Ambulatory Flashcards Preview

Internal Medicine > Ambulatory > Flashcards

Flashcards in Ambulatory Deck (32):
1

Goal hyperlipidemia levels in general population and diabetic patients and diabetic plus CAD patients

General population
Total cholesterol: less than 200 (high is 240)
LDL: less than 130 (high is 160)
Triglycerides: less than 125 (high is 250)

Diabetic
LDL less than 100

Diabetic plus CAD
LDL less than 70

2

Tension headache treatment

Stress reduction possible depression or anxiety
NSAIDs, acetaminophen and aspirin
If don't respond can use migraine drugs

3

Cluster headache treatment

Acute attack:
Sumatriptan, O2 inhalation

Prophylaxis
Verapamil drug of choice
Ergotamine, methysergide, lithium and corticosteroids are alternatives

4

Pseudotumor cerebri diagnosis and treatment

Diagnosis:
Normal CSF, except increased CSF opening pressure
(tetracyclline or isotretenoin use)

Treatment:
Azetazolamide-1st line (can be with furosemide)
If have progressive vision loss: surgical intervention with optic nerve sheath decompression or lumbar peritoeal shunting

5

Migraine treatment

Acute attacks:
NSAIDs or acetaminophen for mild attacks
dihydroergotamine-sertonin agonist
Sumatriptan

Prophylaxiss
amitryptyline and propanolol (most effective)
verapamil, valproic acid and methysergide

NSAIDs for menstrual migraines

6

Treatment of postnasal drip

Fist generation antihistamine/decongestant
Allergic rhinitis: loratadine (long acting non-sedating oral antihistamine)

7

Acute bronchitis treatment

Codeine for symptoms
Bronchodilators (albuterol)

Antibiotics are NOT indicated

8

Common cold treatment

Adequate hydration-loosens secretions and prevents airway obstruction
Rest and analgesics (aspirin, acetaminophen, and ibuprofen) for releif of malaise, headache, fever and aches
dextromehtorphan, codeine for cough suppression
antihistamines for rhinorrhea/sneezing

9

Diagnosis and treatment of acute sinusitis

Diagnosis
Cold for more than 8-10 days
purulent discharge from one of the turbinates
Impaired light transmission in maxillary sinuses
tenderness to palpation

Treatment:
Antibiotics and decongestants for 1-2 weeks
Saline nasal spray aids drainage
Decongestants: pseudoephdrine or oxymetazoline-facilitates sinus drainage and relieves congestion-no more than 3-5 days
antibiotics: amoxicillin-clavulanate, TMP/SMX, levofloxacin, moxifloxacin, and cefuroxime
Antihistamines: use sparingly because can increase secretion thickness

Chronic:
broad spectrum penicilinase resistant antibiotic
Refer to otolaryngologist

10

Diagnosis and treatment of sore throat

Diagnosis:
Throat culture: takes 24 hours but is most accurate
Rapid strep test: takes one hour
Mono suspicion: obtain appropriate blood tests (monospot)

Treatment:
strep throat: penicillin for 10 days
viral: symptomatic treatment
Mono: advise rest and acetaminophen/ibuprofen
Symptomatic treatment:
Acetaminophen or ibuprofen
gargling with warm salt water
Humidifier
Sucking on throat lozenges, hard candy, flavored frozen desserts

11

Dyspepsia workup and treatment

Dyspepsia
Typical GERD-acid support
NSAID use-discontinue
Neither-alarm symptoms or >55=endoscopy
no alarm symptoms and less than 55=H. Pylori test
+H. Pylori test=treat H. pylori
-H. Pylori test=PPI for 4-6 weeks

Alarm symptoms: weight loss, bleeding, dysphagia, persistent vomiting, or early satiety

Also avoid alcohol, caffeine, stop smoking, raise head when sleeping

12

Diagnosis and treatment of GERD

Diagnosis
Endoscopy with biopsy-test of choice if heartburn refractory to treatment, accompanied by dysphagia, odynophagia or GI bleeding

Upper GI series (barium contrast study) if strictures/ulcerations suspected
24 pH monitoring is most sensitive and specific but normally unnecessary

Treatment:
Phase I: diet (avoid fatty foods, coffee, alcohol, OJ, chocolate, avoid large meals before bed time), sleep with trunk of body elevated, stop smoking
Antacids after meals and at bedtime
Phase II: add an H2 blocker
Phase III: switch to PPI
Phase IV: add promitility agent (metoclpramide or bethanechol)
Phase V: increase dose of PPI and/or H2 blocker
Phase VI: antireflux surgery if medical treatment does not work, respiratory problems due to aspiration, severe esophageal injury (nissen funcoplication)

13

Indications for diarrhea diagnostic studies

Chronic diarrhea >4 weeks
severe illness or high fever
presence of blood in the stool
Severe abdominal pain
Immunodeficiency
Signs of volume depletion

Lab tests to order
Stool WBCs
Stool for ova and parasites
Stool culture
Stool for C. difficile culture and toxin
Stool for Giardia Ag (ELISA)

14

Indications for hospitalization of diarrhea

dehydration
unable to tolerate or hold down PO fluids
Blood diarrhea
high fever, toxic appearance

