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Tricky Items Flashcards

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1
Q

MC bacteria pneumonia

A 
*S. Pneumonia
M. Cat
H. Flu
M. Pneumonia
S. Aureus
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2
Q

Pneumonia bacteria associated with Bullous Myringitis

A 
Mycoplasma Pneumonia
(Hint: Both start with MY)
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3
Q

Rust Colored Sputum

pneumonia bacteria

A

S. Pnuemoniae

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4
Q

Treatment for Community Acquired Pneumonia

Otherwise healthy patient

A

Macrolide
or
Doxycycline

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5
Q

Treatment for Community Acquired Pneumonia

Patient with underlying disease

A

Fluoroquinolones (Resp; L/M)
or
Beta Lactam PLUS a Macrolide

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6
Q

CURB-65

A 
Confusion
Urea >7 mmol/L
Resp Rate >30
BP (SBP <90, DBP <60)
Age >65

Interpretation:
0-1 low risk, consider home
2 admission or close monitoring outpatient
3-5 Admission (severe)

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7
Q

Pneumococcal Vaccination Schedule

A

Adults > 65 and Kids < 2 (with medical conditions)

1 dose PCV13 followed by PPSV23 one year later

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8
Q

Atypical Pneumonia Bacteria

A

*M. Pneumonia
C. Pneumonia
Legionella
Moraxella

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9
Q

Atypical Pneumonia Presentation

A

low grade fever
mild pulmonary symptoms
non-productive cough, fatigue, myalgia

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10
Q

Diagnosis of atypical pneumonia

A

WBC is nromal or slightly elevated
CXR unilateral lower lung infiltrates or diffuse
Not usually detected with usual gram staining

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11
Q

Treatment Atypical Pneumonia

A

Azithromycin Or doxycycline (mycoplasma or legionella)
Tetracycline (Chlamidya)
Supportive for viral infection

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12
Q

Bacteria for Hospital Acquired Pneumonia

A

*MRSA
*Pseudomonas
S. aureus/ klebsiella/E. coli/ Enterobacter

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13
Q

Treatment for Hospital Acquired Pneumonia

A

MRSA
Pseudomonas
MRSA AND Pseudomonas (Vanc/Zosyn)

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14
Q

HIV Pneumonia Bacteria

A
  • Streptococci

* Pneumocystis Jiroveci (oppertunistic)

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15
Q

Presentation of HIV Pneumonia

A

More diffure presentation of pneumonia
OR
PJ: fever, tachypnea, dyspnea, non-productive cough

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16
Q

Treatment of Pneumocystis Jiroveci

Prophylaxis too

A

Bactrim

prophylaxis in all patients with CD4 < 200 with bactrim

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17
Q

Tuberculosis Presentation

A 
cough (becomes productive; lasts >3 weeks)
Fever
Night sweats
Anorexia/Weight loss
Hemoptysis
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18
Q

Tuberculosis Chest X-ray (Primary)

A

homogenous infiltrates
Hilar/paratracheal lymph node enlargement
atelectasis
cavitations (Progressive)

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19
Q

Tuberculosis Chest X-ray (Reactivation)

A

apical fibrocavitary disease

nodules/infiltrates

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20
Q

Gohn Complex

significance too

A

Calcified primary focus in tuberculosis

Indicated healed primary infection

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21
Q

Ranke Complex

and significance

A

Calcified primary focus and hilar lymph node

indicates healed primary tuberculosis

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22
Q

Tuberculosis definitive diagnosis

A

Cultures (6-8 weeks to grow)

DNA or RNA amplification techniques (1-2 days)

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23
Q

Lung Biopsy:

Caseating Granulomas

A

Necrotizing Granulomas

Indicates Tuberculosis

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24
Q

Treatment Tuberculosis (Latent)

A

Isolate patient until 2 weeks of treatment completed
Isoniazid for 9 months
Rifampin for 4 months
OR Rifampin + Pyrazinamide for 2 months (if in contact with resistant TB)

