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1144 Cards in this Set

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Pleural Effusions
(2)
Malignant
Pneumo
Secondary medical Tx for chronic stable angina after first 5 (2)
1) If bp room add CCB
2) If refractory add Ranolazine
Dx Irregularly irregular rhythm, with no P waves
Afib
Who should get coronary angiography?
1) Lifestyle limiting angina despite medical tx
2) Markedly positive results on non-invasive stress testing
3) hx of Vtach
4) hx of Non specific CP with recurrent hospitalizations
Who should get coronary Ca testing?
Intermediate risk group (10-20% framingham risk score)
Dx short PR and delta wave
Wolf Parkinson White
(n.b. can become either orthodromic or antidromic AVRT)
Dx Wide QRS tachycardia in setting of known hx of ischemic damage
VTach
Tx for Left NSTEMI
Beta blocker
Dx New murmur and respiratory after recent MI (2). Dx study? Tx?
1) Acute MR
2) VSD
Dx study is Echo
Tx is IABP
Dx STEMI, respiratory distress, hypotension, new systolic murmur, and thrill.
Ventricular Septal defect
Dx 1-4 days after MI, heart failure, tamponade or pulseless electrical activity.
Ventricular free wall rupture
Dx Afib or Aflutter spurts between a baseline of bradycardia
Tachy-brady (a type of sick sinus sx)
Dx Baseline bradycaria with dropped beats
Sick sinus sx (sinoatrial node dysfunction)
Dx Drug induced heart block
Donepezil (ACh esterase inhibitor) causes increased vagal tone, bradycardia, and AV block
Tx for Hemodynamically unstable patients with arrhythmia
Electrical cardioversion
Dx study for Aflutter or AVNRT
Adenosine bolus
Dx study for Sinus tachycardia
Find underlying cause (e.g. TSH)
What is the CHADS2 risk score?
CHF
HTN
Age >75 years
Diabetes
Stroke or TIA (2 points)
-3 or greater get chronic anti-coagulation tx (warfarin)
*1-2 consider ASA vs warfarin
Tx chronic Afib
Beta blocker (or rhythm control e.g. verapamil) and Warfarin
Dx study and tx for asymptomatic PVCs
No studies or therapy needed
Tx for symptomatic PVCs
Beta blocker or CCB (e.g. verapamil)
Indication for ICD in CHF
EF less than 35%
Indications for pacemaker
1) Sick Sinus
2) symptomatic bradycardia due to 2nd or 3rd degree AV block
Tx for Cardiac arrest (Ventricular arrhythmias)
Medical management
1) ASA
2) Beta blocker
3) Statin
4) Plavix
5) ACE-I
Dx Recurrent syncope with cardiac arrest with family history of sudden death
Long QT syndrome
(cardiac arrest is in form of torsade de pointe)
Indication for Digoxin tx
Class III or IV heart failure (has no improved mortality, just keeps people out of hospital and makes them feel better)
Dx Dyspnea, S3 or S4, displaced apical impulse, and EF less than 45% after delivery
Peripartum cardiomyopathy
Dx study for new onset CHF (DOE or orthopnea or edema) in the setting of angina (including stable) +/-abnormal EF
Coronary angiography
Dx study for New onset CHF
Echo
Tx for Class I or II CHF (2)
(even if asymptomatic)
1) ACE-I
2) Beta blocker
3) Amlodipine only if refactory sx on 1 and 2
Suitable substitute for spironolactone in Class III or IV CHF (bc they got gynecomastia)
Epleronone
Tx for Class III or IV CHF
1) ACE-I
2) Beta blocker
3) Spironolactone
Dx Aortic regurg in pt with prosthetic valve
Prosthetic valve failure
Dx split S2, right ventricular heave
Atrial septal defect
Dx opening snap, low pitched middiastolic murmur best heard over mitral valve
Mitral stenosis
Dx and Tx for Short, soft (less than 3), midsystolic murmur in elderly patient
Usually aortic stenosis. No management needed.
Diagnostic criteria for DM
1) HbA1C greater than 6.5
2) Fasting glucose over 125
3) Random glucose over 200
4) 2 hour glucose tolerance test over 200
All of these have to be done twice except random BG with signs of hyperglycemia
Tx Prediabetes
Lifestyle modifications
Dx chronic pancreatitis with diabetes
Secondary diabetes
Tx Initial for T2DM
Metformin (and lifestyle modification)
Tx Inpatient for controlling hyperglyecemia
Long acting insulin with rapid acting insulin before meals (ISS)
Tx for proliferative diabetic retinopathy or macular edema
Laser photocoagulation
Tx for chronic hypogycemia in DM
Long acting and rapid acting prandial insulin
Dx BG over 250, anion gap acidosis (less than 7.3), bicarb less than 15, and positive serum or urine ketones.
Diabetic ketoacidosis (DKA)
Dx BG over 600, ph more than 7.3, bicarb more than 15, serum osmolality greater than 320, and absent urine or serum ketones.
Hyperglycemic hyperosmolar non-ketosis (HHNK)
Tx HHNK
IV fluids and identifying underlying cause
Tx DKA
Insulin drip
Dx soft, non-tender, non-pruritic plaques on eyelids
Xanthelasma (see in familial dyslipidemia)
Tx for Isolated low HDL
Lifestyle changes:
1) Exercise
2) Smoking cessation
3) Weight loss
LDL goal for 0 or 1 CV risk factor
Less than 160
LDL goal for a diabetic
Less than 100
(diabetes is a CVD equivalent)
LDL goal for pts with hx of CVA or TIA
Less than 100
Mgmt for hypothyroidism
Treat - Levothyroxine
Hashimoto disease is the most common cause of hypothyroidism, confirmation via TPO antibody unnecessary.
