Family med Flashcards
(102 cards)
1
Q
[USPSTF] Grade A and B recs for: Screening 1. Lung ca 2. Colon ca 3. Cervical ca 4. Breast ca 5. BRCA
A
Screening
1. Lung ca - Low-dose CT every year for those between 55- 80 yo who have 30+ pack-year hx and smoke or quit <15 years
- CRC screening - from 50 - 75 years
- FOBT yearly
- stool DNA testing (cologard) q3yrs
- sigmoidoscopy q5yrs with FOBT q3yrs
- colonoscopy q10yrs - Cervical cancer screening - 21+ screening with pap smear q3 yrs, starting at 30 can do q5yrs pap smear and HPV screening - until age 65 (can stop earlier if mammo for non-HPV reasons eg fibroids)
- if ASCUS - do reflex high risk HPV DNA testing –> if (-), continue routine screening, if (+) –> colpo
- if ASC, LSIL, or HSIL –> do colpo - Breast cancer screening - mammo every 1 or 2 years for women 50 - 75 yo
* ACA says women 40- 44 should get yearly mammos if they want, 45-54 yearly, 55+ q2yrs or yearly if they want - BRCA
A. Non-Ashkenazi
- 2 1st degree relatives w breast cancer, one diagnosed prior to age 50
- 3+ 1st or 2nd degree relatives w breast cancer
- 2+ 1st or 2nd degree relatives w ovarian cancer
- 1st and 2nd degree relatives w breast and ovarian cancer, or one with both cancers
- 1st degree relative w b/l breast ca
- male relative with breast ca
B. Ashkenazi Jew
- any 1st degree relative with breast or ovarian ca
- 2 2nd degree relatives on same side of family w breast or ovarian ca
2
Q
[USPSTF] Grade A and B recs for: Screening 6. AAA 7. Osteoporosis 8. Hep C 9. GCC 10. Diabetes 11. HIV
A
Screening
6. AAA screening in men - one time U/S screening in men 65-75 yo who have ever smoked (100+ cigs)
- DEXA scan for women 65+ or <65 yo with risk factors (low body weight, prev fractures, FHx)
if T = -2.5 –> start bisphosphonates (eg alendronate)
* AAFP says men 70+ should also be screened - Hep C - screen one time HepCAb in baby boomers born bw 1945 - 1965
- GCC testing - GCC testing for chlamydia and gonorrhea in sexually active women 24 yo and younger
- Diabetes - screen blood glucose in adults 40- 75 who are overweight or have HTN (>130/85) or HLD (as part of CV risk assessment)
- HIV - one-time in 15 - 65 years old, testing for all pregnant women
* also depression screening in 12+ if there are support resources available
3
Q
[USPSTF] Grade A and B recs for: 12. Aspirin preventive medications 13. HLD screening 14. Statin-preventive medications
A
- Aspirin preventive medications - low-dose aspirin for primary prevention of CVD and CRC in adults 50-59 yo with a >10% 10-year CV risk
- need to take aspirin for 10 years (so have life expectancy of that timeframe) and cannot have increased risk bleeding - HLD - screening nonfasting total and HDL cholesterol
- screen M > 35 yo or F > 45 yo or either M or F > 20 yo with risk factors (smokers, DM, FHx, HTN)
- if >240 or 200+ with risk factors - get fasting lipid panel - Statin-preventive medications - adults w/out hx of CVD should use low or moderate-dose statin if:
- 40-75 yo
and 1+ CVD risk factors (HLD, DM, HTN, or tobacco)
and >10% 10-year CVD risk
4
Q
[USPSTF] Grade A and B recs for: 15. Screening in pregnant women 16. Immunizations 17. Tetanus booster for clean vs dirty wounds
A
- Pregnant women:
- Bacteriuria screening - UA and urine cx bw 12-16 wks or at 1st prenatal visit
- gestational DM screen post 24 weeks gestation
- type and screen (Rh, ABO incompatibility)
- pap smear + Rb Ab, CBC
- Hep B, HIV, GCC, syphilis (RPR) - Immunizations
- influenza yearly (need to be <50 for live nasal spray, egg allergy c/i IM inactivated)
- PCV23 for immunocompromised or chronic conditions (COPD, DM, smoking, cancer) for 19-64 yo
- at 50 yo, start giving herpes zoster vaccine (Shingrix > Zostavax)
- at 65 yo (or 5 yrs after last PCV) - PCV 13 (Prevnar), then PCV23 (Pneumovax) at least 8 weeks apart - Tetanus booster q10yrs, replace one with Tdap; also Tdap to >65 yo in contact w infant <12 mos
Wounds: need 3
A. Clean
- if 3+ doses, incl 1 in past 10 years –> nothing
- if <3 doses or >10 yrs since last dose –> tetanus toxoid vaccine
B. Dirty
- if 3+ doses, incl 1 in past 5 years –> nothing
- if 3+ doses but >5 yrs since last dose –> TTvax
- if <3 doses –> TTvax + TIG
5
Q
[Pediatrics] Immunizations / Vaccinations At birth 2,4,6 mos 6 mos and yearly 12 mos Age 2 Kindergarten Age 12
A
At birth - Hep B; if mom HbsAg + –> Hep B and HepBIG in separate thighs; also erythromycin eye drops (prevent GC) and vitamin K IM
2,4,6 mos - Hep B, Rota, Dtap, HiB, PCV (pneumococcal), IPV (polio)
6 mos and yearly - flu (first time get 2 doses, 4 weeks apart)
*6+ mos for inactivated shot, 2+ yo for live attenuated nasal spray
12 mos - MMR (neomycin/streptomycin allergy is c/i), Varicella, HepA
Age 2 - Dtap and 2nd HepA (6 mos after 1st one)
Kindergarten (~age 4) - Dtap, last IPV, MMR, Varicella
*5 doses total of Dtap from 6 weeks to 6 years
Age 12 - Tdap booster (every 10 years), meningococcal, Gardasil (3 doses)
- Only need two doses gardasil if 11-14 but they need to be 6+ mos apart. If less then need three doses
- Need 2 doses Hep A, 3 B - pick up where you left off; if you don’t know - then redo vaccination schedule
- can’t play catchup with Rota >15 weeks after schedule
6
Q
[Pediatrics] Developmental milestones - motor, language, social 1 month 2 months 4 months 6 months 9 months
A
Developmental milestones: 1 month A. Motor - reacts to pain B. Language - responds to noise C. Social - regards face, eye contact
2 months
A. Motor - sustains head, follows object to midline
B. Language - coos
C. Social - social smile, recognizes parents
4 months
A. Motor - rolls over, follows objects / hands to midline, sits with support
B. Language - laughs
C. Social - looks around and turns to voice, regards hand
6 months
A. Motor - rolls over both ways, sit with support or unsupported, transfers objects hand to hand
B. Language - babbles
C. Social - stranger anxiety
9 months
A. Motor - sits unsupported, pulls to stand / cruises, crawls, 3 finger pincer grasp, holds cup
B. Language - says dada and mama
C. Social - explores, waves bye
7
Q
[Pediatrics] Developmental milestones - motor, language, social 12 (1 year) 24 (2 years) 36 (3 years) 60 (5 years)
A
12 (1 year)
A. Motor - walks, throws object, 2 finger grasp
B. Language - 1-3 words, follows 1-step commands (“come”)
C. Social - separation anxiety
24 (2 years)
A. Motor - walks up and down stairs, runs, kicks ball, holds spoon
B. Language - 1/2 speech comprehensible, 2 word sentences
C. Social - parallel play
36 (3 years)
A. Motor - copies circle, rides tricycle
B. Language - 3/4 speech understandable, recognizes 3 colors
C. Social - group play, knows name age and sex
48 (4 years)
A. Motor - copies cross and square, hops on 1 foot, throws ball, goes to toilet alone, can ID 4 body parts
B. Language - speech understandable
60 (5 years)
A. Motor - copies triangle, catches ball, dresses mostly independently
B. Language - writes name
72 (6 years)
A. Motor - ties shoes, skips w alternating feet, draws person w 6 parts
B. Language - IDs left and right
8
Q
[Pediatrics]
Describe causes, clinical, mgmt of wheezing in kids:
1. RSV bronchiolitis
2. Croup
A
- RSV bronchiolitis - MCC acute wheezing in infants <6 mos; more common in winter
A. Cause - viral, more common in winter
B. Clinical - URI prodrome (rhinorrhea, nasal congestion) –> wheezy cough, low grade fever, decreased feeding, dehydration
- respiratory distress (tachypnea with retractions and low Sa02) but NO stridor
C. Mgmt - give 02 if Sa02 < 90% + supportive care (humidified 02, fluids)
- pavalizumab vaccine if preemie <29 weeks, chronic lung disease of prematurity, or CHD
- complication is apnea esp if <2 mos - Croup (laryngotracheobronchitis)
A. Cause - parainfluenza virus, 6 mos - 3 yrs, more common in fall/winter
B. Clinical - URI prodrome (rhinorrhea, nasal congestion) –> gradual onset of low grade fever with barking cough, inspiratory stridor 2/2 laryngeal subglottic edema
- sx improve in cold air
C. Mgmt - steroids- glucocorticoids (dexamethasone), nebulized racemic epi for moderate to severe distress
9
Q
[Pediatrics]
Describe causes, clinical, mgmt of wheezing in kids:
3. Epiglottitis
4. Bacterial tracheitis
A
- Epiglottitis
A. Cause - HiB is MCC (Even in immunized children),also GABHS; peak incidence ~3 yo
B. Clinical - bacterial infection of supraglottic tissue –> acute onset of high fever + drooling, dysphagia, distress (no prodrome of cough, rhinorrhea, congestion)
- signs of impending airway obstruction - worsening inspiratory stridor, muffled hot potato voice, tripod position of sitting, hyperextension of neck
C. Mgmt - emergency! OR for endotracheal intubation; IV Augmentin (amoxicillin + clavulanate) + ceftriaxone - Bacterial tracheitis
A. Cause - S aureus, GABHS, H flu, Moraxella
B. Clinical - sudden worsening post-URI with high fever, stridor, cough
- thick secretions –> risk of upper airway obstruction
C. Mgmt - similar to epiglottitis - OR for intubation + ceftriaxone, clinda, unasyn (amp + sul)
10
Q
[Pediatrics]
Describe causes, clinical, mgmt of wheezing in kids:
5. Retropharyngeal abscess
6. Peritonsillar abscess
A
- Retropharyngeal abscess
A. Causes - polymicrobial –> S aureus, S pyogenes, anaerobes; direct spread of bacterial infection
B. Presentation - abrupt onset fever w sore throat, refusal of food or to turn head or extend neck (neck pain and limited mobility), posterior pharyngeal bulge, tender cervical LAD, muffled voice, stridor and wheezing
- in kids <4 yo
- prevertebral soft tissue swelling and widening of retropharyngeal space on lateral cervical X-ray
C. Tx - do CT w contrast to determine presence and size of abscess
- needle aspiration or I and D
- abx - IV clinda or 3rd gen ceph + amp, then PO abx
D. Complications - mediastinitis, upper airway obstruction - Peritonsillar abscess - MCC deep neck infection in pediatrics, most common in adolescents
A. Causes - extension of tonsillitis; polymicrobial –> GABHS, S aureus, anaerobes
B. Presentation - “hot potato” voice, uvula deviated, u/l throat and ear pain, dysphagia with drooling
- more common in young teens
- abscess on CT –> hypodensity w rim enhancement, can see extension to contiguous structures
C. Tx - needle aspiration or I and D
- abx (penicillin or unasyn or clinda) for 14 days
- tonsillectomy if recurrent (>5x/year for 2 yrs or >3x/year for 3 yrs)
D. Complications - airway obstruction, cellulitis, nec fasc
11
Q
[Pediatrics] Describe DDx for causes of limp in: 1. Infants and toddlers 2. Young children 3. Adolescents
A
- Infants and toddlers
A. Septic arthritis - Kocher criteria –> systemic sx (fever >101.4F), no weight bearing, ESR >40, WBC>12K
- hip kept flexed and abducted, externally rotated; pain with internal abduction
- GABHS and S aureus in <4 mos, S aureus and Strep pyogenes in >4 mos
- tx - joint aspiration, abx + I&D
B. Fractures - stress or traumatic, do plain films
- toddler’s fracture = spiral fracture of tibia in <2 yo, tenderness over site
C. DDH - painless limp, toe-walking on affected side; dx - U/s if <6mos, XRay if >6 mos; tx - Pavlik harness - Young children - workup includes X-rays and CBC/CRP/ESR if there are systemic signs (fever); do U/S to r/o joint effusion; all nl –> do MRI and bone scan
A. Transient synovitis - post-viral hip pain leading to limp and refusal to bear weight and decreased ROM; low-grade fever and normal or slightly elevated ESR CRP WBC
B. Legg-Calve-Perthes - idiopathic avascular necrosis of femoral head, MC in ages 4-8 yo, M>F
- gradual onset hip, thigh, or knee pain with antalgic limp, TTP, and proximal thigh muscle atrophy
- cast leg to maintain femoral head in acetabulum - Adolescents
A. SCFE - overweight boys with pain in hip, thigh, or knee and antalgic limp
- hip flexed and externally rotated
- tx - surgically pinning of femoral head in place to avoid avascular necrosis
B. Osgood-Schlatter - overuse injury with repeated jumping, in male athletes ~13 yo
- painful bump below knee where patellar tendon attaches to tibia
C. Gonoccocal arthritis - purulent arthritis or triad of polyarthralgias, tenosynovitis, and dermatitis (pustules)
12
Q
[Pulm] COPD Pathophys, CXR and clinical findings: 1. emphysema vs 2. chronic bronchitis
A
COPD - fixed airway obstruction that is irreversible and progressive
1. Emphysema - “pink puffers”
A. Pathophys - destruction of alveolar walls (smoking, antitrypsin deficiency) –> enlargement of alveoli and respiratory bronchioles –> ↑ compliance and ↓ recoil –> SOB, exhalation through pursed lips to ↑ airway pressure and prevent collapse, skinny bc of ↑ respiratory effort
B. CXR - ↑ AP diameter and flattened diaphragm (barrel chest), ↑ lung field lucency and hyperinflation –> distant heart sounds
- Chronic bronchitis - “blue bloater”
