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109 Cards in this Set

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  • Back
what to do if diabetes not well controlled on a sulfonylurea (eg glyburide)?
add metformin (synergy rather than substitution); sulfonylurea is an insulin secretagogue, and metformin is an insulin sensitizer
what to do in diabetic hypoglycemic attack
give glucagon followed by carbohydrate intake (esp in Type I diabetics); half-life of glucagon is on the order of minutes
what factors affect creatinine CLEARANCE besides serum creatinine?
body mass, gender, age; eg lean pt with low body mass can have renal insufficiency with "normal-range" creatinine values like 1.3
how can renal insufficiency cause hypoglycemia? (2)
1) decreased alanine substrate for gluconeogenesis (==> dec glucose production during fasting); 2) renal insufficiency prolongs circulating insulin action
what hormones facilitate enzymes involved in gluconeogenesis?
cortisol and thyroid hormone
effect of gestational diabetes on risk of developing DM II
increased risk
drugs vs lifestyle intervention in preventing diabetes in prediabetic pts
both helpful, but lifestyle intervention more effective than drugs (metformin, acarbose, glitazones); only lifestyle intervention is recommended
fasting glucose level needed to confirm diabetes
goal BP in diabetics?
antihypertensives to use in diabetics (2)? Benefits of each?
thiazides (cardioprotective) + ACEi (nephroprotective)
what complication of diabetes tx can masquerade as behavioral problems? How to diagnose?
hypoglycemia (often undetected) ==> need more frequent glucose monitoring
what to do if DM II not well controlled with sulfonylurea + metformin?
add insulin
3 ways to diagnose DM
1) sx of diabetes + casual plasma glucose > 200; 2) 2-hr plasma glucose > 200 during oral glucose tolerance test; 3) fasting glucose > 126 [**recommended test]; EACH MUST BE CONFIRMED ON SUBSEQUENT DAYS BY ONE OF THE OTHER METHODS
use of HbA1c in diagnosis of DM
not recommended; use primarily to monitor glycemic control (like fructosamine)
fructosamine vs HbA1c
both used to monitor glycemic control; HbA1c over 120 days, fructosamine over 3 wks
target preprandial glucose values in diabetics type I
target bedtime glucose values in diabetics type I
tx of acutely symptomatic type II DM
insulin (also in type II DM with pregnancy or hyperglycemic emergencies); can maybe discontinue later once glucose toxicity / lipotoxicity reversed
how to protect vision in pt with very poor glycemic control and evidence of proliferative retinopathy
urgent laser therapy
how to manage diabetes in hospitalized pt who is NPO?
insulin infusion
ability to prove diabetic foot ulcer directly to the bone suggests what?
osteomyelitis (90% likelihood)
what finding on urinalysis presents with a maltese cross appearance under polarized light?
oval fat droplet ==> suggests nephrotic-range proteinuria (eg in diabetic nephropathy)
what do hyaline casts suggest?
normal, concentrated urine; consist of tubular protieins (Tamm-Horsfall protein) but contain few/no cellular elements; can also be seen in diabetic nephropathy -- correlate with protein content on urinalysis
how to treat drug-resistant acinetobacter pulmonary infection?
potent carbepenems (imipenem, meropenem) or some of the aminoglycosides (eg amikacin and tobramycin) active in vitro, but aminoglycosides have poor lung penetration (amiNO O2); cephalosporines, quinolines usu ineffective;
persistent fever despite successful tx of nosocomial infection
drug fever (allergic basis, but can lack other signs of allergy; rash and Eos are rare)
common sources of candidal bacteremia
GI tract, central venous catheter (==> seen in surgical ICUs bc of GI surgical prcedures, parenteral nutrition via CV catheter, ARF requiring hemodialysis, and use of broad spectrum antibiotics)
tx for candidal bacteremia
systemic fluconazole
what needs to be done for pts with resolving staph aureus bacteremia before discharge?
