More Family Medicineeee

Front 1

Actinic keratosis predisposes to....

Back 1

Cutaneous squamous cell carcinoma. 

Front 2

Edit Action of thiazolidinediones (TZDs)

Back 2

Improving insulin sensitivity in muscle and adipose tissue

Front 3

Edit Antidepressant ok in preg

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Fluoxetine

Front 4

Edit Antidepressent for those with depression and weight loss

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mitazapine (Remeron)

Front 5

Edit Apraxia, agnosia, aphasia

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Apraxia is a transmission disturbance on the output side, which interferes with skilled movements. Even though the patient understands the request, he is unable to perform the task when asked, but may then perform it after a time delay. Agnosia is the inability to recognize previously familiar sensory input, and is a modality-bound deficit. For example, it results in a loss of ability to recognize objects. Aphasia is a language disorder, and expressive aphasia is a loss of the ability to express language. The ability to recognize objects by palpation in one hand but not the other is called astereognosis.

Front 6

Edit BP goals for patients with HTN

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For most patients, JNC-7 recommends a goal blood pressure of <140/90 mm Hg. However, the goal for patients with chronic kidney disease (CKD) or diabetes mellitus is <130/80 mm Hg. Both conditions are independent risk factors for cardiovascular disease. 

Front 7

Edit Best initial treatment for rheumatoid arthritis

Back 7

Disease modifying agents like methotrexate. First line!!!!!!!!!!!!!!!!

Front 8

Edit Best treatments for anorexia

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Family and adolescent focused individual therapy

Front 9

Edit Best validated second step therapies for diabetes

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Insulin or sulfonylurea (insulin secretogogues that stimulate beta cells to secrete insulin)

Front 10

Edit Characteristics of gait changes with visual impairment, cerebellar degeneration, frontal lobe degeneration, parkinson's, motor neuropathy

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It is characterized by abducted arms and legs; slow, careful, “walking on ice” movements; a wide-based stance; and “en bloc” turns. Patients with cerebellar degeneration have an ataxic gait that is wide-based and staggering. Frontal lobe degeneration is associated with gait apraxia that is described as “magnetic,” with start and turn hesitation and freezing. Parkinson’s disease patients have a typical gait that is short-stepped and shuffling, with hips, knees, and spine flexed, and may also exhibit festination and “en bloc” turns. Motor neuropathy causes a “steppage” gait resulting from foot drop with excessive flexion of the hips and knees when walking, short strides, a slapping quality, and frequent tripping.

Front 11

Edit Contrainidications ot levonorgestrel intrauterine system (mirena)

Back 11

Contraindications to levonorgestrel intrauterine system (LNG-IUS) include uterine anomalies, postpartum endometritis, untreated cervicitis, and current pelvic inflammatory disease. Nulliparity may increase discomfort during insertion but is not a contraindication. 

Front 12

Edit Criteria for diagnosing diabetes

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any one of following: Sx of diabetes (polyuria/polydipsia/weight loss) + casual glucose level >200 mg/dl, fasting >126, or 2 hour postprandial >200 after 75 gram glucose load

Front 13

Edit Criteria for diagnosing gestational diabetes

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50g 1 hour glucose challeng screening at 26-28 weeks followed by 100g 3 hour oral glucose tolerance. 

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Edit Criteria for doing an endometrial biopsy

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A patient over the age of 35 who experiences abnormal vaginal bleeding must have an endometrial assessment to exclude endometrial hyperplasia or cancer. An endometrial biopsy is currently the preferred method for identifying endometrial disease. 

Front 15

Edit Criteria for gastric bypass surgery

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Indications for laparoscopic bariatric surgery for morbid obesity include a BMI >40 kg/m2 or a BMI of 35–40 kg/m2 withsignificant obesity-related comorbidities. Weight loss by nonoperative means should be attempted before surgery, and patients should be evaluated by a multidisciplinary team that includes a dietician and a mental health professional before surgery.

Front 16

Edit Criteria for treatment of influenza

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Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness or who require hospitalization. Antiviral treatment is recommended as soon as possible for outpatients with confirmed or suspected influenza who are at higher risk for influenza complications based on their age or underlying medical conditions. Clinical judgment should be an important component of outpatient treatment decisions.  Antiviral treatment also may be considered on the basis of clinical judgment for any outpatient with confirmed or suspected influenza who does not have known risk factors for severe illness, if treatment can be initiated within 48 hours of illness onset.

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Edit Criteria for use of aspirin

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he USPSTF recommends the use of aspirin for men 45–79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation)  The USPSTF recommends the use of aspirin for women 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation)  The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement)  The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation)

Front 18

Edit Diabetic related neuropathys. Femoral neuropathy vs. diabetic polyneuropathy vs. meralgia paresthetics (latera fmeoral cutaneous neuropathy)

Back 18

These findings weakness of the lower left leg, giving way of the knee, and discomfort in the anterior thigh. )are typical of femoral neuropathy, a mononeuropathy commonly associated with diabetes mellitus, although it has been found to be secondary to a number of conditions that are common in diabetics and not to the diabetes itself. Diabetic polyneuropathy is characterized by symmetric and distal limb sensory and motor deficits. Meralgia paresthetica, or lateral femoral cutaneous neuropathy, may be secondary to diabetes mellitus, but is manifested by numbness and paresthesia over the anterolateral thigh with no motor dysfunction. S

Front 19

Edit Diagnosis for duchenne muscular dystrophy

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The diagnosis of Duchenne muscular dystrophy, the most common neuromuscular disorder of childhood, is usually not made until the affected individual presents with an established gait abnormality at the age of 4–5 years. By then, parents unaware of the X-linked inheritance may have had additional children who would also be at risk. The disease can be diagnosed earlier by testing for elevated creatine kinase in boys who are slow to walk. The mean age for walking in affected boys is 17.2 months, whereas over 75% of developmentally normal children in the United States walk by 13.5 months. Massive elevation of creatine kinase (CK) from 20 to 100 times normal occurs in every young infant with the disease. Early detection allows appropriate genetic counseling regarding future pregnancies.

Front 20

Edit Diagnosis of Type II diabetes

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patient’s fasting blood glucose level is ≥126 mg/dL on two separate occasions. It can also be diagnosed if a random blood glucose level is ≥200 mg/dL if classic symptoms of diabetes are present. A fasting blood glucose level of 100–125 mg/dL, a glucose level of 140–199 mg/dL 2 hours following a 75-g glucose load, or a hemoglobin A 1c of 5.7%–6.9% signifies impaired glucose tolerance. If they meet those criteria, do lifestyle changes. 

Front 21

Edit Diagnosis of pericardial effusion

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Echocardiography is the most effective imaging study for the diagnosis of pericardial effusion. It is a simple, sensitive, specific, noninvasive test that can be used at the patient’s beside (SOR A). The test also helps to quantify the amount of pericardial fluid and to detect the presence of any accompanying cardiac tamponade. 

Front 22

Edit Diagnosis of scrotal pain

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Do transillumiation first. If the diagnosis is uncertain, ultrasonography with color Doppler imaging has become the accepted standard for evaluation of the acutely swollen scrotum (SOR B). Ultrasonography alone can confirm the diagnosis in a number of conditions, such as hydrocele, spermatocele, and varicocele. For other conditions such as orchitis, carcinoma, or torsion, color Doppler ultrasonography is essential because it will show increased flow in orchitis, normal or increased flow in carcinoma, and decreased blood flow in testicular torsion.

Front 23

Edit Diagnostic criteria for diabetes

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1) random glucose 200 mg/dl or more along with classic symptoms that include polydipsia, polyuria, polyphagia, frequent infections, weight loss 2) Fasting glucose more than 125 mg/dl on at least two occasions 3) two hour plasma glucose two hundred mg/dl or more after 75 g glucose load

Front 24

Edit Distinguishing MGUS from MM

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 diagnosis of multiple myeloma is based on evidence of myeloma-related end-organ impairment in the presence of M protein, monoclonal plasma cells, or both. This evidence may include hypercalcemia, renal failure, anemia, or skeletal lesions. Monoclonal gammopathy of undetermined significance does not progress steadily to multiple myeloma. 

Front 25

Edit Drug for diabetes that increases insulin sensitivity

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Metformin

Front 26

Edit Drugs that can cause acute intersitial nephritis

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Antibiotics, especially penicillins, cephalosporins, and sulfonamides, are the most common drug-related cause of acute interstitial nephritis. Corticosteroids may be useful for treating this condition. The other drugs listed may cause renal injury, but not acute interstitial nephritis.

Front 27

Edit First line diabetes drug in patient with renal failure. 

Back 27

Glipizide (sulfonylurea)

Front 28

Edit First line drug for diabetes

Back 28

Metformin

Front 29

Edit First line for hirsutism

Back 29

spironolactone

Front 30

Edit First line for inducing ovulation in patients with PCOS

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First-line agents for ovulation induction and treatment of infertility in patients with polycystic ovary syndrome (PCOS) include metformin and clomiphene, alone or in combination, as well as rosiglitazone (SOR A). In one study of nonobese women with PCOS, metformin was found to be more effective than clomiphene for improving the rate of conception (level of evidence 1b). However, the treatment of infertile women with PCOS remains controversial. One recent group of experts recommended that metformin use for ovulation induction in PCOS be restricted to women with glucose intolerance (SOR C).

Front 31

Edit First line treatment for n

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v in pregnancy / The combination of vitamin B 6 and doxylamine was studied in more than 6000 patients and was associated with a 70% reduction in nausea and vomiting, with no evidence of teratogenicity.

