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by baddoctormd, Oct. 2016

Subjects: USMLE, board preparation

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	A patient presents with acute pulmonary edema. Now what?	Tx: 1) Oxygen 2) Furosemide 3) Morphine 4) Nitrates Dx: 1) Chest xray 2) EKG 3) Pulsox/ABG 4) Echo **Treatment should with started WITH diagnostic maneuvers
	A pt comes in with dyspnea, S3 on exam and rales. What do you suspect	Acute pulmonary edema
	Treatment for diastolic CHF	1) β-blockers 2) Diuretics
	What is an absolute contraindication to using β-blockers in CHF?	Symptomatic bradycardia COPD should be considered but is not an absolute contraindication. Usually the benefit is greater than the risk.
	When is a biventricular pacemaker indicated in CHF?	Severe CHF with a QRS >120 msec
	When is an ICD indicated in CHF?	When EF remains <35% on medical management
	Which medications have been shown to have a mortality benefit in systolic CHF?	1) β-blockers 2) ACEIs/ARBs 3) Spironolactone No mortality benefit: digoxin, diuretics
	You float a right heart catheter in CHF. What do you expect?	Cardiac output: Down Wedge pressure (L atrium): Up Right atrial pressure: Up Systemic vascular resistance: Up
	You float a right heart catheter in hypovolemic shock. What do you expect?	Cardiac output: Down Wedge (L atrium): Down Right atrial pressure: Down Systemic vascular resistance: Up
	You float a right heart catheter in pulmonary hypertension. What do you expect?	Cardiac output: Down Wedge (L atrium): Down Right atrial pressure: Up Systemic vascular resistance: Up
	You float a right heart catheter in septic shock. What do you expect?	Cardiac output: Up Wedge (L atrium): Down Right atrial pressure: Down Systemic vascular resistance: Down
	Guidelines for cholesterol screening	Get fasting lipids (LDL, HDL, trigs) every 5 years in everyone over age 20. Goals: LDL <200 (high is >240) Trigs <150 (high is >200)
	In lipid management, what are considered CAD equivalents?	1) Diabetes 2) Peripheral arterial disease 3) Symptomatic carotid artery disease 4) AAA
	In lipid management, what are the CAD risk factors?	1) Age: Men ≥45 yo and women ≥55 yo 2) Smoking: ≥1/2 ppd 3) Hypertension: ≥140/90 or on medication 4) HDL <40 (NB: HDL >60 is a protective factor)
	Mesenteric Ischemia	Etiology: Most often due to embolus in SMA, SMA thrombosis, venous thrombosis or nonocclusive ischemia Hx: Sudden pain out of proportion to physical exam (at least initially); may have hematochezia or + FOBT Dx: increased WBC, increased amylase, late metabolic acidosis with increased lactate; angiography or CT angiography Tx: Surgery
	When should you transfuse platelets?	1) Active bleeding/needs surgery AND 2) Plts <50,000
	How do you reverse elevated PT/INR?	If you have some time: Vit K Emergently: FFP
	Initial Tx for Large Volume GI Bleeding	Bolus of Saline or LR CBC Type and Cross PT/INR EKG Consult GI
	When should you suspect lithium toxicity?	Elderly patient on lithium with: 1) Renal failure and/or 2) Hyponatremia (may be caused by diuretics, nausea, vomiting, etc.) ***Well known interaction with thiazides!
	What is the treatment for lithium toxicity?	Dialysis
	When should you suspect neuroleptic malignant syndrome?	Either: 1) Pt who recently started taking antipsychotics or 2) Parkinson's patient who has recently stopped levodopa Presentation: High fever, muscle rigidity, AMS, autonomic dysfunction, mutism, agitation, elevated CK and LFTs
	Treatment for neuroleptic malignant syndrome?	Transfer to ICU Stop antipsychotic Bromocriptime to overcome dopamine receptor blockade Dantrolene or diazepam to reduce muscle rigidity Mortality 10-20%!