Mgmt of Thyroid nodule
If greater than 1 cm --> biopsy
If less than 1 cm, biopsy only if cancer risk hx
Mgmt of Hypothyroidism in pregnacny
Monitor, bc Thyroxine requirements go up 30-50%, want T4 1.5 normal
Tx for Grave's disease
Methimazole and Beta blocker
(better than radiation bc can achieve euthyroid. Also better than PTU)
Mgmt of new Hyper or Hypothyroid post partum
Recheck TSH and T4 to diagnose Postpartum Thyroiditis
Mgmt abnormal thyroid studies in the setting of acute illness
Recheck TSH and T4 to diagnose Euthyroid Sick Syndrome
Mgmt of incidentally discovered adrenal adenoma in asymptomatic patient
Get plasma-free metanephrine levels and overnight dexamethasone suppression test
(want to rule out hypersecretion of glucocorticoids and catecholamines)
Dx study for Resistant HTN and hypokalemia
Serum aldosterone to plasma renin activity ratio to diagnose Primary Hyperaldosteronism
Dx study for High dose dexamethasone sensitive elevated ACTH
MRI of pituitary
Dx ACTH dependent hypercortisolism
1) High dose dexamethasone resistant
2) High dose dexamethasone sensitive
1) Ectopic ACTH tumor
2) Pituitary tumor
Mgmt of Palpitations, sweating, HA, HTN
Abdominal CT scan to confirm Dx of Pheochyromocytoma
Dx low ACTH, low cortisol, and high glucocorticoids in setting of exogenous corticosteroids
Adrenal insufficiency due to exogenous corticosteroids
Tx for Pts with adrenal insufficiency in setting of stress (as from illness or surgery)
Stress level doses of corticostreroids (Hydrocortisone or Dexamethasone)
Tx for Osteoporosis
Vitamin D, Ca supplementation, Bisphosponates (or zoledronate annually if cannot tolerate bisphosphonates)
When and with what to screen for osteoperosis
Screen with DEXA in women over 65 or women 60-65 with increased risk of osteoperosis (i.e. weight below 154 lbs)
Tx for Osteoporosis prevention
Vit D and Ca
Bone mineral density T score cutoffs for Osteopenia and Osteoperosis
Osteopenia: -1 to -2.5
Osteoperosis: -2.5 or more
Dx unilateral flank pain, n/v, gross or microscopic hematuria
Nephrolithiasis
Dx study for Nephrolithiasis
Helical abdominal CT scan
Dx study for Acute abdominal pain
Supine and upright abdominal radiographs (to look for air fluid level --> bowel obstruciton, and free peritoneal air --> perforated bowel)
Dx Abdominal pain, back pain, syncope
Abdominal aortic aneurysm
Dx Recurrent abdominal pain or discomfort, relieved with defecation, with diarrhea
Irritable Bowel Syndrome
Tx for Irritable bowel syndrome
Fiber and/or polyethylene glycol with reassurance
Dx crampy abdominal pain, with bloody stool, in eledery atherosclerotic patients
Ischemic colitis
Mgmt LLQ pain, fever, leukocytosis
Contrast enhanced CT scan to confirm Diverticulitis
Mgmt Chronic upper abdominal pain radiating to back, diabetes, steatorrhea, pancreatic calcifications
Abdominal CT to look for pancreatic calcifications to confirm Chronic Pancreatitis
Dx Thrombotic microangiopathy (schistocytes, elevated retic count, elevated LDH) and Thrombocytopenia
Hemolytic Uremic Syndrome
Dx Diarrhea and tenesmus within 6 weeks of radiation therapy
Radiation proctitis
Dx mid-epigastric abdominal pain, postprandial diarrhea, +/-DM
Chronic pancreatitis
Alarm criteria in IBS
1) Fever
2) Weight loss
3) Blood in stool
4) Abnormal PE
5) FHx of IBD or Colon ca
6 Pain or diarrhea that interferes with sleep
Dx 10-15 stool/day, lower abdominal pain, cramping, fever, leukocytosis in setting of Abx
C Diff
Tx for Salmonella gastroenteritis
Self limiting, no tx
Dx Anti-mitochondrial Ab
Primary Biliary Cirrhosis
Tx for Primary Billiary cirrhosis
Ursodeoxycholic acid
Which liver disease is associated with UC and Crohn's
Primary sclerosing cholangitis
Beading of the biliary duct
PSC
Pattern of bilirubin elevation
1) Prehepatic
2) Intrahepatic
3) Posthepatic
1) Prehepatic - Unconjugated hi
2) Intrahepatic - Both hi
3) Posthepatic - Conjugated hi
Dx Unconjugated hyperbilirubinemia with normal Hgb levels and otherwise normal LFTs
Gilbert Syndrome
Tx for Symptomatic gallstone disease
Cholecystectomy
Dx Elevated bilirubin and alkphos with IBD
PSC
Dx fever, jaundice, RUQ pain and common bile duct obstruction
Acute cholangitis
Dx biliary colic, Murphy sign, fever, leukocytosis, mild biliruibin and AST/ALT elevation, thickened gallbladder wall.
Acute cholesystitis
Tx for Gallstone pancreatitis
ERCP with sphincterotomy and stone extraction
Dx epigastric pain radiating to back, n/v, fever, tachycardia, abdominal distension, hypoactive bowel sounds.
Acute pancreatitis
Dx Stones in gallbladder, dilated bile duct, and elevated AST/ALT with acute pancreatitis.
Acute pancreatitis due to gallstones
Tx for Severe acute pancreatitis
Enteral nutrition with nasojejunal feeding tube
Mgmt GERD sx with dysphagia
Upper endoscopy
(Dysphagia is an alarm sx)
Tx Erosive Esophagitis
PPI
Dx study for gastric ulcer
Biopsy
(all ulcers should be biopsied for possible malignancy)
Mgmt of dyspepsia with NSAIDs
Stop the NSAID
Tx for Functional dyspepsia
PPI
(i.e. dyspepsia/gastritis without visible organic pathology)
Dx study for GI Bleed of unknown etiology after endoscopy and colonoscopy
Repeat upper endoscopy
Dx LLQ pain, urgent defecation, red or maroon rectal bleeding not requiring transfusion usually in older people
Colonic ischemia
Mgmt of Upper GI bleed after fluid resuscitation
Upper endoscopy for Diagnosis, Prognosis, and possible therapy
Tx for GI bleeding in hemodynamically unstable patients
Fluid resuscitation
Dx Painless lower GI bleeding
Diverticulosis and vascular ectasia
Dx BRBPR and pain with defecation
Anal fissure
Screening for chronic Hep B infection
Liver ultrasound to look for hepatocellular ca
Dx Acute hepatitis, fatigue, n/v, jaundice, AST/ALTs over 1000.