Front 32

Edit Goal for patient with type II diabetes 

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A1c less than 7 percent

Front 33

Edit Highest risk factor for AAA

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Smoking

Front 34

Edit How to diagnose diabetes!!!!!!!!!

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An international expert committee issued a report in 2009 recommending that a hemoglobin A1c level ≥6.5% be used to diagnose diabetes mellitus. Other criteria include a fasting plasma glucose level  ≥126 mg/dL, a random glucose leve l≥200 mg/dL in a patient with symptoms of diabetes, or a 2-hour oral glucose tolerance test value ≥200 mg/dL. While a urine dipstick may be used to screen for diabetes, it is not a diagnostic test.

Front 35

Edit Indications and schedule of pneumonia immunization

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Both the CDC and the American Academy of Family Physicians recommend that all adults over the age of 65 receive a single dose of pneumococcal polysaccharide vaccine. Immunization before the age of 65 is recommended for certain subgroups of adults, including institutionalized individuals over the age of 50; those with chronic cardiac or pulmonary disease, diabetes mellitus, anatomic asplenia, chronic liver disease, or kidney failure; and health-care workers. It is recommended that those receiving the vaccine before the age of 65 receive an additional dose at age 65 or 5 years after the first dose, whichever is later.

Front 36

Edit Inital treatment of WPW?

Back 36

Procainamide, maybe amiodarone

Front 37

Edit Issues with omeprazole

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Although proton pump inhibitors are the most effective treatment for patients with asymptomatic gastroesophageal reflux disease, there are several potential problems with prolonged therapy. Omeprazole is associated with an increased risk of community-acquired pneumonia and Clostridium difficile colitis. Omeprazole has also been shown to acutely decrease the absorption of vitamin B 12 , and it decreases calcium absorption, leading to an increased risk of hip fracture. The risk for Clostridium difficile colitis is also increased.

Front 38

Edit LDL goal of patient with diabetes but no known coronary artery disease. 

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High-risk patients should have a target LDL-cholesterol level of <100 mg/dL. High risk is defined as the presence of known coronary heart disease (CHD), diabetes mellitus, noncoronary atherosclerotic disease, or multiple risk factors for CHD (SOR C). Patients at very high risk (known CHD and multiple additional risk factors) have an optional target of <70 mg/dL.

Front 39

Edit Lithium can cause what (besides hypothyroidism)

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Hypercalcemia via Increased PTH

Front 40

Edit Management of ASCUS

Back 40

The ASC-US/LSIL Triage Study (ALTS) demonstrated that there are three appropriate follow-up options for managing women with an ASC-US Papanicolaou (Pap) test result: (1) two repeat cytologic examinations performed at 6-month intervals; (2) reflex testing for HPV; or (3) a single colposcopic examination. This expert consensus recommendation has been confirmed in more recent clinical studies, additional analyses of the ALTS data, and meta-analyses of published studies (SOR A).

Front 41

Edit Management of C diff

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Clostridium difficile infection is more common with aging and can be treated with either metronidazole or vancomycin daily. For mild recurrent disease, repeating the course of the original agent is appropriate (SOR B). Multiple recurrences or severe disease warrants the use of both agents. The effectiveness of probiotics such as Lactobacillus remains uncertain. Intravenous vancomycin has not been effective. Antiperistaltic drugs should be avoided.

Front 42

Edit Management of somatization

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The management of somatizing patients can be difficult. One strategy that has been shown to be effective is to schedule regular office visits so that the patient does not need to develop new symptoms in order to receive medical attention. Regular visits have been shown to significantly reduce the cost and chaos of caring for patients with somatization disorder and to help progressively diminish emergency visits and telephone calls. In addition, it is important to describe the patient’s diagnosis with compassion and avoid suggesting that it’s “all in your head.”

Front 43

Edit Mechanism of mentformin (and toerh biguanides)

Back 43

decrease glucose output during gluconeogenesis. Secondary are improved insulin sensitivity in liver and muscle an decrease in intestinal absorption of glucose

Front 44

Edit Medications that can prevent hip fracture in osteoperosis

Back 44

Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture, and these are the anti-osteoporosis drugs of choice.

Front 45

Edit Most common of all movement disorders. Diagnosis and treatment

Back 45

Essential tremor: Tremor comes on during action, remits when limb is relaxed. After age of 50 usually. Often decreases with alcohol. Can be increased with caffiene, levothyroxine, etc. Hands, head, lower extremities (most commonly hands). Tx: betal blocker propanolol or anticonvulsant primidone. Can use gabapentin but second line. 

Front 46

Edit Most common side effects of metformin

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Gastrointestinal: nausea, diarrhea

Front 47

Edit Nonketotic hyperosmolar syndrome

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Blood sugar levels become very high (more than 200mg)

Front 48

Edit Nursemaid's elbow

Back 48

“Nursemaid’s elbow” is one of the most common injuries in children under 5 years of age. It occurs when the child’s hand is suddenly jerked up, forcing the elbow into extension and causing the radial head to slip out from the annular ligament.

Front 49

Edit Obesity hypoventilation syndrome. Diagnosis

Back 49

treatment / besity-hypoventilation syndrome, often referred to as Pickwickian syndrome. These patients are obese (BMI >30 kg/m 2 ), have sleep apnea, and suffer from chronic daytime hypoxia andcarbon dioxide retention. They are at increased risk for significant respiratory failure and death compared to patients with otherwise similar demographics. Treatment consists of nighttime positive airway pressure in the form of continuous (CPAP) or bi-level (BiPAP) devices, as indicated by sleep testing. The more hours per day that patients can use this therapy, the less carbon dioxide retention and less daytime hypoxia will ensue. S

Front 50

Edit Physical signs of parkinson's. Dx and treatment

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Distal resting tremor, rigidity, bradykinesia, postural instability, asymmetric onset.  Primary treatment: Levadompa, can cause dyskinesia, and psychosis. Give with carbidopa.  Adjuvent: dopamine agonists, COMT inhibitors (capones), MAO (b) ( inhibitors.

Front 51

Edit Possible cause of poorly controlled hypertension in patient with hypokalemia. 

Back 51

As many as 20% of patients referred to specialists for poorly controlled hypertension have primary hyperaldosteronism. It is more common in women and often is asymptomatic. A significant number of these individuals will not be hypokalemic. Screening can be done with a morning plasma aldosterone/renin ratio. If the ratio is 20 or more and the aldosterone level is >15 ng/dL, then primary hyperaldosteronism is likely and referral for confirmatory testing should be considered.

Front 52

Edit Postural orthostatic tachycardia syndrome presentation and treatment. 

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Postural orthostatic tachycardia syndrome (POTS) is manifested by a rise in heart rate >30 beats/min or by a heart rate >120 beats/min within 10 minutes of being in the upright position. Symptoms usually include position-dependent headaches, abdominal pain, lightheadedness, palpitations, sweating, and nausea. Most patients will not actually pass out, but some will if they are unable to lie down quickly enough. This condition is most prevalent in white females between the ages of 15 and 50 years old. Often these patients are hardworking, athletic, and otherwise in good health. There is a high clinical correlation between POTS and chronic fatigue syndrome. Although no single etiology for POTS has been found, the condition is thought to have a genetic predisposition, is often incited after a prolonged viral illness, and has a component of deconditioning. The recommended initial management is encouraging adequate fluid and salt intake, followed by the initiation of regular aerobic exercise combined with lower-extremity strength training, and then the use of β-blockers.

Front 53

Edit Preferred initial test for renovascular hypertension in patients with impaired renal function

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Duplex Doppler ultrasonography is the preferred initial test for renovascular hypertension in patients with impaired renal function. Tests involving intravenous radiographic contrast material may cause deterioration in renal function.

Front 54

Edit Presentation and treatment of ethylene glycol poisoning. 

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Ethylene glycol poisoning should be suspected in patients with metabolic acidosis of unknown cause and subsequent renal failure, as rapid diagnosis and treatment will limit the toxicity and decrease both morbidity and mortality. This diagnosis should be considered in a patient who appears intoxicated but does not have an odor of alcohol, and has anion gap acidosis, hypocalcemia, urinary crystals, and nontoxic blood alcohol levels. Ethylene glycol is found in products such as engine coolant, de-icing solution, and carpet and fabric cleaners. Ingestion of 100 mL of ethylene glycol by an adult can result in toxicity. The American Academy of Clinical Toxicology criteria for treatment of ethylene glycol poisoning with an antidote include a plasma ethylene glycol concentration >20 mg/dL, a history of ingesting toxic amounts of ethylene glycol in the past few hours with an osmolal gap >10 mOsm/kg H O2 (N 5–10), and strong clinical suspicion of ethylene glycol poisoning, plus at least two of the following: arterial pH <7.3, serum bicarbonate <20 mmol/L, or urinary oxalate crystals. Until recently, ethylene glycol poisoning was treated with sodium bicarbonate, ethanol, and hemodialysis. Treatment with fomepizole (Antizol) has this specific indication, however, and should be initiated immediately when ethylene glycol poisoning is suspected

Front 55

Edit Presentation and treatment of polymyalgia rheumatica

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Polymyalgia rheumatica is an inflammatory disorder that occurs in persons over the age of 50. White women of European ancestry are most commonly affected. The clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder and pelvic girdle. One review found that 4%–13% of patients with clinical polymyalgia rheumatica have a normal erythrocyte sedimentation rate (ESR). As many as 5% of patients initially have a normal ESR that later rises. Polymyalgia rheumatica can have a variety of systemic symptoms. Fever is common, with temperatures as high as 39°C (102°F) along with night sweats. Additional symptoms include depression, fatigue, malaise, anorexia, and weight loss. Corticosteroids are the mainstay of therapy for polymyalgia rheumatica. Typically, a dramatic response is seen within 48–72 hours.

