Common Conditions Flashcards
1
Q
Diff for Chest Pain
A
Angina
MI
Pericarditis - sharp pain inc w/ inspiration, friction rub, effusion, global ST elevation
Aortic dissection - tearing to back, wide mediastinum
Pneumonia
Pneumothorax - pleuritic, hyperesonance, dec sounds
HF - JVD, displaced apical impulse, edema
PE - tachycardia, tahypnea, D dimmer, V/Q scan, CTA
GERD - inc w/ meals, better w/ PPIs, pH probe
Peptic Ulcer Disease - H pylori testing
Pancreatitis - epigastric, inc amylase and lipase, CT
Costochondritis - tender to palpation
Anxiety - tightness and SOB
Herpes Zoster - pain b/f rash, unilateral dermatome
2
Q
4 Steps in MI Work Up and Tx
A
1- order ECG and CXR
2- Start meds - MONA + beta
Morphine - less catecholamines Oxygen 2-4L NC for 6 hrs Nitroglycerin - start sublingual q 5 min then IV (unless hypotension or on sildenafil) A - ASA (clopidogrel if allergy) Beta blocker
3- 2 IVs –> labs
CBC, BMP, PT/PT/INR, CK-MB and troponins q 6-10 hrs X 3, later lipids, LFTs, Mg, UA, homocysteine
4- If confirmed MI then add heparin, GPIIb/IIIa receptor blocker, ACE inhibit (prevent remodeling), Mg if low (prevent torsades), reduced fat and cholesterol diet, statin w/in few days, HTN control and exercise 30 min / day + wt mgt
3
Q
NY Heart A Functional Classification
A
I - angina w/ strenuous activity
II - angina w/ above daily activity
III - angina w/ family activity
IV - angina at rest
4
Q
What condition can mask MI on ECG?
A
LBBB
If LBBB and angina symptoms, get cardiac enzymes
5
Q
When is obstructive spirometry considered reversible?
A
if FEV1 inc by 12% or 200 mL w/ bronchodilator (asthma)
6
Q
COPD Maintenance Therapy by Severity
A
0 - normal spirometry but at risk - smoking cessation + flu and pneumonia vaccines
1- FEVI > 80% - short acting bronchodilator (albuterol or ipratropium)
2 - FEV1 50-80% - add long sting bronchodilator (salmeterol or triotropium) $$ expensive
3- FEV1 30-50% - add inhaled steroid to dec frequency of exacerbations (fluticasone)
4 - FEV1 < 30% - if sat is < 88% at rest then use O2 for 15 hrs per day to dec mortality
7
Q
Tx of COPD Exacerbation
A
- ABC’s
- Combo of short acting bronchodilators (beta agonist and muscarinic)
- O2 target of 88-92% sat (face mask or intubation if needed)
- Systemic steroids - take longer to set in but dec duration of exacerbation (10-14 day course prednisone)
- Abx if purulent sputum
8
Q
Common Organisms of COPD Exacerbation
A
Mild - cover pneumo, H flu, M catarhalis
Severe - also cover Klebsiella and Pseudomonas
9
Q
Diff for Non-Infectious Cough
A
Asthma or COPD
Malignancy
Postnasal drip
GERD (give PPI and see if improves; worse supine)
Meds - ACE inhibitors ( 1 wk to 6 mo after starting, stop med and re-evaluate at 4 wks, if cough gone switch to ARB)
CHF
10
Q
Bronchitis (dx, organisms, tx)
A
- Dx of exclusion
- Usually viral and self-limited (color of sputum does not indicate bacterial)
- Influenza, parainfluenza, adenovirus, rhinovirus, Chlamydia pneumonia, mycoplasma pneumonia
- 2 wks but cough may remain for 2 mo
- Suspect pneumonia if fever, tachycardia, tachypnea and dullness - chest X-ray (Higher suspicion if elderly or underlying COPD)
- Tx - bronchodilator, antitussive (dextromethorphan or codeine) f/u 2-3 wks, no abx
11
Q
Signs that Rhinosinusitis may be Bacterial (+ what bacteria and abx)
A
- persists > 7 days in adults or > 10 days in kids
- purulent d/c
- maxillary tooth or facial pain
- worsened symptoms after initial improvement
Strep pneumo, H flu, M catarrhalis
If chronic more anaerobes - Bacteroides, Fusobacterium
Amox or TMP-sulfa
If fail use amox-clavulanic acid, fluroquinolones, macrolides or cephalosporins
12
Q
Diff for Pharyngitis
A
GAS - abrupt onset sore throat, fever, petechiae in tonsil area, tender cervical lymphadenopathy, absence of cough, plus exudate
Mono - adenopathy and splenomegaly; atypical lymphocytes on smear
Epiglossitis - stridor, drooling, toxic appearance, lean forward on arms (tripod); may need to intubate
Peritonsillar abscess - swelling pushes tonsils midline, contralateral deviation of uvula; need surgical drainage
13
Q
GAS Testing + Centor Criteria
A
1- Rapid antigen test - high specificity low sensitivity; if pos treat if neg do throat cx
2- Throat cx takes 24-48 hrs
Centor Criteria (1 pt ea) - absence of cough, cervical nodes, temp > 100.4, age 3-14, deduct 1 pt if > 45
0-1 no abx
2-3 do rapid antigen test or throat cx
4+ give abx right away
14
Q
GAS Tx
A
10 dys PCN oral OR sngl IM dose
If allergy use cephalosporins or macrolides
15
Q
External v Internal Ear Infection
A
External
- pain, inflammation, exudate, tympanic membrane not involved
- Staph, strep, skin flora