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25
Treatment Tuberculosis (Active)
Isolate patient until 2 weeks of treatment completed RIPE therapy for 2 months (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) Plus 4 months of additional therapy based on cultures
26
Side effects of Anti-Tuerculosis Medications Isoniazid Rifampin Ethambutol
I: hepatitis, peripheral neuropathy R: hepatitis, flu-like symptoms, orange body fluids E: Optic Neuritis
27
What should be given with Isoniazid and why
Vitamin B | to prevent peripheral neuropathy
28
MC causes of bronchitis
(90% Viral) rhinovirus, coronavirus, RSV | Bacteria: s. pneumo/ H. flu/ M. cat
29
Presentation of Bronchitis
COUGH (> 5 days; productive or non; mucus color doesn't suggest bacterial involvement) fever, sore throat, headache NO tachypnea/tachycardia (because O2 exchange fine)
30
Bronchitis Diagnosis
CXR: Clear Procalcitonin (elevated if bacterial cause)
31
Treatment Viral Bronchitis
Supportive measures | hydration, expectorants, analgesics, anti-tussives
32
Treatment Bacterial Bronchitis
(#1) 2nd generation cephalosporin | (#2) Macrolide or Bactrim
33
Characteristics Small Cell Lung Cancer
"oat cell" Likely to metastasize and spread early Rarely amenable to surgery
34
Characteristics Non-Small Cell Lung Cancer | types
grows more slowly more amenable to surgery (squamous cell, large cell, adenocarcinoma)
35
Squamous Cell Lung Carcinoma Characteristics | rate, location, presentation
25-35% Centrally located mass Hemoptysis (dx via sputum increased)
36
Adenocarcinoma of the lung | rate, characteristics, location
MC (35-40%) commonly metastatic to distant origins Peripherally located
37
Large Cell Lung Carcinoma
large cells with rapid doubling time | may be peripherally or centrally located
38
Presentation of Lung Cancer
``` cough (new or changing) hemoptysis pain anorexia/weight loss asthenia LAD clubbing of the fingers hepatomegaly ```
39
Low Dose Screening for Lung Cancer
Less radiation ages 55-80 smoker for > 30 years Has not quit smoking in the past 15 years
40
Diagnosis of Lung Cancer
Chest X-ray and CT (demonstrate abnormalities) Cytologic examination of Sputum Bronchoscopy PET Scan Tumor Tissue Analysis (to aid treatment selection)
41
Treatment Non-Small Cell Lung Cancer
Surgery | +/- adjuvant chemo or radiation to improve survival
42
Treatment Small-Cell Lung Cancer
Combination chemotherapy | Patients rarely live > 5 years after diagnosis
43
Solitary Pulmonary Nodule Rate of malignancy Etiology
"Coin Lesion" or mass if >3 cm 40% are malignant more often infectious granulomas from previous infection or foreign body resection
44
Pulmonary Functioning Diagnosis of Asthma
FEV1/FVC <75% Bronchodilator Administration >12% or 200mL increase in functioning
45
Diagnostics of Asthma
Pulmonary Functioning Tests (fev1/fvc <75%; reversible) Methacholine Challenge Test (dec >20%) Chest X-ray ABG
46
Management of Asthma
Peak Expiratory Flow Monitoring to help patients monitor their symptoms and know when to ask for help
47
Long Term Asthma Symptoms Management Medications
``` Corticosteroids Cromolyn sodium Long acting bronchodilators Leukotriene modulators theophylline ```
48
Short acting asthma symptoms management drugs
short acting beta agonists ipratropium systemic corticosteroids
49
``` Intermittent Asthma Characteristics -Symptoms -Night Time Symptoms -Rescue Inhaler Use -Lung Functioning (FEV1 and FEV1/FVC) ```
``` Symptoms = 2 days per week (doesnt interfere with daily activity) Night: = 2 times monthly Rescue: < days weekly Fev1 >80% predicted Fev1/FVC Normal ```
50
``` Mild Persistent Asthma Characteristics -Symptoms -Night Time Symptoms -Rescue Inhaler Use -Lung Functioning (FEV1 and FEV1/FVC) ```
``` Symptoms > 2 days per week (minor daily limitation) Night: 3-4 times monthly Rescue: > 2 days per week (not daily or more than once on affected days) FEV1 > 80% FEV1/FVC Normal ```
51
``` Moderate Persistent Asthma Characteristics -Symptoms -Night Time Symptoms -Rescue Inhaler Use -Lung Functioning (FEV1 and FEV1/FVC) ```
``` Symptoms daily (Some limitation of daily activity) Night: >1 time per week (not nightly) Rescue: Daily FEV1 <80% but >60% FEV1/FVC decreased 5% ```
52
``` Severe Persistent Asthma Characteristics -Symptoms -Night Time Symptoms -Rescue Inhaler Use -Lung Functioning (FEV1 and FEV1/FVC) ```
``` Continuous Symptoms (extremely limited physical activity) Night: Often nightly Rescue: Several times per day FEV1 <60% FEV1/FVC reduced >5% ```
53
Step 1 Asthma Treatment
Rescue Inhaler (SABA PRN)
54
Step 2 Asthma Treatment - Preferred - Alternative
P: Low Dose ICS Alt: Cromolyn, LTRA, Nedocromil, Theophylline
55
Step 3 Asthma Treatment - Preferred - Alternative
P: -Low dose ICS + LABA OR -Medium dose ICS ALt: - Low dose ICS + - LTRA OR Theophylline OR Zileuton
56
Step 4 Asthma Treatment - Preferred - Alternative
P: -Medium Dose ICS + LABA Alt: - Med Dose ICS + - LTRA OR Theophylline OR Zileuton
57
Step 5 Asthma Treatment - Preferred - Alternative
P: -High dose ICS + LABA Alt: -Omalizumab (for patients who have allergies)
58
Step 6 Asthma Treatment - Preferred - Alternative
P: -High Dose ICS + LABA + PO steroid Alt: -Omalizumab (for patients who have allergies)
59
What to confirm before you step up asthma treatment
Adherence, environmental control, co-morbid conditions
60
When to attempt step down
When asthma is well controlled for at least 3 months
61
High Risk Solitary Pulmonary Nodule
Older age (>30) Uneven/Indistinct margins (Spiculated) Usually > 2 cm Rapidly progressive
62
Treatment Malignant Solitary Pulmonary Lung Nodule