Hepatitis A
Dx AST;ALT ratio greater than 2, elevated alk phos
Alcoholic hepatitis
Dx Elevated AST/ALTs, hi GGT, mild bilirubinemia, mildly elevated alk phos, present of auto antibodies.
Autoimmune hepatitis
Dx Positive HBsAg and Anti-HBc IgM
Acute HepB
(The IgM tells you its acute and not chronic infxn)
Dx anti-hepatitis C Ab
Exposure to Hep C or vaccine
Dx Cirrhosis, obesity, T2DM, and hyperlipidemia
Non-Alcoholic Steatohepatitis
NASH
Dx UC and marked elevation in alk phos
PSC
Dx Ascitic fluid analysis showing serum to ascites albumin gradient greater than 1.1
Portal hypertension
(caused by Liver disease, such as cirrhosis, right sided HF (congestive hepatopathy), or Budd-Chiari)
Tx for Hepatic Encephalopathy
Lactulose
Dx kidney dysfunction in setting of portal htn after exclusion of prerenal azotemia, intra renal disease, and renal obstruction.
Hepatorenal syndrome
Dx small, exquisitely tender nodules on shins in IBD
Erythema nodosum
Dx Contiguous inflammation of rectum proximally
UC (Ulcerative colitis)
Tx for Ulcerative colitis
Mesalamine
Dx Chronic watery diarrhea without bleeding without findings on colonoscopy
Microscopic colitis
Which test characteristics are robust or sensitive to prevalence.
Robust - Sensitivity, Specificity, LR
Sensitive - PPV,. NPV
What is the relationship between LRs and Post Test Probability
LRs of 2, 5, and 10 increase Post test probability 15, 30, and 45% respectively
Screening recommendation for AAA
All men 65-75 who have ever smoked
Flu vaccine recommendations for COPD
All COPD patients regardless of age
Pneumovax recommendations
1) Anyone over 65
2) Smokers, COPD, or asthma can be younger
3) RE-Vaccination in everyone over 65 if last vaccination was more than 5 years ago AND before 65.
4) RE-Vaccination in immunosuppressed people if first vaccine more than 5 years ago
What is the best end point for any trial?
Mortality
Zoster vaccine recommendations
All patients over 60 regardless of prior varicella/zoster hx
HPV vaccine recommendations
All women 9-26
Colon Ca screening recommendations
Starting at age 50
1) Colonoscopy every 10 years
2) Flex sig every 5 years with home FOBT every 3 years
3) Annual home FOBT
Dx Syncope in ischemic HF
VTach
How to diagnose orthostatic hypotension
Drop in systolic BP of 20 or 10 diastolic after 3 minutes of standing
Dx Syncope, nausea, lightheadedness, diaphoresis
Vasovagal syncope (situational)
Dx LOC irrespective of body position without preceding symptoms
Cardiac arrhythmia
Dx study for infrequent syncope
Implantable loop recorder
Tx for Depression after failing 1 antidepressant
A different antidepressant
Tx for Depressive sx of 2 weeks more than 8 weeks after death of loved one
Pharmacologic antidepressants
Tx for Acute cocaine intoxication
Benzodiazepine
Tx for short term alcohol dependence
Naltrexone
Tx for Acute opioid intoxication
Naloxone (narcan)
Tx for Spinal stenosis with neurologic deficits and pain refractory to NSAIDs and PT
Surgery
Dx study for Vertebral osteomyelitis
MRI
Tx for Acute non-specific low back pain
NSAIDs or Acetaminophen
Dx Back pain, muscle weakness, and bowel or bladder incontinence
Spinal cord compression
Dx study for Spinal cord compression
MRI of spine
Mgmt Cough variant asthma
Albuterol inhaler trial for tx and dx
Mgmt for Chronic cough in non-smoker
Antihistamine/decongestant combination
2 Most common causes of hemoptysis
1) Bronchitis
2) Malignancy
Dx study for Hemoptysis with and without alarms for malignancy
1) CXR
2) If over 40, or more than 1 week, or 40 pyhx than Chest CT
Tx Acute bronchitis
Symptom management
Effects of smoking cessation on lung function (2)
1) Absolute improvement (minor)
2) Decreased rate of decline (major)
Tx for Smoking cessation
Varenicline
(Bupropion and nortriptyline effective but less so)
Indications for bariatric surgery
1) BMI over 40 regardless of comorbidities
2) BMI over 35 w/ comorbidities
When drug therapy was unsuccessful
Tx for Obesity after diet and exercise fail
Orlistat
Dx Nausea and vomiting within months of bariatric surgery
Stomal stenosis
Mgmt Unintentional weight loss with negative labs and imaging
Recheck in 6 months
(risk of ca low)
Most common cause of unintentional weight loss in ca negative patients
Depression
Medication that can cause weight loss
Bupropion
Dx Unintentional weight loss, skeletal muscle dysfunction, osteoperosis, depression
COPD
Tx for Menorhagia
Medroxyprogesterone for 10-21 days
(Menoroghia is heavy menstrual bleeding)
Dx Oligomenorrhea, hirsutism, acne, alopecia
PCOS
Tx for Menopausal sx
Estrogen replacement therapy
Dx study for Amenorrhea after pregnancy rule out
FSH, TSH, and Prolactin levels
Dx study for Abnormal uterine bleeding in patients over 35
Endometrial biopsy
Dx Well-demarcated, rapidly spreading area of warmth, swelling, tenderness, and erythema +/- fever
Cellulitis
Dx Erythematous, dry or greasy scales and crusts
Seborrheic dermatitis
Dx Light pink to red papules and thin plaques with scaling, active borders and central clearing
Tinea
Dx Erythematous macules and plaques that progress to epidermal necrosis and sloughing on less than 10% of body
Steven Johnson
Dx Targetoid lesions of both skin and mucosal surfaces
Erythema multiforme
Tx for Zoster reactivation
Oral antiviral if within 72 hours of onset of rash
Dx Erythema, telangiectasias, papules, pustules, and sebaceous hyperlasia of the face and nasolabial folds
Rosacea
Dx brown to black, well demarcated, stuck on papules
Seborrheic keratoses
Tx Extensive or inflammatory acne
Oral abx
Dx Rapid appearance of wheal lasting less than 24 hrs
Acute uriticaria
Mgmt Solitary, mobile, LAD of less than 2 cm