- If associated w/ swimming then likely Pseudomonas (irrigate, topical abx and steroid)
- If DM can get invasive external otitis w/ Pseudomonas (surgical debridement and 4-6 wks IV abx if cranial bones involved)
Internal
- (OM) infection of middle ear, obstruction thru edematous Eustachian tubes, dec hearing, vertigo, red tympanic membrane
- Must see dec membrane mobility or fluid behind membrane to diagnose
- Tx - amox only if severe, recurrent, prolonged; usually self-limited
- Strep pneumo, H flu, M catarhallis
16
Q
Thyroid Storm
A
Thyroid Storm - sudden inc release of thyroid hormone –> fever, confusion, tachy, HTN, dysrhythmia, psych problems
EMERGENCY - give beta blockers, PTU and hydrocortisone in case of adrenal crisis
17
Q
Hyperthyroid Tx Considerations
A
- Definitive tx is radioactive iodine ablation (not if preg, breast feeding, kids)
- PTU and methimazole can be used temporarily or if ablation is contraindicated (often used in adolescents b/c likely spontaneous remission)
- Methimazole - prevents organification, safe in 2nd and 3rd trimester, risk of agranulocytosis
- PTU - prevents organification AND peripheral conversion, used in 1st trimester; hepatotoxic and agranulocytosis
- Thyroidectomy - if compressing nearby structures, meds and ablation do not work, safe in pregnancy
**Need thyroid replacement after ablation or surgical removal
18
Q
Hypothyroid Work Up
A
1- Check TSH (high if primary - low if secondary) and free thyroxine (low)
2- If think secondary (low TSH) then do TRH test - if respond w/ inc TSH then pituitary is okay, if no inc then suspect pituitary problem and do imaging
3- If primary and no nodule on PE then treat w/ hormone replacement
4- If nodule then cont w/ US, FNA, etc
19
Q
Thyroid Replacement Considerations
A
- Start at low dose and gradual inc over 3-4 wks in adults > 50 or if CAD
- May need to inc dose in pregnancy by 30%
- If primary then can follow w/ TSH checks; should check TSH 4-6 wks after dose adjustment
TSH > 5 need more or pt not taking supplement
TSH < .35 then decrease dose
-W/ age thyroid binding dec w/ dec albumin so dec dose
20
Q
Thyroid Nodule Work Up
A
1- TSH and free thyroxine
(Hyperfunctinoing are rarely malignant so treat w/ surgery or ablation)
2 - US (can tell cystic v solid)
3- If > 1 cm and normal or elevated TSH then do FNA (cytology)
- Cannot distinguish b/n follicular adenoma and adenocarcinoma on cells alone - need surgical biopsy
- Can tell papillary, medullary and anaplastic
4- If < 1 cm and no concerning H&P then repeat US in 6 mo
**If preg, can do FNA and resection in 2nd or 3rd trimester but no radio scan; usually just follow until postpartum because indolent course
21
Q
Definition of Acute Diarrhea
A
< 2 wks
90% are viral gastroenteritis
22
Q
Timing of Food Poisoning by Organism
A
6 hrs - staph
6-12 C perfringens
12-14 hrs E. coli
23
Q
When should you cx stool for acute diarrhea?
A
Bloody
(Bloody stool = invasive - Yersinia, Shigella, Entamoeba)
Immuncompromised
> 3-7 days
24
Q
Which organisms are associated w/ leuks in stool?
A
Salmonella, Shigella, Yersinia, enteroinvasive and enterohemorrhagic E coli, C diff, campylobacter, E histolytica
25
Associations b/n food and diarrhea
Chicken - Salmonella, Shigella
Beef - E. coli
Creamy food - staph or Shigella
Raw seafood - Hep A, Vibrio, Salmonella
26
Traveler's Diarrhea (organisms and recs)
ETEC
- No ppx recommendations unless Chrons, renal disease or immune comp (then give fluroquinolones)
- Try bismuth unless pregnant, allergic to ASA or on methotrexate/doxy/probenacid
27
Work-Up for Microscopic Hematuria
1- Take hx to ID source - exercise, mensturation, recent urology procedure, certain meds
2- If ID source ... stop source and repeat UA in 6 wks --> if neg for RBCs in 6 wks then no need to f/u
3- If symptoms of UTI then cx urine and treat w/ abx if pos --> repeat UA in 6 wks --> if neg then n need to f/u
4 - if do NOT ID source ... move on to kidney labs (BMP - creatinine, BUN, GFR)
- If pos then consult renal
- If neg and / or risk of bladder cancer then do imaging; upper GU via CT (unless kidney disease or preg then MRI) and lower GU gets cystoscope (may defer if < 35 w/o risk factors)
5- if still no source and persists then follow for at least 3 yrs to monitor for underlying source
28
6 Types Melanoma
1- In Situ - still in epidermis; excise
2- Superficial Spreading - (most common) slow radial growth phase
3- Lentingo Maligna - (least common) often seen in elderly
4- Acral Lentiginous - nails, feet, palms, more common in blacks and Asians
5- Amelanotic - RARE (<5%) non-pigmented so present at later stage
6- Nodular - (2nd most common) most aggressive, often black mole
29
When do you give packed RBCs for anemia?