Front 56

Edit Presentation and tx of intrahepatic cholestasis of pregnancy

Back 56

This patient’s symptoms and laboratory values are most consistent with intrahepatic cholestasis of pregnancy. Ursodiol has been shown to be highly effective in controlling the pruritus and decreased liver function (SOR A) and is safe for mother and fetus. Topical antipruritics and oral antihistamines are not very effective. 

Front 57

Edit Presentation of Giardiasis

Back 57

The diagnosis of giardiasis is suggested by its most characteristic symptoms: foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and the virtual absence of mucus or blood in the stool. Stools are usually mushy between exacerbations, though constipation may occur

Front 58

Edit Presentation of choledochal cyst

Back 58

A choledochal cyst  presents with the classic triad of right upper quadrant pain, jaundice, and a palpable mass

Front 59

Edit Presentation of cutaneous leishmaniasis

Back 59

he indolent course of the sore described favors the diagnosis of cutaneous leishmaniasis. Neither malaria nor schistosomiasis produces these sores. The chancres of syphilis and trypanosomiasis are more fleeting in duration.

Front 60

Edit Presentation of frozen shoulder

Back 60

Frozen shoulder is an idiopathic condition that most commonly affects patients between the ages of 40 and 60. Diabetes mellitus is the most common risk factor for frozen shoulder. Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain. Laboratory tests and plain films are normal; the diagnosis is clinical (SOR C). 

Front 61

Edit Presentation of henoch schonlein purpura

Back 61

Henoch-Schönlein purpura. This condition is associated with a palpable purpuric rash, without thrombocytopenia. Other diagnostic criteria include bowel angina (diffuse abdominal pain or bowel ischemia), age ≤20, renal involvement, and a biopsy showing predominant immunoglobulin A deposition. The long-term prognosis depends on the severity of renal involvement. 

Front 62

Edit Presentation of infectious cause of lower back pain

Back 62

Fevers, direct vertebral tenderness, recent infections, history of IV drug use. osteomyelitis, septic diskitis, paraspinous abcess, epidural abcess. Eval by CVC, ESR, MRI. IV abx and surgical drainage needed. 

Front 63

Edit Presentation of intussuseption

Back 63

 paroxysms of colicky abdominal pain. A mass is palpable in about two-thirds of patients.

Front 64

Edit Presentation of polycythemia vera

Back 64

Pruritus after a hot shower (aquagenic pruritus) and the presence of splenomegaly helps to clinically distinguish polycythemia vera from other causes of erythrocytosis (hematocrit >55%). Specific criteria for the diagnosis of polycythemia vera include an elevated red cell mass, a normal arterial oxygen saturation (>92%), and the presence of splenomegaly. In addition, patients usually exhibit thrombocytosis (platelet count >400,000/mm3 ), leukocytosis (WBC>12,000/mm3 ), a low serum erythropoietin level, and an elevated leukocyte alkaline phosphatase score. 

Front 65

Edit Presentation of pyogenic tenosynovitis. Treatment.

Back 65

Pain, redness, warmth, getting worse, pain increases with passive movement, tenderness to palpation. In hand. Tx. When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient’s infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics

Front 66

Edit Presentation of spinal stenosis

Back 66

Congenital or acquired spinal canal narrowing that puts pressure on the spinal cord. Lower back and leg pain, leg weakness, and pseudoclaudication (claudication like symptoms but normal vascular exam). Pain better with bending over or sitting. Tx: NSAIDS, pt, epidural corticosteroids

Front 67

Edit Presentation of superior mesenteric artery thrombosis

Back 67

The sudden onset of severe abdominal pain, vomiting, and diarrhea in a patient with a cardiac source of emboli and evidence of a separate embolic event makes superior mesenteric artery embolization likely. In this case, evidence of a brachial artery embolus and a cardiac rhythm indicating atrial fibrillation suggest the diagnosis. 

Front 68

Edit Presentation of vertebral compression fracutres. dx and tx

Back 68

Older patients and those with osteoporosis or chronic steroid use. Low impact or no trauma preceeds. Well localized pain to spine, brought on by sudden movements. Dx via plain xrays. Tx: Pain conrtrol with calcitonin or alendronate. Sx with vertebroplasty or kyphoplasty

Front 69

Edit Presentation of vocal cord dysfunction

Back 69

Vocal cord dysfunction is an idiopathic disorder commonly seen in patients in their twenties and thirties in which the vocal cords partially collapse or close on inspiration. It mimics, and is commonly mistaken for, asthma. Symptoms include episodic tightness of the throat, a choking sensation, shortness of breath, and coughing. A careful history and examination reveal that the symptoms are worse with inspiration than with exhalation, and inspiratory stridor during the episode may be mistaken for the wheezing of asthma. The sensation of throat tightening or choking also helps to differentiate it from asthma.

Front 70

Edit Presentation, dx, and tx of herniated disk

Back 70

sciatica: pain along path of sciatic nerve caused by herniated disk of lumbar region of the spine, radiate to buttocks and back of thigh. Increases with valsalva, sneezing, coughing, contralateral leg raise. No MRI unless sx last for more than 1 month, or if patient not a candidate for surgery or epidural injection. Tx: NSAIDS, short course seroids, avoidance of sitting. 

Front 71

Edit Presetation of NAFLD (non alcoholic fatty liver disease). 

Back 71

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver tests in the developed world. Its prevalence increases with age, body mass index, and triglyceride concentrations, and in patients with diabetes mellitus, hypertension, or insulin resistance. There is a significant overlap between metabolic syndrome and diabetes mellitus, and NAFLD is regarded as the liver manifestation of insulin resistance. Assoc. with metabolic syndrome

Front 72

Edit Prevention of altitude sickness

Back 72

Ginkgo biloba has been evaluated for both prevention and treatment of acute mountain sickness and high-altitude cerebral edema, and it is not recommended. Acetazolamide is an effective prophylactic agent (SOR B), but is contraindicated in patients with a sulfa allergy. If used, it should be started a minimum of one day before ascent and continued until the patient acclimatizes at the highest planned elevation. Dexamethasone is an effective prophylactic and treatment agent (SOR B), and it is not contraindicated for those with a sulfa allergy. It would be the best option for this patient.

Front 73

Edit Primary v secondary hyperparathyroidism

Back 73

This woman most likely has primary hyperparathyroidism due to a parathyroid adenoma or hyperplasia. Secondary hyperparathyroidism is unlikely with normal renal function, a normal vitamin D level, and hypercalcemia. Likewise, tertiary hyperparathyroidism is unlikely with normal renal function. The parathyroid hormone level is suppressed with hypercalcemia associated with bone metastases. Parathyroid hormone–related protein, produced by cancer cells in humoral hypercalcemia of malignancy, is not detected by the assay for parathyroid hormone.

Front 74

Edit Process of testing for Hep C

Back 74

 A positive enzyme immunoassay should be followed by a confirmatory test such as the recombinant immunoblot assay. If negative, it indicates a false-positive antibody test. If positive, the quantitative HCV RNA polymerase chain reaction is used to measure the amount of virus in the blood to distinguish active from resolved HCV infection. In this case, the results of the test indicate that the patient had a past infection with HCV that is now resolved.

Front 75

Edit Red flag for autism spectrum disorder

Back 75

No single words by 16 months of age. 

Front 76

Edit Screen for TB and Hep B

Back 76

C before starting what drugs? / TNF alpha inhibitors: Infliximab por ejemplo

Front 77

Edit Screening for osteoperosis

Back 77

All women ≥65 (SOR A) and all men ≥70 (SOR C) should be screened for osteoporosis. For men and women age 50–69, the presence of factors associated with low bone density would merit screening. Risk factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions.

Front 78

Edit Signs of malaria, Treatment

Back 78

appropriately targeted recent travel history, a prodrome of delirium or erratic behavior, unarousable coma following a generalized convulsion, fever, and a lack of focal neurologic signs in the presence of a diffuse, symmetric encephalopathy. The peripheral blood smear shows normochromic, normocytic anemia with Plasmodium falciparum trophozoites and schizonts involving erythrocytes, diagnostic of cerebral malaria. Treatment of this true medical emergency is intravenous quinidine gluconate.

Front 79

Edit Situations where meglitinides would be useful. What are they?

Back 79

Short acting secretogogues. Increase insulin secretion from pancreas. Good for when blood sugar varies at mealtime but who have overall controlled glucose levels. BAD for hepatid dysfunction. 

Front 80

Edit Steps in tresting older male with decreased sexual desire

Back 80

serum total testosterone level is recommended as the initial screening test for late-onset male hypogonadism. Due to its high cost, a free testosterone level is recommended only if the total testosterone level is borderline and abnormalities in sex hormone–binding globulin are suspected. Follow-up LH and FSH levels help to distinguish primary from secondary hypogonadism.

Front 81

Edit Sx and eval of stress fracture

Back 81

 little pain while at rest, but the pain intensifies with weight bearing and ambulation. History of intense exercise. lain radiographs should be the initial imaging modality because of availability and low cost (SOR C). These are usually negative initially, but are more likely to be positive over time. If the initial films are negative and the diagnosis is not urgently needed, a second plain radiograph can be performed in 2–3 weeks.

Front 82

Edit Sx, dx, and tx of cuada equina syndrome

Back 82

Increasing neuro deficits and leg weakness, bowel and urinary incontinence, sensory loss in a saddle distribution, and bilateral sciatica. Immediate eval with lumbar MRI, surgical decompresion of entrapped cuada equina, surgery. 

