IM 2.0 Flashcards
CASTLE-AF study (2022)
Found that in patients with coexisting Afib and HF, catheter ablation was associated with a 12% less reduction of death from any cause and a 15% reduction for less HF
Persistent-Post perceptual dizziness
-PPPD is persistent, nonvertiginous dizziness or imbalance that worsens with personal motion, upright positioning, and movement of objects in the surrounding environment, with symptoms present on most days for at least 3 months.
-Often preceded by trauma (concussion or fracture), previous vertiginous illness now with no physical exam signs, infection, or psychiatric conditions
-Tx: CBT, balance therapy, SSRI/SNRI for 1 year if effective
Pemberton Sign
Congestion and erythema of the face and eventual cyanosis and distress associated with raising the arms above the head.
Associated with substernal or retroclavicular goiters, mediastinal masses, and superior vena cava syndrome Caused by compression of the trachea, esophagus, or neck veins when patients flex or elevate their arms.
Body Lice
Findings: Linear excoriations on the trunk, may be concentrated around the waist and axillary folds where clothing seams lie close to the body. May have hemorrhagic puncta or wheals from fresh bites.
-Has increased risk for… Bartonella quintana endocarditis, bacillary angiomatosis, and trench fever
Ketosis-prone diabetes mellitus
Characterized by the patient’s autoantibody status (for example, glutamic acid decarboxylase [GAD65] and tyrosine phosphatases IA-2 antibodies) and the pancreatic β-cell function. This information is helpful in determining the patient’s long-term clinical course and need for insulin.
*Should be checked 3 months after initial DKA as there can be recovery of B-cell function with stable glucose control over that period of time
Chronic Migraine
Headache on 15 or more days per month that either meets full criteria for migraine on at least 8 of those days or responds to migraine-specific medication.
-Affects 2% of the adult population; transformation from episodic migraine to chronic migraine occurs in the general population at an annual rate of 3%.
RFs: Older age, female sex, head trauma, major life changes or stressors, obesity, chronic pain, mood and anxiety disorders, and inadequate acute migraine management, medication/nicotine or caffeine overuse
Diabetic Amyotrophy
Lumbar polyradiculopathy affecting primarily muscles of the thigh (L2 through L4 spinal levels).
-Can follow a period of significant weight loss in persons with diabetes mellitus
-Presents with acute, asymmetric, focal onset of pain followed by weakness involving the proximal leg, with about half of patients developing autonomic symptoms (such as orthostatic hypotension, tachycardia, constipation, diarrhea, and urinary and sexual
dysfunction).
-Progression occurs over weeks to months, sometimes with spread to the contralateral lower extremity or upper extremities.
**The disorder can occur in well-controlled and even undiagnosed diabetes.
Type 1 Hepatorenal syndrome
Characterized by a rise in serum creatinine of at least 0.3 mg/dL (26.5 µmol/L) and/or ≥50% from baseline within 48 hours, bland urinalysis, and normal findings on kidney ultrasound. It is also supported by a lack of improvement in kidney function after withdrawal of diuretics and 2 days of volume expansion with intravenous albumin. Often, patients also have low urine sodium, low fractional excretion of sodium, and oliguria.
-Treated with IV octreotide and PO midodrine in conjunction with IV albumin
Type 2 Hepatorenal Syndrome
Gradual decline in kidney function associated with refractory ascites.
Conditions associated with pyoderma gangrenosum
IBDs
RA
Malignancies/hematologic conditions (often AML)
Seronegative spondyloarthropathies
Urinary stones associated with topiramate
Calcium phosphate stones
Carbonic anhydrase promotes proximal tubule sodium, bicarbonate, and chloride reabsorption. Inhibitors of carbonic anhydrase produce both sodium chloride and bicarbonate urinary loss. The resultant mild metabolic acidosis causes decreased citrate excretion, and the persistent alkaline urine favors the precipitation of calcium phosphate.
Basophilic stipling
The blue granules are ribosomal precipitates. Basophilic stippling is associated with megaloblastic anemias (such as cobalamin deficiency), thalassemia, sickle cell anemia, sideroblastic anemia, alcohol abuse, and lead poisoning.
Dumping Syndrome
Develops in patients usually post-gastrectomy and is due to rapid emptying of hyperosmolar gastric chyme into the small intestine
Common early symptoms of dumping symptoms are palpitations, tachycardia, diaphoresis, and lightheadedness with abdominal pain and diarrhea presenting within 30 minutes of eating. Late symptoms can occur 1 to 3 hours after eating in 25% of patients and include sweating, tremor, hunger, and difficulty with concentration and cognition (hypoglycemia)
Tx: Small but more frequent meals
Empyema management
When performed twice daily for 3 days, intrapleural administration of tPA-DNase has been shown to decrease the radiographic pleural opacity, lower the rate of surgical intervention, and decrease hospital stay of patients with empyema (MIST-2 trial). It should be noted that the tPA-DNase has not been shown to decrease mortality. In addition, video-assisted thorascopic surgery has also been shown to effectively manage empyema in greater than 90% of cases, and a delay in surgery increases the risk of open thoracotomy
Initial treatment for ulcers related to Behcet syndrome
Topical glucocorticoids
Behcet Syndrome
-Vasculitis that can affect small to large arterial vessels and is one of the few forms of vasculitis that also can affect veins.