A. Pathophys - hyperplasia of mucous-secreting glands in bronchi (smoking, occupational exposure) –> Reid index >50%, ciliary dysfunction, poor mucous clearance –> productive white thick cough >3 months of year for >2 years
- wheezing, cyanosis (hypoxemia 2/2 shunting), C02 retention, 2 polycythemia
- over time - DOE, pulm HTN, cor pulmonale (RHF 2/2 ↑ pressures in pulm circulation)
B. CXR - bronchial wall thickening, cardiomegaly
13
Q
[Pulm] COPD 3. Mgmt of COPD A. Stage I B. Stage II C. Stage III D. Stage IV
- Acute exacerbation
A. Causes
B. Clinical presentation
C. Mgmt
A
- Mgmt of COPD - FEV1/FVC <70%; decline in lung function is irreversible
A. Stage I - FEV1 > 80% –> inhaled SABA (albuterol) prn, inhaled ipratropium BID
B. Stage II - FEV1 50-80% –> add inhaled LABA (salmeterol) BID
C. Stage III - FEV1 30-50% –> add inhaled steroids (fluticasone, triamcinolone) BID to reduce frequency of exacerbations *increase risk bruising, candida, PNA
D. Stage IV - FEV1 <30% –> 02 therapy if evidence of hypoxemia (Sa02 <88%, Pa02 <60mmHg) *only intervention that decreases mortality other than smoking cessation; must be used at least 15 hrs / day - Acute COPD exacerbation
A. Causes - viral or bacterial infection, air pollutants
B. Clinical presentation - cough and change in sputum color (white to green), wheezing, tachypnea, mild respiratory distress (use of accessory muscles), cyanosis
C. Mgmt - short-acting bronchodilator (SABA and anticholinergic), systemic steroids (IV or PO prednisone) for 5-7 days, and oral abx (doxy, ammo, TMP-SMX)
- sputum cx (MCC S pneumo, H flu, and M catarrhalis - and Pseudomonas) and abx (azithro, cipro, augmentin)
- hospitalize if severe sx, nonresponders, AMS, etc
14
Q
[Pulm] Causes, clinical, and mgmt of URIs: 1. Cough 2. Acute bronchitis 3. Cold
A
I. Cough
A. Causes - URI, pulm disease (PNA, COPD, Asthma, Cancer, TB), CHF w pulm edema, smoking, postnasal drip, sinusitis, GERD, ACEIs
B. Clinical - acute (<3 weeks) vs chronic (>3, MCC are postnasal drip, GERD, and asthma)
C. Mgmt - treat underlying cause, antitussives eg codeine dextromethorphan
II. Acute bronchitis - inflammation of the tracheobronchial tree (vs PNA which is infection of distal bronchioles and alveoli) –> mucus oversecretion
A. Causes
- MCC is viral; dx of exclusion - r/o PNA, asthma, GERD
- bacterial - higher fever and productive cough (Myco, Chlamydia, B pertussis) esp in young adults
B. Clinical - persistent cough w sputum lasting 1-2 weeks +/- mild fever / malaise, rhinorrhea, nasal congestion
C. Mgmt - self-limited illness - no abx! regardless of duration
- antitussive, albuterol bronchodilator, analgesics
- if persistent cough, likely due to hyperresponsive airways –> inhaled steroids or oral steroid taper
- CXR to r/o PNA if: fever >100.0°F, bloody sputum, or signs of consolidation on PE, tachypnea/cardia
III. Cold - most common URI
A. Cause - viral MCC rhinovirus also adeno, corona, parainfluenza,
B. Clinical - rhinorrhea, sore throat, nonproductive cough, nasal congestion
C. Mgmt - hydration, rest, analgesia, antitussive, nasal decongestant spray, 1st gen antihistamines
15
Q
[Pulm]
Causes, clinical, and mgmt of URIs:
4. Sinusitis - acute vs chronic
A
IV. Sinusitis - inflammation of the mucosa of the paranasal sinuses (MC maxillary) and nasal mucosa
A. Causes - allergic rhinitis, viral URIs, nasal obstruction r/t polyps, deviated septum, foreign body
- viral (NCC) - copious b/l clear rhinorrhea; if it lasts > 10 days, fever, worsening sx, or b/l purulent discharge –> think bacterial
- bacterial - S pneumo MCC, H flu –> consider if >7-10 days symptoms (since most viral etiologies resolve by then); anaerobes (more likely chronic)
B. Clinical - acute vs chronic
i. acute - purulent rhinorrhea, cough, stuffiness, sinus or thooth pain or pressure (in maxillary - over the cheeks), fever, worsening of sx after initial improvement
ii. chronic - >2 months with nasal congestion, nasal d/c, facial fullness/discomfort (not really pain), HA
C. Mgmt
i. acute - saline nasal spray, peudoephedrine decongestant (no more than 3-5 days), abx (augmentin, 2nd gen cephs eg cefuroxime), antihistamine if pt has allergies; no CT or MRI necessary
ii. chronic - augmentin, clinda, or moxi + intranasal steroid, endoscopic drainage if needed
16
Q
[Pulm]
Causes, clinical, and mgmt of URIs:
5. Pharyngitis incl Centor criteria
A
V. Pharyngitis
A. Causes - MCC is viruses (EBV, HSV, rhino, parainfluenza, adeno), GABHS, GCC, Candida
B. Clinical
- viral more likely to have cough, coryza, rhinorrhea
- Centor criteria for GABHS - 1 point for each:
Cough absent
Exudate on tonsils
Nodes (tender anterior cervical LAD)
Temperature >100.4F
OR - young <14 add one point, OR old >45 subtract 1 point
C. Mgmt
<1 - reassurance that it is viral, analgesia, salt water gargle, lozenges
2-3 - rapid strep, then throat culture
>4 - no rapid strep necessary, empiric tx - PCN, ammo, or erythro to prevent ARF (will not present PSGN)
tender cervical LAD and splenomegaly - do monospot for CMV
17
Q
[Pulm] PNA A. Causes i. CAP ii. HAP iii. HCAP
B. Clinical
A
Pneumonia (PNA) - infection of lung parenchyma (LRTI)
A. Causes -
i. CAP
- bacterial typicals (- S pneumo, H flu, Moraxella) - more common in young/old; atypicals (Myco, Chlamydia, Legionella) - more common in adolescents / young adults
- viral - influenza, adeno, RSV, parainfluenza
ii. HAP - at least 48 hours post admission to hospital; Klebsiella, Pseudomonas, Actinebacter, S aureus
iii. HCAP - within 90 days of hospital, nursing home, dialysis - same bugs as HAP
B. Clinical - f/c, productive cough with green sputum, dyspnea, pleuritic chest pain; can present as AMS in elderly
- abrupt onset - more common in bacterial (staph or strep)
- diarrhea, LFTs, hyponatremia - Legionella
- postflu PNA - Staph
- PE - dullness to percussion or egophony, decreased breath sounds, rhonchi or rales; reduced Sa02, tachypnea, tachycardia, hypotension
18
Q
[Pulm] PNA C. DIagnosis D. Mgmt E. Complications
A
C. Diagnosis - need fever and infiltrate on CXR to dx (lobar in typicals, b/l and diffuse in atypicals)
- if fever and cough but no infiltrate (negative CXR) –> bronchitis
- if fever and cough and cavitation on CXR –> abscess, do CT to look for fungus, TB
D. Mgmt - determining whether to hospitalize: admit if 2-5 on CURB65 (Confusion, Urea>7, RR>30, BP<90/60, age >65)
- CXR, sputum Gram stain and Culture, blood cultures + CBC / CMP
- infants and school-age kids - MCC is S pneumo –> give ammo
- adolescents + adults –> give azithro + doxy
- chronic comorbidities (DM, CAD, COPD) –> levofloxacin or azithro + augmentin (or cefuroxime or other beta lactam)
- HAP or HCAP - vanc + zosyn (pip/taz)
E. Complications - bacteremia, sepsis, pleural effusion, empyema
19
Q
[Pulm] Asthma 1. Risk factors 2. Pathophys A. Acute response B. Late phase C. Diagnosis
3. MOA and adverse effects of alcohol pharmacotherapy A. SABA B. LABA C. Corticosteroids D. Montelukast
A
Asthma - median age of onset 4 yrs
- Risk factors - atopy (hx atopic dermatitis, nasal polyps), family hx
- early respiratory infections eg RSV bronchiolitis - Pathophys - airway inflammation
A. Acute response - IgE response to environmental triggers in lower airways –> mast cell activation –> vasodilation, vascular permeability, smooth muscle bronchoconstriction, mucous secretion –> cough, wheezing
B. Late phase reaction - infiltration of CD4+ T cells into airway parenchyma, inflammatory response comes on after 2-4 hours and persists for weeks
C. Diagnosis - do spirometry (PFTs) –> if pt has normal spirometry, methacholine challenge is gold standard - MOA of alcohol pharmacotherapy
A. SABA (albuterol) - agonizes B2R on bronchial smooth muscle cells –> Reverses bronchoconstriction
- side effects - tachycardia, HA, dizziness
B. LABA (salmeterol) - same MOA; rarely used and never alone bc a/w increased mortality
C. Corticosteroids (prednisone, prednisolone) - block late phase reaction and reduce hyperresponsive airways
D. Montelukast (LRAs) - blocks leukotriene receptors (which increase bronchial tone), good for aspirin- or exercise-induced asthma, or in pts intolerant of ICS; takes 2-4 weeks for effects
*use peak expiratory flow (PEF) to monitor asthma, 80-100% of personal best is good range, <50% needs hospitalization
20
Q
[Pulm] Asthma Differentiate different types by symptoms, lung function, and management: 1. Intermittent 2. Mild persistent 3. Moderate persistent
A
1. Intermittent A. Symptoms - daytime sx and SABA use <=2x week - nighttime awakenings <=2x/month - 0-1 exacerbations yearly requiring systemic steroids B. Lung function - normal PFTs bw exacerbations - FEV1/FVC > 85% C. Mgmt - SABA (albuterol) prn
Persistent - >= 2 exacerbations yearly requiring steroids
- Mild persistent
A. Symptoms
- daytime sx and SABA use >2x week
- nighttime awakenings 3-4x / month
B. Lung function - FEV1 > 80%, FEV1/FVC > 80%
C. Mgmt - SABA prn + low-dose inhaled corticosteroid (ICS) - Moderate persistent
A. Symptoms
- daytime sx and SABA use daily
- nighttime awakenings >1x week
B. Lung function - FEV1 = 60-80%, FEV1/FVC = 75%
C. Mgmt - SABA prn + ICS + LABA (salmeterol)
21
Q
[Pulm] Asthma Differentiate different types by symptoms, lung function, and management: 4. Severe persistent 5. Asthma exacerbation
A
- Severe persistent
A. Symptoms
- daytime sx and SABA use multiple times / day
- nighttime awakenings nightly
B. Lung function - FEV1 < 60%, FEV1/FVC <75%
C. Mgmt - SABA prn + medium-dose ICS + LABA + oral steroids / montelukast - Asthma exacerbation
A. Symptoms - tachypnea, pulsus paradoxus (weak with inspiration), inspiratory wheezing, absent expiratory breath sounds
- signs of impending respiratory collapse - drowsiness, delayed capillary refill, use of accessory muscles
B. Lung function - worsening bronchoconstriction + airway inflammation + mucus plugging
C. Mgmt - low PC02 (due to hyperventilation) –> inhaled albuterol (B2 agonist) and PO/IV steroids (prednisone) and 02 + IVF
*wheezing increases as airways respond to tx and open up
- intubate if PC02 normalizes (impending resp failure)
- complications – > allergic bronchopulmonary aspergillus
22
Q
[CV]
CHF
1. Pathophys
2. CXR findings
A
CHF
- Pathophys - MCC are CAD (2/3) and also HTN, MI, valvular disease, chagas; systolic vs diastolic dysfunction; R vs L HF
- systolic (HFrEF) - dilated ventricle with impaired contractility
- diastolic (HFpEF) - normal LVEF but impaired ventricular relaxation and filling –> LVH, S4
- end result, impairment of ventricle’s ability to fill with or eject blood –> inadequate circulation of blood to meet metabolic needs –> fatigue, fluid retention, overloading of fluid in lungs, low Sa02
- fluid overload –> dyspnea and anxiety –> increased SNS release of catecholamines –> tachycardia, increased PVR –> worsening of symptoms - CXR
- cardiomegaly 2/2 systolic dysfunction
- central vascular congestion (hilar fullness)
- cephalization of pulmonar vessels (can be seen extending from hilum in upper lung fields) 2/2 increased preload
- Kerly B lines (linear densities in periphery of lung fields, represent interstitial fluid in lung tissue) - seen in progressed HF
- pleural effusions (blunting of costophrenic angles)
23
Q
[CV] CHF 3. Clinical - common signs and sx A. LHF B. RHF
- Mgmt
A
CHF
- Clinical - RHF vs LHF signs and symptoms
- common symptoms - fatigue, weakness, HA, PND, S3 (volume overload in dilated LV 2/2 rapid ventricular filling OR poor functioning)
- common signs - PMI displaced towards axillary line, tachycardia, cyanosis, oliguria / nocturia, peripheral pitting edema
A. Left HF - increased pressure in pulmonary veins –> pulm congestion and edema
- Symptoms - DOE, SOB, orthopnea, wheezing, tachypnea, cough
- Signs - crackles, Cheyne-Stokes respirations, pleural effusion
B. Right HF - MCC is LHF –> RV systolic dysfunction w dilation and tricuspid regurg –> increased pressure in systemic veins
- Symptoms - n/v, abd distension, RUQ pain, decreased appetite
- Signs - JVD, peripheral edema, jaundice, hepatomegaly or ascites (shifting dullness) or hepatojugular reflex (JVD when you press on liver)
- Mgmt - evaluate via echo, MCC hospitalization in >65 yo
- morphine - anxiolytic AND vasodilator
- furosemide - loop diuretic AND immediate vasodilator of bronchial vasculature
- also ACEI/ARB, BB to decreased preload/afterload and reduce cardiac remodeling
24
Q
[CV]
Acute decompensated CHF
1. DDx
2. Mgmt of CHF exacerbation
A
Acute decompensated CHF
- DDx:
- MC triggers are infection and anemia
- MI
- arrhythmias eg afib
- diastolic dysfunction 2/2 uncontrolled HTN –> HFpEF
- ischemic cardiomyopathy
- non-ischemic (dilated, hypertrophic, restrictive, RV dysplasia)
- PE
- hypothyroid or hyperthyroid
- valvular disease - Mgmt of CHF exacerbation - goal is to stabilize cardiopulm system
- reduce preload by sitting patient up, maintain airway and give high-flow 02, and sublingual nitroglycerin (reduces myocardial 02 demand); consider CPAP if still hypoxic