Front 83

Edit Symptoms and treatment of huntington's disease

Back 83

Autosomal dominant. Chorea, dysarthria, dysphasia. Comorbid depression common.  Treat chorea: haloperidol (but can make movement worse), resperpine, tatrabenazine, clonazepam. 

Front 84

Edit Target BP in diabetes

Back 84

130/80

Front 85

Edit Test for gait and balance disorder

Back 85

Correctly identifying gait and balance disorders helps guide management and may prevent consequences such as injury, disability, loss of independence, or decreased quality of life. The “Timed Up and Go” test is a reliable diagnostic tool for gait and balance disorders and is quick to administer. A time of <10 seconds is considered normal, a time of >14 seconds is associated with an increased risk of falls, and a time of >20 seconds usually suggests severe gait impairment.

Front 86

Edit Tests recommended for newly diagnosed diabetics

Back 86

fasting lipid profiles (at dx then yearly after), serum creatinine, urinalysis, urine microalbumin: creatinine ratios (at time of diagnosis and then annually in type II, In type I, after 5 years post diagnosis and then annually), annualy dilated eye exam, foot exams, EKG, TSH (in type I)

Front 87

Edit Tinea that requires oral treatment

Back 87

Dermatophyte infections caused by aerobic fungi produce infections in many areas. Tinea capitis requires systemic therapy to penetrate the affected hair shafts. Tinea cruris and tinea pedis rarely require systemic therapy. Extensive outbreaks of tinea corporis and tinea versicolor benefit from both oral and topical treatment (SOR A), but more localized infections require only topical treatment. Griseofulvin?

Front 88

Edit Tourette's disorder. Dx, treatment

Back 88

Most common tic disorder. Multiple motor and one or more vocal tics occuring several times a day for over one year.  Majority also have ADHD, OCD, and/or migraines.  Tx: Haloperidol, pimozide (antipsychotics). 

Front 89

Edit Treatmenet of deep vein thrombosis

Back 89

 Low molecular weight (lovenox) heparin should be given for 5 days, and an oral vitamin-K antagonist for at least 3 months.

Front 90

Edit Treatment for intermittent claudication

Back 90

stopped smoking and started a walking program. His LDL-cholesterol is at target levels; further lowering is not likely to improve his symptoms. In the presence of diffuse disease, interventional treatments such as angioplasty or surgery may not be helpful; in addition, these interventions should be reserved as a last resort. Cilostazol has been shown to help with intermittent claudication, but additional antiplatelet agents are not likely to improve his symptoms.

Front 91

Edit Treatment of Afib

Back 91

Atrial fibrillation is the most common arrhythmia, and its prevalence increases with age. The major risk with atrial fibrillation is stroke, and a patient’s risk can be determined by the CHADS 2 score. CHADS stands for Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and previous Stroke or transient ischemic attack. Each of these is worth 1 point except for stroke, which is worth 2 points. A patient with 4 or more points is at high risk, and 2–3 points indicates moderate risk. Having ≤1 point indicates low risk, and this patient has 0 points. Low-risk patients should be treated with aspirin, 81–325 mg daily (SOR B). Moderate-or high-risk patients should be treated with warfarin. Amiodarone is used for rate control, and clopidogrel is used for vascular events not related to atrial fibrillation.

Front 92

Edit Treatment of CKD

Back 92

The National Kidney Foundation and the American Society of Nephrology recommend treating most patients with CKD with an ACE inhibitor or angiotensin receptor blocker (ARB), plus a diuretic, with a goal blood pressure of <130/80 mm Hg. Most patients with CKD will require two drugs to reach this goal.

Front 93

Edit Treatment of IBS

Back 93

Daily use of peppermint oil has been shown to relieve symptoms.

Front 94

Edit Treatment of MRSA

Back 94

Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is resistant to β-lactam and macrolide antibiotics, and is showing increasing resistance to fluoroquinolones. FDA-approved treatments include clindamycin and doxycycline. Other commonly used treatments include minocycline and trimethoprim/sulfamethoxazole.

Front 95

Edit Treatment of acute cervical radiculopathy

Back 95

Patients who present with acute cervical radiculopathy and normal radiographs can be treated conservatively. The vast majority of patients with cervical radiculopathy improve without surgery. Of the interventions listed, NSAIDs are the initial treatment of choice. Tricyclic antidepressants, as well as tramadol and venlafaxine, have been shown to help with chronic neuropathic pain. Cervical MRI is not indicated unless there are progressive neurologic defects or red flags such as fever or myelopathy.

Front 96

Edit Treatment of antibiotic resistant depression

Back 96

Up to one-third of patients with unipolar depression will fail to respond to treatment with a single antidepressant, despite adequate dosing and an appropriate treatment interval. Lithium, triiodothyronine (T3 ), and atypical antipsychotics can all provide clinical improvement when used in conjunction with the ineffective antidepressant. The American Psychiatric Association and the Institute for Clinical Systems Improvement both recommend a trial of lithium or low-dose T 3 for patients who have an incomplete response to antidepressant therapy. A meta-analysis showed that a serum lithium level ≥0.5 mEq/L and a treatment duration of 2 weeks or greater resulted in a good response (SOR A).

Front 97

Edit Treatment of chronic plaque psoriasis

Back 97

This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. For patients with a history of previous stroke, JNC-7 recommends using combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke. Other classes of drugs have not been shown to be of benefit for secondary stroke prevention. 

Front 98

Edit Treatment of clavicular fracture in kid

Back 98

Fractures of the medial third of the clavicle in pediatric patients are common and are best treated by a figure-of-8 apparatus.

Front 99

Edit Treatment of community acquired pneumonia in children. 

Back 99

 Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal respiratory finding in the history or physical examination. Children under 2 years of age who are in day care are at higher risk for developing community-acquired pneumonia. Antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration. Streptococcus pneumoniae is one of the most common etiologies in this age group, and high-dose amoxicillin is the drug of choice.

Front 100

Edit Treatment of grade 2 and grade 33 ascites

Back 100

In patients with grade 2 ascites (visible clinically by abdominal distention, not just with ultrasonography), the initial treatment of choice is diuretics along with salt restriction. Aldosterone antagonists such as spironolactone are more effective than loop diuretics such as furosemide (SOR A). Chlorthalidone, a thiazide diuretic, is not recommended. Large-volume paracentesis is the recommended treatment of grade 3 ascites (gross ascites with marked abdominal distention), and is followed by salt restriction and diuretics.

Front 101

Edit Treatment of intox with calcium channel blocker

Back 101

 all children suspected of ingesting a calcium channel blocker should be admitted to a pediatric intensive-care unit for monitoring and management.

Front 102

Edit Treatment of jnursing home aquired pneumonia in hospital 

Back 102

should be suspected in patients with a new infiltrate on a chest radiograph if it is associated with a fever, leukocytosis, purulent sputum, or hypoxia. Nursing-home patients who are hospitalized for pneumonia should be started on intravenous antimicrobial therapy, with empiric coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. The 2005 American Thoracic Society/Infectious Diseases Society of America guideline recommends combination therapy consisting of an antipseudomonal cephalosporin such as cefepime or ceftazidime, an antipseudomonal carbapenem such as imipenem or meropenem, or an extended-spectrum β-lactam/β-lactamase inhibitor such as piperacillin/tazobactam, PLUS an antipseudomonal fluoroquinolone such as levofloxacin or ciprofloxacin, or an aminoglycoside such as gentamicin, tobramycin, or amikacin, PLUS an anti-MRSA agent (vancomycin or linezolid). Ceftazidime, levofloxacin and vancomycin

Front 103

Edit Treatment of patients with hypertension who had a previous stroke

Back 103

This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use specific classes of antihypertensives. For patients with a history of previous stroke, JNC-7 recommends using combination therapy with a diuretic and an ACE inhibitor to treat the hypertension, as this combination has been clinically shown to reduce the risk of recurrent stroke. Other classes of drugs have not been shown to be of benefit for secondary stroke prevention. 

Front 104

Edit Treatment of pneumothorax

Back 104

Studies have found that an average of 30% of patients will have a recurrence within 6 months to 2 years. An initial pneumothorax of <20% may be monitored if the patient has few symptoms. Follow-up should include a chest radiograph to assess stability at 24–48 hours. Indications for treatment include progression, delayed expansion, or the development of symptoms. The majority of patients with spontaneous pneumothoraces, and perhaps almost all of them, will have subcutaneous bullae on a CT scan.

Front 105

Edit Treatment of posteromedial tibial stress fracture. 

Back 105

Midshaft posteromedial tibial stress fractures are common and are considered low risk. Management consists of relative rest from running and avoiding other activities that cause pain. Once usual daily activities are pain free, low-impact exercise can be initiated and followed by a gradual return to previous levels of running. A pneumatic stirrup leg brace has been found to be helpful during treatment (SOR C). Non–weight bearing is not necessary, as this patient can walk without pain. 

Front 106

Edit Treatment of severe or refractory osteoporosis

Back 106

Teriparatide is indicated for the treatment of severe osteoporosis, for patients with multiple osteoporosis risk factors, or for patients with failure of bisphosphonate therapy (SOR B). Therapy with teriparatide is currently limited to 2 years and is contraindicated in patients with a history of bone malignancy, Paget disease, hypercalcemia, or previous treatment with skeletal radiation. It

Front 107

Edit Treatment of symptomatic atrial flutter

Back 107

Atrial flutter is not ordinarily a serious arrhythmia, but this patient has heart failure manifested by rales, jugular venous distention, hepatojugular reflux, hypotension, and angina. Electrical cardioversion should be performed immediately. This is generally a very easy rhythm to convert. Digoxin and verapamil are appropriate in hemodynamically stable patients. A pacemaker for rapid atrial pacing may be beneficial if digitalis intoxication is the cause of atrial flutter, but this is unlikely in a patient with no previous history of cardiac problems. Amiodarone is not indicated in this clinical situation.