No mgmt needed
Mgmt Enlarging, firm, axillary LAD in woman over 40
Biopsy
Screening for hearing loss in elderly
Whispered voice test even if claiming asymptomatic
Dx study for Fall in elderly patient
Get up and go test
Tx Urge urinary incontinence
Tolterodine or Oxybutynin
Mgmt of Non-specific dizziness in eldery patient
PT
Initial Tx for Stage I HTN
Lifestyle modification for 6 to 12 months
(then you go to HCTZ)
Initial Tx for HTN in eldergy pt
HCTZ (more salt sensitive)
BP Goal in diabetics or CKD
130/80
Dx HTN, radial to femoral artery delay, rib notching
Coarctation of Aorta
Initial Tx for Stage II HTN
2 drugs, usually HCTZ and ACE-I
Dx Serum ferritin levels lower than 100-120
Iron deficiency anemia
Dx Pancytopenia, low retic count, hypoplastic bone marrow (usually with fat)
Aplastic anemia
Tx Iron deficiency anemia
Ferrous sulfate
Dx bite or blister cells
G6PDase Deficiency
Dx Low MCV and target cells with normal iron studies
Thalassemia minor
Dx Macrocytic anemia, thrombocytopenia, elevated LDH
Vitamin B12 deficiency
Dx study for suspected Vit B12 deficiency with low normal Vit B12
Methylmalonic acid and homocysteine
Dx Elevated LDH, decreased serum haptoglobin, and elevated retic count
Hemolytic anemia
Dx Hemolytic anemia, schistocytes, in setting of prosthetic valve
Prosthetic valve hemolytic anemia
Dx Microcytic anemia, hypochromia, variable size, and variable shape
Iron deficiency anemia
Dx Spherocytes on blood smear
Warm antibody-mediated hemolytic anemia
Dx Long PT and PTT, high D-dimer, low serum fibrinogen and platelets, and microangiopathic hemolytic anemia
Disseminated intravascular coagulation
Dx Long bleeding time, borderline PTT, low factor VIII wit FHx of coagulopathy
Von Willebrand
Dx Transient aplastic crisis in patients with chronic hemolytic anemia (e.g. sickle cell disease)
Parvovirus
Dx Right sided heart failure in sickle cell anemia
Pulmonary HTN
(common in sickle cell anemia)
Tx Acute chest syndrome in sickle cell anemia
Transfusion
Dx study Osteonecrosis
MRI of the hip
Dx study for Sickle cell anemia
Blood smear
Dx Decreased platelets, thrombotic event in setting of recent heparin
Heparin induced thrombocytopenia and thrombosis
Dx Microangiopathic hemolytic anemia, thrombocytopenia with normal coagulation, CNS sx, renal failure, fever
Thrombotic thrombocytopenic purpura
Dx Large platelet clumps on stained blood film
Pseudothrombocytopenia
Tx for Immune thrombocytopenic purpura
Corticosteroids
Tx for Antiphospholipid syndrome after thrombus
Warfarin for life
Dx Lupus anti-coagulant or anticardiolipin or B2 glycoprotein antibodies
Antiphospholipid
Dx decreased AG with anemia, proteinuria, hypercalcemia, and renal failure
Multiple myeloma
Dx hypercalcemia, osteopenia, anemia, leukopenia, and renal insufficiency
Multiple myeloma
Dx M spike less than 3.0 with less than 10% plasma cells in bone marrow
Monoclonal gammopathy of unknown significance
Auer Rods
AML
Dx BCR/ABL oncogene, granulocytes with left shift, and myeloid proliferation in bone marrow
CML
Dx Blanching rythematous macules around wrists and ankles after tick exposure
Rock mountain spotted fever
Dx Very high or brief fever spikes and rapid defervescence without chills
Factitious fever
Dx Fever after inhaled anesthetics and depolarizing muscle relaxants
Malignant hyperthermia
Tx for Sepsis with hemodynamic instability
Fluids
Flu vaccine recommendations for COPD
Annually regardless of age for everyone with COPD
Dx Low MCV, low serum Fe, elevated TIBC, and low transferrin saturation
Iron deficiency anemia
Tx Rocky Mountain Spotted Fever
Doxycycline
Indication for Norepinephrine in septic shock
If MAP is less than 65 after fluid resuscitation
Criteria for Sepsis
1) Positive BCx or visible infxn
2) Systemic response to infxn, at least 2: fever, tachycardia, tachypnea, leukocytosis
aka SIRS with positive BCx
Criteria for Systemic inflammatory response syndrome (SIRS)
At least 2 of:
Fever
HR over 90
Respiration greater than 20 (or PCO2 less than 32)
Leukocytosis (or Immature bands 10%)
Criteria for Septic shock
Sepsis with hypotension or evidence of perfusion abnormalities with adequate fluid resuscitation (or on vasopressors)
Severe complications of Group A Strep (3)
1) Peritonsillar abscess (quinsy)
2) Post-streptococcal glomerulonephritis
3) Rheumatic fever
Tx for Acute otitis media
Amoxicillin
(Amox-clav or Ceftriaxone if not improved within 3 days)
Centor Criteria for Strep Throat (4)
1) Fever
2) Tonsillar exudates
3) Tender LAD cervical
4) Absence of cough
Mgmt according to Centor Criteria
0-1 Nothing
2-3 Rapid strep antigen test
4 Empiric Abx tx
Mgmt for Asymptomatic UTI in pregnant woman
Ampicillin
Dx
Prostatitis refractory to Abx
Prostatic abscess
Tx
Asymptomatic UTI
No treatment
Dx
Fever, chills, sweats, n/v, diarrhea, and flank pain
Pyelonephritis
Tx
Pyeloneophritis in non-pregnant woman
Oral Fluoroquinolone
Tx
Recurrent UTI in healthy women
Trimethoprim sulfamethoxazole (bactrim) PRN for days with symptoms
Dx
Mucoprurulent discharge or bleeding of os
Cervicitis
Tx
Cervicitis
Ceftriaxone with doxy or azithromcyin
Dx
Arthritis, tenosynovitis, sparese peripheral necrotic pustulues
Gonorrhea
Dx
Fever, HA, and painful, ulcerated vesicular lesions on junk
Genital herpes
Tx
Pelvic inflammatory disease
Ceftriaxone and oral doxycycline
Dx
CD4 less than 200, fever, dry cough, dyspnea for several days or weeks
Pneumocystis jirovecii
Tx
Pneumocystis jirovecii
Bactrim
and Steroids if hypoxic
HIV Abx prophylaxis by CD4 count and PPD
1) Less than 200 - Bactrim for PJP and Toxo
2) Less than 50 - Azithromcyin for Mycobacterium Avium