-Behçet syndrome has an increased prevalence in a belt from East Asia to Turkey and therefore conveys an ethnic/genetic risk in individuals with a Mediterranean/Asian background.
-Characterized by recurrent painful oral ulcers plus at least two of the following: recurrent painful genital ulcers, eye involvement, skin involvement (typically acneiform lesions), and pathergy (development of a pustule following a needle stick).
-Oral ulcers typically resolve spontaneously after 1 to 3 week
Idiopathic Intracranial Hypertension
“Pseudotumor cerebri”
-Commonly found among young women with obesity and frequently presents with headache, visual disturbances, and tinnitus. Abducens nerve (cranial nerve VI) palsy is a false-localizing sign associated with elevated intracranial pressure.
-Diagnosis of idiopathic intracranial hypertension requires a lumbar puncture that documents elevated intracranial pressure with otherwise normal CSF findings
Tx: Acetazolamide
IgA vasculitis
IgA vasculitis is an IgA immune complex–mediated small-vessel vasculitis that almost always affects the skin but frequently affects the bowel, leading to pain, bleeding, and occasionally intussusception; less commonly, it affects the kidneys and rarely causes pulmonary hemorrhage.
Triad: Palpable purpura, abdominal pain, arthralgia
-Tends to appear after upper respiratory infections.
-Biopsy of the most accessible affected organ will establish the diagnosis by demonstrating leukocytoclastic vasculitis with predominance of IgA deposits on immunofluorescence; findings are characterized by IgA deposition in the mesangium on immunofluorescence microscopy that is identical to that in IgA nephropathy.
Apnea-Hypopnea Index (AHI)
An apnea-hypopnea index (AHI) of 5 to 15 is indicative of mild obstructive sleep apnea (OSA). Severe = >30
Neurally-mediated syncope
Neurally mediated syncope (also known as neurocardiogenic or reflex syncope) is the most common form of syncope and is seen primarily in younger adults. The underlying syncopal mechanism, termed the neurocardiogenic or vasodepressor reflex, is a response of vasodilation, bradycardia, and systemic hypotension, which leads to transient hypoperfusion of the brain. Neurally mediated syncope includes vasovagal syncope, which may be provoked by noxious stimuli, fear, stress, or heat overexposure; situational syncope, which is triggered by cough, micturition, defecation, or deglutition; and carotid sinus hypersensitivity, which is sometimes experienced during head rotation, shaving, or use of a tight-fitting neck collar. Prodromal symptoms, including nausea and diaphoresis, are classically present before the syncopal event, and fatigue and generalized weakness are typically present afterward.
IV antiepileptics to give to someone after they have received benzodiazepines for status epilepticus
Fosphenytoin
If allergic, use valproic acid
Linaclotide
Linaclotide is a peripherally acting guanylate cyclase-C receptor agonist that is FDA approved for the treatment of chronic idiopathic constipation in adults. Linaclotide increases intracellular and extracellular cyclic guanosine monophosphate, which results in chloride and bicarbonate secretion into intestinal lumen, increasing intestinal fluid content and accelerated transit time
Medication to treat if patient has BPH AND erectile dysfunction
Trial of tadalafil is first recommended prior to other treatments
Lab that needs checked while treating hypoparathyroidism
24 hour urine calcium
-The reason for this is that hypercalciuria can often limit therapy as supplementing calcium without PTH present will cause this to occur
Criteria for resectability of hepatic metastases
Most patients with good performance status can be considered for surgical resection unless they have one of three conditions: tumor involvement of the common artery or portal vein or common bile duct; more than 70% liver involvement, more than six involved segments, or involvement of all three hepatic veins; and a predicted inadequate hepatic reserve after resection.
First lab to order when evaluating Paget disease of the bone
AP; assesses the metabolic activity of the disease
Adynamic Bone Disease
Adynamic bone disease can occur in patients with chronic kidney disease (CKD) or those on dialysis. It is typically associated with significant vascular calcifications.
The gold standard for the diagnosis of adynamic bone disease is bone biopsy; however, this is rarely performed.
Adynamic bone disease has no specific markers, but a constellation of findings may suggest this diagnosis. Patients with adynamic bone disease may present with fracture or bone pain. The latter has been attributed to the inability to repair microdamage because of low turnover.
Serum calcium may be normal or elevated because the bone is unable to take up calcium.
High PTH and alkaline phosphatase would exclude adynamic bone disease; in this disorder, both are typically normal.
Treatment is targeted at factors that allow PTH secretion to rise. This includes avoiding calcium-based binders, conservative use of vitamin D, and decreasing the dialysate calcium concentration.
Osteitis fibrosa cystica
Osteitis fibrosa cystica is due to abnormally high bone turnover in secondary hyperparathyroidism and increases the risk of fracture. Patients can be asymptomatic, or they may have bone pain. Classic skeletal changes on radiograph include subperiosteal resorption of bone, most prominently at the phalanges of the hands, and radiolucent bone cysts of the long bones.