Front 108

Edit Treatment of urethritis in men

Back 108

the initial workup for urethritis in men includes gonorrhea and Chlamydia testing of the penile discharge or urine, urinalysis with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing. Empiric treatment for men with a purulent urethral discharge or a positive urine test (positive leukocyte esterase or ≥10 WBCs/hpf in the first-void urine sediment) includes azithromycin, 1 g orally as a single dose, OR doxycycline, 100 mg orally twice a day for 7 days, PLUS ceftriaxone, 125 mg intramuscularly, OR cefixime, 400 mg orally as a single dose. If the patient presents with the same complaint within 3 months, and does not have a new sexual partner, the tests obtained at his first visit should be repeated, and consideration should be given to obtaining cultures for Mycoplasma or Ureaplasma and Trichomonas from the urethra or urine. Treatment should include azithromycin, 500 mg orally once daily for 5 days, or doxycycline, 100 mg orally twice daily for 7 days, plus metronidazole, 2 g orally as a single dose.

Front 109

Edit Treatment that can lower potassium rapidly

Back 109

Insulin and glucose intravenously will provide the fastest and most consistent early lowering of serum potassium (SOR C). Calcium is important for arrhythmia prevention, but does not lower the potassium level. Sodium polystyrene sulfonate given orally or rectally will only lower potassium in a delayed fashion.

Front 110

Edit What can lithium cause?

Back 110

Hypothyroidism (weaknes, dry skin, slow speech, eyelid edema)

Front 111

Edit What can subclinical thyroid dysfunction cause?

Back 111

Low or high TSH. Can cause elevated LDL cholesterol 

Front 112

Edit What is the best way to treat A fib?

Back 112

Beta or calcium channel blocker (rate control) + warfarin

Front 113

Edit What to do to limit oxalate stone formation. 

Back 113

Calcium oxalate stones are the most common of all renal calculi. A low-sodium, restricted-protein diet with increased fluid intake reduces stone formation. A low-calcium diet has been shown to be ineffective. Oxalate restriction also reduces stone formation. Oxalate-containing foods include spinach, chocolate, tea, and nuts, but not yellow vegetables. Potassium citrate should be taken at mealtime to increase urinary pH and urinary citrate (SOR B).

Front 114

Edit What to give older patients with previous stroke during surgery?

Back 114

Beta blocker (atenolol) before and after surgery. 

Front 115

Edit When to introduce solid foods?

Back 115

4-6 months

Front 116

Edit When to use beta blockers in diabetics

Back 116

β-Blockers are recommended for patients with diabetes mellitus who also have a history of myocardial infarction, heart failure, coronary artery disease, or stable angina (SOR A)

Front 117

Edit Why get Tdap?

Back 117

Tetanus vaccine is indicated for adults with clean minor wounds who have received fewer than three previous doses of tetanus toxoid, or whose immune status is unknown. Tetanus immune globulin is not recommended if the wound is clean. The CDC recommends that adults aged 65 years and older who have not received Tdap and are likely to have close contact with an infant less than 12 months of age (e.g., grandparents, child-care providers, and health-care practitioners) should receive a single dose to protect against pertussis and reduce the likelihood of transmission. For other adults aged 65 years and older, a single dose of Tdap vaccine should be given instead of a scheduled dose of Td vaccine if they have not previously received Tdap. Tdap can be administered regardless of the interval since the last vaccine containing tetanus or diphtheria toxoid, and either Tdap vaccine product may be used. After receiving Tdap, persons should continue to receive Td for routine booster immunizations against tetanus and diphtheria, according to previously published guidelines.

Front 118

Edit Workup for child with suspicion of autism spectrum disorder

Back 118

Level 1 standard autism specific screening tool. Refer to comprehensive ASD eval, audiologic eval, and early intervention/early childhood education services. 

Front 119

Edit Workup for patient with bowel issues and family history of IBD

Back 119

The diagnosis of inflammatory bowel disease (IBD) can be elusive but relies primarily on the patient history, laboratory findings, and endoscopy (or double-contrast radiographs if endoscopy is not available). Endoscopy is usually reserved for patients with more severe symptoms or in whom preliminary testing shows the potential for significant inflammation. It is recommended that this preliminary evaluation include a WBC count, platelet count, potassium level, and erythrocyte sedimentation rate.

Front 120

Edit Workup of positive protein on urine dipstick. 

Back 120

When proteinuria is noted on a dipstick and the history, examination, full urinalysis, and serum studies suggest no obvious underlying problem or renal insufficiency, a urine protein/creatinine ratio is recommended. This test correlates well with 24-hour urine protein, which is particularly difficult to collect in a younger patient. Renal ultrasonography is appropriate once renal insufficiency or nephritis is established. If pathogenic proteinuria is confirmed, an antinuclear antibody and/or complement panel may be indicated. 

Front 121

Edit Workup of woman with hirsutism

Back 121

Elevated early morning total testosterone is most often associated with polycystic ovary syndrome, but other causes of hyperandrogenism and other endocrinopathies should be eliminated. These studies should include pregnancy testing if the patient has amenorrhea, as well as a serum prolactin level to exclude hyperprolactinemia. DHEA-S and early morning 17-hydroxyprogesterone can detect adrenal hyperandrogenism and congenital adrenal hyperplasia. Assessment for Cushing syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present. Pelvic ultrasonography can be performed to evaluate for ovarian neoplasm or polycystic ovaries, although PCOS is a clinical diagnosis and ultrasonography has a low sensitivity.

Front 122

Edit eval of pulmonary nodules

Back 122

Solitary pulmonary nodules are common radiologic findings, and the differential diagnosis includes both benign and malignant causes. The American College of Chest Physicians guidelines for evaluation of pulmonary nodules are based on size and patient risk factors for cancer. Lesions ≥8 mm in diameter with a “ground-glass” appearance, an irregular border, and a doubling time of 1 month to 1 year suggest malignancy, but smaller lesions should also be evaluated, especially in a patient with a history of smoking. CT is the imaging modality of choice to reevaluate pulmonary nodules seen on a radiograph (SOR C). PET is an appropriate next step when the cancer pretest probability and imaging results are discordant (SOR C). Patients with notable nodule growth during follow-up should undergo a biopsy (SOR C).

Front 123

Edit presenation and management of possible underlying cancer in back pain

Back 123

Hx of cancer, unexplained weight loss, no improvement after 1 month of therapy, or age over 50 yo. CBC, ESR, and plain radiographs first, if abnormal, do MRI and/or bone scan. Multiple myeloma, metastatic prostate, breast, lung. 

Front 124

Edit presentation of vsd

Back 124

Ventricular septal defect causes overload of both ventricles, since the blood is shunted left to right. The murmur is harsh and holosystolic, generally heard best at the lower left sternal border. As the volume of the shunting increases, cardiac enlargement and increased pulmonary vascular markings can be seen on a chest radiograph.

Front 125

Edit primary tx for mitral valve prolapse

Back 125

The primary treatment for symptomatic mitral valve prolapse is β-blockers

Front 126

Edit procedure for working up child with low hemoglobin

Back 126

The patient’s response to a therapeutic trial of iron would be most  helpful in establishing the diagnosis. Additional tests might be necessary if there is no response.

Front 127

Edit sx of central retinal artery occlusion

Back 127

he painless, unilateral, sudden loss of vision over a period of seconds may be caused by thrombosis, embolism, or vasculitis.

Front 128

Edit treatment of cat scratch diease. presentation

Back 128

Azithromycin has been shown to reduce the duration of lymphadenopathy in cat-scratch disease (SOR B). Other antibiotics that have been used include rifampin, ciprofloxacin, trimethoprim/sulfamethoxazole, and gentamicin. 

Front 129

Absolute contraindication to use of ACE inhibitors

Back 129

Angioneurotic edema can be life-threatening, and ACE inhibitors should not be given to patients with a history of this condition from any cause. 

Front 130

Edit Blood result that is diagnostic for iron deficiency anemia

Back 130

low serum ferritin

Front 131

Edit Chronic excess thyroid hormone replacement over a number of years in postmenopausal women can lead to: 

Back 131

Osteoperosis

Front 132

Edit Growth chart findings in Cystic Fibrosis

Back 132

Bone age and height age equivilant but lagging behind chronologic age

Front 133

Edit Growth chart findings in child with hypothyroidism

Back 133

Delayed bone age relative to height age and chronologic age

Front 134

Edit Growth chart findings in kids with chromosomal issues or maternal substance abuse

Back 134

Height age delayed relative to bone age. 

Front 135

Edit Indications for parathyroid surgery in a patient with increased calcium level with elevated parathyroid hormone level

Back 135

Indications for parathyroid surgery include kidney stones, age less than 50, a serum calcium level greater than 1 mg/dL above the upper limit of normal, and reduced bone density.

Front 136

Benifits of eradicating H. Pylori in patients with ulcers

Back 136

significantly reduces the risk of ulcer recurrence and rebleeding in patients with duodenal ulcer, and reduces the risk of peptic ulcer development in patients on chronic NSAID therapy

Front 137

Edit Best study to diagnose gallstones

Back 137

Abdominal ultrasonography is considered the best study to confirm this diagnosis because of its high sensitivity and its accuracy in detecting gallstones.