3) PPD positive but lungs clear - Isoniazid
Dx study for
Acute HIV infxn
RNA viral load
Dx
Ring enhancing lessions on MRI, neurologic deficits, in setting of HIV
Toxoplasmosis
How to reduce ventilator associated PNA
Semi erect positioning of patient
Infectious precautions for C Diff
Barrier protection and soap and water
Precautions for Meningoccocal meningitis
Droplet precautions (surgical mask)
Precautions for TB
Airborne N95 mask
Mgmt for
Positive PPD
CXR
PPD cutoffs by risk (3)
5 mm Immunosuppressed or highest risk (close contact with TB)
10 mm Immigration form endemic country or prison worker
15 mm for healthy people
What must you get tested before starting a TNF-alpha inhibitor
TB tested with PPD (and treat if more than 5 mm)
Dx
Severe, progressive PNA during flu season
MRSA
Tx
Community acquired PNA
Azithromycin
Tx
PE from valve endocarditis (Right heart valve)
Vancomycin plus cefepime
Tx
Left sided native endocarditis
Penicillin plus gentamycin
or
Ceftriaxone plus gentamycin
Dx
Positive BCx, vegetation on Echo, and new valvular regurg
Endocarditis
Dx study for
Suspected Vertebral osteomyelitis
Spine MRI
Dx study for
Osteomyelitis
MRI
Dx study for
Confirmed Osteomyelitis
BCx or Bone culture
Pneumovax is indicated in everyone after their 65th birthday or after 65 if there have been more than 5 years since last vaccine
.
Dx
Severe, progressive PNA during flu season
MRSA
Tx
Community acquired PNA
Azithromycin
Tx
PE from valve endocarditis (Right heart valve)
Vancomycin plus cefepime
Tx
Left sided native endocarditis
Penicillin plus gentamycin
or
Ceftriaxone plus gentamycin
Dx
Positive BCx, vegetation on Echo, and new valvular regurg
Endocarditis
Dx study for
Suspected Vertebral osteomyelitis
Spine MRI
Dx study for
Osteomyelitis
MRI
Dx study for
Confirmed Osteomyelitis
BCx or Bone culture
Dx
Confusion and agitation in setting of chronic dementia with recent anesthesia
Postooperative delirium
Tx
Acute delirium inpatient
Haloperidol
Dx
Mental status changes, nystagmus, ophthalmoplegia, unsteady gait
Wernicke's encephalopathy
Tx
Wernicke's encephalopathy
Thiamine
Dx
Smudge cells
CML
Dx
Proteinuria during day but not over night
Orthostatic proteinuria
Dx
AKI with sterile pyuria (PMNs in urine) and WBC casts
AIN
Dx study for
Persistent hematuria of non glomerular origin
Cytoscopy
Dx
Muscle pain, weakness, dark urine, elevated serum creatine kinase
Rhabdomyolysis
Dx
AKI, thrombocytopenia, microangiopathic hemolytic anemia
Hemolytic uremic syndrome
Dx
Muddy brown casts in setting of drugs or prolonged renal ischemia
ATN
Tx for
Diabetic nephropathy
ACE-Is or ARBs
Indications for dialysis in CKD (4)
1) Hypervolemic
2) Hyperkalemic
3) Acidemic
4) Uremic
Dx
Proteinuria, HTN, and decreasing GFR
Diabetic nephropathy
Dx study for
AKI with suprapubic tenderness
Renal US
Dx study for
Non diabetic nephropahty (hematuria) in a diabetic
Renal biopsy
Dx
Bone disease, elevated PTH, hypocalcemic, and hyperphosphatemic
Bone disease 2/2 hyperparathyroidism in CKD
What does the Urine anion gap (UAG) tell you? (3)
If negative - Extra renal metabolic acidosis
If positive (30-50) - Normal
If positive in setting of metabolic acidosis - RTA
Formula for Serum osmolality
= Na*2 + BUN/2.8 + gluc/18
Dx
Hypokalemia with low urine K
Extra renal losses of K (laxatives or diarrhea)
Dx
Hypocalcemia in setting of acute pancreatitis
Free fatty acid chelation of Ca
Tx for
Hypercalcemia in Sarcoidosis
Corticosteroids (prednisone)
(decrease macrophages which produce 1alpha-hydroxylase which increases vit D)
Most common cause of hypercalcemia outpatient
Hyperparathyroidism
Dx
Severe muscle weakness following glucose therapy in alcoholic
Hypophosphatemia
(Insulin release from glucose moves phosphate into cells which is low bc of low oral intake)
Risk for demented patients during surgery
General anesthesia
Tx for
Delirium inpatient
Haloperidol
Dx
MS changes, ophthalmoplegia, nystagmus and unsteady gait
Wernicke's encephalopathy
Cause of wenicke's encephalopathy
Thiamine deficiency
Dx
Neurologic sx including vision loss, hallucinations, numbness, tingling, weakness or confusion prior to HA
Migraine with aura
Dx
Dull, bilateral, diffuse headache described as squeezing
Tension type headache
Dx study
For sudden worst HA of life
Non contrast Head CT
Tx for
Migraine prophylaxis
(indication more than 2 per week)
Amitrptyine (TCAs), Beta blockers, CCBs, valproic acid, topirmarate
Abortive Tx for Migraine
Triptans (5-HT1 agonists), NSAIDs, Ergotamine
Dx
Prominent memory loss, anomia, impaired recognition of illness, variable degree of personality change
Alzheimers
Dx
Dementia of a few month onset with startle myoclonus
Creutzfeldt-Jakob
Dx
Parkinsonism, visual hallucinations, fluctuating symptoms, impaired learning and attention, less memory impairment
Dementia with Lewy bodies
Tx for
Mild Alzheimer's
Donepezil
(ACh esterase inhibitor)
Tx for
Moderate or advanced Alzheimer's
Memantine
Dx
Resting tremor, bradykinesia, rigidity, postural instability
Parkinson Disease
Dx
Tremor with voluntary movement that resolves with alcohol
Essential tremor
Tx for
Essential tremor
Propanolol
Dx
Meningitis with Gram positive bacilli in immunocompromised
Listeria monocytogenes
Dx
Fever, HA, myalgia, purpuric rash that begins on wrists and ankles and spreads centripetally
Rocky mountain spotted fever
Dx
Bacterial meningitis with Gram negative cocci
Nisseria meningitidis
Empiric Tx for bacterial meningitis in patients over 50
Ceftriaxone + Vancomycin + Ampicillin
Empiric Tx for bacterial meningitis in patients under 50
Ceftriaxone + Vancomycin
When should rehab begin after stroke?
