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1

Pharm. Clinical Intervention, Peripheral arterial disease

Platelet inhibitors:
1. Cilostazol (mainstay of TX).
2. ASA
3. Clopidogrel

*If acute occlusion use heparin for embolism or thrombolytics for throumbus.

2

Surgical Clinical Intervention, Peripheral arterial disease

Revascularization:
1. Percutaneous transluminal angio. (PTA)
2. Bypass grafts: fem-pop bypass
3. Endarectomy: Surgical removal of plaques in arteries

4. For acute occlusion: Embolectomy
5. For severe necrosis or gangrene: Amputation

3

Non-pharm Clinical Intervention, Peripheral arterial disease

Supportive: Foot care and exercise: Fixed walking distance to the point of claudication rest until go away and repeat (do for 1-hr/day).

4

Clinical Therapeutics, STABLE Atrial fibrillation

1. Rate control: Metoprolol. CCBs (non-dihydropyridines, verapamil, diltiazem) if BBs are contraindicated. Use digoxin for elderly or Hx of hypotension or CHF.

2. CHADS2 risk to determine anticoagulation Tx. CHADS>2=Warfarin and maintain INR 2-3. CHADS of 1 = Warfarin or ASA at clinician discretion.
CHADS of 0= No anticoagulation.

5

Diagnostic Studies, Abdominal aortic aneurysm (AAA)

1. "Initial study" Abdomn. US. If >5cm = surgery
2. "Gold standard"- Angiography
3. MRI if angio. cannot be done.

NOTE: CT scans are "test of choice" for THORACIC aneurysms

AXR if done will show a calcified aorta.

6

History and Physical, Mesenteric artery ischemia

Patient with HX of MI, a-fib, and/or atherosclerosis presenting with severe abdominal pain out of proportion with physical exam.

7

History and Physical, Peripheral Venous Insufficiency

1. Occurs after superficial thrombophlebitis, after a DVT, or trauma to affected leg.
2. Will present with leg pain worse w/ prolonged sitting/standing and improves with walking or leg elevation.
3 . CYANOTIC LEG.
4. Eczematous rash and thickening of skin w/ brownish pigmentation.
5. PULSES and SKIN TEMP NORMAL
6. Ulcer at medial malleolus w/uneven margins

8

History and Physical, Peripheral Artery Disease

1. Patient with Hx of atherosclerosis
2. Claudication (leg pain worsens with activity) and worsening pain with leg elevation
3. RED LEG (dependent rubor when feet hanging down). Legs will turn CYANOTIC w/ ELEVATION.
4. Thin shiny skin w/ loss of hair, muscle atrophy, pallor, thick nails.
5. PULSES DECREASED AND COLD SKIN
6. Ulcer lateral malleolus with clean margins

9

History and Physical, Subclavian steal syndrome

Patient w/ Hx of atherosclerosis and arm claudication. Px will reveal blood pressure difference in arms w/ reduction in BP in affected arm >15mmHg compared to unaffected arm.

10

Clinical Intervention, dermatitis

Avoid irritants: chemicals, detergents, cleaners, acids, prolonged water exposure, metals, etc...if diaper rash do frequent diaper changes, topical petroleum, or zinc oxide to affected area.

11

Clinical Therapeutics, Cellulitis

1. Cephalexin or dicloxacillin 7-10 days if PCN allergy then clindamycin or erythromycin
2. MRSA- IV vancomycin on linezolid. Oral option is bactirm

12

History and Physical, local cellulitis

erythema, flat margins that are NOT sharply demarcated, swelling, warmth, and tenderness

13

History and Physical, systemic cellulitis

fever, chills, tender lyphadenopathy, myalgias, vesicles, bullae, hemmorrhage & necrosis may develop.

14

History and Physical, Erysipelas cellulitis

Group A strep. Well demarcated margins and intensely erythematous.

15

Clinical Intervention, Cat bite dermatitis

Amoxicillin/Clavulante (augmentin)

16

Clinical Intervention, Human bite dermatitis

Amoxicillin/Clavulante (augmentin)

17

Clinical Intervention, puncture wound through tennis shoe

Ciprofloxacin (for pseudomonas coverage)

18

Clinical intervention, Pheochromocytoma

Dx with 24-urine catecholamines and CT scan. Tx is Adrenalectomy.
- Pre-op is non-selective alpha blockade with Phenoxybenzamine or pentolamine x-7-14 days followed by beta blockade or CCBs if BB's are contraindicated.