If high probability of malignancy then resect | If unsure then it is okay to do a biopsy first
63
Low Risk/Benign Solitary Pulmonary Lung Nodule
``` < 30 years old Round/Oval Well demarcated/smooth edges Up to 3cm Surrounded by normal tissue May be calcified ```
64
Management of benign/low risk solitary lung nodule
CT Q 3mo for 1 year Followed by CT Q 6mo for 2 years
65
Bronchiectasis definition
permanent dilation of the bronchi and damage to the bronchial wall subsequent to injury from severe infection or persistent inflammation
66
Presentation Bronchiectasis
Chronic purulent sputum (foul smelling) hemoptysis Chronic cough recurrent pneumonia
67
Diagnosis of Bronchiectasis
High Resolution Chest CT- Gold Standard (dilated tortuous airways) CXR- tram track markings Bronchoscopy (rule out other causes)
68
Treatment Bronchiectasis
Chest Physiotherapy Pneumonia (Abx 10-14 days) Exacerbation- Bronchodilators Lung Transplant
69
Pink Puffer
Emphysema Dominant
70
Blue Bloater
Chronic Bronchitis Dominant
71
Emphysema Characteristics and X-ray Findings
Quiet lungs Thin, Barrel Chest Pursed Lip Breathing ``` Decreased lung markings Flattened Diaphragm Hyperinflation Small/thin appearing heart *Subpleural Blebs *Parenchymal bullae ```
72
Chronic Bronchitis Characteristics and X-ray Findings
Chronic Productive Cough Noisy Lungs (Ronchi/Wheezing) Overweight and Cyanotic Increased lung markings at bases
73
Chronic Bronchitis Definition
Chronic productive cough most days for 3 months of the year for 2+ consecutive years
74
Emphysema Definition
enlarged air spaces due to alveolar septum damage
75
COPD Risk Factors
SMOKING pollutants eosinophilia alpha-antitrypsin 1 deficency
76
Diagnosis of COPD
Chest X-ray (depends on presentation) Pulmonary Function Testing Genetic Screening (Alpha antitrypsin 1)
77
COPD Pylmonary Functioning Tests
Decreased FEV1/FVC | Not Reversible
78
Treatment COPD (Basic)
``` Smoking Cessation Supplmental Oxygen (O2 <88%) Yearly vaccines (flu and pneumonia) ```
79
Pulmonary Hypertension Presentation
``` Dyspnea Angina like retrosternal chest pain weakness fatigue edema, ascites Cyanosis Syncope ```
80
Pulmonary Hypertension Diagnosis
Chest X-ray EKG- RVH, RV strain *Echo- estimates pulmonary arterial pressure *Cardiac Catheterization- mean pulmonary arterial pressure (>25 mmHg)
81
Idiopathic Fibrosing Interstitial Pneumonia Risk Factors
``` Cigarette Smoking Exposure (wood/metal/dust) viruses diabetes GERD ```
82
Idiopathic Fibrosing Interstitial Pneumonia Presentation
``` Insidious Dry cough Exertional Dyspnea Constitutional Symptoms (fatigue, malaise...) Clubbing Inspiratory Crackles ```
83
Idiopathic Fibrosing Interstitial Pneumonia Diagnosis
CXR- progressive fibrosis CT- Patchy fibrosis, pleural honeycombing Pulmonary Functioning Tests (Restrictive) Bronchiolar Lavage Biopsy
84
Idiopathic Fibrosing Interstitial Pneumonia Treatment
Nothing is shown to improve survival or QOL
85
Pneumoconioses Definition
chronic fibrotic lung disease due to inhalation of inorganic dusts/debris
86
Asbestosis - Occupation - Diagnosis - Complications
Insulation, demolition, construction Biopsy: Asbestos Bodies CXR: linear opacities at bases and pleural plaques Increased risk of lung cancer (Mesothelioma)
87
Coal Workers Pneumoconioses - Occupation - Diagnosis - Complications
Coal mining CXR: Nodular Opacities upper lung fields Progressive massive fibrosis
88
Silicosis - Occupation - Diagnosis - Complications
mining, sand-blasting, quarry work, stone work CXR- Nodular opacities in upper lung fields Increased risk of TB Progressive massive fibrosis
89
Berylliosis - Occupation - Diagnosis - Complications
High-tech fields, nuclear power, aerospace, ceramics, foundries, tool and die manufacturing CXR: diffuse infiltrates and hilar adenopathy Requires chronic steroids (steroid complications)
90
Pneumoconioses Presentation
``` Usually asymptomatic (progressive; long duration) Dyspnea inspiratory crackles clubbing of the fingers cyanosis ```
91
Pneumoconioses Diagnosis
Pulmonary Functioning Tests (Restrictive; reduced diffusing capacity) CXR (Varies depending on cause)
92
Pneumoconioses Management
*No effective treatment avilable Supportive (O2, vaccinations, rehab) Smoking Cessation
93
Berylliosis and Silicosis (pneumoconioses) treatment
Chronic Steroid Use | -Relief from alveolitis
94
Sarcoidosis Definition
Multiorgan disease of non-caseating granulomatous inflammation 90% have lung involvement Increased in N. european whites and Aerican Blacks
95
Sarcoidosis Presentation
Cough, dyspnea (insidious), chest discomfort malaise, fever SX based on organ systems involved
96
Sarcoidosis Extrapulmonary symptoms
Erythema Nodosum | Enlargement of parotid glands, lymph nodes, liver, spleen
97
Sarcoidosis Diagnosis
Blood Tests Radiographs *Biopsy
98
Sarcoidosis Blood Tests and Results
``` Leukopenia Eosinophilia Elevated ESR Hypercalcemia Hypercalcuria Elevated ACE levels ```
99
Sarcoidosis Radiographic Findings
symmetrical bilateral hilar/right paratracheal lymphadenopathy bilateral diffuse reticular infiltrates
100
Sarcoidosis Biopsy Results | Types of biopsies used
Transbronchial biopsy of the lung Fine Needle Node Biopsy Non-caseating granulomas
101
Sarcoidosis Treatment
No cure 90% responsive to steroids (moderate doses) Refractory to steroids -Immunosuppressant cytotoxic drugs
102
Treatment for GERD (Step-wise)
COnservative (elevate HOB, Low risk foods, X Smoking) Antacids H2 Blockers PPI Combo PPI and H2 Blocker
103
Endoscopy Results for Infectious Esophagitis | HSV, HIV, CMV, Candida