Immediately
Tx for
Acute Stroke within 3 hrs of onset
tPA
Hold ASA until 24 hours after tPA
BP cutoffs to treat HTN in post ischemic stroke
Over 220/120
Dx study for
Sudden worst HA of life with negative non contrast Head CT
LP
Agent in Bell's palsy
HSV-1
Dx
Rapidly progressive Ascending extremity weakness, paresthesias, and areflexia.
Guillaain-Barre
Dx
Wrist pain sparing palm, numbness and tingling in the median nerve distribution, weakness of thenar muscles
Carpal tunnel
Dx
Stocking glove paresthesias or painful dysesthesias
Diabetic neuropathy
Positive Finkelstein test
de Quervain tenosynovitis
Dx study for
New small breast mass on mammography
Ultrasound
Dx
Persistent, scaling, eczematous, ulcerated lesion on breast around nipple
Paget disease of breast
(indicates invasive or intraductal cancer)
Dx study for
New breast mass
Palpation, Mammography, and FNA
Tx for
Small focal breast cancer tumor (3)
Lumpectomy
Sentinel node dissection
Radiation
Colonoscopy screening for 1st degree relative
1) Starting at 40 or 10 years before relative
2) Every 5 years
Dx study for
Single positive FOBT in asymptomatic pt
Colonoscopy
Screening for colon ca in IBD
1) Starting 8 years after onset of disease
2) Every year
Dx screening for lung ca
None
Dx study for
Pulmonary nodule less than 4 mm in low risk population
No study necessary
Dx study for
Diagnosed lung cancer
Lymph node biopsy for staging
Tx for
Small cell lung cancer
Chemotherapy and radiation
(surgery is not effective)
Indications for prostate biopsy (2)
1) PSA over 4
2) Rising PSA
Tx for
Prostate ca
Leuprolide
Dx study for
Atypical pap smear results
Colposcopy with biopsy
HPV vaccination recommendations
Females and males 9-26
Pap screening recommendations
1) Start at 21 or 3 years after first sex
2) Annually for 21-30
3) Every 3 years after if normal in 30-65
Dx
Berry like lesion
Nodular melanoma
Hyperkeratotic precursor to squamous cell carcinoma
Actinic keratosis
Dx
Pink, pearly, nodules with telangiectasias
Basal Cell carcinoma
Dx
Rapidly progressive, crater like firm nodule
Keratoacanthoma
Tx for
Keratoacanthoma
Surgical excision
(can cause tissue damage or become malignant)
How to treat cancer pain
1) Non narcotics
2) Short acting narcotics
3) Then from that determine there long acting narcotic needs and Rx short acting for break through pain
Tx for
Dyspnea in hospice ca care
Opioids (short acting)
Definition of unstable angina
Angina is new, worsening, or occurring at rest
Antihypertensive for a diabetic patient with proteinuria
ACE-I
Dx
Hypotension, distant heart sounds, JVD
Cardiac tamponade
Drugs that slow AV node conduction (3)
1) Beta blockers
2) Digoxin
3) CCBs
HOCM murmur
Systolic ejection murmur along lateral sternal border that increases with Valsalva maneuver and standing
Murmur aortic insufficiency
Diastolic, decrescendo, high pitched, blowing murmur best heard when standing up
Murmur aortic stenosis
Systolic crescendo/decrescendo murmur that radiates to the neck, increases with increased preload
Murmur mitral regurg
Holosystolic murmur that radiates to the axilla or carotids
Murmur mitral stenosis
Diastolic, mild to late, low pitched rumble
Tx for
Afib or Aflutter
1) If unstable
2) If stable
1) If unstable - Cardiovert
2) If stable - Rate control with Beta blockers
Tx for
Vfib
Cardioversion
Autoimmune complication 2-4 weeks post MI
Dressler's syndrome: fever, pericarditis, elevated ESR
Tx for
IV drug use with JVD and holosystolic murmur at left sternal border
Treat existing HF and replace tricuspid valve
Dx study for
Hypertrophic cardiomyopathy
Echo
Dx
Fall in systolic BP greater than 10 mm with inspiration
Pulsus parodoxus --> Cardaic tamponade
Classic EKG findings in pericarditis (2)
1) Low voltage
2) Diffuse ST segment elevation
Indications for surgical repair of AAA
Greater than 5.5 cm
Rapidly enlarging
Symptomatic
or Ruptured
EKG findings in MI (3)
1) ST segment elevations
2) Flattened T waves
3) Q waves
Dx
Young patient with angina at rest, ST segment elevation, nl cardiac enzymes
Prinzmetal's angina
Dx
CHF, shock, altered MS
Silent MI
Agent that reverses effect of heparin
Protamine
Endocarditis prophylaxis
1) Dental
2) GI or GU surgery
1) Dental - Amoxicillin
2) GI or GU surgery - Ampicillin + Gentamicin
Most common cause of HTN in young women
OCPs
Most common cause of HTN in young men
EtOH
Asplenic patients are susceptible to these organisms
Encapsulated organisms
1) Strep pneumo
2) Nisseria meningitidis
3) H flu
4) Klebsiella
Number of bac needed on urine sample to think UTI
100,000
(100k)
Dx
Fever, malaise, cough, night sweats recent SW US travel.