Front 138

Edit Cancer screening guidelines for patients with UC

Back 138

  Initial colonoscopy for patients with pancolitis of 8-10 years duration (regardless of the patient's age) should be followed up with surveillance examinations every 1-2 years, even if the disease is in remission. 

Front 139

Edit Criteria for Hep C screening

Back 139

 if they have a history of any of the following: intravenous drug abuse no matter how long or how often, receiving clotting factor produced before 1987, persistent alanine aminotransferase elevations, or recent needle stick with HCV-positive blood.

Front 140

Edit Diarrheal bugs that can resist chlorine in water. 

Back 140

Cryptosporidium oocysts and Giardia cysts are resistant to chlorine and are important causes of gastroenteritis from drinking water. Entamoeba histolytica and hepatitis A virus are also relatively chlorine resistant. 

Front 141

Edit Elevated Homovanillic acid? (HVA) and VMA? hcG? Alpha fetoprotein?

Back 141

. Serum neuron-specific enolase (NSE) testing, as well as spot urine testing for homovanillic acid (HVA) and vanillylmandelic acid (VMA), should be obtained if neuroblastoma or pheochromocytoma is suspected; both should be collected before surgical intervention. Quantitative beta-human chorionic gonadotropin (hCG) levels can be elevated in liver tumors and germ cells tumors. Alpha-fetoprotein is excreted by many malignant teratomas and by liver and germ cell tumors. 

Front 142

Edit First and second line treament for C. diff

Back 142

1: metronidazole, 2: vancomycin oral 

Front 143

Edit Gilbert's syndrome. Characteristics

Back 143

Most common inherited disorder of bilirubin metabolism. In patients with a normal CBC and liver function tests, except for recurrent mildly elevated total and unconjugated hyperbilirubinemia, the most likely diagnosis is Gilbert’s syndrome.

Front 144

Edit Leading cause of bacterial diarrhea in the usa

Back 144

Campylobacter jejuni

Front 145

Edit Next step in eval of patient with RLQ pain

Back 145

If nonpreg women and if not a high degree of suspicion of gyn disease, do CT. If yes, do ultrasound

Front 146

Edit Physical findings and next step in patient with recent onset ascites. Findings diagnostic for spontaneous bacterial peritonitis. 

Back 146

Clues are pre-existing cirrhosis. Diffuse abdominal discomfort, fever, night sweats. Soft abdoman, vague tenderness in all quadrants. No rebound or gaurding.  Diagnostic paracentesis is recommended for patients with ascites of recent onset, as well as for those with chronic ascites who present with new clinical findings such as fever or abdominal pain. A neutrophil count >250/mL is diagnostic for peritonitis. Once peritonitis is diagnosed, antibiotic therapy should be started immediately without waiting for culture results.

Front 147

Edit Presentation and diagnosis of zenker's diverticulum

Back 147

The combination of halitosis, late regurgitation of undigested food, and choking suggests Zenker’s diverticulum. Patients may also have dysphagia and weight loss. The diagnosis is usually made with a barium swallow. The treatment is surgical.

Front 148

Edit Presentation and dx of hypertrophic pyloric stenosis

Back 148

Hypertrophic pyloric stenosis is a narrowing of the pyloric canal caused by hypertrophy of the musculature.  It usually presents during the third to fifth weeks of life.  Projectile vomiting after feeding, weight loss, and dehydration are common.  The vomitus is always nonbilious, because the obstruction is proximal to the duodenum.  If a small olive-size mass cannot be felt in the right upper or middle quadrant, ultrasonography will confirm the diagnosis. 

Front 149

Edit Presentation and dx of intusseption

Back 149

Intussusception is seen most frequently between the ages of 3 months and 5 years, with 60% of cases occurring in the first year and a peak incidence at 6-11 months of age.  The disorder occurs predominantly in males.  The classic triad of intermittent colicky abdominal pain, vomiting, and bloody, mucous stools is encountered in only 20%-40% of cases.  At least two of these findings will be present in approximately 60% of patients.  The abdomen may be distended and tender, and there may be an elongated mass in the right upper or lower quadrants.  Rectal examination may reveal either occult blood or frankly bloody, foul-smelling stool, classically described as currant jelly.  An air enema using fluoroscopic guidance is useful for both diagnosis and treatment

Front 150

Edit Presentation and tx of infantile colic

Back 150

 usually begins during the second week of life and typically occurs in the evening.  It is characterized by screaming episodes and a distended or tight abdomen.  Its etiology has yet to be determined.  There are no abnormalities on physical examination and ancillary studies, and symptoms usually resolve spontaneously around 12 weeks of age.

Front 151

Edit Presentation of meckels diverticulum

Back 151

Meckels diverticulum is the most common congenital abnormality of the small intestine.  It is prone to bleeding because it may contain heterotopic gastric mucosa.  Abdominal pain, distention, and vomiting may develop if obstruction has occurred, and the presentation may mimic appendicitis. 

Front 152

Edit Presentation, dx of volvulus

Back 152

may present in one of three ways:  as a sudden onset of bilious vomiting and abdominal pain in a neonate; as a history of feeding problems with bilious vomiting that appears to be a bowel obstruction; or less commonly, as failure to thrive with severe feeding intolerance.  The classic finding on abdominal plain films is the double bubble sign, which shows a paucity of gas (airless abdomen) with two air bubbles, one in the stomach and one in the duodenum.  However, the plain film can be entirely normal.  The upper gastrointestinal contrast study is considered the gold standard for diagnosing volvulus.

Front 153

Edit Presentation, dx, of necrotizing enterocolitis in infant

Back 153

typically seen in the distressed neonate in the intensive-care nursery, but it may occasionally be seen in the healthy neonate within the first 2 weeks of life.  The child will appear ill, with symptoms including irritability, poor feeding, a distended abdomen, and bloody stools.  Abdominal plain films will show pneumatosis intestinalis, caused by gas in the intestinal wall, which is diagnostic of the condition.

Front 154

Edit Presentations of celiac disease

Back 154

Half the adults in the U.S. with celiac disease or gluten-sensitive enteropathy present with anemia or osteoporosis, without gastrointestinal symptoms. Individuals with more significant mucosal involvement present with watery diarrhea, weight loss, and vitamin and mineral deficiencies.

Front 155

Edit Prophylaxis of patients with past history of postop venous thromboembolism undergoing another major surgery

Back 155

A patient with a past history of postoperative venous thromboembolism is at risk for similar events with subsequent major operations. The most appropriate treatment of the choices listed would be subcutaneous enoxaparin. 

Front 156

Edit Risk factors for Hep C and protocol for partner of infected patient. 

Back 156

Key risk factors for hepatitis C infection are long-term hemodialysis, intravenous drug use, blood transfusion or organ transplantation prior to 1992, and receipt of clotting factors before 1987. Sexual transmission is very low but possible, and the likelihood increases with multiple partners. The lifetime transmission risk of hepatitis C in a monogamous relationship is less than 1%, but the patient should be offered testing because she may choose to confirm that her test is negative

Front 157

Edit Risk factors for acute pancreatitis

Back 157

Gallstones, extreme hypertriglyceridemia, and excessive alcohol use

Front 158

Edit Rotatvirus vaccine schedule

Back 158

 routine vaccination of infants with three doses to be given at 2, 4, and 6 months of age.  The first dose should be given between 6 and 12 weeks of age, and subsequent doses should be given at 4- to 10-week intervals, but all three doses should be administered by 32 weeks of age.  

Front 159

Edit Treatment of thrombosed external hemmoroid

Back 159

a thrombosed hemorrhoid presenting within 48 hours of onset of symptoms is an elliptical excision of the hemorrhoid and overlying skin under local anesthesia 

Front 160

Edit What cancer is alpha fetoprotein a marker for? 

Back 160

Alpha-tetoprotein is a marker for hepatocellular carcinoma and nonseminomatous germ cell tumor, and is elevated in 80% of hepatocellular carcinomas. 

Front 161

Edit What cancers is CEA a marker for?

Back 161

 Carcinoembryonic antigen (CEA) is a marker for colon, esophageal, and hepatic cancers. It is expressed in normal mucosal cells and is overexpressed in adenocarcinoma, especially colon cancer. Though not specific for colon cancer, levels above 10 ng/mL are rarely due to benign disease. CEA levels typically return to normal within 4–6 weeks after successful surgical resection. CEA elevation occurs in nearly half of patients with a normal preoperative CEA level that have cancer recurrence.

Front 162

Edit What to do if exposed to Hep B with needlestick

Back 162

Postexposure prophylaxis after hepatitis B exposure via the percutaneous route depends upon the source of the exposure and the vaccination status of the exposed person. In the case described, a vaccinated person has been exposed to a known positive individual. The exposed person should be tested for hepatitis B antibodies; if antibody levels are inadequate (<10 IU/L by radioimmunoassay, negative by enzyme immunoassay) HBIG should be administered immediately, as well as a hepatitis B vaccine booster dose. An unvaccinated individual in this same setting should receive HBIG immediately (preferably within 24 hours after exposure) followed by the hepatitis B vaccine series (injection in 1 week or less, followed by a second dose in 1 month and a third dose in 6 months

Front 163

Edit What to do with infants born to Hep B positive mothers. When to test baby for seroconversion?

Back 163

Infants born to hepatitis B–positive mothers should receive both immune globulin and hepatitis B vaccine. They should receive the entire series of the vaccine, with testing for seroconversion only after completion of the vaccination series; the recommended age for testing is 9–12 months of age. 