TEE! Risk of endocarditis as high as 25%; followed by 4wks of IV abx if endocarditis seen, 2wks if not seen
what is the risk of antimotility agents for diarrhea in pts with severe inflammatory conditions
increased risk of toxic megacolon
what dz a/w extensive seborrheic dermatitis refractory to corticosteroid tx?
in which pts do you see cryoptococcal meningitis?
only in pts with untreated HIV, pts with HIV who cannot tolerate or do not benefit from antiretroviral tx, and pts with undiagnosed HIV
what causes high mortality with cryptococcal meningitis?
increased intracranial pressure (ICP proportional to mortality); need to normalize pressure, either by therapeutic LP or VP shunt
when to biopsy suspected toxoplasmic encephalitis?
only if not responsive to initial tx
location of lesions typical of toxoplasmic encephalitis
deep in cerebral hemispheres, often basal ganglia
CMV vs Toxo encephalitis
no mass lesion in CMV
how to prevent vertical xmission of HIV?
antiretroviral tx during pregnancy (zidovudine monotherapy in 2nd trimester)
renal findings in HIV nephropathy
nephrotic-range proteinuria, azotemia, and normal-sized kidneys (focal segmental glomerulosclerosis)
what is immune reconstitution syndrome? What do you do about it?
occurs following effective control of HIV by antiretroviral therapy -- see transient paradoxical worsening of underlying infections, such as TB, MAC, and CMV; tx: continue HAART, can add NSAID to control fever/pain
when does HIV lipodystrophy occur?
fat redistribution usu a/w HAART, but can also occur without antiretroviral tx; esp a/w protease inhibitors;
what is seen in HIV lipodystrophy?
lipoatrophy of extremities and face, fat accumulation in abdomen, breasts, and neck
which anti-TB drug contraindicated with HIV tx?
Rifampin (known to interfere with many protease inhibitors); rifabutin can be substituted
adjunctive tx for hypoxemic pneumocystic pneumonia
add corticosteroids to TMP-SMX
what is pentamidine
antimicrobial used for prevention and tx of PCP; also has some anti-protazoal activity
primary CNS lymphoma in immunocompetent vs HIV pts
in HIV, often manifest with central necrosis + ring-enhancing lesions (can be confused for toxo)
EBV and CNS lymphomas
nearly all primary CNS lymphomas in HIV pts a/w EBV; rarely in immunocompetent pts
tx of CNS lymphoma in HIV
methotrexate and brain radiation, but rarely succesfull; usu die within 6 mos
criteria for SIRS
>=2 of the following: 1) T > 100.4 or < 96.8; 2) HR > 90; 3) RR > 20 or Pco2 < 32; WBC > 12000 or < 4000 w 10% bands
criteria for sepsis
SIRS with documented infection
criteria for severe sepsis
sepsis + organ dysfunction/hypoperfusion/hypotension
criteria for septic shock
severe sepsis with sepsis-induced hypotension despite adequate fluid resuscitation
tx of sensitive strpe viridans endocarditis of normal valves
4wks x PCN or ceftriaxone; OR 2wks if combined with gent
stages of chickenpox lesions
macular, papular, vesicular, pustular; rapid progression thru stages, and several stages of development seen in a given area
most common location of molluscum contagiosum
face, anogenital areas
widened mediastinum a/w what bug?
bacillus anthracis
abx used for empiric tx of community acquired pneumonia
ceftriaxone + azythromycin
suspected cause of neutropenic fever without resolution with adequate antiacterial regimen
fungal! (eg candida, aspergillus) ==> start amphotericin B
lyme dz vs RMSF
lyme dz usu doesn’t cause septic findings
areas a/w yellow fever
africa, south america, panama (NOT asia)
tx of pt with central venous port and neutropenic fever
IV antibiotics (eg cephalosporins), if resolving, continue IV abx (no need to pull port); can't do PO meds b/c port puts pt in "high risk" category
tx of neutropenic fever
broad empiric antibiotic coverage, ideally bactericidal, through alternate ports of any indwelling IV lines; ideally tailored to pt, but generally cefepime or carbepenem recommended, with aminoglycoside if critically ill
what to do if neutropenic fever persists >5-7d after administration of broad empiric abx?
add antifungal
when to stop abx in neutropenic fever?
if source known, std duration; if unknown, stop if ANC > 500 and pt afebrile (~7-14d)
what does the physiologic murmur of pregnancy sound like?
early peaking systolic ejection murmur (pulmonary outflow murmur) a/w S3 and displaced PMI
difference in ausculatation between flow murmur and murmur from left ventricular outflow obstruction
flow murmur peaks in 1st 1/2 of systole
which murmurs decrease with valsalva?
aortic and pulmonic stenoses, mitral and tricuspid regurg
appropriate frequency of pap smears in patient with low risk for cervical cancer (long-term, monogomous relationship, many normal pap smears, etc.)
every 3 yrs; annually if high risk
frequency of tetanus boosters
every 10 yrs after pediatric series
what vaccines needed for day care center staff / long-term care facilities?
hep A and B
what lab testing required before low risk procedures (dental extraction, lymph node biopsy, herniorrhapy) to avoid bleeding?
none, as long as history and family history are negative
what lab work prior to moderate- or high-risk procedures?