HSV- multiple shallow ulcers CMV/HIV- Lg. deep ulcers Candida- Lacy, white plaques
104
Treatment for Infectious Esophagitis | Candida, HSV, CMV
Candida- Fluconazole/Ketoconazole HSV- Acyclovir CMV- IV Ganciclovir or FOscarnet (if poor tolerability) Should test for HIV or immunocompromised
105
Types of Esophageal Carcinoma
Squamous Cell Carcinoma | Adenocarcinoma
106
Risk Factors of Esophageal Cancer
``` Smoking Drinking Alcohol GERD Spicy foods Poor oral hygiene HPV History ```
107
Presentation of Esophageal Cancer
``` Progressive Dysphagia weight loss hoarsness nausea/vomiting heartburn ```
108
Diagnosis of Esophageal Cancer
``` #1 (Initial) Barium swallow Endoscopy with Biopsy (GS) CT/Sonogram (staging) ```
109
Screening for Esophageal Carcinoma
biannual screening if at increased risk | Achalasia, tylosis, radiation, barrets esophagus
110
Esophageal Carcinoma Treatment
Generally Surgery +/- Adjuvant chemo and radiation Possible to use combination chemo/radiation without surgery
111
Mallory Weiss Tear Definition | associated with what
Multiple linear tears at the gastroesophageal junction due to forceful vomiting and results in hematemesis It is associated with alcohol use
112
Diagnosis of Mallory Weiss Tear
Endoscopy | visualized
113
Treatment of Mallory Weiss Tear
Most resolve without treatment If resolved PPI may be used to prevent re-bleed If not resolved endoscopy and injection of Epi or thermal coagulation
114
Boerhaave Syndrome
Esophageal rupture secondary to a large bolus of food leading to hematemesis
115
Esophageal Varices Definition and Causes
Dilation of esophageal veins due to portal hypertension (from liver damage) Common causes include -alcoholism, Tylenol, Hepatitis -Budd-Chiari (thrombosis in portal system)
116
Esophageal Varices Presentation
Generally asymptomatic until they bleed (when they bleed they can be life threatening) Painless upper GI bleed (bright red or coffee grounds) +/- Hypovolemic shock Can be exacerbated by NSAIDs use
117
Screening and Diagnosis of Esophageal Varices
Generally made by endoscopy Cirrhotic patients should be screened at the time of diagnosis
118
Prevention of Esophageal Varices
Beta-Blockers | Discontinuation of hepatotoxic drugs (ETOH,
119
Prevention of Esophageal Variceal Bleeding
Beta-Blockers +/- Isosorbide mononitrate Discontinuation of hepatotoxic substances (ETOH, Tylenol...) Endoscopic Band Ligation
120
Treatment of Esophageal Variceal Bleeding
``` Hemodynamic Support (2 lg. bore IVs) Vasopressors +Octreotide Control Bleeding (sclerotherapy, tamponade, *band ligation...) ``` TIPS Procedure
121
Common Causes of Gastritis
``` Autoimmune Disease *H. Pylori *NSAIDs Stress *Alcohol ```
122
Presentation of Gastritis
Dyspepsia | Abdominal Pain
123
Diagnosis of Gastritis
Endoscopy with Biopsy (GS) Test for H. pylori - Urea Breath Test (H. Pylori) - Fecal Antigen Testing
124
Treatment of Gastritis
Remove offending agents | Treat the Underlying Cause
125
Peptic Ulcer Disease Causes
Alcohol NSAIDs H. Pylori Stress
126
Peptic Ulcer Disease Presentation
Abdominal Pain (Gnawing/Burning) Dyspepsia (Heartburn Sx) Nausea
127
Peptic Ulcer Disease Complications
Bleeding Peptic Ulcer | Melena
128
Peptic Ulcer Disease Diagnosis
Endoscopy and Biopsy (GS) Barium Studies (if endoscopy not possible) H. Pylori Testing (*Urea Breath Test, *Fecal Antigen Test, Serum Tests)
129
Peptic Ulcer Disease Treatment | Not H. Pylori
Remove offending agents Antacids H2 Inhibitors PPI
130
Peptic Ulcer Disease Treatment | H. Pylori
CAP Therapy Clarithromycin Amoxicillin PPI ``` Quadruple Therapy (If CAP fails) Bismuth Tetracycline Metronidazole PPI ```
131
Types of Gastric Cancer
Zollinger-Ellison Syndrome (Gastrin Secreting) Gastric Adenocarcinoma Carcinoid Tumors Gastric Lymphoma
132
Zollinger-Ellison Syndrome Definition
Gastrin secreting tumor in the stomach or the pancreas causes increased acidity of the stomach and can lead to peptic/duodenal ulcers.
133
Zollinger-Ellison Presentation
``` PUD Symptoms (advanced/treatment resistant) Abdominal Pain Secretory Diarrhea (improves with H2X or PPI) Occult/Frank Bleeding ```
134
Diagnosis of Zollinger-Ellison
Fasting Gastrin level (>150) Secretin Test Endoscopy/CT or MRI (localize tumor)
135
Secretin Tests Procedure and Interpretation for Zollinger-Ellison
Give 2U/Kg IV of secrtin | Increase in gastrin levels by >200
136
Treatment Zollinger Ellison
PPI use to decrease acidity | Surgical resection of tumor when possible
137
Risk Factors for Gastric Adenocarcinoma
Smoking H. pylori infections Genetics
138
Gastric Adenocarcinoma Presentation
Dyspepsia Weight loss Anemia (occult bleeding) Progressive dysphagia (impinging the esophagus) Postprandial vomiting LAD (Virchow node, Sister-Mary-Joseph Node)
139
Gastric Adenocarcinoma Diagnosis
Iron Deficiency anemia (Occult bleeding) +/- Elevated Liver Enzymes *Endoscopy and Biopsy CT (to determine the extent)
140
Gastric Adenocarcinoma Treatment
``` Surgical resection (curative or palliative) -80% cure rate if not invasive or metastatic +/-Adjunctive Chemo or ``` Chemo and/or radiation (palliative)
141
Gastric Lymphoma
most common site of metastasis from non-hodgekin lymphoma
142
Presentation of Gastric Lymphoma
The same as Gastric Adenocarcinoma Dyspepsia Weight loss Anemia (occult bleeding) Progressive dysphagia (impinging the esophagus) Postprandial vomiting LAD (Virchow node, Sister-Mary-Joseph Node)
143
Diagnosis of Gastric Lymphoma
Iron Deficiency anemia (Occult bleeding) +/- Elevated Liver Enzymes *Endoscopy and Biopsy CT (to determine the extent)
144
Treatment of Gastric Lymphoma