Front 164

Presentation and treatment of polymyalgia reumatica

Back 164

There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica. Joint swelling occurs occasionally, but neither swelling nor early morning stiffness is necessary to make the diagnosis. Polymyalgia rheumatica does not respond to NSAIDs. The erythrocyte sedimentation rate should be ≥40 mm/hr.

Front 165

Treatment of aortic stenosis

Back 165

Watchful waiting is recommended for most patients with asymptomatic aortic stenosis, including those with severe disease (SOR B).

Front 166

Eval of pulm nodule

Back 166

Pulmonary nodules are a common finding on routine studies, including plain chest radiographs, and require evaluation. Radiographic features of benign nodules include a diameter <5 mm, a smooth border, a solid appearance, concentric calcification, and a doubling time of less than 1 month or more than 1 year. Features of malignant nodules include a size >10 mm, an irregular border, a “ground glass” appearance, either no calcification or an eccentric calcification, and a doubling time of 1 month to 1 year (SOR B).

Front 167

Treatment of hypothyroidism in pregnancy

Back 167

Because of hormonal and metabolic changes in early pregnancy, the levothyroxine dosage often needs to be increased at 4–6 weeks gestation, and the patient eventually may require a 30%–50% increase in dosage in order to maintain her euthyroid status.

Front 168

Treatment of rotator cuff tear

Back 168

Surgery for rotator cuff tears is most beneficial in young, active patients. In cases of acute, traumatic, complete rotator cuff tears, repair is recommended in less than 6 weeks, as muscle atrophy is associated with reduced surgical benefit (SOR B). Advanced age and limited strength are also associated with reduced surgical benefit.

Front 169

When to give aspirin????

Back 169

The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin use for males 45–79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage, and for females 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage

Front 170

When to switch from rear facing to front facing car seat

Back 170

The U.S. Preventive Services Task Force (USPSTF) recommends daily aspirin use for males 45–79 years of age when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage, and for females 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage

Front 171

Treatment of fibromyalgia

Back 171

A meta-analysis of antidepressant medications for the treatment of fibromyalgia syndrome concluded that short-term use of amitriptyline and duloxetine can be considered for the treatment of pain and sleep disturbance in patients with fibromyalgia.

Front 172

Aortic transection injury

Back 172

eceleration-type blows to the chest can produce partial or complete transection of the aorta. A chest radiograph shows an acutely widened mediastinum and/or a pleural effusion when the condition is severe.

Front 173

Tx of wheezing 10 week old

Back 173

While the guideline does not support routine use of bronchodilators in the management of bronchiolitis, it does allow for a trial of bronchodilators as an option in selected cases, and continuation of the treatment if the patient shows objective improvement in respiratory status. Bronchodilators have not been shown to affect the course of bronchiolitis with respect to outcomes.

Front 174

Screening for colon cancer in high risk individuals

Back 174

A history of a first degree relative diagnosed with colon cancer before age 60 predicts a higher lifetime incidence of colorectal cancer (CRC) and a higher yield on colonoscopic screening. The overall colon cancer risk for these persons is three to four times that of the general population. Screening should consist of colonoscopy, beginning either at age 40 or 10 years before the age at diagnosis of the youngest affected relative, whichever comes first.

Front 175

Presentation of dermatomyositis

Back 175

One of the most characteristic findings in dermatomyositis is Gottron’s papules, which are flat-topped, sometimes violaceous papules that often occur on most, if not all, of the knuckles and interphalangeal joints.

Front 176

Treatment of SVT (narrow complex tachycardia)

Back 176

After vagal maneuvers are attempted in a stable patient with supraventricular tachycardia, the patient should be given a 6-mg dose of adenosine by rapid intravenous push. If conversion does not occur, a 12-mg dose should be given. This dose may be repeated once. If the patient is unstable, immediate synchronized cardioversion should be administered.

Front 177

Treatment of TB

Back 177

Standard regimens including INH, ethambutol, rifampin, and pyrazinamide are recommended, although one regimen does not include pyrazinamide but extends coverage with the other antibiotics. Treatment regimens can be modified once culture results are available.

Front 178

Workup of adrenal mass

Back 178

The incidental discovery of adrenal masses presents a common clinical challenge. Such masses are found on abdominal CT in 4% of cases, and the incidence of adrenal masses increases to 7% in adults over 70 years of age. While the majority of masses are benign, as many as 11% are hypersecreting tumors and approximately 7% are malignant tumors; the size of the mass and its appearance on imaging are major predictors of malignancy. Once an adrenal mass is identified, adrenal function must be assessed with an overnight dexamethasone suppression test. A morning cortisol level >5 μg/dL after a 1-mg dose indicates adrenal hyperfunction. Additional testing should include 24-hour fractionated metanephrines and catecholamines to rule out pheochromocytoma. If the patient has hypertension, morning plasma aldosterone activity and plasma renin activity should be assessed to rule out a primary aldosterone-secreting adenoma.

Nonfunctioning masses require assessment with CT attenuation, chemical shift MRI, and/or scintigraphy to distinguish malignant masses. PET scanning is useful to verify malignant disease. Nonfunctioning benign masses can be monitored for changes in size and for the onset of hypersecretory states, although the appropriate interval and studies are controversial. MRI may be preferred over CT because of concerns about excessive radiation exposure. Fine-needle aspiration of the mass can be performed to differentiate between adrenal and non-adrenal tissue after malignancy and pheochromocytoma have been excluded.

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Treatment of Diabetes in pregos

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There is strong evidence that such treatment to maintain fasting plasma glucose levels below 95 mg/dL and 1-hour postprandial levels below 140 mg/dL results in improved fetal well-being and neonatal outcomes. While oral therapy with metformin or glyburide is considered safe and possibly effective, insulin therapy is the best option for the pharmacologic treatment of gestational diabetes. Thiazolidinediones such as pioglitazone have not been shown to be effective or safe in pregnancy.

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Dx of schogren's

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It results from lymphocytic infiltration of exocrine glands and leads to acinar gland degeneration, necrosis, atrophy, and decreased function. A positive anti-SS-A or anti-SS-B antigen test or a positive salivary gland biopsy is a criterion for classification of this diagnosis. In addition to ocular and oral complaints, clinical manifestations include arthralgias, thyroiditis, pulmonary disease, and GERD.

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Treatment of endocarditis

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This patient has endocarditis caused by a gram-positive coccus. Until sensitivities of the organism are known, treatment should include intravenous antibiotic coverage for Enterococcus, Streptococcus, and methicillin-sensitive and methicillin-resistant Staphylococcus. A patient who does not have a prosthetic valve should be started on vancomycin and gentamicin, with monitoring of serum levels. Enterococcus and methicillin-resistant Staphylococcus are often resistant to cephalosporins. If the organism proves to be Staphylococcus sensitive to nafcillin, the patient can be switched to a regimen of nafcillin and gentamicin.

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Dx and tx of dysthymia

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Psychological disorders, including anxiety, depression, and dysthymia, are frequently confused with premenstrual syndrome (PMS), and must be ruled out before initiating therapy. Symptoms are cyclic in true PMS. The most accurate way to make the diagnosis is to have the patient keep a menstrual calendar for at least two cycles, carefully recording daily symptoms. Dysthymia consists of a pattern of ongoing, mild depressive symptoms that have been present for 2 years or more and are less severe than those of major depression. This diagnosis is consistent with the findings in the patient described here.

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Eval of enlarged lymph node

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Immediate biopsy is warranted if the patient does not have inflammatory symptoms and the lymph node is >3 cm, if the node is in the supraclavicular area, or if the patient has coexistent constitutional symptoms such as night sweats or weight loss. Immediate evaluation is also indicated if the patient has risk factors for malignancy. Treatment with antibiotics is warranted in patients who have inflammatory symptoms such as pain, erythema, fever, or a recent infection.

In a patient with no risk factors for malignancy and no concerning symptoms, monitoring the node for 4–6 weeks is recommended. If the node continues to enlarge or persists after this time, then further evaluation is indicated. This may include a biopsy or imaging with CT or ultrasonography. The utility of serial ultrasound examinations to monitor lymph nodes has not been demonstrated.

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Treatment of STEMI

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This patient has an ST-segment elevation myocardial infarction (STEMI). STEMI is defined as an ST-segment elevation of greater than 0.1 mV in at least two contiguous precordial or adjacent limb leads. The most important goal is to begin fibrinolysis less than 30 minutes after the first contact with the health system. The patient should be given oral clopidogrel, and should also chew 162–325 mg of aspirin.

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Treatment of refractory htn

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Resistant or refractory hypertension is defined as a blood pressure ≥140/90 mm Hg, or ≥130/80 mm Hg in patients with diabetes mellitus or renal disease (i.e., with a creatinine level >1.5 mg/dL or urinary protein excretion >300 mg over 24 hours), despite adherence to treatment with full doses of at least three antihypertensive medications, including a diuretic. JNC 7 guidelines suggest adding a loop diuretic if serum creatinine is >1.5 mg/dL in patients with resistant hypertension.

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Dupuytren’s contracture

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Dupuytren’s contracture is characterized by changes in the palmar fascia, with progressive thickening and nodule formation that can progress to a contracture of the associated finger. The fourth finger is most commonly affected. Pitting or dimpling can occur over the nodule because of the connection with the skin.

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thyroid nodule workup

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All patients who are found to have a thyroid nodule on a physical examination should have their TSH measured. Patients with a suppressed TSH should be evaluated with a radionuclide thyroid scan; nodules that are “hot” (show increased isotope uptake) are almost never malignant and fine-needle aspiration biopsy is not needed. For all other nodules, the next step in the workup is a fine-needle aspiration biopsy to determine whether the lesion is malignant (SOR B).