HgB < 7 or sooner if CAD
30
Vit B12 v Folic Acid Def
Vit B12 - inc methylmalonic acid, neuro symptoms, takes longer to develop
- IM replacement 7 days, then 1/ wk for 4 wks then 1/ mo for yrs
Folic acid - just inc homocysteine, no neuro, associated w/ alcoholics so do CAGE screen
- oral supplement until corrected
31
Pathophysiology of Allergic Rhinitis
- IgE response --> inflammation of mucus membranes in response to external proteins
- IgE pre-formed on mast cells then binds protein --> granulation
1- histamine, tryptase, chymase, kinase
2 - leukotrienes and prostaglandin D2
- Secretions, vasodilation, sensory nerve stimulation leading to itching and sneezing
- Seasonal, perennial (whole yr), occupational
32
PE Signs of Allergic Rhinitis
Allergic shiners - dark circles around eyes from vasodilation
Nasal crease -horizontal line from rubbing tip of nose w/ palm
Boggy, blue-gray turbinates and clear secretions
Conjunctiva
Dennie-Morgan lines
Cobblestoning of posterior pharynx from streaks lymphoid tissue
Tonsil hypertrophy
Lungs - wheezing, tachypnea, prolonged expiration (ASTHMA)
33
Meds for Allergic Rhinitis
AVOID ALLERGEN
-nasal corticosteroids are first line for longstanding allergy
-antihistamines - prefer 2nd generation because less sedation and anticholinergic effects
1st - diphenhydramine, chlorpheniramine, hydroxyzine
2nd - loratadine, desloratadine, fexofenadine, azelastine, cetirizine
- Decongestants - alpha 1 agonists to vasoconstrict (phenylephrine) - REBOUND
- Leukotriene inhibitors esp if concomitant asthma - montelukast, zileuton
- Oral steroids only for short amount of time
- Desensitization w/ progressive inc dose exposure as last resort if fail other meds
34
Anaphylaxis
- urticaria, angioedema, hypotension, dyspnea
- Give .2-.5 mg epi in 1:1000 solution as subQ or IM injection plus IV fluids (causes vasoconstriction, bronchodilation and ionotropy)
- Monitor for 24 hrs
35
Diff for Conjunctivitis
1- Infection - staph, strep, H flu, M catarrhalis, Pseudomonas (local sulfonamide 3X daily)
2- Epidemic keratoconjunctivitis (pink eye) - spread by fomites, adenovirus, pharyngitis, fever, malaise, auricular lymph nodes
- Usually lasts 2 wks
- Give decongestants, artificial tears, compresses, weak topical steroid
3- Allergies / Chemicals
- Itching, tears, red, photophobia, stringy d/c
- Avoid irritants + oral or topical antihistamine + anti-inflammatory eye drops
36
Intussusception
* Telescope of intestine w/in self
* Portions that become trapped --> edema, ischemia, necrosis and perforation
* Periods of pain, fever and billious vomiting then pain free intervals b/c slow process
* Sausage like mass in abdomen
* Currant jelly stools - blood and mucus from sloughing
* Tx - fluids if unstable, NG tube if obstruction, surgery consult if perforation, otherwise barium enema is diagnostic and therapeutic b/c inc hydrostatic pressure causes reversal of telescope (fluoroscopy until normal bowel)
* Observe 12-24 hrs after until BM prod
37
Hypertrophic Pyloric Stenosis
* Younger infant - 1 mo (males > females)
* Projectile non-bile vomiting then hungry immediately after
* Olive mass in RUQ; may see peristaltic waves b/f vomit; thick pyloric muscles on US
* Tx - surgical
38
Malrotation w/ Volvulus
* As embryo the SI mesentery is small so more mobile SI that can eventually twist --> twist around SMA so dec blood supply
* Most present in 1st mo but may be asymptomatic even into adulthood
* Billious vomiting and ab pain --> ischemia/necrosis --> fluid loss and sepsis
* Dx - if stable do X-ray (beak like duodenum obstruction or misplaced duodenum) if unstable right to surgery
39
Cholinergic v Anti-cholinergic Poisoning
* Cholinergic - nicotine or insecticides
* Nausea, vomiting, diarrhea, cramps, salivation, lacrimation, sweating, sz
* Anti-cholinergic - antihistamines or TCAs
* Dry skin, dry mucosa, urinary retention, decbowel sounds
40
ROME Diagnostic Criteria for IBS
* Recurrent ab pain or discomfort for 3 days a mo for 3 mo + 2 of the following ...