PT, APTT, platelet count; NOT bleeding time (no predictive value)
mgmt of person recently exposed to TB
PPD, followed by repeat PPD in 3 months (takes weeks to seroconvert)
cervical cancer screening in pts who have had hysterectomy for benign disease
no need for routine pelvic exam / pap smear (no proven benefit for detection of cancer)
modifiable risk factor for head and neck cancer
alcohol abuse
use of pap smears to detect uterine cancer
pap smears do NOT reduce mortality from uterine cancer; they DO lower incidence of cervical cancer and its mortality
risks of post-menopausal hormone replacement therapy (HRT)
increased relative risk of coronary heart disease and breast cancer
raloxifene as tx for hot flushes
no good! Raloxifene can INCREASE hot flushes
when to use estrogen tx for hot flushes?
if low risk of breast cancer and cardiovascular dz (and ?absence of uterus?)
best screening strategy for ovarian cancer
annual rectovaginal pelvic exams
impact of PSA screening on prostate cancer detection and mortality
markedly increased detection with unclear impact on overall mortality
digital rectal exam vs PSA as screening tool for PrCa
DRE less sensitive than PSA, but can pick up tumors missed by PSA
at what age to pts with hereditary genetic cancer syndromes get cancer?
prophy for malaria in subsaharan africa
mefloquine, doxycycline, or atovaquone/proguanil; NOT chloroquine -- resistance rampant; quinine used for tx, not prophy
what to do for pt with positive PPD and history of positive PPDs?
chemoprophylaxis (unless cannot be tolerated, eg chronic liver dz); std chemoppx is isoniazid 300mg x 9mo
what endocarditis ppx to use in pts undergoing dental procedures and allergic to PCN?
clindamycin (1 dose 1hr before procedure)
what to do if needle stick with HBV?
check vaccination status (ie endogenous antibody response); have 72 days to start ppx, so if vax status negative, begin IVIg and vaccination
common lesions on hands/feet of teenagers
verruca vulgaris (common warts),
tx of common warts
usu resolve spontaneously; can use topical salicylic acid if painful. Cryotherapy also possible, but can cause painful neurlagia on digits
what is imiquimod and what is it used for?
topical immunotherapy used for genital warts
tx for actinic keratosis
topical 5-FU, cryotherapy
tx of chickenpox
high dose oral acyclovir within 24 hrs of rash; after 24 hrs, acyclovir not helpful -- can give antihistamines to control itching
tx for shingles (herpes zoster)
ORAL acyclovir, +/- corticosteroids (accelerate healing and improve quality of life, but don’t decrease post-herpetic neuralgia)
when to use IV acyclovir?
to tx herpes zoster in an immunocompromised host
role of corticosteroids in preventing post-herpetic neuralgia?
features of Sweet's syndrome (4)
1) fever; 2) leukocytosis; 3) acute, tender, red plaques; 4) papillary dermal infiltrate of neutrophils
red, pruritic papules and plaques, lesions last <24 hrs each
urticaria vs other red pruritic papules and plaques
urticarial lesions last < 24h
where does cutaneous candidiasis occur?
warm, moist skin areas
in whom does cutaneous candidiasis occur?
pts with altered local immunity, eg increased moisture at site of infection, diabetes, or altered systemic immunity
cutaneous psoriasis vs candidasis
both can occur in intertriginous areas (skin folds) and appear bright red with pustules; PSORIASIS has more distinct borders, pustules are distributed throughout lesion rather than just periphery, and also apperas on the trunk with heavy silver-white scale
characteristic features of tinea corporis
peripheral expanding lesion with central clearing --> annular
distinguishing characteristic of tinea versicolor
fine, powderly scale when lesions are lightly scraped
where is tinea cruris found?
groin, pubic region, and inner thighs; often a/w tinea pedis, so also see lesions on feet
where does seborrheic dermatitis occur?
oily areas (scalp, central face, upper mid chest)
what is an aphthous ulcer?
"canker sore" -- painful, small, shallow, white-based lesion with yellow border surrounded by a red areola
rosacea vs SLE
rosacea does not spare the nasolabial folds, has more prominent acne-like pustules, is unrelated to sun exposure, and does not have other systemic sx such as arthritis
what causes all types of psoriasis to improve?
herpes simplex lesions in immunocompromised patient
vesicles quickly break down, leaving large, painful ULCERS and erosions that do not heal
tx for severe cystic and pustular acne
oral antibiotics, followed by oral isotretinoin if abx fail
where does eczema commonly occur?
skin flexures (elbows, neck, wrists, ankles, sides of neck)