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When to do lovenox prophylaxis

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Prophylaxis is generally recommended for patients over the age of 40 who have limited mobility for 3 days or more and have at least one of the following risk factors: acute infectious disease, New York Heart Association class III or IV heart failure, acute myocardial infarction, acute respiratory disease, stroke, rheumatic disease, inflammatory bowel disease, previous venous thromboembolism, older age (especially >75 years), recent surgery or trauma, immobility or paresis, obesity (BMI >30 kg/m2), central venouscatheterization, inherited or acquired thrombophilic disorders, varicose veins, or estrogen therapy.

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presentation of lung abcess

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Anaerobic lung abscesses are most often found in a person predisposed to aspiration who complains of a productive cough associated with fever, anorexia, and weakness. Physical examination usually reveals poor dental hygiene, a fetid odor to the breath and sputum, rales, and pulmonary findings consistent with consolidation.

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Treatment of status epilepticus

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Lorazepam, 0.1–0.15 mg/kg intravenously, should be given as anticonvulsant therapy after cardiopulmonary resuscitation. This is followed by phenytoin, given via a dedicated peripheral intravenous line. Fosphenytoin, midazolam, or phenobarbital can be used if there is no response to lorazepam

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Osteoporosis drug that can decrease risk of invasive breast cancer

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Raloxifene is a selective estrogen receptor modulator. While it increases the risk of venous thromboembolism, it is indicated in this patient to decrease the risk of invasive breast cancer (SOR A

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Presentation of retinal detachment

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In a patient complaining of flashes of light and a visual field defect, retinal detachment is the most likely diagnosis. Many cases of vitreous detachment are asymptomatic, and it does not cause sudden visual field defects in the absence of a retinal detachment. A vitreous hemorrhage would cause more blurring of vision in the entire field of vision. Ocular migraine causes binocular symptoms.

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Drug that can decrease PSA

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Finasteride has considerable efficacy in treating obstructive symptoms, but it unfortunately falsely depresses PSA levels. In patients taking finasteride, this can affect the evaluation for carcinoma of the prostate.

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Presentation of subacute, sclerosing panecephalitis

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Subacute sclerosing panencephalitis usually occurs in children and young adults between the ages of 4 and 20 years and is characterized by deterioration in behavior and work. The most characteristic neurologic sign is mild clonus.

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Workup of child with microcytic anemia

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This patient has a microcytic, hypochromic anemia, which can be caused by iron deficiency, thalassemia, sideroblastic anemia, and lead poisoning. In a child with a microcytic anemia who does not respond to iron therapy, hemoglobin electrophoresis is appropriate to diagnose thalassemia.

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Presentation of Somatization Disorder

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Somatization disorder is a psychological disorder characterized by the chronic presence of several unexplained symptoms beginning before the age of 30 years. It is diagnostically grouped with conversion disorder, hypochondriasis, and body dysmorphic disorder. By definition, the symptom complex must include a minimum of two symptoms relating to the gastrointestinal system, one neurologic complaint, one sexual complaint, and four pain complaints. The condition is more common in women than in men, and the incidence is increased as much as tenfold in female first degree relatives of affected patients.

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How to ID a child who is dehydrated

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The most useful findings for identifying dehydration are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern (SOR C). Capillary refill time is not affected by fever and should be less than 2 seconds. Skin recoil is normally instantaneous, but recoil time increases linearly with the degree of dehydration. The respiratory pattern should be compared with age-specific normal values, but will be increased and sometimes labored, depending on the degree of dehydration.
n combination with other clinical indicators, a low serum bicarbonate level (<17 mmol/L) is helpful in identifying children who are dehydrated, and a level <13 mmol/L is associated with an increased risk of failure of outpatient rehydration efforts.

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Eval of patient with active hematochezia

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A blood pool scan allows repeated scanning over a prolonged period of time, with the goal of permitting enough accumulation of the isotope to direct the arteriographer to the most likely source of the bleeding. If the scan is negative, arteriography would be unlikely to reveal the active source of bleeding, and is also a more invasive procedure. Exploratory laparotomy may be indicated if a blood pool scan or an arteriogram is nondiagnostic and the patient continues to bleed heavily.

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tx of CO poisoning

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Patients with carbon monoxide poisoning should be treated immediately with normobaric oxygen, which speeds up the excretion of carbon monoxide.
Ref: Weaver LK: Carbon monox

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Treatment of multiple myeloma

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This patient has smoldering (asymptomatic) multiple myeloma. He does not have any organ or tissue damage related to this disease and has no symptoms. Early treatment of these patients does not improve mortality (SOR A) and may increase the likelihood of developing acute leukemia. The standard treatment for symptomatic patients under age 65 is autologous stem cell transplantation. Patients over 65 who are healthy enough to undergo transplantation would also be appropriate candidates. Patients who are not candidates for autologous stem cell transplantation generally receive melphalan and prednisolone with or without thalidomide. Radiotherapy can be used to relieve metastatic bone pain or spinal cord compression.

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Treatment of chronic nonspecific back pain

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This patient has nonspecific chronic back pain, most likely a lumbar strain or sprain. In addition to analgesics (e.g., acetaminophen or NSAIDs) (SOR A) and spinal manipulation (SOR B), a multidisciplinary rehabilitation program is the best choice for management (SOR A). This program includes a physician and at least one additional intervention (psychological, social, or vocational). Such programs alleviate subjective disability, reduce pain, return the person to work earlier, and reduce the amount of sick time taken in the first year by 7 days. Benefits persist for up to 5 years. Back school, TENS, and SSRIs have been found to have negative or conflicting evidence of effectiveness (SOR C). There is no evidence to support the use of epidural corticosteroid injections in patients without radicular signs or symptoms (SOR C).

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Presentation and treatment of urethritis in males

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This patient has epididymitis. In males 14–35 years of age, the most common causes are Neisseria gonorrhoeae and Chlamydia trachomatis. The recommended treatment in this age group is ceftriaxone, 250 mg intramuscularly, and doxycycline, 100 mg twice daily for 10 days (SOR C). A single 1-g dose of azithromycin may be substituted for doxycycline. In those under age 14 or over age 35, the infection is usually caused by one of the common urinary tract pathogens, and levofloxacin, 500 mg once daily for 10 days, would be the appropriate treatment (SOR C).

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What is the deal with alk phos?

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Alkaline phosphatase is elevated in conditions affecting the bones, liver, small intestine, and placenta. The addition of elevated 5'-nucleotidase suggests the liver as the focus of the problem. Measuring 5'-nucleotidase to determine whether the alkaline phosphatase elevation is due to a hepatic problem is well substantiated, practical, and cost effective (SOR C).

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Autoimmune disorder highly associated with cancer

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dermatomyositis. The risk of cancer was highest at the time of diagnosis, but remained high into the third year after diagnosis. The cancer types most commonly found were ovarian, pulmonary, pancreatic, gastric, and colorectal, as well as non-Hodgkin’s lymphoma

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Proctalgia fugax

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Symptoms consistent with proctalgia fugax occur in 13%–19% of the general population. These consist of episodic, sudden, sharp pains in the anorectal area lasting several seconds to minutes. The diagnosis is based on a history that fits the classic picture in a patient with a normal examination. All the other diagnoses listed would be evident from the physical examination, except for sacral nerve neuralgia, which would not be intermittent for years and would be longer lasting.

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Interstitial nephritis. Most common cause

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Approximately 85% of cases of acute interstitial nephritis result from a drug-related hypersensitivity reaction; other cases are due to mechanisms such as an immunologic response to infection or an idiopathic immune syndrome. Hypertension and dehydration do not cause interstitial nephritis. Medications that most commonly cause acute interstitial nephritis through hypersensitivity reactions include penicillins, sulfa drugs, and NSAIDs.
Urinalysis typically reveals moderate to minimal proteinuria, except in NSAID-induced acute interstitial nephritis, in which proteinuria may reach the nephrotic range. Other typical findings include sterile pyuria, the absence of red blood cell casts, and frequently eosinophiluria, but none of these findings is pathognomonic. Withdrawal of the causative agent leads to resolution of the problem within 7–10 days in the majority of cases, and most patients have a good recovery.

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Telogen effluvium
B. Anagen effluvium
C. Alopecia areata
D. Female-pattern hair loss
E. Discoid lupus erythematosus

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The recycling of scalp hair is an ongoing process, with the hair follicles rotating through three phases. The actively growing anagen-phase hairs give way to the catagen phase, during which the follicle shuts down, followed by the resting telogen phase, during which the hair is shed. The normal ratio of anagen to telogen hairs is 90:10.
This patient most likely has a telogen effluvium, a nonscarring, shedding hair loss that occurs when a stressful event, such as a severe illness, surgery, or pregnancy, triggers the shift of large numbers of anagen-phase hairs to the telogen phase. Telogen-phase hairs are easily shed. Telogen effluvium occurs about 3 months after a triggering event. The hair loss with telogen effluvium lasts 6 months after the removal of the stressful trigger.

Anagen effluvium is the diffuse hair loss that occurs when chemotherapeutic medications cause rapid destruction of anagen-phase hair. Alopecia areata, which causes round patches of hair loss, is felt to have an autoimmune etiology. Female-pattern hair loss affects the central portion of the scalp, and is not associated with an inciting trigger or shedding. Discoid lupus erythematosus causes a scarring alopecia.

Ref: Shapiro J: Hair