* Improves w/ defecation
* Onset associated w/ change in stool frequency
* Onset associated w/ change in stool form
41
IBS Tx Based on Subtype
* Ab Pain Predom
* Antispasmodics - dicyclomine, hyoscyamine (first line)
* Low dose TCA (if more severe or persistent)
* SSRI esp if co-morbid dep or anxiety
* Rifaxamin - abx
* Probiotics and peppermint oil
* Constipation Predom
* More fiber
* Polyethylene glycol
* Lubiprostone - selective Cl channel activator to inc fluid secretion in gut (nausea and expensive)
* Linaclotide - cGMP stimulator to inc gut motility and secretion (also costly)
* Diarrhea Predom
* Loperamide
* Alosetron
* Rifamixin - abx
42
Factors that determine whether pneumonia can be treated inpatient or outpatient
* Age
* Comorbidities - cancer, liver, CHF, renal, DM
* Tachypnea/fever/hypotension/tachycardia
* Altered mental status
* Dec pH
* Dec Na
* Dec O2 sat
* Dec HCT
* Inc glucose
* Inc BUN
* Pleural effusion
43
Tx of CAP vs Hospital Pneumonia
Tx = 3 to 10 days of macrolide or doxy; if co-morbidities then fluroquinolone or macrolide + ceph
Tx = 2 to 3 wks; cover pseudo (pip-tazo, cefepime, carbapanem) + fluroquinolone +/- aminoglycoside + vanco if MRSA
44
Bronchiolitis
* Non-specific inflammation of small airways secondary to viral illness
* Esp in kids < 2 and in winter
* Viruses = RSV (50-80%), flu, parainfluenza, adenovirus, metapneumovirus
* Mycoplasma pneumo or chlam pneumo
* Presentation - 1 to 2 days nasal congestion --> 2 to 5 days of wheezing, crackles, inc work breathing, prolonged expiration
* Usually clinical diagnosis
* Self-limited - only hospitalize if severe or young age/premature
* Pulse ox = good indicator of severity (want it 94% or more)
* Tx - supp oxygen, fluid for dehydration, suction
* PPX - immunoglobulin and palivizumab in kids at risk due to lung disease, cong heart disease or prematurity
45
Croup
* Viral infection --> inflammation of subglottic larynx
* Presentation
* Barking cough, hoarseness, stridor, resp distress worse at night
* Fall and winter
* Preceded by 12-72 hr runny nose and low grade fever
* 80% due to parainfluenza
* Dx - clinical, confirmed by "steeple sign" (subglottic narrowing of tracheal lumen) on neck X-ray
* Tx -
* Hospitalized if severe (cyanosis, dec consciousness, severe stridor or retractions)
* Steroids (dexamethasone), nebulozed epi (constrict pre-cap arterioles to reduce laryngeal edema and beta-2 bronchodilation properties)
46
Epiglossitis
* Bac infection of Supra-glottis tissue
* Usually kids < 5 yo and caused by bacteria (strep pyogenes or H flu)
* Presentation
* Toxic, fever, severe sore throat, muffled speech, drooling, dysphagia
* Tripod or sniffing position + anxious
* "thumb sign" on X-ray (protrusion of enlarged epiglottis)
* MED EMERGENCY - need to intubate to secure airway
* Tx - abx and airway management
47
Tracheitis
* Bacterial tracheitis is uncommon but life-threatening; mainly in 5-8 yo
* Presentation
* URI --> worsens w/ high fever, stridor, cough, toxic w/ THICK secretions
* Steeple sign if X-ray
* Bacteria = staph aureus, strep pyrogens, M catarhallis, H flu, anaerobes
* Tx - sedation, intubation, bronchoscope w/ cx and suction of secretions
* Abx - amp/sulbactam, third generation cephalosporin w/ clindamycin +/- vancomycin for MRSA
48
Peritonsillar Abscess
* Common in teens
* Severe sore throat, muffled voice, drooling, trismus, neck pain, enlarged tonsils w/ cervical nodes and uvula deviation
* Staph, strep pyrogens, anaerobes
* CT scan of neck for deeper abscess
* Tx is 14 days amp/sulbactam or clindamycin and/or I&D
49
Retropharyngeal Abscess
* 2 to 4 yo w/ fever, drooling, dysphagia, resp distress, stridor, cervical nodes and dec cervical ROM
* Dx w/ lateral neck films showing bulging posterior pharynx
* Tx w/ cephalosporins or I&D
50
Indications for Statin Therapy (ACC v NICE)
* Known cardiovascular disease and < 75 yo
* LDL > 190
* 40-75 yo w/ DM and LDL > 70
* 40 - 75 yo w/ 10-yr CVD risk > 7.5% and LDL > 70
* **reasonable to consider if ... > 75 yo w/ CVD, if LDL in 70-189 range w/o DM or 7.5% 10 yr risk, < 21
NICE uses a QRISK2 assessment for 10-yr CVD risk and has cut off at > 10%
51
Indications for ICD
* EF < 35%
* NYHA class II or III (so symptomatic despite max medical tx)
* Life expectancy 1 yr
* QRS > 120
52
Work-Up Once HTN Diagnosed
* R/o pheochromocytoma, hyperthyroid, renal disease, Cushing, coarctation, hyper-parathyroid, hyperaldosteronism, sleep apnea
* Calc BMI
* Retinal exam, thyroid, carotid/renal/femoral bruit, AAA, organomegaly, peripheral pulses
* Labs - K, Ca, creat, glucose, lipids, HCT
* Protein in urine
* ECG for LVH or CAD
53
HTN Tx in Blacks, Non-Blacks and > 60
* Blacks - Ca channel blocker then thiazides
* Non-black < 60 - ACE inhibitor, ARB, thiazides then Ca channel blockers
* Non-black > 60 - Ca channel blocker, thiazides, ACE inhibitor then ARB
54
Migraine Symptoms and Diagnosis
