain barre syndrome
- progressive symmetric muscle weakness
- paresthesias
- potentially life-threatening dysautonomia (tachycardia, urinary retention)
- decreased or absent deep tendon reflexes
Note: Usually occurs after a GI or respiratory infection
Management of guillain barre syndrome
- Frequent measurement of vital capacity and negative inspiration force (30% of pts will require mechanical ventilation)
- plasma exchange or IVIG can slow progression and speed recovery (give if nonambulatory or within 4 weeks of symptom onset)
Note: 85% of patients regain the ability to walk after a year and nearly 60% of patients eventually have full neurologic recovery
Common infectious causes of stroke in a young adult
- endocarditis
- varicella zoster virus
- meningovascular syphilis
- bacterial meningitis
- tuberculous meningitis
Note: Also consider cocaine/amphetamine use, inflammatory arteritis as in Takayasu arteritis, or cerebral artery dissection
Signs of a basilar skull fracture
- Periorbital hematomas (raccoon eyes)
- Mastoid or postauricular ecchymosis (battle sign)
- clear CSF leaking from nose or ears
8 yo M with history of staring episodes during which he does not respond followed by rapid blinking and resumption of normal activity…
Absence epilepsy (petit mal seizures)
EEG shows 3 Hz spike and wave discharges
Treatment is effective with ethosuximide and disease usually spontaneously remits by early puberty (ethosuxomide can be stopped after child is seizure free for two years)
Note: Often associated with anxiety/depression/ADHD
Pt presents after an MVA with hypertension to 180s, bradycardia one 50s, and bradypnea to 6…
This pt has Cushings triad suggesting elevated intracranial pressure, likely due to intracranial hemorrhage
Pt should be intubated and CT brain obtained to look for cause
IV mannitol can be used to reduce intracranial pressure in emergency situations
Note: Hyperventilation can be used to reduce intracranial pressure but is contraindicated one traumatic brain injury and stroke due to decreased cerebral blood flow
58 yo obese M with history of erectile dysfunction, diabetes, HTN, and GERD presents after an MVA and is found to have absent cremasteric reflex and loss of pain/temperature/vibration in b/l feet and hands…
Diabetic neuropathy (peripheral neuropathy and neurogenic ED suggest neuropathy is significant enough to cause the cremasteric reflex to fail)
High risk features for pediatric traumatic brain injury in infants younger than 2
- AMS (fussy behavior)
- Loss of consciousness
- severe mechanism of injury (fall from more than 3 ft high, high impact, MVA)
- scalp hematoma anywhere other than the frontal region
- palpable skull fracture
Note: These pts should get a noncon head CT
Pt with an FVC 57% of predicted while seated upright and 42% of predicted while lying supine who has abdominal wall retraction during inspiration while lying supine…
Diaphragmatic paralysis
Note: Pt exhibits paradoxical abdominal wall motion during inspiration because the diaphragm isn’t contracting
What is the significance of forehead sparing when there is unilateral facial droop/weakness?
Forehead sparing (ability to raise eyebrow and wrinkle forehead) suggests a central lesion, so brain imaging should be ordered
If the forehead is not spared, this suggests a lesion of a peripheral nerve (Bell’s palsy of CN VII) and no other workup is needed unless there is suspicion for Lyme disease
Unilateral facial droop with inability to raise eyebrow or wrinkle forehead…
Bell’s palsy of CN VII (if there was forehead sparing there would be concern for a brain lesion/infarction/mass)
No workup is needed unless there is concern for Lyme (in which case an ELISA screening test should be ordered)
Treatment is with corticosteroids (preferably within 3 days of symptom onset) and careful protection of the eyes with artificial tears and eye patching (eyes tend to dry out in Bell’s palsy due to inability to close fully predisposing to corneal abrasions)
Note: Most patients recover within 1-6 months
Elderly pt with wide-based magnetic gait, cognitive dysfunction, and urinary problems…
Normal pressure hydrocephalus
Neuroimaging should show ventriculomegaly out of proportion to sulcal enlargement with no identifiable cause of obstruction of CSF flow. Diagnosis can be confirmed with the lumbar tap/Miller Fisher test (gait and cognitive assessment before and after lumbar drainage of CSF)
Temporary treatment with lumbar puncture and CSF drainage during confirmation of diagnosis. Definitive treatment is with a ventriculoperitoneal shunt
What are the major modifiable risk factors for stroke?
- hypertension (most important)
- diabetes
- smoking
- dyslipidemia
How should blood pressure be managed in a patient with an acute stroke?