Surgical excision | +/- Chemo and/or radiation
145
Celiac Disease Definition
Inflammation of the small bowel (duodenum) due to ingestion of gluten that leads to malabsorption
146
Celiac Diasease Presentation | General, infants, older patients
``` diarrhea steatorrhea flatulence weight loss weakness abdominal distention/bloating ``` Infants/Children -Failure to thrive ``` Older Patients (malabsorption) -iron deficency, coagulopathy, hypocalcemia ```
147
Celiac Disease Diagnosis
*Small Bowel Endoscopy and Biopsy (GS) Serological Screening -IgA Antiendomysial (EMA) -Anti-Tissue Transglutaminase (Anti-TTG)
148
Celiac Disease Treatment
Gluten Free Diet +/- lactose free to help decrease inflammation initially Supplementation if deficencies are present (Folic acid, B12, calcium, vitamin D) Prednisone (if refractory inflammation)
149
IBS Diagnosis
``` It is a diagnosis of exclusion Stool sampling and testing Laboratory tests Colonoscopy Enema (Barium) US CT Endoscopy Rome IV Criteria ```
150
Rome IV Criteria
Recurrent abdominal pain at least 1 day per week in the last 3 months and 2/3 - Related to defecation (relieved by BM) - Associated with change in stool frequency - Associated with a change in stool form (character)
151
IBS Treatment
``` Discovery and avoidance of triggers Treatment depends on the symptoms High fiber diet Bulking agents Anti-diarrheals Prokinetics Antidepressants (if mood related) ```
152
Diverticulosis Vs. Diverticulitis
Diverticulosis is an asymptomatic outpouching of the normal colonic mucosa Diverticulitis is inflammation or infection of a diverticulosis pouch
153
Diverticulitis Presentation
``` Sx range from mild to severe infection (peritonitis) Sudden abdominal pain (Usually LLQ) +/- fever Diverticular bleeding (hematochezia) Altered bowel movements Nausea/vomiting ```
154
Diverticulitis Diagnosis
Blood in the stool X-ray to rule out free air (obstruction) CT (if unresponsive to therapy)
155
Testing to avoid in acute flares involving the colon
Colonoscopy due to increased risk of perforation!
156
Diverticulitis Treatment (Uncomplicated)
Low residue diet (or clear liquid diet) Broad spectrum antibiotics (PO or IV) Colonoscopy after 6 weeks to r/o cancer
157
Antibiotics for Diverticulitis
FLAGYL AND *Ciprofloxacin cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin
158
Diverticulitis Treatment (Complicated)
Bowel resection
159
Screening for Colorectal Cancer
*Colonoscopy (at age 50-75 w/o RF) Q 10 years *Flexible Sigmoidoscopy Q 5 years +FOBT Q 3 years CT
160
COlorectal Cancer Presentation (General)
Slow growing so asymptomatic until later in the disease fatigue/weakness (chronic blood loss) abdominal pain change in bowel habits obstruction
161
Colorectal Cancer Presentation (Right)
``` Blood loss (anemia) Obstruction (less common than left) ```
162
Colorectal Cancer Presentation (Left)
change in bowel habits (thin caliper) Obstructive symptoms tenesmus Fullness
163
Diagnosis
``` Occult blood *Colonoscopy, sigmoidoscopy Barium enema Carcinoembryoic antigen (CEA; follow-up not dx) METS: CT and CXR ```
164
Colorectal Cancer Treatment
Rescetion +/- Chemotherapy (above Duke III) Radiation may be used for rectal tumors
165
Most common anal fistula
Intersphincteric (70%)
166
Anal Fistula Presentation
``` Non-healing anorectal abscess Chronic purulent drainage Firm mass intermittent rectal pain drainage pruritis ```
167
Anal Fistula Diagnosis
*Anoscopy Imaging not required - endosonography - fistulography - CT/MRI (air or contrast)
168
Anal Fistula Treatment (Simple)
*Fistulotomy with probing Ligation of internal tract Fistulectomy
169
Anal Fistula Treatment (Complex)
Seton (loop fistulectomy) | decreased healing time and reduced risk of poor wound healing and incontinence
170
Anal Abscess Treatment
``` Surgical Drainage Warm Water Cleansing (Sitz Baths) Analgesics Stool Softener High Fiber Diet ```
171
Anal Fissure Defintion
Tear in the anoderm (mc posterior midline)
172
Anal Fissure Presentation
Pain WITH defacation (lasting hours after) BRBPR Pruritis External Skin Tages (thickened skin; sentinel pile) Hyoertrophied Pappillae
173
Anal Fissure Treatment (Acute)
``` Increased Dietary Fiber Increased Water Intake Sitz Baths Topical Anesthetic Vasodilator (NTG, Nifedipine) Stool Softener or Laxative ```
174
Anal Fissure Treatment (Chronic)
``` Botox Injection Lateral sphincterotomy (last resort; R of incontinence) ```
175
Anal FIssure Prevention
Proper hygiene High fiber diet Adequate fluids (avoid straining during BM) Promptly treat diarrhea
176
Hemorrhoid Definition
Dilated veins in the anoderm/rectum
177
Hemorrhoid Classification (Internal Only)
Stage 1- VIsible in the lumen Stage 2- Prolapses with bowel movements but reduces automatically Stage 3- Prolapses with bowel movements and requires manual reduction Stage 4- Prolapses and cannot be reduced (Strangulation)
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Internal Hemorrhoid Characterictics
Above/Proximal to the dentate/pectinate line | Painless
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External Hemorrhoid Characteristics
Below/Distal to the dentate/pectinate line | Can be very painful especially if thrombosed
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Conservative Treatment for Hemorrhoids
``` Sitz Baths Ice Bed Rest Stool Softeners High fiber/fluid diet Topical steroids ```
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Treatment of Hemorrhoids (non-conservative)
Rubber Band Ligation Sclerotherapy Surgery (Definitive)
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Sclerotherapy for Hemorrhoids