* Symptoms - PUNT (photophobia/phonophobia, unilateral, nausea, throbbing)
* Triggers - menses, fatigue, hunger, stress (try to ID these during visit)
* Dx - must have repeated epi 4-72 hr ea + normal PE + no other reasonable cause
* + 2 of following - unilateral pain, throbbing pain, aggravation w/ movement + mod/sev intensity
* + 1 following - N&V or photophobia/phonophobia
* ***No imaging needed
55
Tension Headaches
MOST COMMON
- band/ bilat w/ muscle tenderness
- no nausea, vomiting, aggravation w/ movement
Tx - Try ASA, acetaminophen and NSAIDs
Then combine w/ caffeine
Try to limit med use to 2-3 days / wk otherwise get med overuse headaches
If chronic ... stress mgt, antidep, amitriptyline is first line (also venlafaxine, Ca blockers, beta blockers)
56
Cluster Headaches
unilateral
- orbital, supraorbital, temporal
- deep, excruciating pain (15 min - 3 hr)
- ipsilateral autonomic signs
- more common in men
- Tend to pace/ cannot get comfortable
1st line ACUTE -100% O2 at 6L and triptans
2nd line ACUTE - intranasal lidocaine, dihydroergotamine, prednisone, octreotide, somatostatin
PPX - verapamil, lithium, melatonin, anti-epileptics, predisone
57
Migraine Tx
ACUTE - Excedrin (acetaminophen + ASA+ caffeine), NSAIDs, triptans (5-HT1 agonists - oral, nasal, IV, injection), dopamine agonists (metoclopramide or prochlorperazine)
**Do not use oral if associated w/ N&V
PPX - amitryptiline, valproate, topiramate
58
Dx of Metabolic Syndrome
* Dx - 3+ of following
* Waist circumf > 102 cm males and > 88 cm females
* Inc TGs > 150
* Low HDL < 40 males and < 50 females
* HTN >130 systolic or >85 diastolic
* Fasting plasma glucose >100 or previously diag DM
59
Dementia Work Up
* Assessments
* MMSE - mini mental exam (87% sens and 82% specific)
* Mini cog - 3 phrase recall and clock
* MoCa
* Review meds (anti-chol, benzos, sleeping pills, narcotics)
* R/o stroke
* R/o depression
* Labs - check CBC, electrolytes (hyponatremia or abnormal Ca), glucose, folate, B12, LFTs, TSH, ESR
* Screen for chronic syphilis - only if hx or in high incidence area
* Imaging - head CT or MRI
60
AZ Meds
* Cholinesterase Inhibitors
* Donepezil (Aricept) - may cause N&V, diarrhea, dizziness, headache
* Galantamine (Razadyne) - may cause arrhythmias, bradycardia, urinary obstruction
* Rivastigmine (Exelon)
* Memantine (Namenda) - NMDA antagonist; for more severe AZ; can use in combo w/ cholinesterase inhibitors
61
Broad Differential for Palpitations
* Primary Rhythm Prob
* Mental health - anxiety or panic disorder (dizziness, sense of impending doom)
* Drugs - alcohol, caffeine, cocaine, tobacco, decongestants like pseudoephedrine, OTC wt loss drugs, diuretics (electrolyte imbalance), digoxin, beta agonists, theophylline, phenothiazine
* Structural Heart Prob - HOCM, Marian, MV prolapse syndrome (ECHO)
* Non-cardiac - anemia, hypothyroid, hyperthyroid, hypoglycemia, hypovolemia, fever, pheochromocytoma, pulmonary disease, vasovagal syncope
62
Brugada Findings
Brugada - Asian men; RBBB + J pt elevation > 2 mm then slow descending ST and either flat or neg T waves in V1-V3
63
Sick Sinus Syndrome
SA node dysfunction leading to bradycardia, syncope, fatigue
Can also be tachy-Brady
64
Supra ventricular v. Ventricular Tachycardia
* Supraventricular tachy (anything not vent in origin); Ca channel blockers or beta blockers
- Symptomatic paroxysmal SVT can be self-treated w/ carotid massage/Valsalva/ cold compress for reflec Brady and break episode
- Can also try adenosine
* Vent tachy - EMER defibrillation and amiodarone (lidocaine if iodine allergy)
- MOST COMMON CAUSE OF VENT ARRHYTHMIA IS ISCHEMIA
65
A fib Tx Options
* Rate control (< 100) - Ca channel or beta blocker
* Rhythm control - amiodarone/sotalol (K+), 1C drugs like flecainide or proprafenone (unless structural heart disease)
* TEE to check for thrombus b/f cardioversion
66
Lymph Edema (causes, findings, tx, complications)
* protein rich interstitial fluid; often from previous malignancy, radiation, surgery or infections
* Kaposi-Stemmer sign - inability to pinch fold of skin on dorsum of foot at base of second toe
* Warty papillomatosis
* Non-pitting if chronic
* Diuretics do not help; compression, manual drainage
* Commonly get cellulitis
67
Drugs that can cause lower extremity edema
NSAIDs
OCPs
Ca Channel Blockers - amlodipine
68
Indications for Osteoporosis Tx
* Hip or vertebral fracture
* T score < -2.5
* T score -1 to -2.5 w/ WHO FRAX Risk algorithm (3% risk 1- yr hip fracture OR 20% risk 1- yr other major fracture)
69
Osteoporosis Tx Options
* Ca and Vit D supplements (goal = 30 in serum)
* Bisphosphonates (alendronate, risedronate, ibandronate) - inhibit osteoclasts
* Daily, weekly, monthly
* IV 4X a yr or annually
* Oral - take sitting up w/ water and stand 30 min b/c pill esophagitis
* Risk osteonecrosis or jaw and atypical fractures - limit to 5 yrs of use