Progressive Multifocal Leukoencephalopathy
PML is a demyelinating disease of the central nervous system (CNS) caused by the JC polyomavirus. It occurs almost exclusively in severely immunocompromised patients, including those with advanced HIV infection/AIDS.
Clinical findings of PML include dementia, hemiparesis or paralysis of one extremity, ataxia, hemianopia, and diplopia. The characteristic MRI appearance of these lesions is hyperintense (white) areas on T2-weighted images and fluid-attenuated inversion recovery sequences (FLAIR) and hypointense (dark) areas on T1-weighted images. There is usually no mass effect.
In patients with advanced HIV infection/AIDS, the probability of PML exceeds 80% in those with white matter lesions with no mass effect. The finding of a positive JC virus nucleic acid amplification test in cerebrospinal fluid can also make the diagnosis. Treatment involves commencement of antiretroviral therapy to reverse the immunosuppression that interferes with the normal host response to the JC virus.
Impetigo
Impetigo is most commonly caused by Staphylococcus aureus or beta-hemolytic streptococci. Impetigo can be either nonbullous or bullous impetigo.
- Bullous impetigo is a toxin-mediated process usually caused by production of an exfoliative toxin by S. aureus, which induces erythema and loss of the superficial layer of the epidermis.
- Nonbullous impetigo is the more common type and often affects the face or extremities. It appears as erythematous papules or pustules that rupture and then progress to erosions with overlying honey-colored crust. The diagnosis of impetigo often can be made based on clinical presentation; however, culture of the honey-colored crust can confirm the pathologic organism and obtain sensitivity testing, which is important when treating extensive disease or staphylococcal scalded skin syndrome.
Tx: Mupirocin is a topical antibiotic that inhibits bacterial protein synthesis and is used for localized infection; oral antibiotics required only for extensive lesions
Test to order if patient has severe mitral stenosis but only mild findings on echocardiography
Exercise echocardiography
Explanation: Symptoms typically occur with exertion because exercise shortens diastolic filling time and increases the transvalvular flow and diastolic mitral gradient, leading to worsening of left atrial hypertension. Patients can also present with systemic embolization, atrial fibrillation, or, in severe cases, hemoptysis. Heart failure is the cause of death in approximately 60% of patients with mitral stenosis, and thromboembolism is the cause in most others. Symptoms typically are not present until the mitral valve area is less than 1.5 cm2. For patients with mitral stenosis, the valve gradient is heavily flow dependent and may become severely elevated only with exercise. Exercise and the accompanying increases in heart rate augment cardiac output and transvalvular flow and shorten the diastolic filling time in the left ventricle. These conditions can unmask mitral stenosis that does not appear to be echocardiographically severe at rest. With an increase in left atrial pressures during exercise, significant pulmonary hypertension also may become evident.
Babesiosis RFs for severe disease
Asplenia is a major risk factor for fulminant Babesia infection, as is older age, HIV infection, or other immunocompromising conditions. Clinical manifestations are variable, with most relating to severe hemolytic anemia. Infection can be diagnosed by visualization of intraerythrocytic parasites, which appear as either ring forms or tetrads, with the latter often described as having the Maltese cross appearance shown. Complications, including acute respiratory distress syndrome, disseminated intravascular coagulation, heart failure, kidney failure, and coma, are associated with severe anemia (hematocrit level <30%) and parasitemia (exceeding 10%) and are indications for exchange transfusion.
POEMS syndrome
(Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes).
POEMS syndrome is characterized by the presence of a monoclonal plasma cell disorder, peripheral neuropathy, and one or more of the following: osteosclerotic myeloma, Castleman disease (angiofollicular lymph node hyperplasia), elevated serum vascular endothelial growth factor, organomegaly, endocrinopathy, edema, typical skin changes, and papilledema.
It is indicative of an underlying malignancy
Turner Syndrome
-The most common cause of primary amenorrhea is gonadal dysgenesis caused by chromosomal abnormalities, most commonly those associated with Turner syndrome (TS). TS is caused by loss of part or all of an X chromosome (45,X0) occurring in 1 in 2500 live female births. In some studies, more than 20% of patients are diagnosed after 12 years of age; primary amenorrhea may be the presenting sign.
-The most consistent physical finding is short stature, as seen in this patient. Other findings may include neck webbing, hearing loss, aortic coarctation, and bicuspid aortic valve. Primary amenorrhea is seen in approximately 90% of women with TS.
TS should be considered in women with primary or secondary amenorrhea, particularly those of short stature.
-Diagnosis is made by karyotype analysis.
Treatment for chronic calcium pyrophosphate deposition
Low dose prednisone therapy
-Can also use low-dose colchicine or NSAIDs if there are no other comorbidities in the patient
US findings of the hand with rheumatoid arthritis
Hypoechoic material distending the dorsal joint capsule suggests synovial hypertrophy due to rheumatoid arthritis. Erosion can be noted over the metacarpal head.
Ultrasonography is more sensitive than plain radiography for the detection of mild rheumatoid arthritis changes, which include joint fluid, synovial tissue thickening, early erosions, and increased vascularity.