- loops for volume overload
- IV morphine –> analgesic, anxiolytic, and venodilator
- dobutamine or milrinone if HFrEF
- dopamine vasopressor if hypotensive
* avoid NSAIDs - can worsen fluid retention and decrease efficacy of diuretics, ACEIs; avoid BBs - can worsen sx (negative chronotrope, inotrope)
25
[CV]
CHF management
1. HFrEF
2. HFpEF
1. Mgmt of systolic heart failure (HFrEF)
- ACEI or ARB - 1st line; dose-dependent, reduce preload/afterload, improve CO w/out increasing HR, inhibit RAAS and improve myocardial compliance; c/i in pregnancy, b/l renal artery stenosis (bc they dilate efferent arterioles and increase Cr), hypotension, hyperkalemia
- loop diuretics eg Lasix (not for use in HFpEF since diuresis decreases LV filling and worsens HF)
- BBs eg metoprolol, carvedilol - reduce mortality in symptomatic pts when combined w ACEI/ARB; c/i in bradycardia, hypotension, PVD, and bronchospasm
- aldosterone antagonists eg spironolactone, eplerenone - reduce mortality in advanced HF
- digoxin - indicated to reduce hospital stay for uncontrolled HF; no mortality benefit and narrow TI (also increased risk toxicity w renal insufficiency)
* CCBs increase mortality except for amlodipine (treats HTN)
- cardiac resynchronization therapy (pacemaker) - for EF <35%, classes III-IV, QRS >120ms --> prevents cardiac death 2/2 ventricular arrhythmias
2. Mgmt of diastolic heart failure (HFpEF) - goal is to slow HR, increase filling time; avoid reducing preload and excessive diuresis
- BB eg metoprolol
- CCB eg diltiazem, verapamil - lower HR --> more ventricular filling time --> improved CO
26
```
[CV]
Cardiovascular diseases - general risk factors
I. HTN
1. Causes
2. Risk factors
3. Diagnosis
```
Cardiovascular diseases: risk factors --> HLD, DM, smoking, HTN, obesity, age > 60, M>F until age 60, and FHx
```
I. HTN
1. Causes
A. Essential (95% cases)
B. Secondary - HHHARP CO
Hypercalcemia
Hyperthyroid
Hyperaldosteronism (dx - PRA)
Aortic coarct
Renovascular HTN - if good control w renal artery stenosis, no testing other than monitoring renal fx; a/w incr in Cr post ACEI/ARB
Pheo - pain (HA), pressure (HTN), perspiration, pallor
Cushing (dx - dexa suppression test)
OSA
* also meds - sudafed (pseudophedrine, MAOIs, steroids, cocaine, OCPs)
```
2. Risk factors - age, gender, race (blacks > whites), obesity, FHx, sodium and alcohol intake
3. Diagnosis - 2+ readings over 4+ week span greater than 140/90
- get CMP, fasting glucose, lipid panel, UA, and EKG to assess overall CV risk and assess for end-organ damage
27
```
[CV]
Cardiovascular diseases
I. HTN
4. Clinical effect by system
5. Define HTN urgency/emergency and mgmt
```
4. Clinical effect on systems:
A. cardiac - increased SVR (aferload) --> LVH --> decreased LV function --> HF
- accelerates atherosclerosis --> CAD (eg MI), PVD
- aortic dissection
B. neuro - stroke / TIA (most important risk factor for stroke), intracerebral hemorrhage, HTN encephalopathy
C. renal - CKD
D. eyes - retinopathy --> AV nicking, cotton-wool spots, papilledema, hemorrhage and exudates
5. HTN urgency / emergency: >180 / 120, emergency has end-organ damage (HA, AMS, n/v, syncope, CP, dyspnea, decreased UO)
- lower MAP by 25% in 1st 6 hours
- IV labetelol, nitroprusside, fenoldapam, nicardipine
28
```
[CV]
Cardiovascular diseases
I. HTN
6. Mgmt - goals
in blacks, nonblacks, by age, comorbidities (CKD, CAD, DM, CHF, stroke)
```
6. Mgmt - Goals: 150/90 in pts 60+ with no comorbidities (only HTN), 140/90 in <60 w no comorbidities, also with DM or CKD at any age
- lifestyle changes (weight loss via diet/exercise, cut alcohol)
- black - CCB or thiazide, unless they have CKD --> ACEI/ARB
- nonblack <60 yo - ACEI/ARB, thiazides, CCBs
- nonblack >60 yo - CCB, thiazides, ACEI/ARB
- CKD - ACEI/ARB except for stage IV (bc Cr increase can push into stage V --> use hydralazine instead)
- CAD - BB + ACEI/ARB, then CCB
- DM w/out CKD - ACEI/ARB unless black - give CCB or thiazide
- CHF - BB + ACEI, then loops, then spironolactone or combo of vasodilator hydralazine and venodilator isosorbide dinitrate (BiDil)
- stroke - ACEI/ARB + thiazide
29
```
[CV]
Cardiovascular diseases
I. HTN
7. Med side effects
A. ACEI/ARB
B. Thiazide
C. CCB
D. BBs
E. Clonidine
```
7. Med side effects
A. ACEI/ARB - renoprotective, decreased risk new-onset DM; increase in Cr and K, teratogens; ACEI can cause dry cough, angioedema
B. Thiazides - work synergistically w ACEI but can raise blood sugar; decrease serumK and urineCa; K-wasting, do not work well in CKD (GFR <30), can cause ED
C. CCB (dihydropyridine "-dipines") - vasodilation of arterial vasculature --> peripheral edema, hypotension
D. BBs (metoprolol, carvedilol, labetelol) - negative inotrope / chronotrope, decrease CO (=SV x HR), decrease renin release
- good for migraines, anxiety, tremor
- can cause bradycardia, bronchospasm (c/i in asthma), depression, ED
- masks hypoglycemic sx in diabetics on insulin
* NOT a 1st line HTN drug* but good for CHF and CAD
E. Clonidine - rebound HTN w missed doses
30
```
[CV]
Cardiovascular diseases
II. HLD
1. Causes
A. Primary
B. Secondary
2. Risk factors
3. Diagnosis
4. Clinical
```
II. HLD
1. Causes
A. Primary - familial (Type I exogenous hyperlipidemia - chylomicrons, II hypercholesterolemia- LDL, III dysbetalipoproteinemia - IDL, IV endogenous hyperlipidemia - VLD, V hypertriglyceridemia - VLDL, which distribute TGs, + chylomicrons)
B. Secondary - endocrine (DM, Cushing, hypothyroid), renal (nephrotic syndrome), cirrhosis, meds (estrogen, thiazides, BBs, steroids), pregnancy
2. Risk factors - diet, age, obesity, sedentary, FHx, M>F
3. Diagnosis - want total cholesterol <200, LDL < 130, TGs < 125
- LDL = total cholesterol - HDL - TG/5
- get TSH, LFTs, BUN/Cr, and glucose levels to exclude secondary causes (hypothyroid, liver disease, nephrotic, and DM, respectively)
4. Clinical - usually asx or xanthelesma (eyelids), xanthoma (on tendons), pancreatitis
31
```
[CV]
Cardiovascular diseases
II. HLD
5. Mgmt incl MOA, indications, and side effects of meds:
A. Statins
B. Niacin
C. Cholestyramine
D. Gemfibrozil
E. Ezetimibe
```
5. Mgmt - target LDL is <130 UNLESS pt has established coronary heart disease or DM -- target <100
- diet - lower fat intake; aerobic exercise and weight loss and smoking --> increase HDL
- medications:
A. statins - inhibit HMG CoA reductase, lower LDL, reduce mortality; monitor LFTs, can cause myopathy and increase in CPK; teratogen
- ACC/AHC says start high intensity statin (atorvastatin, rosuvastatin) if:
*anyone with LDL > 190
*<75yo w clinical CVD (eg prior MI, ischemic stroke, HF, arrhythmia, valvular disease)
*40-75 w DM and LDL >70
*40-75 w 10-year CVD risk >7.5% and LDL >70
- USPSTF says medium intensity statin if 40-75 yo and 1+ CVD risk factor (DM, HTN, HLD, smoking) and >10% 10-year CVD risk
B. Niacin - best at increasing HDL, moderately lowers TGs; do not use in diabetics bc worsens glycemic control; causes flushing (take NSAIDs) and hyperuricemia, check LFTs and CPK
C. Cholestyramine - bile-acid binding resin (liver must use cholesterol to make more); use w statins or niacin to lower LDL; does increase TGs and causes constipation and bloating, decreased absorption of ADEK
D. Gemfibrozil - fenofibrate, lowers TGs by changing hepatic metabolism of lipoprotein (increasing LPL), 2nd best at increasing HDL; can cause cholesterol gallstones, myopathy
E. Ezetimibe - inhibits absorption of cholesterol in small intestine; 2nd line for decrease in LDL (after statins); can cause increase LFTs and diarrhea
32
```
[CV]
Cardiovascular diseases
III. ACS
1. Compare stable, unstable angina vs NSTEMI, STEMI
2. Diamond criteria
3. Workup for CP
```
ACS
1A. Stable angina - managed outpatient
B. Unstable angina - no heart damage, but demand ischemia 2/2 90% occlusion --> urgent cath
C. NSTEMI - heart damage due to demand ischemia 2/2 90% occlusion --> urgent cath
D. STEMI - heart damage due to supply ischemia 2/2 100% occlusion --> emergent cath (door to balloon 90 min)
2. Diamond criteria for typical angina:
i. substernal or L sided CP
ii. CP worsened with exertion, relieved with rest
iii. CP relieved with nitroglycerin
3. Work-up:
- first, rule out NSTEMI, STEMI
- next, determine if pain is due to coronary ischemia via stress test --> pharm (dobutamine) vs exercise, EKG (look for changes) vs echo (look for stunned myocardium during exertion) vs nuclear (use if prev bypass or HF)
- <3 vessels --> Stent; 3+ vessels --> CABG
* MCC CP in O/P - MSK (eg costochondritis), then GI (eg GERD, PUD, pancreatitis)
33
[CV]
Cardiovascular diseases
III. ACS
4. Medication mgmt
4. Medications for ACS: MONABASHC
Morphine - reduces 02 consumption; a/w increased mortality if used
O2 - give to all to increase 02 carrying capacity
Nitro - subL q5min for 3 doses; treats anginal sx; c/I in right MI (II III avF), hypotension, PDE5 use
Aspirin - give chewable (not enteric) ASAP with chest pain
BBs - give right after aspirin, bc MCC death in first 24hrs after MI is ventricular arrhythmias, also prevent ventricular remodeling
ACEI
Statin
Heparin (therapeutic) - give if NSTEMI/STEMI
Clopidogrel - give load if NSTEMI/STEMI
*give aspirin, BB, ACEI, statin to every patient with ACS
*aspirin and IV nitroglycerin reduce risk of subsequent MI
*CCBs c/i - increase mortality
34
[CV}
| LE edema - cause, clinical, mgmt + compare to PAD
LE edema
A. Cause - MCC is chronic venous insufficiency, also pulm HTN (2/2 OSA) and CHF, DVT, idiopathic esp in younger women, meds (NSAIDs, CCBs, OCPs)
B. Clinical
- CVI - brawny indurated pitting LE edema, stasis dermatitis, large shallow ulcers with irregular edges on medial malleolus; can be u/l or b/l
- lymphedema - 2/2 malignancy (prostate, ovarian, lymphoma), radiation, surgery - nonpitting, varicocities, inability to pinch fold of skin, warty texture
- DVT - u/l leg swelling, tenderness, and pitting edema
- CHF - generalized edema, also seen with renal and hepatic failure
C. Mgmt - first determine u/l vs b/l
- u/l --> get doppler U/S to r/o DVT; erythema --> give abx for cellulitis
- b/l with JVD/crackles/DOE --> get CXR and echo; with ascites --> get LFTs and give spironolactone; otherwise, check U/A for AKI (ATN, nephritic/nephrotic syndrome)
- leg elevation and compression stockings, low sodium diet, decreased fluid intake; diuretics - spironolactone, thiazides
- do not give diuretics for lymphedema, consider abx ppx for cellulitis and pneumatic compression, lymph drainage
- do not biopsy CVI ulcers
D. Compare to PAD --> shiny hairless skin, dependent rubor; intermittent claudication, no edema, weak pulses; round smooth deep ulcers on toes; do venous and arterial Doppler U/S and calculate ABI (lower = more severe)
>1.3 - incompressible vessels eg DM, elderly
1 to 1.3 - normal
.91 - .99 - borderline
<0.4 - severe
35
[CV}
| Palpitations - cause, workup, mgmt
Palpitations
A. Cause -
- MCC is dysrhythmias eg benign disturbances (PAC, isolated PVC, sinus tachy or brady), WPW, sick sinus (tachy-brady), PSVT (AVNRT), VT, Long QT (>440 in M and >460 in F), Brugada (Asian males), afib
- psychiatric - anxiety or panic d/o, stress
- structural heart problems eg MVP, CHF, cardiomyopathy, ASD/VSD - HOCM MCC SCD in adolescents
- noncardiac - anemia, thyroid (hypo or hyper), pheo, hypovolemia, vasovagal syncope
- drugs - caffeine, alcohol, cocaine, decongestants (pseudoephedrine), digoxin, albuterol, theophylline
B. Workup
- EKG for all patients
- CBC, CMP, TSH, urine collection of HMA and VMA (if suspecting pheo)
- can do Holter monitor, echo, exercise stress test (avoid if suspecting HOCM)
C. Mgmt
- BB and CCBs
- SVT - vagal stimulation via valsalva, carotid massage; IV adenosine; if unstable -- cardioversion via defibrillation
- afib - anticoagulate, TEE then cardioversion or rate/rhythm control (amiodarone, sotalol, 1C flecainide *c/i with structural heart disease)
- vtach - defibrillation, then amiodarone or lidocaine then AICD
36
[CV]
Diseases of aorta - causes, clinical, mgmt
1. AAA
2. Dissection
Aorta diseases
1. AAA
A. Cause - atherosclerosis, screen for smokers via abd US in M 65-75 yo who have ever smoked
B. Clinical - pulsatile, asx abd mass; if rupture --> hypotension and back pain
D. Mgmt - aortic diameter >3.5 cm - AAA, observe q1yr with US or CTa
- >4.5 cm - observe q6mos
- >5.5 cm or >0.5cm growth in 6 months - surgery
2. Dissection
A. Cause - HTN, Marfan, syphilis (aortitis 2/2 vaso vasorum destruction)
B. Clinical - tearing chest pain radiating to back, asymmetric BP in arms, widened mediastinum on CXR
C. Clinical - dx via CTa
- Stanford type A (ascending aorta) --> sx
- Stanford type B (descending aorta) --> meds (IV labetolol) to control HTN
37
```
[Endocrine]
1. Diabetes
A. Diagnosis
B. Mgmt goals
C. Meds incl MOA, side effects
- metformin
- sulfas
- glitazones
- AGIs
- GLPa agonists
- DPP4 inhibitors
- SGLT2s
- amylin analogs