* Estrogen replacement - minimal dose for minimal time b/c risk thrombosis and breast cancer; give w/ progesterone if still have endometrium
* Raloxifene - SERM; dec risk of breast cancer but inc risk of DVT and inc vasomotor symptoms
* Calcitonin - nasal spray
* Teriparatide - recombinant human PTH; activates osteoblasts (do not use if Pagets); daily subQ for 2 yrs; only use if severe
* Denosumab - monoclonal antibody that prevents osteoclasts differentiation and limits bone turnover; subQ every 6 mo; Immune suppression
70
Diagnostic Criteria for DM
* Fasting glucose > 126
* Glucose > 200 2 hr after 75 g glucose load
* Random glucose >. 200 + symptoms like polyuria
* HbA1c > 6.5%
71
DM Annual Monitoring & Initial Labs
* Lipids
* Creat, UA (urine microalbumin:creat)
* Dilated eye exam
* Foot exam
* ECG in adults
* TSH in type 1
* Monofilament test for neuropathy
72
Type 1 v Type 2 Emergencies in DM
Type 1
* Worry about DKA - fats metabolized --> ketones
* Hyperglycemia, high serum acetone and beta-hydroxybutyrate, high K+ (overall depleted), high anion gap acidosis
* Tx - IV hydration, K+, insulin
Type 2
* Worry about Hyperosmolar hyperglycemia non-ketotic syndrome
* Hyperglycemia, serum Osm > 320, large fluid deficit
* Tx - rehydration, insulin, electrolyte correction
73
DM Tx Goals
* HbA1c < 7%
* LDL < 100
* BP < 140/90
* Low carb, low sat fats and exercise 3x/wk
74
Types of Insulin
* Rapid (lispro, aspart) - 15 min onset; 3-5 hrs
* Short (regular insulin) - 30 to 60 min onset; 5-8 hr
* Intermediate (NPH) - 13 hr onset; 18-24 hr duration
* Long (glargine, detemir) - 1 hr onset; 24 hr duration
75
1st and 2nd Line Type II DM Tx
First Line - Metformin & lifestyle modification
* Metformin - biguanide; acts on liver to dec glucose output during gluconeogenesis & inc insulin sensitivity of liver and muscle
* No risk of hypoglycemia, some wt loss and dec cholesterol
* Main risk = lactic acidosis (do not use if creat > 1.5 in men or >1.4 in women); stop 48 hrs b/f procedure w/ contrast
Second Line - Insulin & Sulfonylureas
* Sulfonylureas - stim insulin secretion from beta cells
* Wt gain and risk hypoglycemia
76
TZDs
(glitazones)
inc insulin sensitivity in musc and adipose + dec gluconeogenesis
Edema and wt gain; bone fractures; potential inc MI in rosiglitazone
77
GLP-1 Agonists
(tides) - stimulate insulin release; 2 injections per day; GI side effects (do not use if gastroparesis); early satiety too
78
Acarbose
* inhibit alpha-glucosidase in SI to dec carb absorption so less postprandial hyperglycemia
* GI side effects like flatulence
79
Pramlintide
* amylin mimetic (normally made and released w/ insulin from beta cells after meal); inhibits high glucagon secretion after
* Requires 3 subQ injections; GI side effects
80
Sitagliptin
DDP-4 inhibitor
* inhibit degradation of GLP-1 and GIP by blocking enzyme
* URIs and chance of hypersensitivity reaction (titrate)
81
Glinides
short acting secretagogues; rapid onset and short duration so take right b/f meal
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OSA Diagnosis (criteria, severity, testing)
PSG = EEG, ECG, chin EMG, airflow meas and pulse ox
Criteria
* AHI or RDI 15+ w/ or w/o symptoms
* AHI or RDI 5+ w/ symptoms (daytime sleepiness, unrefreshing sleep, fatigue, insomnia, nighttime awakenings w/ gasping, choking, breath holding, witnesses apneic episodes)
Severity
* Mild 5-15 RDI
* Mod 15-30 RDI
* Severe >30 RDI
RDI = apnea, hypopnea, resp effort related arousals per hour of sleep
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Asthma Severity Definitions
* Intermittent - symptoms and SABA use < 2x/wk, night awakenings < 2x/mo, no interference w/ activity
* Mild - symptoms and SABA use > 2x/wk, night awakenings 3-4x/mo, minor limitation
* Moderate - daily symptoms and SABA use, nightly weakening > 1x/wk, some limitation
* Severe - symptoms and SABA use mult times a day, nightly awakenings every night, extremely limited
***Also look at #exacerbations requiring oral steroids in a year... if >2 then no longer considered intermittent
***In pt > 12 yo also consider actual lung function parameters (age norms so dec naturally w/ age)
Intermittent - normal FEV1 b/n exacerbations, normal FEV1/FVC, FEV1 > 80% predicted
Mild - same but FEV1 not normal b/n exacerbations
Moderate - FEV1 b/n 60-80% predicted, FEV1/FVC reduced by 5%
Severe - FEV1 < 60% predicted, FEV1/FVC reduced by >5%
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Asthma Step Wise Tx
* 1- start w/ SABA (albuterol, levalbuterol, pirbuterol); onset in 5 min and last 4 to 6 hr; metered dose w/ spacer or cont nebulizer
* 2- once mild (>2 SABA uses a wk) add low dose inhaled steroid
* May cause dysphonia, sore throat, thrush
* 3- once moderate add LABA (salmeterol or formoterol); last 12 hrs; NEVER USE ALONE
* May also use SABA, low dose inhaled steroid + leukotriene receptor agonist (montelukast) or theophylline or zileutan