19

Diagnosis, Thyroglossal duct cyst

Usually presents before age 20 with average presenting age of 6-10. It is the most frequently encountered neck mass in children. Typical presentation will be a child with a painless midline neck mass near the hyoid bone. US to confirm. Biopsy will show columnar, cuboidal, and/or non-keratinized stratified squamous epithelium.

20

Diagnostic Studies, Thyroid nodule

1. Palpable nodule on thyroid-->RAIU uptake scan--> hot nodules will uptake iodine while cold nodules will not uptake iodine. If allergy to iodine do FNA.
2. If hot nodule observe for Sx. If Asx observe. If Sx then suspect toxic adenoma or toxic multinodular goiter.
3. If cold nodule perform FNA. If cystic, observe. If solid then perform cytology.
4. Cytology: Follicular abnormalities and Hurthle cells = excision. If carcinoma or adenomatous hyperplasia Tx as indicated. If indetermined repeat FNA.

21

Clinical intervention, cold nodule thyroid carcinoma

1. Papillary (D/T radiation exposure, most common, spreads lymphatically)- Near-total thyroidectomy

2. Follicular (elderly, inc. thryroglobulin)- Near-total thyroidectomy w/ post-op radioiodine ablation (to kill cancer in blood)

3. Medullary (genetic, MEN2a/b, inc. calcitonin & serotonin)- Total thyroidectomy

4. Anaplastic (terminal in 80%, very painful, 1-year life exp.)- No Tx. Palliative care only and hospice.

22

Clinical intervention, cold nodule adenomatous hyperplasia

1. Anti-thyroid drugs (methimazole)
2. Observe for growth after methimazole admin.
3. Grows=excision
4. Shrinks=observation
5. No change= repeat FNA

23

History and Physical, Hypocalcemia

1. Hx of hypoparathyroidism and/or renal DZ. If increased PTH suspect renal DZ.
2. Muscle cramps, bronchospasm, siezures, finger & circumoral paresthesias. Chovstek's sign (facial spasm with tapping of facial nerve), and Trousseau's sign (inflation of BP cuff causes carpal spasms). Inc. DTR's.
3. Labs: Ca++ <8.5. Hyerphosatemia, hypomagnesmia, hypoalbuminemia. Inc. PTH if renal. Check renal func. ECG=prolonged QT

24

History and Physical, Thyroidectomy

Post-op check Ca++ level to check for Sx of hypoparathyroidism. Look for Chovstek' sign and Trosseau's sign. Parathyroid could have been damaged during operation.

25

Clinical Intervention, Hepatocellular carcinoma

Surgical resection

26

Clinical Intervention, Obesity

lifestyle modifications, increased exercise, diet changes.

27

Clinical Intervention, Small bowel obstruction

NPO, IVF, decompression via NG tube. If strangulated do surgery

28

Clinical Intervention, Ulcerative colitis

1. Sulfasalazine, corticosteriods (prednisone),
2. Surgery is curative

29

Diagnosis, Celiac disease

1. Presents with Malabsorption, ab. pain, BLOATING, steatorrhea especially after eating gluten porducts.
2. Perform anti-endomysial antibody test if high clinical suspicion.
3. Small bowel biopsy is definitive Dx.

30

Diagnosis, Meckel diverticulum

Presents as 2 y/o child with painless rectal bleeding. Genetic disorder of small intestine. Dx w/ Meckel's scan (Technetium-99m injected into veins. Gamma camera takes pic of abdomen and will usually show diverticulum 2-feet from ileocecal vale.

31

Diagnosis, Peptic ulcer disease

High suspect if pateint has long standing GERD Hx and still has GERD Sx refractory to Tx.

1. Endoscopy (gold standard)
2. Urea breath test (if endoscopy is contraindicated and also used to confirm eradication)
3. Stool antigen to confirm eradication.
4. H. Pylori Antibodies to confirm endoscopy findings.

32

Diagnosis, Zenker diverticulum

Presents with dysphagia, regurgitation of undigested food, fullness in neck, choking snesation or feeling of food stopping in throat. Severe halitosis. Dx with barium esophogram

33

Diagnostic Studies, Acute pancretitis

Presents with epigastric pain that radiates straight to back. LABS- Lipase more specific than amylase, inc. ALT and hypocalcemia.