```
1. Diabetes
A. Diagnosis
- HbA1c > 6.5%
- 2x fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l)
- plasma glucose ≥ 200 mg/dL (11.1 mmol/l) two hours after a 75 g glucose load (OGTT)
- symptoms (such as polyuria, polydipsia, unexplained weight loss) and a random plasma glucose ≥ 200 mg/dL (11.1 mmol/l)
B. Mgmt goals
- HbA1c < 7.0%
- LDL < 100
- BP < 140/90 or <130 systolic
C. Meds
i. Metformin (biguanide) - 1st line for DM2 --> decreased mortality, insulin levels, LDL + weight loss
- MOA - decreases hepatic gluconeogenesis, increases peripheral tissue sensitivity
- side effects - GI (n/v, diarrhea), lactic acidosis - c/i with renal (Cr>1.4) or hepatic insufficiency, CHF
ii. Sulfonylureas eg glyburide, chlorpropamide and meglitinides
- MOA - insulin secretagogues --> fast acting but cause hypoglycemia, weight gain
iii. Glitazones /TZDs eg rosiglitazone
- MOA - increase insulin sensitivity in peripheral tissue (muscle and fat) --> can be used in CKD but cause weight gain, fluid retention, bone fracture
iv. alpha-glucosidase inhibitors eg acarbose
- MOA - delay carb absorption in small intestine --> weight neutral, GI side effects (flatulence)
v. GLP-1 agonists eg exanatide
- MOA - stimulate insulin release, suppress glucagon, can be used as adjuncts - early satiety, weight loss but n/v, pancreatitis; c/i in DM gastroparesis
vi. DPP4 inhibitors eg sitagliptin
- MOA - allow for GLP1 activation --> insulin release, can be used as adjuncts - weight neutral, upper respiratory sx
vii. SGLT2 inhibitors eg "flozins" - can cause UTIs, yeast infections
viii. amylin analogs eg pramlintide - delay gastric emptying, inhibit glucagon; can cause hypoglycemia
38
[Endocrine]
| 2. Gout - causes, clinical, workup, mgmt
Gout:
A. Causes - diet high in purines (red meat, nuts, seafood), alcohol (beer, wine), meds (chemo agents, thiazides / loop diuretics)
B. Clinical - edema, erythema, warmth, effusion of joint; first flare can be confused for cellulitis
4 stages: asymptomatic deposition of crystals --> Acute gout flares --> intercritical segments --> chronic gout (tophi)
C. Workup -MCC acute monoarthritis are infection, crystals, and trauma --> joint aspiration to r/o septic arthritis (>50K WBC with >75% neutrophils); may need X-ray to r/o trauma
- MSU crystals - needle-shaped, negative birefringence
- calcium pyrophosphate - rhomboid, weakly positive birefringence --> pseudogout dx
D. Mgmt
i. acute flare - NSAIDs, colchicine, glucocorticoids eg prednisone (usually 2nd line but use if pt has CKD and NSAIDs are c/i)
ii. maintenance - 24 hr urine collection for uric acid to determine mgmt (don't start these during acute flare)
- <600 mg --> undersecreter --> give probenicid
- if >600 mg --> overproducer --> give allopurinol
* serum uric acid level may be normal or low in acute flare but useful to monitor bw attacks
39
```
[Endocrine]
3. Anemia - workup, types, mgmt
I. Microcytic
II. Normocytic
III. Macrocytic
```
Anemia: <12 in F and <14 in M --> sx based on acuity, Hb level, and cardiac reserve; Hb 10 - 13 asymptomatic --> Hb <10 leads to fatigue, pallor --> lower can lead to DOE, weakness, presyncope --> MI, TIA, high output HF
Workup: get Hb levels, then MCV
I. Microcytic - due to decreased production, TAILS - get iron studies -- ferritin (most important), serum iron, TIBC, % sat
A. Thalassemia - nl iron studies, get Hb electrophoresis - alpha thal is nl and beta thal has ↑HbF, HbA2
- minor - asx (1beta) or mild (2alpha)
- major (3alpha, 2beta) - transfusion + deferoxamine iron chelator
B. ACD - ↑ ferritin, ↓ serum iron, ↓ TIBC
- tx - treat underlying condition w DMARDs, NSAIDs, EPO if severe
C. IDA - ↓ ferritin, ↓ serum iron, ↑ TIBC
- seen in older males with CRC or females with metromenorrhagia --> glossitis, dysphagia
- tx - iron, stool softener (causes constipation) --> should see 0.2g/dL/day increase in Hb
D. Lead/sideroblastic - reversible (alcohol, lead, INH, ↓B6) vs irreversible (myelodysplastic)
II. Normocytic - get retics:
>2% (increased turnover) --> then get LDH, Tbili, hapto
A. Hemolysis - ↑ LDH, ↑ Tbili, ↓ haptoglobin --> then get blood smear to differentiate different types eg sickle cell, G6PD, PNH, AHA, hereditary spherocytosis
B. Hemorrhage - nl LDH, Tbili, hapto
<2% (decreased production) --> get blood smear
C. CKD - nl blood smear
D. Cancer - abnl blood smear eg leukemia, myelodysplastic syndrome
III. Macrocytic - due to decreased production - get smear
- Megaloblastic anemia - 5+ lobed neutrophils (2/2 impaired DNA synthesis)
A. Folate deficiency - develops in months
B. B12 deficiency - develops in years, due to pernicious anemia (no IF), diet, malabsorption (Crohn's, SIBO, post-gastrectomy or ileal resection)
- subacute combined degeneration --> decreased vibratory and positional sense, do Schilling test
- non-megaloblastic anemia
C. Cirrhosis
D. Alcohol, drugs
40
[Endocrine]
4. Thyroid
Hypothyroid - cause, diagnosis, clinical, mgmt
Hypothyroid:
A. Cause - MCC Hashimoto (anti-TPO Ab), post-Graves thyroid ablation, thyroiditis, secondary --> hypothalamic/pituitary dysfunction (2/2 pituitary adenoma removal or intracranial radiation)
B. Diagnosis
- primary - high TSH, low fT4; no other imaging needed
- secondary - low TSH, low fT4 --> TRH test, suspect pituitary cause if no increase in TSH
- subclinical hypothyroid - high TSH, normal fT4
* with nl fT4 the TSH level must be >10 µU/mL for a diagnosis of hypothyroidism
- euthyroid sick syndrome - low TSH, low fT4 - due to nonthyroidal systemic illness
C. Clinical - decreased BMR
- cold intolerance
- bradycardia, hypotension, DOE
- fatigue, lethargy, depression
- weight gain
- constipation
- pedal nonpitting edema
- heavy periods
- decreased DTRs w prolonged relaxation phase
- dry skin, coarse brittle thinning hair
- hypercholesterolemia
- proximal muscle weakness w increased CK (normal CK in hyperthyroid)
D. Mgmt - levothyroxine, needs increased during pregnancy although free levels the same
41
[Endocrine]
4. Thyroid
Hyperthyroid - cause, diagnosis, clinical, mgmt
Hyperthyroid
A. Cause - MCC is Graves (autoAb stimulate TSH receptors on thyroid and dermal fibroblasts), also autonomous thyroid nodule, acute thyroiditis, iatrogenic
B. Diagnosis - low TSH, high freeT4, radionucleotide scan:
- Graves - diffuse hyperactivity and uptake of iodine *all other hyperthyroid causes have decreased radioiodine uptake on scan
- Subacute thyroiditis (destructive phase) - patchy uptake with overall reduced activity / low iodine uptake (release of existing hormone, not overproduction of new thyroxine)
C. Clinical - increased BMR:
- heat intolerance
- tachycardia (palpitations), afib and widened pulse pressure
- fatigue
- weight loss
- diarrhea
- fine resting tremor, insomnia, anxiety
- lighter periods / amenorrhea
- increased DTRs
- gynecomastia (increased SHBGs)
- exophthalmos and pretibial myxedema (Graves only)
- accelerated bone loss --> increased risk osteoporosis (reversible)
D. Mgmt
- definitive is radioactive iodine (~40% eventually become hypothyroid); c/i in pregnancy, breastfeeding, children
- BBs to block peripheral effects
- methimazole (agranulocytosis side effect, teratogen in 1st trimester but can be used in 2nd and 3rd), PTU in 1st trimester (hepatotoxicity side effect)
42
[Endocrine]
4. Thyroid
DDx goiter incl workup of nodules
Goiter (enlarged thyroid) can be caused by:
- dietary lack of iodine
- Hashimoto (hypo)
- Graves (hyper)
- cancer - do U/S - more likely cold nonfunctional nodules; can determine papillary, anaplastic, medullary thyroid carcinomas (not follicular) --> do thyroidectomy and radioactive ablation
- pregnancy - do FNA but not radioisotope scanning or RAI; can do thyroidectomy in 2nd/3rd trimesters or follow until postpartum
- de Quervain thyroiditis - self-limited, following viral illness; granulomatous inflammation; hyper--> hypothyroid with jaw pain, tender goiter, increased ESR
- nodules - best first test is U/S, younger pts have solitary and older have multiple
* if <1 cm and benign-appearing --> redo U/S in 6 mos
* if >1 cm --> measure TSH
* * if low TSH --> do radionucleotide uptake scan to confirm
- -> hot active/functional nodules are commonly adenomas and rarely malignant --> give radioactive iodine
- -> cold are either cancer or colloid cysts --> do FNA
* * if normal or high TSH --> f/u FNA bx to r/o malignancy --> if benign then repeat in 6 mos, if suspicious do frozen section, if malignant do thyroidectomy
43
[Endocrine]
4. Thyroid
Thyroid storm - cause, clinical, mgmt
Thyroid storm
A. Cause- acute hypermetabolic state with sudden release of large amounts of thyroid hormone into circulation
B. Clinical - fever, AMS, restlessness, psychosis
- tachycardia, HTN, fever, dysrhythmia, high output HF (peripheral vasoconstriction --> increased peripheral demand and circulatory overload --> normal systolic fx but HF sx eg DOE)
C. Mgmt - medical emergency! high dose PTU or methimazole, BBs (to control peripheral sx eg tachycardia), glucocorticoids eg hydrocortisone (to prevent adrenal crisis)
44
[Endocrine]
5. Electrolyte abnormalities
Hypercalcemia - causes, clinical
Hypercalcemia: Ca > 12
A. Causes - after Ca2+, check PTH levels --> if lower (think malignancy), if higher --> then check urinary calcium (primary hyperPTH vs FHH)
*CHIMPANZEES - Ca2+ oversupplementation, hyperPTH, immobility, milk alkali, Paget, Addison / acromegaly, neoplasms, ZE when a/w MEN1, Excess Vit A or D, and Sarcoidosis*
Increased bone resorption
i. hyperparathyroidism - MCC
- primary - sporadic, usually benign parathyroid adenoma; familial (eg MEN1, MEN2)
- familial hypocalciuric hypercalcemia - due to defective CaSR; urine Ca2+ is low, as opposed to high in primary hyperPTH
- secondary - early renal disease; low Ca2+ (low intake, Vit D deficiency) --> increased PTH --> increased Ca2+
- tertiary - seen in CKD; hypocalcemia induces PTH secretion --> high Ca2+ and low P043+
ii. Malignancy - 2nd MCC; PTH-rP paraneoplastic secretion in lung, renal, head and neck ca; osteolysis in breast, prostate ca and MM
iii. vitamin A intoxication
iv. immobilization - causes bone demineralization
Increased Ca absorption
i. Vitamin D intoxication --> increased calcitriol --> increased absorption of Ca and P04
ii. granulomatous disease eg TB, sarcoidosis (hint - b/l VII palsy, ↑ ACE and Ca2+), Hodgkin lymphoma (rubbery LAD)
iii. milk alkali syndrome
Others
i. Meds - thiazides, lithium
ii. rhabdo - Ca released from injured muscle
iii. endocrine d/o - hyperthyroid, adrenal insufficiency (Addison), acromegaly
B. Clinical - kidney stones, bones (arthritis, osteoporosis), abdominal groans (n/v, anorexia, constipation), psych overtones (weakness, poor concentration, fatigue, coma)
- shortened QT, arrhythmias
45
[Endocrine]
5. Electrolyte abnormalities
Hyponatremia - hypo vs hyper vs euvolemic vs pseudo
Hyponatremia: Na < 135
I. Hypovolemic - volume depletion, due to GI loss, third-spacing, cerebral salt wasting, diuretics, burns, mineralocorticoid deficiency; signs of dehydration, if severe - AMS, seizures, coma
- urine Na < 20 meq/L
- tx - rehydration with NS (3% hypertonic if Na <125); correct slowly to avoid osmotic demyelination
II. Hypervolemic - decreased renal excretion of water, due to HF, cirrhosis, nephrosis
- tx - diuretics, fluid restriction
III. Euvolemic (SIADH) - due to CNS (stroke, GBS, AIP, meningitis, hydrocephalus, tumor), pulm (TB, PNA), malignancy (SCLC), drugs (SSRI, cyclophosphamide, vincristine, carbamazepine, NSAIDs, amiodarone, antipsychotics, MDMA/ecstasy)
- asymptomatic or n/v, HA, confusion, fatigue
- tx - fluid restriction, vaptans, demeclocycline
IV. Pseudohyponatremia -due to hyperglycemia, hypertriglyceridemia, hyperproteinemia, lab error, mannitol use
- normal volume status w normal osmolality
46
[Endocrine]
5. Electrolyte abnormalities
Hypernatremia - cause, clinical, workup, mgmt
Hypernatremia: Na > 145
A. Cause - net water loss due to impaired thirst response or restricted access to H20 (elderly, infants, intubated)
B. Clinical - anorexia, muscle weakness, n/v, lethargy --> seizures, coma
C. Workup - check urine osmolality
i. high (>400 mOsm/kg) - water losses 2/2 hypotonic fluid loss (sweating, GI)
ii. low (<300) - pure water loss in DI --> low urine spg, high serum osm
- central DI eg pituitary tumor - increase in urine osm post desmopressin
- nephrogenic DI eg lithium, ADHR mutation - no increase
D. Mgmt - give NS, correct slowly to avoid cerebral edema and herniation
- central DI - desmopressin (ADH analog)
- nephrogenic DI - HCTZ, indomethacin, amiloride
47
[Endocrine]
5. Electrolyte abnormalities
Hypokalemia - cause, clinical, mgmt
Hypokalemia: K <3.5
A. Causes
- decreased intake of K
- shift into cells (insulin, alkalosis, trauma)
- extrarenal K losses - vomiting, diarrhea, laxatives, ZE
- renal losses -hyperaldosteronism, ACTH tumor, Cushing, CAH