* 4- once severe switch to high dose inhaled steroid and consider trial of omalizumab (monoclonal antibody injection every 2-4 wks)
85
Asthma Exacerbation Tx
* SABA (+ monitor vitals and PEF); may also add ipratroprium
* If PEF still 40-69% predicted in 20 min then 3 SABA tx in 1 hr
* If PEF < 40% predicted in 20 min (or sat < 90%) then oral or IV corticosteroids
86
Exercise-Induced Asthma
* dec FEV1 by 10% during exercise
* Will have normal spirometry at rest
* Try trial of albuterol b/f exercise
87
Amaurosis Fugax
fleeting, painless, transient monocular vision loss (form of TIA); blockage of ophthalmic artery off internal carotid
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Stroke Work Up
* CT brain w/o contrast (r/o mass, hemorrhage, ulcer)
* 12 lead ECG - r/o MI (can be cause of stroke or result of stroke), see any arrhythmia that may contribute
* Labs - glucose, electrolytes, renal function, urine toxicology
* Later... echo, carotid duplex, MRA or CTA to look at cerebrovascular system, check lipids
89
ABCDD Score for Stroke
* risk of ischemic stroke in 7 days after TIA
* A - age (1 pt if > 60 yo)
* B - BP (1 pt if systolic > 140 or diastolic > 90)
* C - clinical features (2 pts for unilateral weakness, 1 pt for isolated speech disturbance)
* D - duration (2 pts if > 60 min, 1 pt if 10-59 min, no pts if < 10 min)
* D - Diabetes (1 pt)
90
Stroke Tx Principles
* ABCs
* Allow HTN < 185/110 (unless hypertensive encephalopathy, aortic dissection, acute kidney failure or pulmonary edema)
* Use nitroprusside, labaetolol, nicardipine
* ASA w/in 48 hrs as long as not hemorrhagic
* tPA if w/in 3 hrs
* DVT ppx if thrombocytes not used
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Roseola
HHV-6
prodrome of high fever and resp distress followed by red maculopapular rash on trunk that spares face; disappears in 1 to 2 days; no treatment just reassurance
92
Varicella
* clusters of papules or vesicles on red base along w/ fever, malaise and anorexia --> crusted erosions or ulcerations
* Serious complications (rare) - pneumonitis, encephalitis, meningitis, super-infection w/ staph or strep
* Contagious for 4 to 5 days after rash appears
* Treat w/ acyclovir, valacyclovir if in first 24 hrs to dec duration
93
Erythema Infectiosum
(parvovirus B19 or Fifths Disease) -
prodrome of mild fever and upper resp symptoms then confluent erythematous macules on face that spares nose and periorbital area (slapped cheeks) which lasts 2-4 days --> lacy, itchy exanthem on trunk and extremities for 1 to 2 wks
* Arthralgias if in adolescents or adults
* Asplastic crisis in sickle cell
* Fetal hydrosphere if mother to fetus
94
Scarlet Fever
* Group A strep - can cause scarlet fever (Erythematous popular rash from neck to trunk and extremities + strawberry tongue enanthem)
* Rash fades w/ desquamation in 4 to 5 days
* Rapid antigen or throat swab culture
* Tx - PCN (can return to school or work if afebrile and on antibiotics for 24 hrs because no longer contagious)
95
Measles v Rubella
* Measles - Maculopapular from forehead down; prodrome of Koplik spots, fever and malaise
* Rubella - macular rash from head and neck down; prodrome of fever, sore throat and malaise
96
Small Pox
(variola virus) macules, papules and pustules at same stage of development unlike varicella w/ fever, myalgias and malaise
97
N Meningitidis
* maculopapular rash w/o blanching --> petechiae
* Hospitalize/quarantine
* ABCs
* Start empiric abx right away - amp + gentamicin in infants < 30 days; vanco + ceftriaxone in adults
* Once known meningococcal meningitis - PCN
* Rifamipin (or Cipro) for close contacts
98
Hand-Foot-Mouth
(coxsackie) vesicles on tongue, lips and mouth; maculovesicular rash on hands, feet, butt and groin
99
Rocky Mt Spotted Fever
(Rickettsia) maculopapular on wrist and ankles --> palms and soles; fever headache, myalgia; most common in SE US
* Low white count, low platelets, hyponatremia, inc LFTs
* Tx - doxy
100
Lyme Disease
* (Borrelia burg) erythema migrants w/ central clearing w/in 3 to 30 days
* Early dissemination - diffuse myalgias and arthralgias, Bell palsy, aseptic meningitis, carditis, rarely heart block
* Dx - serological antibody test
* Tx - doxy, amox or cefuroxetime
101
Typhoid Fever
(salmonella)
maculopapular rash on lower chest and abdomen ("rose spots") w/ fever, myalgias, diarrhea, abdominal pain, hepatosplenomegaly
102
GERD Alarm Symptoms
MEANS DO ENDOSCOPY
* Unintentional wt loss
* Progressive dysphagia
* Persistent vomiting
* Odynophagia
* Unexplained anemia
* GI bleed / hematemesis
* Family hx GI cancer
* Hx gastric surgery
* Jaundice
* ALSO DO IF >50 YO
103
H Pylori Tx Regimens
* Triple - (7 to 14 days)
* bismuth + metro or clarithromycin + tetracycline
* PPI (omeprazole) + clarithromycin + metro or amoxicillin
* Quad - (10 - 14 days)
* Omeprazole + bismuth + metro + tetracycline
104
What is the preferred H pylori testing?