Medium Grade internal hemorrhoids | Thrombosed symptomatic external hemorrhoids
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Low Grade Internal Hemorrhoids (Grade 1-2)
Conservative therapy | If conservative management fails consider intervention
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Acute Pancreatitis Causes
I GET SMASHED Idiopathic *Gallstones *ETOH Trauma ``` Steroids Mumps Autoimmune Scorpion Venom Hypercalcemia OR Hypertriglyceridemia ERCP Drugs ```
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Acute Pancreatitis Presentation
Gnawing Epigastric Pain (radiates to the back; decreases with leaning forward) Nausea/Vomiting Fever Hemorrhage (Grey Turner or Cullen Sign)
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Grey Turner Sign and Associated Disease
Bruising at the flanks | Hemorrhagic sign of acute pancreatitis
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Cullen Sign and Associated Disease
Bruising around the umbilicus | Hemorrhagic sign of acute pncreatitis
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Acute Pancreatitis Diagnosis
``` Lipase > Amylase +/- increased liver enzymes Ultrasound to look for gallstones CT Scan Ranson criteria to predict severity ```
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Ranson Criteria Components and Interpretation
``` Used to determine severity of acute pancreatitis WBC <16,000 Blood Glucose > 200 LDH >350 AST >250 Arterial PO2 <60 Base Defecit > 4 Calcium Falling BUN Rising ```
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Acute Pancreatitis Treatment
NPO IVF Pain Management (Opioids) +/- Antibiotics
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Gold Standard Diagnosis for Acute Pancreatitis
CT Scan
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Gold Standard Diagnosis for Acute Pancreatitis
CT Scan
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Initial and Gold Standard Diagnosis for Chronic Pancreatitis
CT Scan | ERCP- "Chain of Lakes"
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Treatment of Chronic Pancreatitis (Simple)
NPO IVF Enzymes Treat the Underlying Cause (MC ETOH)
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Treatment of Chronic Pancreatitis (Complex)
Surgical -Pancreatic resection (Whipple or pancreatojejunostomy)
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Charcot's Triad
Acute Cholangitis classic symptoms Jaundice, Fever, RUQ pain
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Reynold's Pentad
Acute Cholangitis Severe Symptoms Jaundice, fever, RUQ pain (Charcot's Triad) PLUS AMS and Shock
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Initial and Gold Standard Diagnosis of Acute Cholangitis
Initial: US GS: *ERCP or PTC
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Most common cause of acute cholangitis
Gallstones
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Treatment of acute cholangitis (stable)
Decompression with *ERCP (sphoncterotomy) or PTC (cath)
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Treatment of acute cholangitis (unstable)
Blood cultures IVF IV Antibiotcs Closely monitor BP, hemodynamics, and Urinary output
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How long must someone be stable and afebrile before ERCP or PTC treatment for acute cholangitis
>48 hours
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Initial and Gold Standard Diagnosis of Cholecystitis
Initial: Ultrasound of RUQ GS: HIDA Scan
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Treatment of cholecystitis (asymptomatic)
No treatment
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Treatment of cholecystitis (symptomatic)
Elective cholecystectomy (for recurrent attacks)
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Diagnostic Criteria for Rheumatoid Arthritis | Categories and total score needed
1. Joint Involvement (0-5 points) 2. Serology (0-3 points) 3. Duration of Symptoms (0-1 point) 4. Acute Phase Reactants (0-1 point) Need 6/10 points
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Diagnostic Criteria for Rheumatoid Arthritis | Joint Involvement Interpretation
``` 1 medium or large joint (0 points) 2-10 medium or large joints (1 point) 1-3 small joints (2 points) 4-10 small joints (3 points) >10 joints (at least 1 small) (5 points) ```
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Diagnostic Criteria for Rheumatoid Arthritis | Serology
RF - and ACPA - (0 points) RF or ACPA low + (2 points) RF or ACPA high positive (3 points)
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Diagnostic Criteria for Rheumatoid Arthritis | Duration of Symptoms
< 6 weeks (0 points) | >6 weeks (1 point)
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Diagnostic Criteria for Rheumatoid Arthritis | Acute Phase Reactants
CRP and ESR not elevated (0 points) | CRP and ESR elevated (1 point)
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Treatment for Rheumatoid Arthritis
Physical and Occupational Therapy 1. NSAIDs 2. DMARDs (Started ASAP after diagnosis) - Methotrexate - Biologics - Non-biologics
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Common Treatment Regimen for Rheumatoid Arthritis
Methotrexate | PLUS another DMARD (commonly a biologic)
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Common Infections that preceed Reactive Arthritis | and their bugs
STDs (Chlamidya) ``` Gastrointestinal Infections (Shigella, Salmonella, Yersinia, Campylobacter) ```
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Treatment for Reactive Arthritis
Physical Therapy NSAIDs Sulfasalazine or Azithioprine (if NSAIDs fail)