- renal tubular defects - Bartter (reabsorptive defect in TAL), Gitelman (reabsorptive defect in DCT), Liddle (increased Na reabsorption)
- RTA I, RTA II 2/2 Fanconi syndrome (generalized reabsorptive defect in PCT)
- increased flow to nephron (K wasting diuretics, salt-losing nephropathy)
- hypoMg
B. Clinical - fatigue, muscle aches, cramps --> rhabdo, paralysis
- bloating, constipation
- ST segment depression, flattened T waves, prominent U waves
C. Mgmt - oral K replacement
48
[Endocrine]
5. Electrolyte abnormalities
Hyperkalemia - cause, clinical, mgmt
Hyperkalemia: K > 5
A. Causes
- meds (ACEI, ARB, K sparking diuretics)
- extracellular shifts (acidosis, burns, lack of insulin)
- reduced renal excretion (CKD, RTA IV, Addison)
B. Clinical - ascending flaccid paralysis, paresthesias, areflexia, paralytic ileus, respiratory failure, arrhythmias
- peaked T waves, flattened P waves, QRS prolongation
C. Mgmt - Calcium gluconate, glucose + insulin, kayexalate, loop diuretics, and/or dialysis
49
[Endocrine]
| 6. Osteoporosis - cause, clinical, mgmt
Osteoporosis
A. Cause - bone mineral density >2.5 SDs below normal (DEXA T-score cortical bone --> vertebral compression and colles fractures (fracture of distal forearm 2/2 FOOSH)
- 2/2 steroids, Cushing, hyperthyroid (accelerated bone loss), heparin, hypogonadism, Vit D deficiency (25-hydroxyvitamin D level <20 ng/mL)
* Osteoporosis in males can be caused by multiple conditions, including multiple myeloma, AIDS, hyperparathyroidism, and hypotestosteronism
* obesity was thought to be protective, but no longer
B. Clinical - silent until fracture
C. Mgmt - do DEXA scans starting at 65
- universal rec for postmenopausal women - Calcium >1200 mg/dL and Vit D >800 IU/d, weight bearing exercise
- bisphosphonates 1st line drugs (block osteoclasts; cause reflux esophagitis, jaw necrosis, stress fractures, hypocalcemia); start after hip fracture regardless of bone mineral density
- teriparatide (recombinant PTH) 2nd line
- estrogen-replacement therapy SERMS eg raloxifene (breast and endometrial antagonist, bone agonist; increased risk DVT/PE)
- calcitonin has analgesic effect on bone pain
50
[Endocrine]
Causes, clinical, mgmt
RTA Types 1, 2, 4
RTA - cause non-AG metabolic acidosis
RTA 1 - inability to secrete H+ at distal renal tubule and collecting duct --> urine pH > 5.5
A. Cause - amphotericin B, analgesics, inherited
B. Clinical - low K, calcium kidney stones, calcifications
C. Mgmt - K
RTA 2 - inability to reabsorp HC03- from PCT --> urine pH <5.5
A. Cause - Fanconi syndrome (generalized reabsorptive defect in PCT), carbonic anhydrase inhibitors (Acetazolamide)
B. Clinical - low K, osteomalacia and hypophosphatemic rickets
C. Mgmt - K, Vit D, Ca2+
RTA 4
A. Cause
- decreased aldosterone - ACEI/ARB, NSAIDs, adrenal insufficiency
- aldosterone resistance - K+ sparing aldosterone -antagonist diuretics (spironolactone, eplerenone)
B. Clinical - high K
C. Mgmt - diuretics, corticosteroids
51
[Renal]
| CKD - causes, clinical, mgmt
CKD:
A. Risk factors - uncontrolled DM or HTN, NSAID use, glomerulonephritis (lupus nephritis, MM, infectious)
B. Cinical
Stages: 1 (GFR >90), 2 (60-89), 3 (30-59), 4 (15-29), 5 ie ESRD (<15 or dialysis)
- normocytic anemia 1st sign of CKD due to decreased EPO (happens at GFR < 60) -->
- loss of protein in urine --> pitting edema, periorbital edema
- high urea --> vomiting
- uncompensated --> pulm edema --> SOB, LE edema, JVD, crackles
C. Mgmt - renal U/S, UA
- HTN control - ACEI/ARB, followed by thiazide or CCB
- blood sugar control
- HLD control - give statin
- remove NSAIDs/diuretics/aminoglycosides, avoid IV contrast
- sodium bicarb for metabolic acidosis
- Vit D supplementation, low phosphate diet
- oral ferrous salts or EPO if Hb <10 to goal of 12-13 (>13 increased mortality 2/2 CVD)
- maintain volume status - dietary sodium restriction, loop diuretics
* more likely to die from CVD than to develop ESRD
* can use fentanyl, methadone but not morphine, codeine in ESRD
52
```
[Renal]
Asymptomatic microscopic hematuria
A. Types
B. Workup
C. Compare to macroscopic hematuria
```
Asymptomatic microscopic hematuria - 3+ RBCs/hpf on UA in absence of obvious benign cause
A. Types
i. Glomerular - RBC casts, dysmorphic RBCs, proteinuria
ii. Renal (nonglomerular) - 2/2 tubulointerstitial eg interstitial nephritis, metabolic, renovascular disorders; proteinuria but no RBC casts
iii. Urologic - tumors, stones, trauma, BPH; no proteinuria nor RBC casts
B. Workup
- <3 RBCs -- repeat UA 3x at 6 week intervals; negative = consistently <3 RBCs --> workup complete (5% microscopic hematuria and 30-40% gross hematuria have malignancy)
- >3 RBCs -- urine cx to r/o UTI; if persistent - renal function testing (BUN, Cr, GFR); if normal --> CT urography and cystoscopy (if >35 yo or risk factors for transitional cell ca)
- repeat UA 6 weeks after etiology found (STD, UTI, strenuous exercise, meds, exposure, etc)
C. Macroscopic hematuria - do U/A, UCx, Ucytology, CT urography (preferred over IV pyelogram), serum Cr
- if normal in pts <40 yo --> reassurance and monitoring
- if >40 yo --> Cystoscopy
53
[GI]
Causes, clinical, mgmt:
1. Dyspepsia
2. PUD
1. Dyspepsia (indigestion)
A. Causes - functional (70%), PUD (20%), GERD (10%), gastric or esophageal cancer (<2%)
B. Clinical - bloating, burping, nausea
i. epigastric pain or burning subtype
ii. postprandial fullness and early satiety subtype
C. Mgmt
- if alarm sx (dysphagia, anemia, weight loss), >45 w new onset sx, UGIB sx, recurrent sx or no response to therapy ---> EGD
- patients with dyspepsia <55 yo and with no alarm sx of gastric cancer --> H. pylori test
* first test = IgG Ab; urea breath test for active infection - stop PPI 2 weeks beforehand
* stool antigen posttx for eradication
* endoscopy is gold standard) and treat
- if heartburn and acid reflux sx --> treat as GERD
- if epigastric pain subtype --> PPI
- if postprandial fullness subtype --> metaclopramide, TCA, buspirone
2. PUD
A. Cause - H pylori (MCC), NSAIDs (2nd MCC) smoking / alcohol --> Chronic exposure of damaged mucosa to pepsin and gastric acid
- MC in stomach (more common in NSAID use) and proximal duodenum (more common overall)
- if in distal duodenum or jejunum -- think Zollinger-Ellison
- can also be Curling, Cushing ulcers, meds (bisphosphonates, steroids, IV fluorouracil)
B. Clinical - same as dyspepsia
C. Mgmt - trial of PPI (C diff colitis, osteoporosis, low Mg Fe and Ca); PUD can cause UGIB, perforation
54
[GI]
Causes, clinical, mgmt:
3. GERD
3. GERD - gastroesophageal reflux disease
A. Cause - decreased LES tone, hiatal hernia, diet (EtOH, tobacco, fat, coffee, chocolate)
B. Clinical - heartburn, dyspepsia, pain after eating and on lying down, chest pain, waterbrash (Reflex salivary hypersecretion), postprandial n/v, dysphagia, acid regurgitation, bad breath, nighttime cough
- complications - erosive esophagitis, stricture, esophageal ulcer, Barretts esophagus (SSE --> columnar), recurrent PNA, laryngitis
C. Mgmt - dx via endoscopy w biopsy, gold standard is 24 hr pH monitoring; do not test for H pylori in pts with GERD diagnosis
- initial tx is lifestyle modifications, stop smoking
- -> then add antacids / H2 blocker
- -> then switch to PPI
- -> then add promotility (metoclopramide Reglan) or bethanochol
- -> then consider sx (Nissen fundoplication) if refractory, respiratory problems, or severe esophageal complications
- can do UGI series to look for complications (strictures, ulcers); manometry to look for motility problems; endoscopy to look for Barrett
55
[GI]
Causes, clinical, mgmt:
4. Diarrhea
A. Causes - acute vs chronic
```
4. Diarrhea
A. Cause
Acute Diarrhea - <2 weeks
- MCC (90%) infectious --> viral- MCC esp rotavirus (no fever and no blood); bacterial --> inflammatory (RBC, WBCs, lactoferrin - Campy, EHEC, Shigella, Salmonella, Yersinia) vs enterotoxic (ETEC, Vibrio); food (S aureus, C perfringens)
- protozoa - Giardia, Entamoeba, Crypto
- medications - abx (--> C diff), laxatives, chemo agents, alcohol
- ischemic bowel
- bacterial enterocolitis
```
Chronic diarrhea - >4 weeks
i. Inflammatory (RBC, WBC) - do colonoscopy eg IBD, celiac
ii. Secretory - Osm < 50, all time even at night, not affected by food, no fecal fat or WBC --> do endoscopy with biopsy eg celiac sprue, VIPoma (watery diarrhea, achlorhydria, hypokalemia), Carcinoid (wheezing, flushing, diarrhea, R side valvulopathy when its in liver), ZE (gastrinoma, PUD)
iii. Osmotic - Osm > 100, fecal fat, worse with food, not at night --> do endoscopy eg lactose intolerance, laxatives
- also CRC, SIBO, fecal impaction, diverticulitis
56
```
[GI]
Causes, clinical, mgmt:
4. Diarrhea
B. Clinical
C. Mgmt
i. uncomplicated
ii. complicated
iii. traveler's diarrhea
```
B. Clinical
- illness and vomiting post eating mayo foods - w/in 6 hrs (S aureus), 8-12 hrs (C perfringens), 12-14 hrs (E coli)
- fever and blood - think Shigella (tenesmus), Campy, EHEC, salmonella
- crampy abd pain + n/v - think food poisoning
- myalgias, malaise, n/v - think acute viral gastroenteritis
- hypokalemic metabolic acidosis (lose bicarb)
C. Mgmt
i. supportive (rehydration, loperamide Immodium) if uncomplicated (3 or fewer episodes in 24 hrs)
ii. if complicated (bloody stool, systemic sx, n/v, dehydration, >2-3 days) -->do stool sample for leuks or lactoferrin
- (+) more likely Shigella campy or other bacterial cause --> do stool culture, Cdiff culture; abx - cipro 500 mg BID x5days
- (-) food poisoning, viral gastro
* don't need to do stool O and P unless suspecting parasitic source
iii. traveler's diarrhea *no abx ppx (only rifamixin in rare cases), can take Pepto (bismuch subsalicylate)
- South / Central America + Africa - cipro
- South Asia - azithro (Campy more common, resistant to cipro)
57
[GI]
Causes, clinical, mgmt:
5. Constipation
5. Constipation
A. Cause - diet (lack of fiber), meds (narcotics, CCBs, iron, antidepressants)
- IBS, ileus
- obstruction (CRC), fissure/hemorrhoids
- endocrine - hypothyroid, hypercalcemia, hypokalemia
- NMS - PD, MS, scleroderma, DM neuropathy
B. Clinical - Rome criteria define constipation as 2+ of the following:
- straining on defecation
- hard stools
- incomplete evacuation (can lead to watery diarrhea)
- less than three bowel movements per week
* can lead to rectal prolapse, hemorrhoids, anal fissures, fecal impaction (stool in rectal vault)
C. Mgmt - r/o obstruction (X-rays), rectal exam, labs (TSH Ca CBC CMP)
- increase fluids, exercise, and fiber
- enema
58
[GI]
Causes, clinical, mgmt:
6. IBS
IBS
A. Cause - idiopathic intrinsic bowel dysmotility disorder
- F>M in 20s-30s
- can get CBC, CRP, anti-IgA Ab, fecal bile acids
B. Clinical - Rome criteria - recurrent crampy abdominal pain at least 3 days/ month for at least 3 mos with 2+:
- improvement with defecation
- onset a/w change in stool frequency
- onset a/w change in stool appearance (alternating constipation and diarrhea)
C. Mgmt - relaxation techniques, exercise
- abdominal pain - antispasmodics eg dicyclomine prn, probiotics, TCA/SSRIs
- constipation - predominant - insoluble fiber supplementation (psyllium), miralax (PEG), lubiprostone (activates intestinal chloride channels), linaclotide (stimulates cGMP production)
- diarrhea - predominant - loperamide, rifamixin off-label
59
[GI]
Causes, clinical, mgmt:
7. Jaundice
Jaundice:
1. Prehepatic - hemolysis (increased LDH and haptoglobin), Gilbert
2. Hepatic - Hepatitis, alcohol
3. Posthepatic - bile duct stones, strictures, tumors, pancreatic cancer
DDx -
- weight loss, LAD --> malignancy
- f/c, RUQ pain --> cholecystitis, choledocholithiasis, acute cholangitis (Triad of jaundice, fever, RUQ pain)
- anorexia, fatigue, myalgias --> viral hepatitis
- bruising, bleeding --> severe hepatic dysfunction
- increasing abdominal girth --> ascites 2/2 cirrhosis
*Hep A (MC vaccine-preventable travel illness) + B vaccines prior to going to Asia, in MSM, although only legally required immunization - yellow fever
60
```
[GI]
Describe types of incontinence
1. Urge
2. Stress
3. Overflow
4. Reflex
5. Functional
```
Types of incontinence:
1. Urge - detrusor instability --> involuntary contractions --> sudden urge to urinate, nocturnal wetting, loss of large volumes urine; tx - oxybutynin
2. Stress - weakness of pelvic floor --> hypermobility of bladder neck --> involuntary urine loss with increase in intraabdominal pressure; tx - kegels, pessaries, urethropexy
3. Overflow - impaired detrusor contractility or bladder outflow obstruction --> urine leakage with large postvoid residual (>200; nl - 50); tx - doxazosin, bethanechol
* BBs can cause urinary leakage and urgency
4. Reflex - spinal cord injury, MS --> cannot sense need to urinate
5. Functional - lower urinary tract function intact, incontinence 2/2 debilitating diseases, immobility, cognitive impairment
61
[Neuro]
I. Headaches - cause, clinical, mgmt of:
1. Tension HA
2. Migraines
Headaches - primary
1. Tension
A. Cause - unknown
B. Clinical - vice-like aching pain encircles entire head in band-like distribution; tightness in posterior neck muscles
C. Mgmt - NSAIDs,aspirin, tylenol - limit to 2-3 days/week to avoid medication overuse HA; stress and caffeine reduction
2. Migraines
A. Cause - unknown, inherited
B. Clinical - can be w/ or w/out aura, w/ menstruation; usually has n/v, photophobia increased sensitivity to smell and phonophobia
- prodromal phase --> severe, unilateral, throbbing HA aggravated by coughing, bending, activity; alleviated by lying down and sleeping
C. Mgmt - give triptan or DHE ergotamine (5HT1R agonist), then NSAID; daily ppx with propranolol or amitriptyline or verapamil
62
[Neuro]
I. Headaches - cause, clinical, mgmt of:
3. Cluster HA
4. Secondary HA
3. Cluster
A. Cause - unknown
B. Clinical - in middle-aged men, always unilateral periorbital stabbing burning pain
- a/w flushing, lacrimation, nasal d/c, and miosis / ptosis
- awakens patient from sleep and occurs in clusters
C. Mgmt - 100% 02 at 6L/min, or IM sumatriptan or ergotamine; ppx with verapamil
4. Secondary HA causes - chronic med conditions (HIV/AIDS, cancer mets), trauma (hematoma), subarachnoid hemorrhage, mass lesions, temporal arteritis, meningitis, brain abscess, infectious encephalitis (HSV, Lyme), medication overuse, pseudotumor cerebri, withdrawal (caffeine)
63
```
[Neuro]
II. Compare contrast causes of dizziness:
1. Vertigo
A. Peripheral
B. Central
```
2. Lightheadedness
3. Dysequilibrium
Dizziness is a subjective symptom
1. Vertigo - rotational sensation - feeling that room is spinning
- central (immediate onset sx, nystagmus direction changes) vs peripheral (latency 3-10 secs, fixed direction of nystagmus, inhibited w visual fixation)
A. Peripheral - inner ear - delayed horizontal nystagmus; tx - antihistamines eg meclizine
- BPPV - due to semicircular canal debris (otoliths); dx via Dix-Hallpike and fix w Epley maneuver, episodes last for a few seconds
- Meniere - fluid buildup in inner ear --> episodic vertigo, tinnitus, hearing loss n/v of several hours duration
- vestibular neuronitis (labryinthitis) - acute postviral onset of severe vertigo lasting several days, (+) head thrust test
- acoustic neuroma (vestibular schwannoma) - slowly progressive u/l tinnitus and hearing loss; b/l a/w NF2
B. Central - nystagmus in any direction + focal neuro findings (eg facial weakness, ataxia)
- stroke
- brain stem or cerebellar lesion
2. Lightheadedness - floating sensation of feeling faint, alleviated on lying down
- orthostatic hypotension
3. Dysequilibrium - sensation of unsteadiness or loss of balance
- cerebellar tumor
64
```
[Neuro]
III. CVA
A. Risk factors
B. Clinical based on etiology
i. MCA
ii. ACA
iii. Vertebrobasilar
iv. ASA
v. PICA
vi. AICA
```
CVA (stroke)
A. Risk factors - HTN is most important
- smoking, diabetes, afib, CAD, HLD, obesity, sickle cell
- age, male, white, prior TIA/CVA
B. Clinical based on etiology
- ischemic - thrombotic or embolic
- hemorrhagic - intracerebral or subarachnoid hemorrhage
i. MCA - contralateral hemiparesis and sensory loss, c/l impaired conjugate gaze
- nondominant (usually right) --> hemineglect
- dominant (usually left) --> aphasia, other cortical defects
ii. ACA - c/l hemiparesis and sensory loss, especially lower limbs
iii. Vertebrobasilar - locked-in syndrome
iv. ASA - medial medullary syndrome (c/l paralysis, tongue deviates ipsilaterally)
v. PICA - lateral medullary Wallenburg syndrome (decreased pain/temp from ipsi face and contra body, dysphagia and hoarseness)
vi. AICA - lateral pontine syndrome (decreased pain/temp from ipsi face and contra body, facial droop)
65
[Neuro]
III. CVA
C. Workup
D. Mgmt
CVA
C. Workup - noncontrast head CT to r/o hemorrhage, abscess, tumors
- MRa or CTa, transcranial Doppler
- EKG, echo, TEE, carotid Doppler
- CMP, utox to r/o hypoglycemia, metabolic or toxic encephalopathy
- CBC, ESR, ANA, RPR
D. Mgmt - permissive HTN up to 220/120 to avoid hypoperfusion to brain tissue; lower with IV labeletol, nicardipine, or sodium nitroprusside
- tPA w/in 3 hrs if eligible; if not - aspirin and statin
- antiplatelet (aspirin + dipyramidole, then clopidogrel) if stroke but no detected source of emboli
66
[Neuro]
| IV. Dementia - causes, clinical, mgmt
IV. Dementia
A. Causes - MCC is Alzheimer's (progressive), 2nd MCC is vascular dementia (suddent-onset, step-wise), 3rd MCC is Lewy body dementia (EPS, disorganized speech, hallucinations), 4th MCC is frontotemporal dementia
- Parkinson, Huntington, chronic alcohol abuse, AIDS
- reversible forms - depression (pseudodementia), NPH, chronic subdural hematoma
- hypothyroid, Vit B12 deficiency, neurosyphilis, hyponatremia
B. Clinical - memory loss and impairment of executive function; patient tries on exams but fails (as opposed to depression), family is more concerned than patient
- compared to delirium - waxing and waning consciousness
C. Mgmt
- Workup - MMSE, noncontrast head CT or MRI; TSH, vitamin B12, RPR
- cholinesterase inhibitors Donepezil, Galantamine, Rivastigmine; NMDA antagonist Memantine
- antipsychotics eg aripiprazole for dementia-related psychosis --> increase mortality (2/2 SCD, stroke); only give as last resort
- do not give benzos for aggression, delirium, insomnia in elderly
- depression - mirtazapine, bupropion, SSRI but avoid paroxetine bc increased anticholinergic effects
67
[Neuro]
V. Eye pathology - cause, clinical, mgmt
1. Age-related macular degeneration
2. Glaucoma
1. Age-related macular degeneration
A. Cause - MCC vision loss in >65 yo
i. wet - exudative, sudden vision loss due to leakage of serous fluid and blood 2/2 neovascularization under retina
ii. Dry - nonexudative, atrophy and degeneration of central retina with drusen
B. Clinical - loss of central vision, blurred vision, scotomas distortion with preservation of peripheral vision, blurred grid lines
C. Mgmt -
i. wet - antiVEGF
ii. dry - vitamins
2. Glaucoma
A. Cause -
i. open-angle - 90%, impaired outflow of aqueous humor
ii. closed angle - 10%, rapid increase in IOP due to occlusion of narrow angle
B. Clinical
i. open - angle - painless, progressive peripheral visual field loss, optic disc cupping
ii. closed - angle - red painful eye with sudden decrease in visual acuity, n/v, HA, dilated nonreactive pupil
C. Mgmt
i. open - angle - BB, alpha agonist (epi), acetazolamide, prostaglandin (latanoprost), pilocarpine
ii. closed - angle - emergency! need pilocarpine, acetazolamide, glycerin, and surgery
68
[Neuro]
V. Eye pathology - cause, clinical, mgmt
3. Cataracts
4. Conjunctivitis
3. Cataracts
A. Cause - opacification of lens of eye
B. Clinical - progressive loss of visual acuity, glare, difficulty driving at night, second sight (no longer require reading glasses bc of increased refractive power of lens)
C. Mgmt - surgery
4. Conjunctivitis
A. Cause, Clinical, Mgmt
- viral (85%) -MCC adenovirus--> keratoconjunctivitis = hyperemia w watery d/c, fever, malaise, palpable preauricular LAD --> supportive tx w cold compresses and lubricating drops, lasts ~2 wks
- bacterial (15%) - S pneumo (also Staph, H flu, M catarrhalis, Pseudomonas) - rapid onset irritation redness and tearing with mucopurulent d/c w crusting, pain, photophobia, "gritty" sensation --> topical erythromycin or cipro and if resistant, most likely MRSA --> oral TMP-SMX ; or due to Neisseria - rapid onset copious mucopurulent exudate --> IM ceftriaxone
- chlamydia - trachoma (MCC blindness worldwide) and inclusion conjunctivitis --> oral doxy
- allergic or irritants
DDx red eye - MCC conjunctivitis, subconjunctival hemorrhage, dry eye (Sjogrens, anticholinergics), acute angle closure glaucoma, blepharitis (inflammation of eyelid 2/2 Staph), episcleritis, scleritis (think RA), uveitis (red eye loss of vision photophobia --> think IBD, Reiter's, ankylosing spondylitis), HSV1 keratitis
69
```
[Rheum]
1. SLE
A. Pathophys
B. Diagnosis
C. Clinical
D. Mgmt
```
1. SLE ie lupus
A. Pathophys - Type III HSN (Antigen-Ab-Complement)
B. Diagnosis - anti-ANA, dsDNA, Smith Ab
- decreased C3, C4 due to immune complex deposition
- anti-histone Ab for drug-induced lupus (sulfa, hydralazine, INH, procainamide, phenytoin, etanercept - SHIPPE)
```
C. Clinical - RASH OR PAIN
Rash - malar or discoid
Arthritis
Serositis
Heme disorder
Oral/nasal ulcers
Renal disease - lupus nephritis
Photosensitivity
Antinuclear ab
Immunologic - antiDNA, Smith Ab
Neurologic - seizures, psychosis
```
D. Mgmt - 1st line is DMARD (hydroxychloroquine ie Plaquenil) also steroids, NSAIDs, immunosuppressants
MCC death - CVD, infections, renal disease
70
```
[Rheum]
2. RA
A. Pathophys
B. Diagnosis
C. Clinical
D. Imaging
E. Mgmt
```
2. Rheumatoid arthritis
A. Pathophys - increase in proinflammatory cytokines (TNFalpha, IL6) in synovial cells of joints --> destruction of cartilage, bony erosions
B. Diagnosis - antiRF, antiCCP Ab (CCP more specific), high ESR and CRP, anemia and thromboytopsis (plts are acute phase reactant), low albumin (level correlates w severity of disease)
C. Clinical - >60 min morning stiffness (<30 min is osteoarthritis)
- 3+ joints, favors the smaller joints eg in the hands, spares DIPs and symmetrical
- Felty syndrome - SANTA --> Splenomegaly, Anemia, Neutropenia (decreased WBC), thrombocytopenia (decreased plts), and RA
D. Imaging - periarticular osteopenia adjacent to inflamed joints
- axial C1 and C2 stiffness - get X-ray to r/o dislocation
E. Mgmt - DMARDs first line (mtx is 1st line, hydroxychloroquine is 1st line for lupus) adjuvants are NSAIDs, glucocorticoids, biologics (TNFalpha inhibitors) eg infliximab, etanercep if severe disease
- for flares, get prednisone
- MCC death is CAD 2/2 accelerated atherosclerosis r/t chronic inflammatory state
71
[Rheum]
Cause, diagnosis, clinical, mgmt:
3. Polymyalgia rheumatica
4. Scleroderma - diffuse vs limited
3. Polymyalgia rheumatica - seen in adults >50 yo
A. Cause - unknown
B. Diagnosis - increased inflammatory markers (ESR > 40, thrombocytosis), rapid response to prednisone
C. Clinical - bilateral shoulder or hip stiffness (limited ROM) and aching for >1 month duration, no localized tenderness or motor weakness
- systemic sx (Fatigue, weight loss, low-grade fever, decreased appetite, depression)
- associated with temporal arteritis (u/l HA, jaw claudication, dx via bx)
D. Mgmt - responds rapidly to low-dose prednisone (15mg) PO in few days, but taper over 1 year or so
4. Scleroderma
A. Cause - autoimmune noninflammatory vasculopathy and collagen deposition w fibrosis
B. Diagnosis
i. CREST - anti-Centromere
ii. diffuse - Anti-Scl70 (anti-topoisomerase) Ab
C. Clinical
i. CREST - Calcinosis, Raynaud, Esophageal dysmotility, Sclerodactyly, Telangiectasia
ii. Diffuse - CREST + visceral involvement eg renal crisis, pulm htn 2/2 interstitial lung disease (MCC death)
D. Mgmt - symptomatic only
- renal involvement - give ACEI, not steroids
- Raynaud - give nifedipine
*nephrogenic systemic sclerosis can present similarly but is post-gadolinium (Eg MRI) in pts with CKD --> 30% mortality, do skin bx
72
[Rheum]
Cause, clinical, mgmt:
5. Allergic rhinitis (Hay fever)
5. Allergic rhinitis ie seasonal allergies ie hay fever
A. Cause - same as asthma but in the upper airway (instead of lower)
- IgE mediated response to extrinsic protein allergen (pollens, dust mites, animals) --> mast cell degranulation --> release of histamine, tryptase, leukotrienes, prostaglandin D --> vasodilation (congestion), stimulation of sensory nerves (sneezing, itching) and mucous glands (secretions); delayed reaction is CD4+ inflammatory response
B. Clinical - seasonal (worse in spring/ fall), itchy and/or red eyes, nasal congestion and discharge, sneezing, rhinorrhea, headache, earache
- boggy pale nasal turbinates, cobblestoning of oropharyngeal mucosa due to postnasal drip, tonsillary hypertrophy
- allergic shiners, nasal crease
* can have allergic asthma eg occupation-related
C. Mgmt
- intranasal steroids (max effectiveness in 2-4 weeks) - 1st line, most effective
- antistamines (2nd gen eg cetirizine has fewer anticholinergic and sedative side effects compared to 1st gen eg diphenhydramine)
- nasal decongestants (eg pseudoephedrine - alpha agonists constrict bv but can cause tremors and tachycardia and rebound sx)
- leukotriene inhibitors (eg montelukast) - good for pts whose persistent asthma is triggered by chronic allergies; narrow TI
73
[Rheum]
Cause, clinical, mgmt:
6. Septic arthritis
6. Septic arthritis
- Septic joint - fever, acute inflammation, limited ROM (osteo cellulitis maintains ROM), plus elevated markers - ESR, CRP
- acute monoarticular infectious arthritis - think bacterial (S aureus, esp in pts on chronic steroids eg RA)
- chronic monoarticular arthritis - think fungi or mycobacteria