Cirrhotic patients who need SBP prophylaxis
Ascitic-fluid total protein level less than 1.5 g/dL (15 g/L) in conjunction with any of the following:
-sodium level less than or equal to 130 mEq/L
-creatinine level greater than or equal to 1.2 mg/dL
-blood urea nitrogen level greater than or equal to 25 mg/dL
-bilirubin level greater than or equal to 3 mg/dL (51.3 µmol/L)
-Child-Turcotte-Pugh class B or C cirrhosis.
-Prior episode of SBP (regardless of ascitic fluid protein level)
-7 day course indicated with episode of variceal bleeding
Adult patient who has never received MMR and now requires a vaccine
Needs two doses; 3 if there is a current outbreak
Basophilic stippling
Basophilic stippling is associated with megaloblastic anemias (such as cobalamin deficiency), thalassemia, sickle cell anemia, sideroblastic anemia, alcohol abuse, and lead poisoning
-Basophilic stippling itself is leftover ribosomal fragments that have yet to be degraded
Ecthyma
Superficial, saucer-shaped ulcers with overlying crusts are the classic findings of classic ecthyma, which is a variant of impetigo. They almost always occur on the legs or feet and are usually caused by streptococci.
Lupus pneumonitis
Lupus pneumonitis is a rare but severe presentation of SLE characterized by shortness of breath, hypoxia, and diffuse pulmonary infiltrates. Other major entities in the differential diagnosis include infection and diffuse alveolar hemorrhage.
Signs pointing to this are: evidence of active SLE with polyarthritis, a high erythrocyte sedimentation rate, hypocomplementemia, and diffuse pulmonary infiltrates on radiologic studies, as well as lymphocytic predominance on bronchoalveolar lavage.
It usually requires rapid and aggressive therapy with glucocorticoids and/or immunosuppressive agents.
Chronic cutaneous lupus erythematosus
“Discoid” lupus consists of ongoing, slowly progressive, scaly infiltrative papules and plaques or atrophic red plaques (also known as discoid lupus erythematosus) on sun-exposed skin surfaces. Other chronic lesions may be hypertrophic or verrucous appearing. Most patients with chronic cutaneous lupus erythematosus, particularly those whose lesions are only on the head and neck, do not have systemic disease. Approximately 10% of patients with CCLE develop systemic lupus erythematosus (SLE).
What to ensure is done to an empyema after drainage?
Administer tPA
When performed twice daily for 3 days, intrapleural administration of tPA-DNase has been shown to decrease the radiographic pleural opacity, lower the rate of surgical intervention, and decrease hospital stay of patients with empyema (MIST-2 trial). It should be noted that the tPA-DNase has not been shown to decrease mortality. In addition, video-assisted thorascopic surgery has also been shown to effectively manage empyema in greater than 90% of cases, and a delay in surgery increases the risk of open thoracotomy.
How to calculate the Alveolar-arterial oxygen difference
Alveolar PO2 = 150 − (1.25 × arterial PCO2)
Alveolar-arterial oxygen difference = Alveolar PO2 – arterial PO2
EKG findings of right ventricular hypertrophy
Evidence of right atrial enlargement
Right axis deviation or indeterminate axis
Incomplete right bundle branch block (or an rSr’ in lead V1)
Low voltage
Persistent precordial S waves
Right ventricular strain pattern
Tall R wave in lead V1
Post-hypoxic myoclonus
Posthypoxic myoclonus (Lance-Adams syndrome) occurs in patients with a history of hypoxic brain injury (suggested in this patient by his previous cardiopulmonary arrest) and is characterized by prominent action-induced myoclonus that impairs ambulation because of a combination of positive (rapid jerky movements) and negative (lapses in muscle tone) myoclonus.
Topical treatments for normal comedonal acne
Topical erythromycin
To reduce the incidence of bacterial resistance, topical erythromycin can be combined with topical benzoyl peroxide
Aeromonas hydrophilia infection management
Aeromonas infections of the skin and soft tissue and of the bloodstream are more likely to occur in patients with underlying immunocompromising conditions, such as cirrhosis and cancer, and are more common in men. Necrotizing fasciitis caused by this gram-negative bacillus requires surgery, supportive care, and antibiotics.
Pending culture data, empiric therapy for necrotizing skin infections typically consists of broad-spectrum antibiotics such as vancomycin plus piperacillin-tazobactam. When the diagnosis of A. hydrophila infection is established, doxycycline plus ciprofloxacin or ceftriaxone is recommended
Vocal cord dysfunction
Vocal cord dysfunction is caused by paradoxical adduction of the vocal cords during inspiration.
The diagnosis is suggested by dysphonia midchest or throat tightness with exposure to particular triggers such as strong irritants or emotions; difficulty breathing in; and symptoms that only partially respond to asthma medications.
Patients may also experience midchest tightness, dyspnea, cough, and dysphonia, and stridor may be detected as inspiratory monophonic wheezing. Vocal cord dysfunction is commonly misdiagnosed as asthma, leading to excessive health care use. Diagnosis is ideally made by visualization of the abnormal vocal cord adduction during laryngoscopy. It may also be diagnosed if spirometry happens to capture a flat inspiratory limb on the flow-volume loop. However, if patients are unable to tolerate laryngoscopy while symptomatic, empiric therapy should be started if there is a high clinical suspicion of vocal cord dysfunction.