** Ab. CT is test of choice.

34

Diagnostic Studies, Diverticular abscess

CT scan

35

Health Maintenance, Colon cancer

1. No Hx or risk- start screening at age @50 until age of 75 with annual fecal occult blood test and colonoscopy every 10-years or felcible sigmoidoscopy every 5-years.

2. One to two < 1cm polyps 5-10 years after removal of polyups and colonoscopy every 5-years.

3. >2 polyups at least 1-cm=3-years after removal and colonoscopy every 5-years.

4. Family Hx 1st deg relative CA Dx < age 60- Start at age 40 or 10-years prior to age of Dx of relative w/ annual fecal occult blood test with colonoscopy every 10-years until age of 75.

5. Age 75 or greater no screening.

36

Health Maintenance, Peptic ulcer disease

1. Antacids + PPIs or H2 blockers. If Sx are refractoyr to Tx do endoscopy to check for H. Pylori. Stop NSAIDs at this step as well.

2. Long standing GERD refractory to Tx = PUD. Endoscopy to check for H. Pylori eradication: Triple therapy= CAP (clarithromycin+amox.+PPI) If refractory do parietal cell vagotmoy (Bilroth II)

2. Confirm eradication w/ H. Pylori stool antigen assay or urea breath test.

3. Misoprostol to prevent NSAID induced ulcers. Not used for healing ulcers.

4. Use of antacids is helpful

3. Sucralfate binds to current ulcers to protect stomach lining and is also used for prevention.

37

History and Physical, Anal fissure

Clinical: Hx of low fiber diet, constipation, or anal trauma. Will present as severe rectal pain and bowel movement and PT is afraid to have BM. Bright red blood per rectum. Px will reveal skin taks and painful linear teat in the distal end of anal cavity.

38

History and Physical, Appendicitis

Hx of anorexia and epigastric pain that moved to periumbilical area. Will move later to RLQ Px findings include:

1. Rosving sign: RLQ pain with LLQ palpation
2. Obturator sign: RLQ pain with internal & external hip rotation
3. Psoas sign: RLQ pain with right hip flexion/extension (raise leg against resistance)
4. McBurney's point tenderness (1/3 the distance from anterior sup. illiac spine and navel).

39

History and Physical, Colon cancer

Progression of adenomatous polyups into malignancy (adenocarcinoma). High suspect in with family Hx. Will present with Fe def. anemia Sx, rectal bleeding, abdominal pain and change in bowel habits. Look for bowel obstruction as Colon CA is the #1 cause of LBO in adults. Changes in stool diameter/caliber. Look for "apple core" lesion on barium enema.

40

History and Physical, Strangulated hernia

Sx depend on type. Ischemia = severe pain.

- Femoral hernias= location is femoral canal and is more likely in women
- Inguinal hernias- location inguinal canal (most common hernia with M>F). Indirect will hit tip of finger. Direct will hit side of finger on test.
- Umbilical hernia- Location umbilical fibromuscular ring. More common in children <2.
- Incisional hernia- More common in post surgical of abdomen of obese people.
- Obturator- Location pelvic floor. More common in women with significant weight loss.

41

Scientific Concepts, Hepatic carcinoma

Commonly secondary metastasis of other cancer (lung, breast,). Risk factors include HEP B, C, D cirrhosis.

42

Clinical Therapeutics, Thromboembolism

1. DVT- LMWH (enoxaparin) or unfrac. heparin (INR 1.5-2.5)-->warfarin. Lifelong in protein C or antithrombin III or factor V leiden defic. IVC filter for those who fail anticoagulation. 1st event for at least 3-months. If pregnant or cancer use LMWH.

PE- Same as DVT but warfarin should be overlapped with heaprin for at least 5-days.

43

Diagnosis, Hemophilia

1. Hemophilia A= Presents with hemarthrosis, excessive to hemorrhage in response to trauma & surgery. Labs: Low factor VIII and prolonged PTT and normal platelets. PTT corrects with mixing study.

2. Hemophilia B-= sames Sx as A. Only way to tell difference is with labs. Low Factor IX, prolonged PTT. PTT corrects with mixing study.

44

Diagnosis, Cerebrovascular accident

Ischemic Stroke Sx: Facial droop, arm drift, slurred speech, hemiparesis. Dx with non-contrast CT. CT will show small punched out hypodense areas.