- acute polyarticular arthritis - think endocarditis, disseminated gonococcal infection, Lyme
Workup: blood culture, CBC, ESR
- U/S is sensitive for detecting effusions if you're not sure; do joint aspiration if effusion present with Gram stain and culture of synovial fluids
Aspiration results:
- normal and osteo - <2K WBC, <25% PMNs
- inflammatory (incl gout, lupus, RA) - 2-50K WBC, <50% PMNs, can be + crystals
- septic - >50K WBC, >75% PMNs, + Gram stain/cx
Mgmt:
- gram + cocci (staph) - vanc
- gram - cocci (gonoccocal) - ceftriaxone
- gram - rods (ecoli, pseudomonas) - zosyn
74
[Rheum]
Cause, diagnosis, clinical, mgmt of:
7. Myositises - poly, dermato, incl body
7. Myositises - inclusion body, poly, dermatomyositis
A. Cause - autoimmune
B. Diagnosis - increased CPfK, + ANA, anti-Jo, Mi-2 Ab
- gold standard is EMG and bx
C. Clinical
i. poly - progressive symmetrical prox muscle weakness esp of shoulders
ii. dermato - like poly but with heliotrope rash, Gottrons papules (violaceous, flat-topped) on knuckles, and shawl and cape rash
- highest a/w malignancy of all the rheum diseases
iii. inclusion body - prox muscle deterioration, frequent falls, M>F and post 50 yo
D. Mgmt - prednisone (except in incl body), mtx if nonresponse
75
```
[Derm]
Compare types of melanoma
A. In situ
B. Superficial spreading
C. Lentigo maligna
D. Amelanotic
E. Acral lentiginous
F. Nodular
```
Types of melanoma: highest mortality of skin cancers (basal is MC)
A. In situ - localized to epidermis, excise with 5 mm borders
all other types require steps beyond local excision incl lymph node bx, chemo, radiation
B. Superficial spreading - MC type in M and F; men on upper torso, women on legs; multicolor lesions w raised borders
C. Lentigo maligna - MC in eldery (~70 yo) on sun-damaged areas; least common overall; brown lesions w irregular borders
D. Amelanotic - uncommon, caught at later stage
E. Acral lentiginous - MC in blacks and asians; found on soles of feet, under nails, palms of hands; flat, irregular, black lesions
F. Nodular - 2nd MC type (after superficial spreading), most aggressive - usually invasive at diagnosis
76
```
[Derm]
Compare eczematous rashes
A. Atopic dermatitis
B. Contact dermatitis
C. Stasis dermatitis
D. Hand dermatitis
```
Eczematous rashes:
A. Atopic dermatitis - involves face on kids (looks like impetigo) but also genitals, extensors --> flexors in adults; tx - emollients, topical steroids
B. Contact dermatitis - Type IV (Delayed, T-cell mediated) HSN; papular, erythematous rash with indistinct margins along areas of exposure w oozing vesicles; tx - medium potency topical steroid
- can be recurrent and symmetric
C. Stasis dermatitis - pooling of blood 2/2 chronic venous insufficiency causing increased pressure in veins
D. Hand dermatitis - from chronic handwashing, in healthcare workers or food industry
77
[Derm]
| Erythasma
Erythrasma - a superficial Gram (+) bacterial infection caused by Corynebacterium minutissimum --> MC in toe web spaces, groin, axillae
- fluoresces under Wood's light 2/2 porphyrins
- tx - topical and oral erythromycin, clindamycin
78
```
[Derm]
Psoriasis - different types and treatment
1. Plaque
2. Guttate
3. Inverse
4. Pustular
5. Erythrodermic
6. Nail
7. Arthritic
```
1. Plaque silvery white scales on salmon-colored plaques, more common on extensor surfaces; lifelong
- tx - topical corticosteroids
2. Guttate - sudden onset post strep infection; many smaller and thicker erythematous lesions on trunk, more common in kids / adolescents
- tx - can go away spontaneously
3. Inverse - bright red, smooth shiny plaques w/out scales, worsens with sweating or rubbing
- found in perianal, genital, armpit skin folds
- tx - topical pimecrolimus
4. Pustular - can cause f/c, n/v if generalized, more common in adults
- triggers are steroids, infections, stress
- oral retinoids, mtx if generalized
5. Erythrodermic - affects almost whole body with widespread, fiery skin --> itching, burning, peeling
6. Nails - pitting, separation of nail from bed, color-changes
7. Arthritic - a/w nail changes, stiff joints + sausage-like swelling, pencil-in-cup DIP deformity
- HLAB27
79
[Derm]
Cause, clinical, mgmt:
Pityriasis rosea
Pityriasis rosea
1. Cause - common but uncertain etiology
B. Clinical prodrome --> sudden onset oval salmon-colored raised herald patch --> multiple smaller pruritic lesions along Langer's cleavage lines eg christmas tree distribution on back
C. Mgmt - self-resolves in 5-8 weeks, give topical antihistamines or steroids to control itching
80
[Derm]
Cause, clinical, mgmt:
Rosacea
Rosacea
A. Cause - idiopathic, triggered by spicy food, environment (eg heat), chemical, emotional triggers
- common in F 30-60 yo
B. Clinical
- facial redness - central facial erythema, flushing, and telangiectasias
- papulopustular - chronic infiltrate
- phymatous - skin thickening and enlargement usually around nose
- ocular - intermittent inflammatory conjunctivitis with burning, stinging
* ddx includes acne, contact dermatitis, photodermatitis, SLE, seborrheic dermatitis
C. Mgmt - use SPF, avoid triggers
- topical metro, azelaic acid, brimonidine for erythema
- clonidine or BB for flushing
- vascular laser tx for erythema, tenalgiectasias
- oral doxy, azithro for severe cases and ocular sx
81
[MSK]
Cause, clinical, mgmt:
I. Back
1. Low back pain
I. Back
I. Low back pain
A. Cause
i. Mechanical (97%) - lumbar sprain (ligament tear)/strain (muscle / tendon tear), degenerative disc disease (ie osteoarthritis), herniated disc (causes sciatica), osteophyte ie bone spur (also causes sciatica)
- also compression fracture, spondylolisthesis (displacement of vertebrae; MCC of low back pain in <26 yo w/out inciting factor)
ii. Visceral (2%) - AAA, GI (pancreatitis, PUD), renal (pyelo, nephrolithasis), pelvic (prostatitis, PID, endometriosis)
iii. Nonmechanical (1%) - cancer mets eg prostate heme breast lung > primary eg MM), infection (psoas abscess, osteo), inflammatory arthritis
B. Clinical
- compression of nerve root 2/2 herniated disk - sciatic pain with valsalva eg coughing, abnormal gait, loss of ankle jerk, positive straight leg test
- vertebral compression fracture - in elderly (osteoporosis) and chronic steroid use; point tenderness and vertebral stepoff of spinous processes, acute onset pain (girdle of pain) after sudden movement; tx - get plain films (MC T12-L2), analgesia, PT, calcitonin and bisphosphonates
- malignancy - weight loss, pain worse at night
- lumbosacral strain - spasm of paraspinous muscles, reproducible with palpation
- spinal stenosis - MCC is degenerative arthritis and spondyloslisthesis; leg weakness and pseudoclaudication; positional - pain improved with leaning forward (flexion); tx - analgesia, PT, epidural corticosteroid injections
C. Mgmt - do not need imaging in first 4-6 weeks in absence of osteoporosis/steroid use, neurologic deficits, constitutional or red flag sx, trauma, IVDU
- MRI if conservative tx (Rest, early mobility and PT, heat, NSAID / tylenol, cyclobenzaprine) failed after 6 weeks (most recover spontaneously by then) and normal X-rays
- surgery if sx persist for 1 yr
82
[MSK]
Cause, clinical, mgmt:
I. Back
2. Cauda equina syndrome
II. Cervical spine
1. Cervical radiculopathy
2. Cervical myelopathy
2. Cauda equina syndrome
A. Cause - severe stenosis 2/2 acute midline disc herniation
B. Clinical - bladder dysfunction (either incontinence OR retention), b/l sciatica, and saddle anesthesia; dec sphincter tone and b/l ankle reflexes, pos straight leg raise test
C. Mgmt - emergency! need MRI and surgical decompression w/in 72 hrs to avoid permanent injury
II. Cervical spine
1. Cervical radiculopathy - due to compression of spinal nerve
A. Cause - cervical spondylosis (osteoarthritis), disc herniation
B. Clinical - arm pain, numbness, tingling, weakness - unilateral neck pain radiating to arm in dermatomal pattern
C. Mgmt - MRI, conservative mgmt
2. Cervical myelopathy
A. Cause - neurologic dysfunction due to compression of spinal cord
B. Clinical -gait disturbance, loss of hand dexterity, pain is not a common finding
C. Mgmt - surgery to decompress spinal cord; loss of ambulation is permanent
83
```
[MSK]
III. Knee pain
A. DDx
B. ACL vs PCL vs MCL vs meniscus
C. Mgmt
```
III. Knee pain
A. Cause - osteoarthritis, rheum (RA, psoriatic, SLE)
- acute monoarticular (Lyme, Septic, gout, ARF, gonorrhea), Osgood-Schlatter
- osteochondritis dissecans (necrotic bone and degenerative changes to overlying cartilage), Baker's cyst
- patellar tendinitis "jumper's knee" and patellofemoral pain syndrome "runner's knee" (esp with up/down stairs)
- plica syndrome (extension of synovial capsule of knee becomes inflamed), trauma
B. ACL tear (MC injury) - noncontact twisting injury, "popping" sound, immediate effusion (hemarthrosis), ability to bear weight but feeling of instability
- PCL tear - direct contact force on extended knee or fall on flexed knee (eg hitting dashboard) - pop, rapid effusion, pain on ROM, posterior tibial sag sign
- meniscus - caused by forceful twisting, a/w ACL tear, cause catching, locking; devlpt of effusion w/in 24 hrs
- MCL - caused by valgus stress, pain over medial aspect of knee; no effusion
- LCL - caused by varus stress, no effusion
C. Mgmt - PT is best, surgery if very young or elite athlete
84
```
[MSK]
Causes, clinical, mgmt
IV. Ankle pain
A. lateral ankle sprain
B. peroneal tendon tear
C. fibular fracture
D. talar dome fracture
E. medial ankle sprain
F. syndesmotic sprain
G. achilles tendon rupture
```
IV. Ankle pain
A. Lateral ankle sprain - pain, warmth, swelling; due to inversion injury of lateral stabilizing ligaments - anterior talofibular ATFL (MC injury), calcaneofibular CFL (laxity during negative inversion test), and posterior talofibular ligaments PTFL
Grade I - stretch of ligament with minor swelling but no loss of function; can bear weight
Grade II - partial ligamentous tear; moderate joint instability, loss of function, inability to bear weight
Grade III - complete ligamentous tear; significant joint instability, swelling, loss of function, inability to bear weight
B. peroneal tendon tear - pain posterior to lateral malleolus; also due to inversion injury
C. fibular fracture - deformity, inability to ambulate, severe pain and swelling; due to fall, high velocity injury
D. talar dome (highest bone of foot) fracture - due to acute inversion injury or direct trauma, can lead to necrosis if not IDed
E. medial ankle sprain - due to forced eversion, injury to deltoid ligament, much less common bc of bony anatomy of tibiotalar joint and strength of deltoid ligament
F. syndesmotic sprain - (high ankle sprain - of ligaments connecting tibia and fibula) - pain OOP to injury, positive ankle squeeze test
G. achilles tendon rupture - popping sound, immediate pain to posterior right ankle; inability to plantarflex
(+) Thompson test
85
```
[MSK]
V. Tendinitis / tendinopathy
1. Rotator cuff
2. Lateral epicondylitis
3. Medial epicondylitis
4. De Quervain's tenosynovitis
5. Biceps tendinopathy
6. Triceps tendinopathy
```
V. Tendinitis / tendinopathy
1. Rotator cuff impingement - MCC shoulder pain, due to impingement of greater tuberosity on acromion --> leads to tendinitis; pain with overhead activity; (+) Neer/Hawkins
- tx - subacromial steroid injections
* suspect rotator cuff TEAR if weakness on shoulder abduction and atrophy --> do MRI
2. Lateral epicondylitis - tennis elbow, degeneration of extensor carpi radialis tendon, due to excessive extension
- self-resolves in 12 mos w conservative mgmt
3. Medial epicondylitis - golfer's elbow, degeneration of flexor tendons (flexor carpi radialis and pronator teres), due to excessive wrist flexion --> weakened grip strength
4. De Quervain's tenosynovitis - inflammation of thumb extensor tendons on radial side of wrist (abductor pollicus longus and extensor pollicus brevus)
- (+) Finkelstein's test and (-) grind test, pain with pinch grip (eg holding coffee cup)
- tx - rest and thumb spica wrist splint, can inject steroids
5. Biceps tendinopathy - vague anterior elbow pain and repeated flexion with forearm supination/pronation (eg dumbbell curls)
6. Triceps tendinopathy - pain in posterior elbow with resisted extension, tenderness over triceps insertion, seen in weight-lifters
86
[MSK]
VI. Bursitis
1. Olecranon
2. Trochanteric
VII.
1. Carpal tunnel syndrome
2. Cubital tunnel syndrome
compare to ulnar tunnel syndrome
VI. Bursitis
1. Olecranon bursitis - swelling at point of elbow (nontender, boggy mass), spongy "bag of fluid" effusion into olecranon bursa; tx - compression dressing
- if pain, erythema, warmth -- septic bursitis; tx - aspiration, abx
2. Trochanteric bursitis - common cause of lateral hip pain, greater trochanter TTP or when lying on affected side, insidious onset; no pain w internal or external ROM
- tx - corticosteroid injection
VII.