Treatment consists of speech therapy utilizing cognitive behavioral techniques.
Management of mediations prior to surgery on pheochromocytoma
Phenoxybenzamine is started approximately 10 to 14 days prior to surgery, and the dose progressively increased to achieve a desired blood pressure of 130/80 mm Hg or lower when seated, and systolic pressure of 90 mm Hg or higher when standing. Because phenoxybenzamine causes vasodilation, an expected consequence of therapy is postural hypotension. To counteract this and allow appropriate dose escalation of phenoxybenzamine, patients are advised to drink plenty of fluids, eat high salt-containing foods, and to make liberal use of the salt shaker at meal times.
If blood pressure is not adequately controlled with an α-receptor blockade (or prohibitive side effects occur with required higher doses), a calcium-channel blocker such as amlodipine can be added.
A short-acting, selective α-blocker such as prazosin, doxazosin, or terazosin, can be considered alternatives to phenoxybenzamine, based on decreased cost and limited data suggesting similar patient outcomes.
Infection-related glomerulonephritis
Acute glomerulonephritis (GN) and rapidly progressive GN are kidney diseases characterized by immune-mediated damage to the glomerular basement membrane, mesangium, and capillary endothelium that presents as acute kidney injury (AKI).
GN can be present at the time of infection (rather than after a delay of at least 1 week after the infection); the term “infection-related” GN is, therefore, is more appropriate.
Diabetes mellitus is a major risk factor for staphylococcal-associated GN, with methicillin-resistant strains more common in patients with diabetes.
A urinary sediment of dysmorphic erythrocytes and proteinuria is consistent with GN as well as decreased complement levels in the blood
The pathogenesis is thought to involve glomerular deposition of preformed circulating immune complexes. The antigen in the immune complex is derived from the infectious agent. After depositing in the subepithelial area, complement activation and subsequent recruitment of inflammatory cells lead to a proliferative GN.
Findings on ophthalmoscopy with nonproliferative diabetic retinopathy
Hard exudates, microaneurysms, and minor hemorrhages,
Nonproliferative diabetic retinopathy is not typically associated with decline in visual acuity but is a marker for future development of more significant abnormalities that can lead to vision loss.
Patients with new diagnosis of colon cancer should receive what screening?
Mismatch repair protein; this will examine for Lynch Syndrome
Loss of expression of mismatch repair proteins would be expected in approximately 15% of patients with colorectal cancer. Of these 15% with mismatch repair protein deficiency, approximately one in five will have a germline mismatch repair deficiency, which is known as Lynch syndrome.
Patients with Lynch syndrome require more extensive surveillance for additional colorectal cancers and other malignancies.
Lynch syndrome is autosomal dominant, and so identification also has important implications for family screening and surveillance. The most common cancers in Lynch syndrome are colorectal and uterine.
Urine Anion Gap and its use
Urine Anion Gap = (Urine Sodium + Urine Potassium) – Urine Chloride
An initial diagnostic step in normal anion gap metabolic acidosis is to determine whether the kidney is appropriately excreting acid. Increased acid excretion by the kidney is reflected as a marked increase in urine ammonium. Because ammonium carries a positive charge, chloride is excreted as the corresponding anion. Therefore, the amount of excreted chloride increases as urine ammonium levels increase. The urine anion gap can be used as an indicator of the ability of the kidney to excrete acid.
*A NEGATIVE urine anion gap indicates the retained ability of the kidney to excrete acid and thus, represents a GI cause for the acidosis
pH abnormality seen with overdiuresis with loop diuretics
Metabolic alkalosis
Management of cirrhotic patients with worsening renal function
As the splanchnic vasculature progressively dilates and renal perfusion decreases with worsening of portal hypertension, hepatorenal syndrome can develop, which manifests as declining renal function.
The initial evaluation of these patients is investigation for a decrease in intravascular volume and for infection and exclusion of other causes of acute kidney injury.
Furosemide and spironolactone may be exacerbating renal hypoperfusion and should be stopped. Assessment for oliguria, urinalysis (bland urinary sediment), and urine sodium concentration (low) is also appropriate in the evaluation for suspected hepatorenal syndrome.
B-blocker in cirrhotic patient with declining renal function
Can contribute to renal hypoperfusion and therefore, should be stopped in these patients
Familial Mediterranean Fever
-A disease driven by several mutations in the MEFV gene. This gene encodes pyrin, a protein important to the production and/or overproduction of interleukin-1β. -Most commonly found in Jewish, Arab, and Turkish populations and follows an autosomal recessive pattern
-Presents as multiple episodes of a systemic inflammatory syndrome characterized by fever, abdominal pain, rash, and arthritis, each lasting only several days
-Can also develop to renal amyloidosis, therefore, it is important to treat with LIFELONG COLCHICINE
Lichen planus
Papules characteristically erupt on the low back, volar wrists, elbows, knees, and ankles. Other variants include nail, genital, bullous, atrophic, and hypertrophic lichen planus. Mucosal lesions have lacy white streaks (Wickham striae), as shown in this patient, or erosions and ulcerations.