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Joint Analysis in Gout
Needle like crystals | Negative Birefringent
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Acute Gout Treatment
Rest and Elevation 1. NSAIDs 2. Colchicine (less than 48 hours) 3. Corticosteroid Injections
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Gout Chronic Management
Lifestyle changes (dec. ETOH, red meat, weight loss...) Allopurinol Febuxistat Probenecid Keep UA levels < 6
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Joint Analysis in Pseudogout
Rhomboid like crystals | Positive Birefringent
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X-Ray results in Pseudogout
Chondrocalcinosis
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Pseudogout Treatment
NSAIDs Colchicine (< 48 hours) Intraarticular Steroids
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Diagnostic Criteria For Lupus
``` Rash (Malar or Discoid) Photosensitivity Oral Ulcers Arthritis Serositis (heart, lungs, peritoneal) Renal Disease (proteinuria, cellular casts) Positive ANA Hematologic Disorders Immunologic Disorders Neurological Disorders (seizures, psychosis) ```
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Treatment of Lupus
Lifestyle Changes - Regular exercise - Smoking Cessation - Sun Protection ``` Pharmacotherapy -NSAIDs -Anti-malarials (hydrochloroquine, quinacrine) -Corticosteroids Methotrexate ```
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Polymyositis Definition
Inflammation of striated muscled | GI tract, esophagus, lungs, heart, joints...
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Presentation of Polymyositis
Insidious painless proximal muscle weakness Dysphagia Polyarthralgias Muscle Atrophy +/- rash (dermatomyositis)
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Diagnosis of Polymyositis
Elevated CPK and Aldolase | Muscle Biopsy
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Diagnostic Criteria for Polymyositis | and interpretation
1. Symmetric Proximal m. weakness 2. Elevated CPK 3. EMG findings consistent 4. Biopsy results consistent 5. Characteristic Rash Interpreted based on first 4 criteria 2/4- possible 3/4- probable 4/4- definite
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Polymyalgia Rheumatica Presentation | commonly associated with?
``` Pain and stiffness in the neck, shoulder and pelvic girdles Constitutional symptoms (fever, fatigue, weight loss) ``` 30% associated with Giant Cell Arteritis -jaw claudication, temporal pain, vision loss
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Diagnostic for Polymyalgia Rheumatica
ESR is Elevated (>50)
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Treatment for Polymyalgia Rheumatica | alone and if combined with GCA
Alone: Low dose steroids (tapered over 2 years) PMR + GCA: HIgh dose steroids (tapered over 2 years) -IF vision loss is present do not delay steroids for result of biopsy.
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Polyarteritis Nodosa Definition (commonly involved locations) (can be associated with?)
Inflammation of small and medium vessels -skin, kidney, peripheral nerves, muscle and gut Can be associated with hepatitis B
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Polyarteritis Nodosa Presentation
Fever anorexia/weight loss abdominal pain peripheral neuropathy arthralgias/arthritis Skin lesions (liverdo reticularis, palpable purpura) renal involvement (HTN, edema, oliguria, uremia)
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Skin lesions associated with Polyarteritis Nodosa
Liverdo Reticularis | Palpable Purpura
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Diagnosis of Polyarteritis Nodosa | GS and others
GS: Vessel biopsy Others: - Elevated ESR/CRP - Proteinuria - Positive Hep B titer
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Treatment of Polyarteritis Nodosa
``` *High dose steroids Cytotoxic drugs Immunotherapy Treatment of Hep B Treat the Hypertension if present ```
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CREST Syndrome | Symptoms and associated disease
``` Calcinosis Crisis Raynaud Phenomenon Esophageal Dysfunction Sclerodactyly Telangiectasis ``` Associated with limited scleroderma
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Scleroderma Definition
deposition of collagen in the skin (mc) and less often in the kidneys, heart, lungs, and stomach
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``` Diffuse Scleroderma (where does it effect) ```
``` skin heart lungs GI tract and kidneys ```
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``` Limited Scleroderma (where does it effect?) ```
skin of the - face - neck - distal elbows and knees
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Classic presentation of scleroderma
``` Skin changes (mc in hands first) polyarthralgias esophageal dysfunction ```
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Diagnosis of Scleroderma | general, limited and diffuse
general: ANA + (90%) - monitor kidney functioning for renal involvement limited: Anticentromere Antibody (ACA) diffuse: anti-SCL-70 antibody (poor prognosis)
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Scleroderma Treatment
There is no cure or specific treatment Treatment is system and symptom based -PPI for GERD -ACE for renal disease -CCBs and avoid triggers for Raynauds syndrome -immunosupressive drugs for pulmonary HTN
242
Sjogren Syndrome definition | associated diseases