Tx?
Dx - Cocciodomycosis
Tx - Amphotericin B
Dx
Blueberry muffin rash
Rubella
What should always be done before LP?
Check ICP with papilledema or head CT
Dx
Gamma globulins in CSF
Multiple sclerosis
Dx
Initial pruritic papule with LAD progresses to eschar in 7-10 days
Tx?
Dx - Cutaneous anthrax
Tx - Penicillin or Ciprofloxacin
Dx
Tabes Dorsalis, general paresis, gummas, argyll robertson pupils, aortitis, aortic root aneurysm
Tertiary syphilis
Dx
Arthralgia, migratory polyarthropathies, Bell's palsy, myocarditis
Secondary Lyme disease
Dx
Cold agglutinins
Mycoplasma
Tx for
Candidal thrush
Nystatin oral suppression
When and what to begin in HIV opportunistic prophylaxis
1) Less than 200 CD 4 count - Bactrim for Pneumocystis jiroveci
2) Less than 100 - Clarithromycin/Azithromycin for MAI
Dx
Alcoholic and smoker with lung sx with no gram stain but positive silver stain
Legionella pneumonia
Dx
Acute onset monoarticular joint pain, bilateral bell's palsy.
Tx?
Dx - Lyme disease
Tx - Doxycycline
Main organisms in endocarditis (2)
1) Stapy aureus
2) Strep epidermidis
Dx
Branching rods in oral infection
Actinomyces israelii
Dx
Painful chancroid
Haemophilus ducreyi
Dx
Dog or cat bite
Pasteurella
Dx
Infection in gardner
Sporothrix (sporotrichosis)
Dx
Infxn pregnant with pets
Toxoplasmosis
Dx
Meningitis in adults
Neisseria meningitidis
Dx
Meningitis in elderly
Strep pneumo
Dx
Alcoholic with pneumonia
Klebsiella
Dx
Currant Jelly sputum
Klebsiella
Dx
Infxn in burn victims
Pseudomonas
Dx
Osteomyelitis from foot wound puncture
Psuedomonas
Dx
Osteomyelitis in sickle cell patient
Salmonella
Dx
HTN with hypokalemia
1) If renin activity low
2) If renin activity high
1) If renin activity low - Primary Hyperaldosteronism
2) If renin activity high - Renovascular HTN (renal artery stenosis)
Dx
Purpura in elderly on back of hands
Tx?
Perivascular connective tissue atrophy
Tx - none
Dx
Palpable purpura, low complement levels, glomerulonephritis, arthralgias, hepatosplenomegaly,
Mixed Essential Cyroglobulinemia
Dx
Muscle weakness (extreme) that resolves with rest
Myasthenia gravis
Tx for
Benign essential tremor
Propanolol
Dx
Tremor with planned, voluntary movement only, family hx
Essential tremor
The 4 criteria of Nephrotic Sx
1) Proteinuria greater than 3 g/day
2) Hypoalbuminemia (less than 3.5)
3) Edema
4) HLD and lipiduria (waxy casts)
3)
What kind of state is nephrotic sx?
Hypercoagulable
Pharmacologic agents that shift K into cells in acute hyperkalemia
1) Insulin and glucose
2) Na bicarb
3) Beta 2 agonists
Dx
Nephrotic sx in Blacks with obesity, heroin, or HIV hx
Focal Segmental Glomerulosclerosis
Most common cause of nephrotic sx in adults
Membranous nephropathy
Most common cause of nephrotic sx in children
Minimal change disease
Dx
Lung and GI involvement in immunocompromised pt
CMV
Dx
Fever, hives, arthralgias, and LAD after infection (usually 7-10 days later)
Drug induced reaction (serum sickness)
Dx
New clubbing in COPD pt
Lung cancer
Dx
Recurrent pain, itching, and red steaks in arms in setting of weight loss
Trousseau's syndrome (migratory thrombophlebitis) caused by occult malignancy usually pancreatic or lung)
Dx
New HA, jaw pain, scalp pain, visual loss.
Temporal arteritis
Tx for
Temporal arteritis
High dose prednisone
(to prevent damage to retinal artery and other vessels)
Dx
Weakness, fatigue, hypotension, cold intolerance, brittle nails, bradycardia
Pituitary tumor causing secondary adrenocortical deficiency
Dx
Hyperpigmentation, amenorrhea in young adult
Congenital adrenal hyperplasia
Most common deficiency in Congential adrenal hyperplasia
21-hydroxylase deficiency
Dx study for
CP in young woman with no risk factors for CAD
None
Dx study for
Newly diagnosed Myasthenia gravis
Chest CT (to look for thymoma)
Tx for
Kidney stones in acidic urine
Potassium citrate
Dx
Palpable mass in RUQ with hyperbilirubinemia in child
Choledochal cyst
Tx for
Cocaine induced CP
Benzos
(also nitrates and aspirin)
Dx
Epigastric pain with voluminous pale foul smelling diarrhea
Chronic pancreatitis
Dx
EKG shows flat and broad T waves, PVCs
Hypokalemia
Dx
Fever, ns, LAD, arthralgias, diarrhea
Acute HIV
Dx
New onset diabetes, arthropathy, and hepatomegaly
Hemochromatosis
Dx
No pulses but telemetry shows beats
Pulseless electrical activity (PEA)
Tx for
PEA (pulseless electrical activity)
Chest compressions, ventilation with 100% oxygen
Door to therapy time for PCTA and fibrinolysis in MI
PTCA - 90 minutes
Fibrinolysis - 30 minutes
Most common cause of uncomplicated UTI in women
Ascending infection of urethra usually from sex (honeymoon cystitis)
Dx
Hazy lung fields, cough, dyspnea, fever, malaise in setting of farming or bird care
Hypersenstivity pneumonitis (bird fancier's lung or famer's lung)
Tx for
Hypersensitivity pneumonitis
Avoidance of antigen
Dx
Arthritis, lesions on shins, bloody diarrhea, P-ANCA positive
UC (IBD)
Ankylosing spondylitis and Ulcerative colitis share this HLA type
HLA-B27
Most common sites of thrombus for PE
1) Iliac
2) Femoral
3) Popliteal
Dx
Elevated alk phos and bowed legs on xray
Paget's disease
Dx
RUQ pain, mildly elevated liver enzymes, firm hepatomegaly.