1. Carpal tunnel syndrome
A. Cause - median nerve compression, a/w pregnancy, DM, hypothyroid, repetitive use, trauma, wrist fracture
B. Clinical - pain numbness tingling, worse at night, thenar atrophy
- positive tinel's sign and phalen's test
C. Mgmt - clinical dx but can confirm with U/S, EMG and NCS
- wrist splints, steroids (NOT NSAIDs), yoga
- corticosteroid injection, if no sx improvement in 4-6 mos --> surgical decompression
2. Cubital tunnel syndrome (in elbow)
A. Cause - prolonged elbow compression or flexion
B. Clinical - ulnar nerve dist paresthesias, intrinsic hand muscle weakness (weak grasp), ulnar claw
C. Other place ulnar nerve can be compressed is in Guyon's canal in the wrist - seen with bike riders --> loss of finger abd/adduction, clawing
87
[MSK]
Cause, clinical, mgmt:
VIII. Osteoarthritis
VIII. Osteoarthritis
A. Cause - degeneration of cartilage and hypertrophy of bone at articular margins
B. Clinical - joint pain when bones start rubbing against each other once the cartilage has been completely destroyed; deep dull ache worse with activity, limited ROM due to osteophytes, bony crepitus on passive ROM; Bouchard and Heberden's nodes
- hip osteoarthritis presents as groin pain
C. Mgmt - plain X-rays normal at first, gradual development of joint space narrowing, subchondral cysts, sclerosis of bony end-plates, osteophytes
- 1st line - exercise-based PT, tylenol weight loss if BMI > 25
- then steroids or surgery
88
```
[MSK]
Cause, clinical, mgmt:
IX. Hip labral tear
X. UCL tear
XI. Scaphoid fracture
```
IX. Hip labral tear (labrum = outside ring of cartilage lining socket)
A. Cause - acutely after traumatic event or insidious onset due to arthritis or femeroacetabular impingement (bone spur --> friction --> labral tear --> cartilage damage --> arthritis)
B. Clinical -
- gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position
- catching or clicking sound and sharp pain with activity, ROM intact but pain on extremes of internal and external rotation, feeling of instability
- pain on FADIR and FABER tests for intra-articular pathology, MR arthrography is gold standard for diagnosis
X. UCL (ulna collateral ligament - joints ulna and distal humerus) tear
A. Cause - valgus stress on elbow during overhead throwing (baseball, javelin, volleyball)
B. Clinical - pop followed by immediate pain, bruising on medial elbow
- dx via moving valgus stress test - pain from 70 to 120deg
C. Mgmt - RICE, sx
XI. Scaphoid fracture
A. Cause - FOOSH; MC carpal bone fracture, MC in M 15-30 yo
B. Clinical - positive grind test, pain over anatomic snuff box and with axial loading (compression)
- proximal scaphoid has highest risk of avascular necrosis
C. Mgmt -
- nondisplaced - short arm thumb spica cast
- displaced - surgery bc more prone to nonunion
89
```
[MSK]
Specific tests for:
1. Shoulder / rotator cuff injury
A. Supraspinatus
B. Infraspinatus, teres minor
C. Subscapularis
D. Impingement
```
E. DDx for shoulder pain aggravated by movement
Specific tests: initial imaging for painful joint is plain film X-ray; normal X-ray and suspected soft-tissue injury (ligament, tendon, cartilage) --> MRI
1. Shoulder/rotator cuff injury (SITS muscles)
A. Supraspinatus (abduction) - empty can test
B. Infraspinatus, teres minor (external rotation) - External rotation with elbows at sides and flexed, or Apley's test (scratch back)
C. Subscapularis (internal rotation) - Lift-off test - attempt to lift dorsal hand off lower back, and internal rotation with elbows at sides and flexed
D. Impingement
- Hawkins - pain with internal rotation of shoulder when arm and shoulder are flexed
- Neer - passive abduction w internally rotated shoulder
E. DDx for shoulder pain aggravated by movement:
- rotator cuff tendinopathy - limited active ROM with preserved muscle strength
- rotator cuff tear - normal passive but limited active ROM w significant pain (cannot raise arm above head), weakness w strength testing
- adhesive capsulitis (frozen shoulder) - insidious onset of severe pain (esp at night), restricted active AND passive ROM, pain at extremes of motion; risk factors incl endocrine d/o (hypothyroid, DM)
- impingement syndrome - (+) Neers/Hawkins
- labral tear - (+) Clunk and O'briens tests; often dx of exclusion
90
[MSK]
Specific tests for:
2. Ankle
3. Knee
2. Ankle
A. Anterior drawer - pull forward on heel while stabilizing lower leg --> ATFL tear
B. Inversion stress test - invert ankle while stabilizing lower leg --> clunk of talus on tibia --> CFL ligament tear
C. Squeeze test - compress tibia / fibula at midcalf --> pain below where the squeezing is --> syndesmosis ("high ankle" injury)
3. Knee
A. Lachman test - knee in 20deg flexion, pull forward on upper tibia while stabilizing lower leg --> ACL tear
B. Anterior drawer test - knee in 90deg flexion, pull forward on upper tibia while stabilizing lower leg --> ACL tear
C. Valgus stress - medial force on knee and lateral on ankle --> MCL tear
D. Varus stress - lateral force on knee and medial on ankle --> LCL tear
E. Grind test - patellofemoral pain syndrome, chondromalacia
F. Apprehension - subluxation of patella
G. Mcmurray test - click indicates meniscal tear
91
```
[MSK]
Fractures
1. Mallet
2. Boxer's
3. Trigger finger
4. Jersey finger
5. Flexor tenosynovitis
6. Toe
```
1. Mallet fracture (baseball finger) - disruption of extensor digitorum longus tendon distal to DIP joint --> splint DIP joint in extension for 8 weeks
- most common closed tendon injury in athletes - can be caused by sudden forced flexion of DIP
- cannot actively extend DIP
- intra-articular fractures with >25% joint surface involvement - surgical
2. Boxer's - punching immoveable object with closed fist --> fracture of neck of 5th metatarsal (pinky) --> swelling and depression of involved knuckle
- closed reduction, then splint MCP in flexion for 6 weeks
3. Trigger finger (stenosing tenosynovitis) - swelling of flexor tendon and sheath --> snapping of affected finger at MCP joint, worst after rest and better with use
- mgmt similar to dequervain's tenosynovitis - NSAIDs, rest, immobilization, corticosteroid injection (can be curative)
4. Jersey finger - injury to flexor digitorum profundus at attachment to distal phalynx
- due to sudden force applied to distal phalynx while in flexion (eg catching finger in opponent's jersey)
- cannot actively flex DIP
5. Flexor tenosynovitis - due to penetrating injury / puncture wound (dog bite), infection (gonorrhea)
- Kanavel signs - finger held in flexion with swelling, tenderness along tendon sheath, and pain with passive extension
- fever + dermatitis - think gonococcal
- need IV abx, RICE
6. Toe - most common fracture of foot
- nondisplaced lesser toe - rigid sole shoe or buddy taping
- great toe - short leg walking cast with toe plate for 2-3 weeks, then buddy taping or rigid sole shoe for 3-4 weeks
- intra-articular fractures with >25% joint surface involvement - surgical
92
[MSK]
DDx neck pain
When to do C-spine imaging
neck pain
- osteoarthritis or spondylosis - pain aggravated by movement, worse after activities, a/w dull ache, limited ROM
- chronic mechanical problems - TTP
- cervical nerve root irritation - radiation, weakness, numbness
- cervical dystonia = torticollis; tx - botox
Canadian cervical spine rules for C-spine imaging:
- age > 65 yo
- extremity paresthesias
- dangerous mechanism
- lack of low-risk criteria (sitting / ambulatory, no midline tenderness, simple rearend)
- inability to actively rotate 45deg to L and R
93
[MSK]
| Ottowa ankle and knee rules
Ottowa ankle rules:
A. Ankle x-ray if 1+:
- point tenderness at distal 6 cm of posterior edge of fibula or tip lateral malleolus
- point tenderness at distal 6 cm of posterior edge of tibia or tip medial malleolus
- inability to bear weight (4 steps) immediately and at time of evaluation
B. Foot x-ray if 1+:
- point tenderness at base of 5th metatarsal
- point tenderness at navicular
- inability to bear weight (4 steps) immediately and at time of evaluation
Ottawa Knee Rules:
- knee x-ray if 1+ of following:
(1) Age 55+
(2) isolated patellar tenderness
(3) tenderness of fibular head
(4) inability to flex knee 90deg
(5) inability to bear weight for 4 steps immediately and at time of evaluation
94
```
[ID]
SSTI
1. Erysipelas
2. Cellulitis
3. Osteomyelitis
4. Nec fac
```
SSTI:
1. Erysipelas - infection of upper dermis and lymphatics w well-defined demarcation, MCC GABHS
tx - cefazolin
2. Cellulitis - acute, painful infection of deeper dermis and subQ tissue, usually due to break in skin (trauma, another infection); MCC - Strep (spreads out) or Staph (spreads down and causes abscess)
- if moderate nonpurulent cellulitis --> cefazolin / cephalexin, ceftriaxone, clindamycin
- if toxic, severe cellulitis, or purulent drainage - probably staph --> vancomycin
- if diabetic - bring out the big guns --> IV vanc + zosyn ie pip-tazo (to cover pseudomonas)
- if abscess - I and D + doxy/clinda/bactrim
3. Osteomyelitis - consider as dx if cellulitis does not improve --> do MRI and bone bx
- need I and D and 4-6 weeks abx (IV vanc/zosyn or cipro/clinda transition to PO), f/u ESR and CRP and blood cx
4. Nec fac - MCC is GABHS or anaerobes; severe pain out of proportion and skin changes outside realm of cellulitis eg bullae, deep discoloration and crepitus (due to methane and C02 production)
- see gas on X-ray
- need urgent surgical consult and operative I and D w/in 12 hrs to reduce risks of amputation and death
- IV vanc + zosyn + clinda
95
[ID]
| Steps of sepsis
Sepsis steps:
1. SIRS - 2+ of the following: T>100.4F (38C) or <96.8F (36C), HR>90, RR>20 or PC02<32, WBC>12K or <4K or >10%bands
2. Sepsis - SIRS + source of infection (suspected or documented)
3. Severe sepsis - Sepsis + signs of end-organ damage (rise in Cr>0.5 and AKI, thrombocytopenia and DIC, hyperbilirubinemia and jaundice, hypoxia and ARDS, lactate >2 and AMS)
4. Septic shock - sepsis + continued hypotension after adequate fluid resuscitation
96
```
[ID]
Bites
1. Insects
2. Spiders
3. Animal
4. Human
```
Bites:
1. Insects
- local reaction - immediate redness, swelling, pain, itching; tx - Tdap, ice, antihistamines
- delayed reaction - large areas of redness and warmth after 1-2 days; tx - oral steroids (prednisone)
- anaphylaxis - urticaria, angioedema, hypotension, shock; tx - epinephrine, fluids, observe inpatient for 12-24 hrs
2. Spiders
- cool compress, NSAIDs, tylenol
- if erythema, warmth, pain develop --> consider MRSA cellulitis; tx - oral clinda or bactrim
3. Animal bites - saline irrigation, debridement, Tdap, rabies
- Pasteurella, staph and strep
A. Cat - oral augmentin 10-14 days
B. Dog - oral augmentin 5-7 days; if signs of cellulitis - 10-14 days
4. Human bites - saline irrigation, debridement, Tdap and consider Hep B and HIV PEP
- Eikenella, staph, strep
- tx - oral augmentin 5-7 days
97
[ID]
HIV/AIDS
1. Stages
2. Mgmt
1. HIV/AIDS stages:
Stage 1 - CD4 > 500 or % lymphs >29
Stage 2 - CD4 200 - 499 or % 14-28
Stage 3 (AIDS) - CD4 < 200 or % < 14 and AIDS-defining illness eg coccidio, CMV, histo, Burkitt, MAC, toxo, HIV encephalopathy, TB, PML, invasive cervical cancer, Kaposi sarcoma, CNS lymphoma, PCP, Salmonella septicemia, HSV or candidiasis of bronchi, trachea, or lungs, crypto
Stage 4 (AIDS) - more severe AIDS-defining illnesses
2. Mgmt
*CD4 count best prognostic indicator of immune suppression, check q3mos initially then space out - no live vaccines if <200
A. HAART - start ASAP, usually 2 NRTIs and integraseI
- NRTI (MC tenofovir, also didanosine, zidovudine (AZT) - can cause bone marrow suppression, osteopenia
- NNRTI (efavirenz, nevirapine) - rash, hepatotoxic
- protease inhibitors ("-navir") - can cause Cushing-like syndrome
- integrase inhibitors ("-gravir") - increased CK
B. Ppx
- PJP @ CD4 < 200 w TMP-SMX
- Toxo @ CD4 <100 w TMP-SMX
- MAC @ CD4 < 50 w azithro
- PrEP - Emtricitabine/tenofovir; can be initiated after (-) 4th gen HIV antibody/antigen testing, normal renal
function (c/i if GFR < 60), and hepatitis B (-)
98
```
[ID]
Compare genital ulcers
1. Syphilis
2. LGV
3. Chancroid
4. HSV
```
Genital ulcers:
1. Syphilis - primary has single painless chancre at site of inoculation and nonpainful LAD; dx - Darkfield microscopy; tx - 1 dose PCN IM
secondary - fever, rash on palms and soles, condyloma lata; dx - RPR, then FTA-ABS; tx - 1 dose PCN IM
latent - serology (+) but asx, either early <1 yr (tx - 1 dose PCN IM) or late >1 yr (3x weekly x 3 weeks)
tertiary - tabes dorsalis, aortitis, Argyl-Robertson; tx - IV PCN q4hrs 10-14 days
2. LGV - single, painless ulcer and tender LAD - can drain pus "buboes" (inflamed lymph nodes) eg groove sign (above below inguinal ligament, pathognomonic)
caused by C trachomatis; tx - doxy
3. Chancroid - single, painful ulcer with tender LAD
caused by H ducreyi; dx - Gram stain and cx; tx - azithro, cipro
4. HSV - burning prodrome --> multiple painful vesicles that can unroof into one ulcer
caused by 1 or 2; do PCR to determine which one (not Tzanck smear, or culture, which can be neg); tx - acyclovir, valacyclovir
99
[ID]
1. Scabies
2. Lice
3. Bedbugs
4. Chigger
1. Scabies - severe relentless pruritus caused by itch mite, small eczematous papules with excoriation with burrow lines on folds of skin such as web spaces of fingers, axillae, genitals, and palms/soles (back/head usually spared)
- treat pt and fam members with topical permethrin, oral ivermectin, or lindane shampoo (2nd line) and decontaminate
2. Lice - base of hairshaft, pubic hair; pruritus and sores 2/2 scratching; skin discoloration around midsection
- body lice transmit Bartonella quintana, which causes trench fever
- head lice - permethrin 1% shampoo and return to class
3. Bedbugs - red, itchy welts on upper body and neck, forearms and lower legs
4. Chigger - larval form of mite (eight-legged arthropod)
- crawls near constricted clothing --> welts along neckline, waistline, sockline
100
```
[Surgery]
Preop eval
A. Cardiac
B. Pulm
C. Hepatic
D. Nutrition
```
Preop eval:
A. Cardiac
- revascularization (Eg stent) in last 5 years or clean angiogram in last 6 months and USH --> medically cleared
- intermediate or low risk eg poor functional capacity and risk factors (compensated CHF, DM, HTN, prior MI or stroke) - noninvasive stress test
- high risk factors eg decompensated CHF (EF <35%), arrhythmias, unstable angina, MI w/in past 6 mos --> coronary angiography
B. Pulm - no recommendation for CXR, pulseox, ABG
- could do PFTs if pt has COPD or asthma to determine baseline status -- look for high C02 or low 02
- smoking cessation 8 weeks preop
C. Liver - look at Child-Peugh or Meld score
- albumin - decreased, clotting factors - absent and PT/PTT elevated, Tbili - elevated
- sx (ascites, encephalopathy)
* any 1 derangement --> 40% chance death; all 5 --> 100%
D. Nutrition - look at protein via skin anergy test (looking at Igs), albumin levels (look at albumin and prealbumin to differentiate liver vs nutritional pathology)
- oral > IV feeds, do 10 days if possible
E. Glucose - high glucose 2/2 DKA is c/i
*no preop eval needed prior to cataract sx if pt is in usual state of health
BB should be started weeks before surgery, c/I in immediate preop period
statins should also be started beforehand and can be started right before surgery w/out complications
101
[Surgery]
| Causes of postop fever
Postop fever - MC postop complication
- Wind, Water, Wound, Walking, Wonder drugs
- intraop - 24 hrs: bacteremia, TSS, blood products, malignant hyperthermia (give dantrolene)
- 1 day - 1 week: atelectasis (24 hrs) and PNA (2-3 days), UTI (3+ days), wound infection eg SSI, cellulitis (5-7 days)
also intraperitoneal leak, viral URI, alcohol / drug withdrawal, pancreatitis, gout, acute MI
- 1 - 4 weeks: DVT/PE (7-10 days)
also SSI, C diff colitis, abscess, thrombophlebitis
- >1 month: infective endocarditis, SSI, vascular graft infection, postpericardiotomy syndrome (immune pericarditis post CABG)
102
[Surgery]
| Workup of solitary pulm nodule
DDx solitary pulm nodule - benign hamartoma, scarring, cancers, granulomatous dz (TB, fungal) --> determine likelihood of malignancy
- if low (nonsmokers <35 yo w nodule <2cm) --> repeat CXR q3-6 mos
medium/high risk factors: age > 35 yo, size >3cm, irregular/spiculated borders/no calficications/ground glass, increasing size over time, smoking hx
- if medium --> further w/u PET scan --> if (-) then follow, if (+) then biopsy via bronchoscopy, CT-guided needle bx, or VATS w resection
- if high --> stage then VATS