-Can exhibit the Koebner phenomenon, which describes its occurrence in areas of trauma, such as those caused by scratching.
-Lichen planus is typically treated with topical glucocorticoids or ultraviolet light therapy. Lichen planus tends to resolve over the course of 1 to 2 years, although oral and nail lichen planus are more persistent.
P2Y12 inhibitor used for patients who received percutaneous coronary intervention
Ticagrelor
Length of DAPT therapy for patients following STEMI q
It is reasonable to extend DAPT beyond 12 months (up to 36 months) in patients who have successfully tolerated 12 months of DAPT and remain at high risk for recurrent vascular events (e.g., those with depressed left ventricular systolic function, saphenous vein graft stenting, or diabetes mellitus), for whom the benefit exceeds the increased bleeding risk.
-Use DAPT bleeding risk score to help make this determination
Urinary stone you are at increased risk for following gastric bypass surgery
Calcium oxalate
There are several mechanisms responsible, including a urine volume decrease caused by mild volume contraction, which increases calcium oxalate saturation; an increase in oxalate excretion caused by fat malabsorption and decreased availability of calcium to bind oxalate in the gastrointestinal (GI) tract; and metabolic acidosis due to base loss in stools, causing a decrease in citrate excretion.
In addition, because of malabsorption of fat-soluble vitamins following Roux-en-Y bypass surgery, patients such as this one are placed on high-dose vitamin D, which may increase GI absorption of calcium.
Treatment of acute bacterial conjunctivitis
Trimethoprim-polymyxin ophthalmic solution
-Use of topical antibacterial therapy is associated with earlier clinical and microbiological remission compared with placebo in days 2 to 5 of treatment but is ok to defer in more mild cases. Treatment may also reduce transmissibility.
- Use of topical antibacterial therapy is associated with earlier clinical and microbiological remission compared with placebo in days 2 to 5 of treatment. Treatment may reduce transmissibility.
-Lack of improvement should prompt ophthalmology referral
Treatment of tophaceous gout in a patient in whom allopurinol and probenecid are contraindicated
Febuxostat, a nonpurine, noncompetitive xanthine oxidase
-It may be used in patients with CKD without dose adjustment if the estimated glomerular filtration rate is 30 to 60 mL/min/1.73 m2
-The starting febuxostat dosage is 40 mg/d, which may be increased to up to 80 mg/d if needed on the basis of serum urate level
-Should coadminister with prednisone for first 3-6 months of therapy
Chronic Nitrous Oxide Toxicity
Subacute combined degeneration most commonly occurs with severe and prolonged vitamin B12 deficiency. Repeated use of nitrous oxide inhalants can result in vitamin B12 deficiency due to nitrous oxide-induced conversion of vitamin B12 from its active monovalent state into an inactive bivalent isoform. Nitrous oxide is commonly found as an aerosol spray propellant in whipped cream canisters and cooking sprays.
-Myelopathy, myeloneuropathy, and subacute combined degeneration have been reported in abusers of nitrous oxide, as have mood disorders and psychosis.
Medication to administer for myxedema coma
Stress-dose glucocorticoids
HOWEVER, If a random cortisol level is above 18 μg/dL (497.0 nmol/L), hydrocortisone administration can be avoided or discontinued.
Patient who has the worst headache of their life but there is nothing seen on head CT
Perform LP; looking for xanthochromia
Iron labs to check for hemochromatosis
Ferritin (>1000)
TSAT (>45%)
CLL management from primary care perspective
Diagnosis is confirmed by flow cytometry, which shows monoclonal B cells that usually co-express CD5 (typically a T-cell marker) along with the B-cell antigens CD19 and CD20. Routinely, cytogenetics and fluorescence in situ hybridization studies are performed, along with determination of immunoglobulin variable region heavy chain (IgVH) status, to help confirm the diagnosis and provide prognostic information.
Favorable prognostic features include the presence of del(13), absence of del(17p), and the presence of a mutated IgVH as opposed to unmutated status. Patients with CLL without systemic symptoms, bulky adenopathy, or significant cytopenias should not be treated
Favorable prognostic features found on FISH for CLL
-the presence of del(13)
-absence of del(17p)
-the presence of a mutated IgVH as opposed to unmutated status
Medications that reduce the proximal tubule excretion of creatinine (but do not actually cause decreased GFR)
Cimetidine
Trimethoprim
Cobicistat
Dolutegravir
Bictegravir
**Can consider checking cystatin C levels to more accurately predict kidney function
Medication to start on ADPKD patients who are experiencing progressive renal decline
Tolvaptan; vasopressin receptor antagonist
Small cell lung cancer information
Small cell lung cancer typically presents as bulky symptomatic masses with mediastinal involvement. It originates from neuroendocrine cell precursors and is characterized by rapid growth and early metastases. Extrathoracic spread is present in 75% to 80% of patients at initial diagnosis. Symptom onset is rapid (typically <8-12 weeks) and includes cough, wheezing, dyspnea, hemoptysis, weight loss, fatigue, anorexia, and manifestations of paraneoplastic syndromes.