autoimmune destruction of the salivary and lacrimal glands | can be associated with rheumatoid arthritis, lupus, polymyositis, or scleroderma
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Sjogren Syndrome Presentation
Xerostomia (dry mouth) Xeropthalmia (dry eyes) Keratoconjunctivitis (infx 2' to dry eyes) +/-enlarged parotid glands
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Sjogren Syndrome Diagnosis of associated diseases | factors
RF + (70%) ANA + (60%) Anti-Ro + (60%) Anti-La + (40%)
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Sjogren Syndrome Diagnosis
``` Schrimer Test (dry eyes) -< 5mm of filter paper wet after being in the eye for 5 minutes ``` Biopsy of the lower lip -lymphocytic infiltration and gland fibrosis
246
Fibromyalgia Definition and Associated Disorders
Central pain disorder -Can be ssociated with RA, SLE, Sjogren Syndrome, hypothyroidism and sleep apnea (men)
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Fibromyalgia Presentation
``` Nonarticular muscle aches and pains fatigue/sleep disturbances mood changes (anxiety/depression/irritability) headaches irritable bowel syndrome ```
248
Fibromyalgia Diagnosis
Pain above and below the waist (bilateral and axial for at least 3 months) Tenderness at 8/18 specific tender points
249
Fibromyalgia Treatment
``` Antidepressant Medications -TCA**, SSRIs, SNRIs Pregabalin/Gabapentin (if antidepressants fail) -decrease pain and improve sleep Aerobic exercise CBT and mildfulness ```
250
Hyperparathyrodism Presentation
Classic: Stones, Bones, Moans, and Groans Other Symptoms:
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Acute Gout Treatment
1. NSAIDs 2. Steroids 3. Colchicine
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Most common cause of gout
Underexcretion (90%)
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Maintenance of Gout (Prophylaxis)
``` Lifestyle changes (decreased alcohol, red meat, seafood) ``` Allopurinol (overproducers) Probenecid (underexcreters)
254
Medications that increase gout
Loop and Thiazide Diuretics | Aspirin
255
Polyarteritis Nodosa is associated with what?
Hepatitis B
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Polyarteritis Nodosa Angiogram
String of pearls/beads
257
Factors and viruses associated with polymyalgia rheumatica
HLA-DR4 | Parovirus B19 and Adenovirus
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Reactive Arthritis most common Bug for prior infection
Chlamidya
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Felty Syndrome and its significance
Rheumatoid Arthritis Splenomegaly and Neutropenia Can lead to severe infections
260
Hypoparathyroidism Presentation (acute)
``` Tetany Spasms Cramps Parasthesias Hyperreflexia (Chovstek and Trousseau Sign) Teeth/Nail/Hair Defects ```
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Hypoparathyroidism Presentation (chronic)
``` lethargy anxiety parkinsonism mental retardation personality changes blurred vision (cataracts) ```
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Diagnosis of Hypoparathyroidism
Low PTH Low Serum Calcium Increased Phosphate Levels
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EKG Changes with Hypoparathyroidism
Prolonged QT | T wave abnormalities
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X-ray results with Hypoparathyroidism
Increased bone density due to lack of PTH to call for increased serum calcium
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Hypoparathyroidism Treatment
1. Calcium and Vitamin D
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Most common Type of Hyperthyroidism
Grave's Disease
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Types of Hyperthyroidism
*Grave's Disease *Toxic Multinodular Goiter Hashimoto's Pituitary Tumor Pregnancy Exogenous Thyroid Hormone Excessive Iodine Intake Radiograph Contrast Amiodarone Use
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High TSH | High T3 and T4
Secondary Hyperthyroidism
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Low TSH | High T3 and T4
Primary Hyperthyroidism
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Hyperthyroidism Treatment
Beta Blockers (Symptomatic Control) Polythiouracil (pregnancy) or Methimazole Radioactive Iodine Ablation Thyroidectomy
271
Radioactive Iodine Ablation Indications for Hyperthyroidism
If not pregnant or nursing | Failed medical treatment
272
Thyroidectomy Indications for Hyperthyroidism
``` Large/obstructing/malignant nodules In pregnancy (if medications fail) ```
273
Treating Opthalmopathy in Hyperthyroidism
*High dose tapered prednisone Retrobulbar radiation Optic Nerve decompression surgery
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Thyroid Storm Presentation
``` Fever Tachycardia Agitation Sweating Tremor Instability Delirium Vomiting Diarrhea ```
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Thyroid Storm Treatment
*Polythiouracil or Methimazole +/- Hydrocortisone +/- Sodium Iodide *Beta Blocker (symptomatic relief)
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Most Common Cause of Hypothyroidism
Hashimoto's Thyroiditis
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Presentation of Hypothyroidism
``` Weakness Dry Skin Lethargy Slow Speech Cold Intolerance Forgetfulness Constipation Weight Gain Depression Bradycardia Hyporeflexia ```
278
Low TSH | Low T3 and T4
Secondary Hypothyroidism
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High TSH | Low T3 and T4
Primary Hypothyroidism
280
Treatment for Hypothyroidism
Levothyroxine (adjust Q 4-6 weeks based on TSH)

PANCE Prep (2 decks)

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