15

Treatment of acute diarrhea

No complications: rehydrate and consider loperamide
monitor electrolytes (metabolic acidosis with hypokalemia)

Complications (blood diarrhea, high fever, severe diarrhea)-ciprofloxacin for 5 days or specific antibiotic for bug

If diarrhea lasts longer than expected: sigmoidoscopy with biopsy

16

Treatment of shigella diarrhea

TMP/SMX

17

Treatment of campylobacter diarrhea

erythromycin

18

Treatment of irritable bowel syndrome

diarrhea: diphenoxylate, loperamide
constipation: colace, psyllium, cisaride

Avoid dairy products and excessive caffeine

Tegasrod maleate (zelnorm) serotonin agonist works in women

19

Treatment of nausea and vomiting

fluid replacement is first step: use 1/2 Normal saline with potassium replacement

Prochlorperazine (compazine) and promethazine (phenergan)
Liquid diet
Avoid large meals and fatty meals
Nasogastric suction may improve symptoms

Correct electrolytes: metabolic alkalosis with hypokalemia

20

Treatment of hemorrhoids

painless BRBPR

General:
Sitz bath
Ice packs
Stool softeners
High fiber and high fluid diet
topical steroids

Rubber band ligation for internal hemorrhoids

Surgery if do not respond to conservative methods-severe prolapse, strangulation, very large anal tags or fissure is present

21

Goal for hypertension in general population vs diabetic

General population: less than 140/90
Diabetic: less than 135/85

22

Most commonly injured ankle ligament

anterior talofibular ligament

23

when are ankle radiographs not necessary

patient is able to walk four steps at the time of injury and at time of evaluation
No bony tenderness over distal 6 cm of either malleolus

24

Diagnosis of osteoarthritis

Plain radiographs are the initial test-joint space narrowing, osteophytes, sclerosis at end plates, subchondral cysts
MRI is indicated if neurologic findings or before surgery

Treatment:
Avoid activities involving joint
Weight loss, physical therapy (swimming)
Use can or crutches

Acetaminophen is first line
then NSAIDs or celecoxib
intra-articular injections of corticosteroids
Viscosupplementation

Surgery for serious disability: total joint replacement

25

Osteoporosis diagnosis and treatment

Diagnosis
DEXA scan: women >65, postemenopausal women less than 65 with 1+ risk factors, men with risk factors
If normal repeat in 3-5 years

Treatment:
Diet: 1200 g of calcium, 800 international units of Vitamin D
Smoking cessation
Reduce alcohol intake
weight bearing exercise

Pharmacological: postmenopausal women with T score less than 2.5 or fragility fracture, high risk postmenopausal women with score -1 to -2.5
Bisphosphonates: inhibit bone resorption-first line
PTH therapy: max of 24 months
Calcitonin: short term therapy

26

Diagnosis and treatment of age related macular degeneration

Diagnosis: loss of central vision-peripheral vision preserved
Distortion of straight lines

Treatment
Exudative: sudden visual loss due to abnormal vessel formation (anti-VEGF inhibitors)-Ranibizumab
Nonexudative: atrophy and degneration of central retina-OTC vitamins antioxidant

27

Open angle glaucoma diagnosis and treatment

Diagnosis: enlargment of optic cup (cupping)
Impaired outflow of aqueous humor
Painless increased IOP
Visual field loos sparing central vision

Tanometroy measures IOP
Opthalmoscopy
Gonioscopy: gold standard visualizes the anterior chamber
Visual field testing: monitors

Treatment
B blocker, a agonist, carbonic anyhydrase inhibitor, and or prostaglandin analog
Laser or surgical treatment if refractory

28

Closed angle glaucoma diagnosis and treatment

Opthalmologic emergency can lead to irreversible vision loss
Red painful eye
Sudden decrease in visual acuity,, seeing halos
N and V
Pupil is dialted and nonreactive

Diagnosis
Tanometry-measures IOP
Opthalmoscopy
Gonioscopy: gold standard
Visual field testing

Treatment
Opthalmic consult
emergently lower IOP
Pilocarpine drops, IV acetazolamide and oral glycerin

Laser or surgical iridectomy is definitive

29

Viral conjunctivitis diagnosis and treatment

watery discharge, pereauricular lymph node palpable, eye stuck shut

cold compress, strict hand washing, topical antibiotics possible

30

Bacterial conjunctivitis diagnosis and treatment

Diagnosis: S. pneumo or gram - (gonorrhea)
Mucopurulent discharge with crusting
rapid onset

Treatment
Acute: erytormycin, ciprfloxacin (contacts), sulfacetamide
Hyperacute: one time dose of ceftriaxone IM (gonnococcal) and topical therapy

31

Amaurosis Fugax

Transient monocular loss of vision
Embolization of cholesterol plaque from the carotid arterial system
Reperfusion established and vision returns

Diagnosis: carotid ultrasonography (duplex study of neck) and cardiac workup

32

Diagnosis and treatment of obesity

Diagnosis
BMI:
19.5-24.9 is normal
25-30 is overweight
30-40 is obese
40+ is morbidly obese

Treatment
Lifestyle modifications
Orilistat can be used for 4 years
Bariatric surgery if BMI over 40 (roux-en-Y bypass)