Prefer serological testing for H pyloria antibodies (cannot distinguish between active or old infection so do not repeat)
If unresolved, later do stool antigen test
Urea breath test is expensive but used if stool is inconclusive
Biopsy is gold std but only done if doing scope anyway
105
GERD Mgt
* Start w/ H2 antagonist 1/day
* Inc frequency or inc to more potent PPI if needed
*
If undergo to 8 wks w/o control then should get upper endoscopy
* Advice - avoid smoking, alcohol, spicy foods, citrus, large or fatty meals, chocolate, peppermint and eating 3-4 hrs before laying down
* PPIs inc risk of CAP, C diff, bone demineralization and dec Ca/Mg/iron absorption
* May develop Barret's - use PPIs for life and surveillance upper endoscopy for esophageal adenocarcinoma
106
Bee Sting Reactions (3)
* Local Reaction - red, swelling, pain, itching from local histamine release; ice and anti-histamines + tetanus
* Delayed Reaction - IgE against venom leads to larger area of redness and warmth in 24-48 hrs; looks like cellulitis but not infection so give oral prednisone NOT antibiotics + tetanus
* Anaphylaxis - mild urticaria and angioedema OR full hypotension/shock/airway edema/ death; ABCs, IM epi + anti-histamine, bronchodilator, steroids; observe 12-24 hrs
107
Cat, Dog, Human and Rodent Bites
ALL GET TETANUS
* Cat - think Pasteurella; give 10-14 days amox-clavulanate (more risk infection)
* Dogs - 5 to 7 days amox-clavulanate (10 to 14 if cellulitis develops)
* Human bite - staph, Steph, Hemophilus, Eikenella, anaerobes ; 5 to 7 days amox- clav (10 to 14 if cellulitis develops)
* Rodent bites not associated w/ rabies
108
What are brown recluse spider bites associated with? What is the treatment?
associated w/ MRSA (if develop cellulitis) --> give clindamycin or TMP-SMX; if oral abx do not resolve it then may be abscess and need IV vanco w/ I&D
109
PCOS Diagnosis
Rotterdam Diag Criteria (need 2/3)
* 1- hyperanrogenism (hirsutism or elevated androgens in serum - testosterone, androstenedione, DHEA)
* 2- Oligomenorrhea w/ cycle length > 35 days
* 3- 12+ follicles in an ovary on US
110
PCOS Treatments
* Treat irregularity w/ oral contraceptives
* Treat infertility w/ clomiphene citrate, aromatase inhibitors, gonadotropins
* Treat insulin resistance w/ metoformin and thiazolidinediones
111
Abnormal Menstrual Bleeding w/ Normal Timing
*** Generally means ovulation is occurring so endocrine pathways are working; anatomic problem
Heavy Bleeding
* Leiomyomata (uterine fibroids) - esp submucosal; inc endometrium SA
* ENdometrial polyps also inc endometrial SA
Coagulopathy - VW disease, on Warfarin, thrombocytopenia, liver disease, heme disorders
Reduced Bleeding Volume
* Asherman Syndrome - scarring in uterine cavity from curettage which can dec size of uterus as walls become scarred and adhere to each other --> min or absent menstruation
112
DUB
"dysfunction uterine bleeding" (abnormal and irregular timing)
generally represents a hypo-pituitary-ovary axis problem
Work Up and Tx Dep on Age and Risks ...
* If right after menarche then watch and wait for 1 to 2 yrs
* If < 35 yo and no risks for endometrial cancer then hormone cycling treatment w/o further work up
* If risk factors (obesity, tamoxifen use, unopposed estrogen), if post-menopausal bleeding or if persistent symptoms in someone < 35 despite tx ...then do full EVALUATION
* Transvaginal pelvis US + endometrial biopsy; together tell endometrial thickness and look for masses or abnormalities
* May do D&C of endometrial lining, hysterectomy if cancer or endometrial ablation
* If US and biopsy neg - OCPs (combo or program only)