Hemorrhagic Stroke presents differently dependent on area of bleed and MOI:

1. Epidural (usually temporal bone Fx)- Brief LOC followed by lucid interval then to coma. HA, N/V and rhinorheea w/ CSF. CT shows convex lens shaped bleed in temporal area.

2. Subdural- Sx vary. CT shows concave crescent shaped bleed. Bleeding can cross suture lines.

3. Subarachnoid- Sx include "thunderclap HA" describe as "worse headache of my life," stiff neck, photophobia, delirium, retinal hemorrhages (Terson syndrome). CT is first step-->if negative do LP (xanthochromia=RBCs in CSF and ICP)--> Do 4-vessel angiography to confirm LP.

4. Intracranial- HA, N/V +/- LOC with hemiplegia, hemiparesis, with no lucid intervals. CT will show intraparenchymal bleed.

45

Pre-Operative/Post-Operative Care : Clinical Intervention, Deep vein thrombosis

prophylactic measures: LMWH (Lovenox®), subQ heparin (5000 units subQ every 8 hrs; must be started
preoperatively), sequential compression
device BOOTS beginning in O.R. (often
used with subQ heparin), early ambulation post op to prevent DVT.

46

Clinical Intervention, Pneumonia

For peri-op aspiration pneumonia- Clindamycin or metronidazole or augmentin (amox+clavulanic acid)

For HAP (concern for pseudomonas and MRSA): Anti-pseudomonal B-lactam & anti-pseudomonal aminoglycocide (gentamycin or streptomycin) or fluroquinolone (cipro). Add vanco or linezolid if MRSA is suspected.

47

Clinical Therapeutics, Hypovolemia

1. Evaluate ABCDE's
2.

48

Diagnostic Studies, Pleural effusion

1. Usual complaint is dyspnea, cough, and pleuritic chest pain (sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. It is exacerbated by deep breathing, coughing, sneezing, or laughing).

2. Px reveals decreased tactile fremitis dec. breath sounds, and dullness to percussion.

3. Initial test CXR (PA and lateral): blunting of costophrenic angles.

4. Test of choice is thoracentesis- Use lights criteria to help Dx:

Light's Criteria:
Pleural: Serum protein: Transudative <0.5; exudative >0.5
Pleural: Serum LDH: Transudative <0.6; exudative >0.6
Pleural fluid LDH: Transudative <2/3 upper limit of normal; exudative >2/3 upper limit of normal
Main Causes: Transudative- HF, Cirrhosis, Nephrotic Syndrome, Pulm. Embolism; Exudative- Malignancy, Bacteril/viral pneumonia, TB, pulm. embolism, pancreatitis, esophageal rupture, Collagen vascular DZ, chylothorax/hemothorax

49

Clinical Intervention, Chronic kidney disease

CKD stages:
Stage 1 with normal or high GFR (GFR > 90 mL/min)
Stage 2 Mild CKD (GFR = 60-89 mL/min)
Stage 3A Moderate CKD (GFR = 45-59 mL/min)
Stage 3B Moderate CKD (GFR = 30-44 mL/min)
Stage 4 Severe CKD (GFR = 15-29 mL/min)
Stage 5 End Stage CKD (GFR <15 mL/min)

Treat underlying cause: Cholesterol, anemia, HTN, proteinurea, DM, coagulopathy, bone DZ,

50

Diagnostic Studies, Microhematuria

UA dipstick, UA culture, CMP, CBC, urine protein

51

Diagnostic Studies, Nephrolithiasis

Presents w/ renal colic (sudden and constant upper, lateral back, flank pain over the CVA radiating to the groin anteriorly), N/V, unable to find comfortable position. Inc. frequency and urgency.

Px: CVA tenderness and flank pain= midureter. Midabdominal+flank pain=midureter. Groin + flank pain=distal ureter.

Dx:

1. Initial labsUA=hematuria, obtain culture. If pH 5.5-6.8 = Calcium oxalate/phosphate. pH < 5= Uric acid, cystine. pH > 7.2= struvite stones.

2. Initial test: Non-contrast Ab. CT; Intravenous Pyelography is gold standard as it determines extent of obstruction and severity.
3. US only used if CT is contraindicated
4. KUB radiograph only shows calcium & struvite stones not used often.

52

Diagnostic Studies, Testicular cancer

1. Initial test is scrotal US
2. Alpha-fetaprotein, BHCG, and LDH: Beta HCG is elevated in nonseminomatous tumors. Alpha-fetaprotein is elevated in Nonseminomatous tumors.