Mets to the liver (usually from GI)
Dx
High fever, chills, tenosynovitis, migratory polyarthralgias and pustular lesions on extremities, negative BCx
Disseminated gonococcus
Dx
4th and 5th finger decreased sensation and weakened grip
Ulnar nerve syndrome
(medial elbow compression)
Dx
Heel pain, +/- shoulder, hip, and shin pain
Enthesitis due to Ankylosing spondylitis
Blood lab findings in Vit D malabsorption (3)
1) V. Low phosphate
2) Low Ca
3) High PTH
Which vitamin increases INR
Vitamin E
Dx
High Ca, low Phosphate, abdominal pain, constipation, fatigue, excessive urination, urinary stones
Hyperparathyroidism
Hyperparathyroidism predisposes to what arthralgia?
Pseudogout
Which joint does pseudogout usually affect
Knee
Dx
Intermittent abdominal distension, flatulence, greasy stools, iron deficiency anemia
Celiac sprue
Skin condition associated with celiac sprue
Dermatitis herpetiform
Dx study for
BRBPR under 50 with no risk factors for colon cancer
Anoscopy
Most common causes of osteomyelitis in sicke cell (2)
1) Salmonella
2) Staph
Dx
Smudge cells
CLL
Dx
Cause of erectile dysfunction following urethral surgery
Neurogenic
Mechanism of fatty liver
Insulin resistance increases lipolysis leading to fat accumulation in hepatocytes
Dx
High PaCO2 and low PaO2
Alveolar hypoventilation
Dx
COPD with sudden onset of catastrophic worsening of respiratory sx
Pneumothorax (dilated alveolar blebs rupture in the pleural space)
Most common cause of osteomyelitis in children
Staph aureus
Dx
Air fluid levels in the gall bladder in elderly diabetic male
Emphysematous cholecystitis
Dx
Slow onset hazy visual loss
Cataracts
Dx
Focal site of increased radio active iodine uptake with otherwise decreased uptake in the thyroid
Toxic nodule
Dx
HAs worse in morning, n/v early in day, vision changes, somnolence, confusion, hypertension and bradycardia
Increase intracranial pressure
Dx
Bilateral lower extremity weakness following termporal arteritis tx
Steroid induced myopathy
Dx study for
New onset dyspepsia in
1) Over 55
2) Alarm sx of weight loss, dysphagia, vomiting
3) All others
1) Upper endoscopy
2) Upper endoscopy
3) PPI or H Pylori serology
Dx
Insidious onset dry cough in absence of constitutional sx, also with skin lesions and uveitis in african american women
Sarcoid
Dx
Lower leg discomfort at night relieved by massage or movement of them
Restless leg syndrome
Tx for
Restless leg syndrome
Dopamine agonists
Dx study for
Adult with recurrent bacterial infections
Serum Ig levels to consider humoral immunity deficiency
Dx study for
Cancer patient with back pain and neurologic sx particularly bowel or bladder incontinence
MRI of spine
Tx for
Cancer patient with back pain and neurologic sx particularly bowel or bladder incontinence
Dexamethasone to decrease swelling on spine
(while awaiting MRI results)
Tx for
Lactic acidosis from septic shock (3)
1) Fluids
2) Vasopressors if necessary
3) Abx
In patients refractory to HTN tx always treat their lifestyle problems before adding more therapeutics
.
Dx
HA, n/v with enclosed air space occupation
Carbon monoxide poisoning
Dx study for
Elderly pt with new onset delirium
Urinalysis and electrolytes
Dx
Elderly male with dysphagia, regurgitation, foul-smelling breath, aspiration, possibly palpable mass
Zenker's diverticulum
Dx
Chest scan showing primary nodules with a halo sign
Aspergillosis
Dx
Acute pneumonia, cough, fever malaise, hilar lymphadenopathy on CXR, recent travel to Southeastern, mid Atlantic, and central US
Histoplasmosis
Dx
Pneunomia with arthralgias recent travel to SW US
Coccidio
Dx
Liver cysts with multiple cysts inside of the cysts.
What exposure?
Hydatid cysts from Echinococcosis.
Sheep exposure
Dx
Right sided effusion with cirrhosis
Hepatic hydrothorax
Tx for
Hepatic hydrothorax
Tx Thoracentesis and diuretics
If refractory, TIPS
Common drugs that cause hyperkalemia
1) ACE-Is
2) NSAIDs
3) K sparing diuretics (spironolactone and amiloride)
Dx
Hematemesis following multiple episodes of non-bloody vomiting
Mallory Weiss tear (ruptured submucosal arteries of distal esophagus)
Which HepB serology is most useful to determine acute Hep B infection? (2)
ABsAg and anti-HBc antibody
Dx
Corneal vesicles and dendritic ulcers
Herpes simplex keratitis
Mgmt
New onset lupus
Get kidney biopsy then start methylprednisone
Dx
Verrucuous, skin colored or pink papules around anus
Anogenital warts (HPV)
Tx for
Anogenital warts (HPV)
Podophyllin
Tx for
Prolactinoma
Dopamine agonists (bromocriptine or cabergoline)
Mgmt
GERD with dysphagia, weight loss, odynophagia
Upper endoscopy
Prophylaxis for MAC when CD 4 count less than 50
Azithromycin for Mycobacterium avium complex
Most common type of thyroid malignancy
Papillary carcinoma of the thyroid