-The most frequent paraneoplastic syndrome is the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This syndrome results from production of antidiuretic hormone by malignant cells. Other paraneoplastic syndromes associated with SCLC include Cushing syndrome, Lambert-Eaton syndrome, encephalomyelitis, and sensory neuropathy.
Colonoscopy screening intervals
A 3-year colonoscopy interval is appropriate for :
-larger adenomas (≥10 mm)
-5 to 10 tubular adenomas less than 10 mm
-adenomas with tubulovillous or villous histology
-adenomas with high-grade dysplasia.
A 3- to 5-year interval is appropriate for three or four tubular adenomas less than 10 mm.
Conditions to screen for when someone has recurrent pseudogout flares
Hyperparathyroidism
hypothyroidism
hypophosphatasia
hypomagnesemia
hemochromatosis
TL;DR - Check CMP, PTH, Phos, Mg, iron studies
Codeine
Prodrug that is activated by the CYP2D6 enzyme to its active form
-Therefore, in patients with increased function of this enzyme, they will be at higher risk for codeine (opioid) toxicity
Polyarteritis nodosa
Unlike small-vessel vasculitis, which causes glomerulonephritis, PAN affects the renal vasculature; therefore, it does not generally cause an active urinary sediment but can cause renal insufficiency and hypertension.
-Presence of nodular skin lesions suggest medium-vessel vasculitis.
-Postprandial abdominal pain points to mesenteric ischemia.
-Mononeuritis multiplex, which can be seen in small- or medium-vessel disease, is common in PAN and will present as something like foot drop on one side
Dx: When a patient suspected of having PAN has abdominal symptoms, imaging of the mesenteric vasculature can be diagnostic.
-Can see multiple aneurysms and luminal irregularities (stenosis) in bigger arteries, with occlusive lesions in smaller ones.
Patient who becomes hypoxic 1 day after surgery at night, has egophony, and has a developing fever
Atelectasis is reported to occur in up to 90% of all anesthetized subjects, and it may persist for several days following surgery. Atelectasis can be the result of impaired respiratory mechanics after thoracic and abdominal surgeries resulting in shallow breathing patterns and avoidance of coughing.
-Atelectasis is associated with increased morbidity, including hypoxemia, retained secretions, and pneumonia.
Management: Multimodal pain control, which may include increased dosage of morphine, NSAIDs, acetaminophen, gabapentin, or nerve blocks, will improve pain control and chest expansion and may resolve the atelectasis.
-In addition to pain control, the application of chest physiotherapy is one of the first steps in management of atelectasis, if it can be tolerated by the patient.
Dog-bite in a patient with cirrhosis/hyposplenism
Capnocytophaga canimorsus
Howell-Jolly bodies, nuclear remnants seen in erythrocytes, are typically seen in the setting of splenic hypofunction or asplenia. The increased risk for C. canimorsus infection in patients with asplenia/splenic hypofunction results from an impaired ability to clear intravascular bacteria and deficient antibody production. Management includes supportive care, empiric antibiotics with a carbapenem or a β-lactam/β-lactamase inhibitor combination, and possible surgical debridement.
Sjogren Syndrome and a feared complication
Patients with Sjögren syndrome are at high risk for lymphoma (5% lifetime risk); 60% of these cases are mucosa-associated lymphoid tissue lymphomas.
Risk factors:
-parotid gland enlargement
-depressed C4 complement level, elevated rheumatoid -factor level
-elevated anti-Ro/SSA or anti-La/SSB antibody levels,
-monoclonal gammopathy
-cryoglobulinemic vasculitis
New recommendations regarding HIV patients ON ART and with a CD4 <50
NO NEED FOR AZITHROMYCIN
However. this is ONLY if you know they are compliant with ART
Therefore, you only need to keep these patients on Bactrim for PCP, toxoplasma prophylactic treatment
Outpatient criteria for management of neutropenic fever
Published criteria for outpatient management include:
(1) residence ≤1 hour or ≤30 miles (48 km) from the clinic or hospital
(2) patient’s primary care physician or oncologist agrees to outpatient management
(3) ability to comply with logistic requirements, including frequent clinic visits
(4) family member or caregiver at home 24 hours/day
(5) access to a telephone and transportation 24 hours/day
(6) no history of noncompliance with treatment protocols.
Exanthematous drug eruptions
Exanthematous or morbilliform (measles-like) eruptions are the most common form of cutaneous drug reactions, most likely representing a type IV delayed hypersensitivity reaction. The rash appears during the first or second week after drug exposure, although subsequent exposures can produce a reaction much more quickly. Patients develop erythematous papules and macules that coalesce symmetrically to form plaques, beginning on the trunk and progressing distally across the limbs and usually sparing the palms and soles. The papules are often dense and monomorphic and are accompanied by varying degrees of pruritus. Lymphadenopathy is not uncommon
Treatment: cessation of the causative agent, use of potent topical glucocorticoids, and oral H1 antihistamines. If widespread rash, may need PO glucocorticoids
When will a CMV - patient who receives a donor CMV + organ start to display symptoms if there is infection?