If the pt is getting tPA, then maintain strict blood pressure control using IV antihypertensives to maintain a BP less than 185/105, but greater than 140/90 (to maintain perfusion if the penumbra)
If the pt is not getting tPA, then allow permissive hypertension up to 220/120
Note: If tPA given IV antihypertensives such as labetalol, nicardipine, or sodium nitroprusside should be used
Postconcussive syndrome
Headache, confusion, amnesia, difficulty concentrating, vertigo, photophobia, mood alteration, sleep disturbance, and/or anxiety that can persist for weeks to months after a concussion, regardless of the severity of the concussion
Note: Most resolve within weeks but can persist for up to 6 months
Pain and numbness in the right wrist and palmar surface of first three fingers in a pt who works at a bakery requiring a lot of dough rolling requiring hyperextension of the wrist and pronation of the forearm…
Carpal tunnel syndrome
Treat with splint (surgery for refractory cases)
65 yo M with severe left sided headache associated with transient left vision impairment with left pupil smaller than right on exam…
Carotid artery dissection (unilateral headache and associated Horner syndrome with transient loss of vision)
Confirm diagnosis with CT angiography (Note: TIA or acute stroke are common complications)
Treat with thrombolysis (if within 4.5 hours of last known normal) and antiplatelet therapy +/- anticoagulation
Note: Theombolysis is used if possible because carotid artery dissections are associated with intramural thrombus formation causing luminal obstruction
19 yo M on treatment for severe acne presents with headaches and found to have visual field deficits and fundoscopy with flame hemorrhages, venous engorgement, and hard exudates…
Pseudotumor cerebri/idiopathic intracranial hypertension (due to chronically elevated intracranial pressures which usually occurs in obese females but can also happen in other cases such as with the use of isotretinoin for severe acne)
Note: Headaches + papilledema think about pseudotumor cerebri
Infant born with red sac with an overlying membrane over the infants lumbar spine…
Myelomeningocele subtype of spina bifida due to maternal folate deficiency during pregnancy
Elevated alpha-fetoprotein during pregnancy is suspicious and diagnosis is confirmed with prenatal ultrasound
Treatment is with urgent surgical repair often complicated by hydrocephalus requiring ventriculoperitoneal shunt placement
Note: Even with appropriate treatment, motor/sensory/autonomic function below the level of the lesion is usually impaired (neurogenic bladder with urinary retention/incontinence and frequent UTIs is nearly universal requiring intermittent catheterization and neurogenic bowel requiring laxatives/enemas is also common)
Common complications of parathyroidectomy for symptomatic parathyroid adenoma
- hypocalcemia (perioral numbness, muscle cramps/spasms, Chvostek/Trousseau’s signs
- severe hypocalcemia (AMS, seizures)
Note: Hypocalcemia results from either relative hypoparathyroidism (due to chronic suppression of normal parathyroid tissue) or due to hungry bone syndrome (due to rapid influx of calcium to bone stores in states of higher bone turnover with post surgical decrease in parathyroid hormone, this happens 2-4 days post operation)
Leftward tongue deviation after carotid endarterectomy…
Injury to left hypoglossal nerve during surgery
Cranial nerve deficits associated with impaired sensation over ipsilateral face and contralateral body…
Brainstem lesion
Vertigo, nystagmus, ipsilateral limb ataxia, loss of pain/temperature sensation on ipsilateral face and contralateral legs, dysphagia/aspiration, hoarseness, decreased gag reflex, intractable hiccups, ipsilateral hornets syndrome (miosis/ptosis/anhidrosis)…
Wallenberg syndrome due to a lateral medullary infarction (often due to an occluded intracranial vertebral artery)
Confirm diagnosis with MRI
Treat with tPA (if within 4.5 hours)
Clinical manifestations of lateral medullary infarction
Dysphagia, hoarseness, diminished gag reflex (due to CN IX and X involvement)
Clinical manifestations of lateral mid-pontine infarction
Weakness in the muscles of mastication, diminished jaw jerk reflex
Quality-adjusted life years
QALYs is way to measure the burden of a disease. The pt thinks about how many years with their current disease they would be willing to trade for 1 year of life at full health.
If a pt states that 5 years in their current state is equivalent to 1 year at full health, then the time trade off is 1/5 or 0.2, which can then be used to calculate QALYs. If this pt was healthy until age 30, then had disease until present at age 40. The quality adjusted life years would be 32 (30 years at full health + 10 years at 0.2)
Note: The goal is to maximize QALYs through treatments that increase the time trade off factor (treatments that increase quality of life)
Disability-adjusted life years
DALYs are a way to measure disease burden that estimates the total number of years of life lost due to that disease. It can be calculated by adding the years of life lost due to decreased quality of life PLUS the years of life lost due to premature mortality
If a pt develops depression at age 30 and commits suicide at age 50 (assuming life expectancy at age 50 is 84 and that the disability weight for depression is 0.35), then:
DALY = years of life lost (84-50) + years of life with disability (30 + (20 x 0.35)) = 41 years (lost 7 years due to loss of quality of life during disability and lost 34 years due to premature mortality)
Note: DALYs should be minimized. Disability weights are similar to time trade offs used for quality-adjusted years of life but are standard values used for populations, whereas TTOs are an individual pts self-reported number
Absolute contraindications to combined hormonal contraceptives
- migraine with aura
- at least 15 cigarettes/day PLUS age of 35 or greater
- hypertension of 160/100 or greater
- heart disease
- diabetes with end organ damage
- history of thromboembolic disease
- antiphospholipid antibody syndrome
- history of stroke
- breast cancer
- cirrhosis and liver cancer
- major surgery with prolonged immobilization
- less than 3 weeks postpartum
Treatment for strep pharyngitis
Penicillin or amoxicillin
Of allergic to penicillin, then use a cephalosporins (if a mild reaction to penicillins) or azithromycin or clindamycin (if anaphylaxis to penicillins)