Typically, valganciclovir prophylaxis lasts 6 months and these patients may develop fever +/- (esophagitis, adrenalitis, colitis, rash, myocarditis, hepatitis) in this time frame once prophylaxis starts so be highly suspicious if fever develops after prophylaxis ends as these patients are ALWAYS immunosuppressed
Frequency of medication use in medication-overuse headache
Use of triptans, ergot alkaloids, opioids, or combination analgesics for 10 or more days per month or simple analgesics for 15 or more days per month constitutes medication overuse.
Stress test to order on someone with baseline LBBB abnormality
Vasodilator single-photon emission CT using perfusion with adenosine, regadenoson, or dipyridamole is the most appropriate and preferred stress testing option for this patient with left bundle branch block (LBBB). In patients with LBBB undergoing myocardial perfusion imaging, vasodilator stress minimizes septal abnormalities frequently seen with exercise and dobutamine, which are associated with higher heart rates.
Dobutamine echocardiography contraindications
Presence of LBBB
Resting wall motion abnormalities
(Contraindications to dobutamine):
Acute MI
Severe aortic stenosis
HOCM
Uncontrolled HTN
Arrhythmia
Heart failure
Germline mutations in Lynch Syndrome
MLH1
MSH2
MSH6
PMS2
EPCAM
-Lifetime risk of colorectal or endometrial cancer is approximately 50-80%
Screening recommendations for patients with Lynch Syndrome
Colorectal:
-Start colonoscopy at age 20-25
-Repeat colonoscopy every 2 years
-Start upper endoscopy at age 30-35 years
-Repeat every 2-5 years
Treatment of status migrainosis
Includes dopamine antagonists (prochlorperazine, promethazine, metoclopramide), hydration, and ketorolac. Diphenhydramine is often added to prevent dystonic reactions. Glucocorticoids are commonly used in this setting as evidence suggests dexamethasone may reduce headache recurrence.
Diagnosing IgG4-related disease
Diagnosis is made by tissue biopsy, which demonstrates a dense lymphoplasmacytic infiltrate, CD4-positive T cells and plasma cells in germinal centers, IgG4-staining plasma cells, storiform fibrosis, obliterative phlebitis or arteritis, and tissue eosinophilia. IgG4 levels are elevated in the serum in 70% to 80% of patients; therefore, a normal serum IgG4 level does not rule out the disease.
Initial treatment is prednisone.
Treatment of left sided ulcerative colitis
5-ASA ENEMAS
FeNO uses and diagnostic levels
Used to diagnose eosinophilic airway inflammation; levels >50ppb are indicative of airway inflammation responsive to glucocorticoid therapy (like asthma) whereas levels <25 make this diagnosis less likely
-Can be used as an adjunct for diagnosing asthma when patient has known obstructive lung disease
Reason high resolution CT is not used for pulmonary nodule imaging
Skips some windows; low resolution CT takes more “slices”
Creutzfeldt-Jakob disease
CJD is a prion-related disorder that often presents with rapidly progressive dementia. The cause of CJD is an abnormally folded prion protein, which occurs by a spontaneous mutation (85%), is acquired by exposure to a transmissible protein, or is an inherited genetic mutation. Prion diseases have no known therapy. Time from disease onset to death is approximately 12 months in as many as 80% of patients with CJD.
-The rapid cognitive decline seen with this disorder is associated with myoclonus, gait problems, visual compromise, and interruption of the circadian rhythm. -MRI is one of the most sensitive diagnostic tools for CJD, typically showing a pattern of increased intensity in the diffusion-weighted sequence in the basal ganglia and various cortical regions.
***The real-time quaking-induced conversion assay is the most sensitive and specific test for prion proteins in the CSF. It uses recombinant prion protein and thioflavin T, a fluorescent dye, to detect prion protein present in the CSF despite its being present in only small quantities. The prion protein in the CSF induces the recombinant prion protein to change shape and form fibrils that bind thioflavin T and begin to fluoresce. The quantity of fluorescence is measured in real time.
Pure Red Cell Aplasia
Several conditions have been implicated in the pathogenesis of PRCA, and chief among them are parvovirus B19 infection, thymoma, autoimmune disease (systemic lupus erythematosus), and lymphoid leukemias and lymphomas; patients with SCD are also at risk
-Bone marrow findings: decreased erythrocyte precursors in the bone marrow and with giant proerythroblasts with intranuclear viral inclusions characteristic of parvovirus B19 infection.
-Parvovirus infection in adults may be asymptomatic or associated with fever, coryza, headache, nausea, and diarrhea, followed by a rash. In adults, the classic “slapped cheek” rash may not be apparent but other cutaneous manifestations may occur. ***TREATMENT: Immunocompromised patients can have sustained viremia leading to prolonged anemia requiring IVIG treatment to hasten viral clearance.
Indications for aortic valve replacement with aortic stenosis
The indications for aortic valve replacement in severe aortic stenosis are (1) the presence of symptoms, (2) left ventricular systolic dysfunction (ejection fraction <50%) in an asymptomatic patient, or (3) a concomitant cardiac surgical procedure for other indications.
Repeat imaging on thyroid nodules
Repeat ultrasonography should be performed in 6 to 12 months for all high-suspicion nodules, 12 to 24 months for intermediate- and low-suspicion nodules, and 24 months or longer for very low-suspicion nodules