	When should you suspect serotonin syndrome?	History of SSRIs AND a migraine medication (triptan)/MAOI Presentation: agitation, hyperreflexia, hyperthermia, muscle rigidity with volume contraction, myoclonus
	Treatment for serotonin syndrome	IV fluids Cyproheptadine to reduce serotonin production Benzo to reduce muscle rigidity
	Possible sequelae of lithium toxicity	AMS Nephrogenic diabetes insipidus Thyroid dysfunction Tremor
	When should you suspect MAOI-Induced Hypertension?	Acute hypertension, MAOI use AND: (one of the following) - antihistamines - nasal decongestants - tyramine-rich foods (cheese, pickled foods) - TCA
	When should you suspect TCA toxicity?	Presentation: Hypotension, flushing, tachycardia, dilated pupils, dry mucous membranes, arrhythmia, urinary retention, constipation [Think anticholinergic, sympathetic activation]
	What is the most serious complication of TCA toxicity?	Vtach, vfib, torsade de pointes
	What are the most common side effects of lithium?	Weight gain Acne Dose-related tremors GI distress Headaches Hypothyroidism (5%) ***Causes cardiac defects in the first trimester of pregnancy
	Depression Mimics	Hypothyroidism Parkinson's Disease Medications: Beta blockers, steroids, antipsychotics, reserpine Alcohol abuse Amphetamine abuse
	Mania Mimics	Hyperthyroidism Amphetamine use Pheochromocytoma
	Treatment of acute mania	Hospitalize Mood stabilizer (lithium) Antipsychotics until the acute mania is controlled (risperidone) *Intramuscular depot phenothiazine may be considered in noncompliant patients
	How does invasive aspergillosis usually present?	Immunocompromised patient Involves the respiratory tract, including lungs and sinuses
	What are the current screening guidelines for breast cancer (USPSTF)?	- Screen women ages 50-74 with mammogram q2yrs - No proven benefit to self exam - Insufficient data to recommend clinical breast exam or mammogram after age 75 NB: ACS and NCI recommend yearly after age 40
	Initial treatment for AMS of unknown etiology	Tx: - Dextrose - Naloxone - Thiamine (give prior to dextrose to prevent Wernicke's) - Oxygen - Saline Dx: - Glucose - Tox screen - CBC, chemistries - UA
	Initial treatment for Overdose	Tx: - Specific antidote (if known) - Otherwise --> thiamine, dextrose, naloxone - Charcoal - Psych consult, if intentional Dx: - CBC, chemistries - UA - Tox screen
	Antidote to acetaminophen	N-acetyl cysteine
	"Antidote" to aspirin	Give bicarbonate to alkalinize the urine
	Antidote to benzos	Flumazenil BUT DO NOT GIVE IT! May precipitate a seizure
	Antidote to carbon monoxide	Oxygen (100% or hyperbaric)
	Antidote to digoxin	Digoxin-binding antibodies
	Antidote to methanol	Ethanol or fomepizole
	Antidote to ethylene glycol	Ethanol or fomepizole
	"Antidote" for Neuroleptic Malignant Syndrome	Dantrolene, bromocriptine
	Antidote to narcotics	Naloxone
	Antidote to organophosphates	Atropine, pralidoxime
	"Antidote" to TCAs	Give sodium bicarbonate to protect the heart
	Antidote to B-blockers	Glucagon
	Antidote to heparin	Protamine sulfate
	Antidote to warfarin	Vitamin K Fresh frozen plasma (immediate reversal)
	Routine Prenatal Tests: Initial Visit	CBC Blood type and screen (Rh incompatibility) UA with culture (treat asymptomatic bacteriuria) Pap smear (if due) Syphilis Rubella antibody screen (do NOT vaccinate while pregnant!) HIV Hepatitis serology (Hep B surface antigen) Optional: - Chlamydia and gonorrhea cultures, if <25 yo
	Rh negative mothers: When do they get Rhogam?	28 weeks and within 72 hours after delivery Also after any procedures i.e. amniocentesis NB: This is useless if the mother has strongly positive Rh antibodies.
	Routine Prenatal Tests: Third Trimester	Gestational Diabetes screening Group B strep cultures
	What are the options for prenatal genetic screening (Down's neural tube defects, aneuploidy)? When is each test available?	First trimester: - Sequential screen - Full integrated screen - Serum integrated screen Second trimester: - Quad screen plus ultrasound
	Initial treatment for Tylenol overdose	1) N-acetyl cysteine (always do first, never wrong) 2) Acetaminophen level
	Presentation with Tylenol Overdose	N/V for 24 hours --> liver failure
	Initial Treatment for Suspected Aspirin Overdose	Dx: - CBC - Chem - PT/INT/PTT - ABG (respiratory alkalosis and metabolic acidosis) - Salicylate level Tx: - D5W with bicarbonate to alkalinize the urine - Charcoal, if recent - Dialysis, if severe
	Alkalinizing the urine helps with excretion of which drugs?	Aspirin TCAs Phenobarbitol Chlorpropamide
	What should you order on a tox screen?	Alcohol Aspirin Acetaminophen Benzodiazepines
	Initial Treatment for Benzo Overdose	Dx: Standard overdose work-up Tx: If benzos alone, let them sleep it off
	Presentation of Digoxin Overdose	Arrhythmia Encephalopathy Seeing yellow halos around objects Blurred vision
	What is the difference (in presentation) between heat exhaustion and head stroke?	Heat Exhaustion: Think Mom - Excessive sweating - Nausea/vomiting Heat Stroke: Can't compensate any more - Dry skin - ALTERED MENTAL STATUS
	How do you treat heat exhaustion?	IV fluids (room temp) Get them out of the heat
	How do you treat heat stroke?	Spray with water Ice packs/baths
	How does narcotic overdose kill you?	Respiratory depression
	When should you suspect organophosphate poisoning?	Situation: - Farm/crop duster exposed to insecticides - Nerve gas attack Presentation: Think cholinergic aka parasympathetic! - Salivation - Lacrimation -Urination - Diarrhea - Bronchospasm with wheezing
	Treatment for organophosphate poisoning?	- Toxin is absorbed through skin so remove clothes/wash patient - Atropine (best initial) or pralidoxime (most effective)
	How does a TCA overdose kill you?	Arrhythmia Seizures
	Initial treatment for TCA overdose	#1: Get an EKG If widened QRS --> give bicarb and transfer to ICU NB: Giving bicarb has its own risks so get EKG first
	When should you suspect a black widow bite?	Abdominal pain withOUT tenderness Rigidity Hypocalcemia *May look as if they have an abdominal perforation
	How do you treat a black widow bite?	Antivenin
	When should you suspect a brown recluse bite?	Local necrosis Bullae Dark lesions
	Treatment for a brown recluse bite	Debridement Occasionally, steroids and dapsone help
	What is the most common early and late cause of death with burns?	Early: Carbon monoxide poisoning Late: Infection
	Initial Treatment for Someone in a Fire	- Give oxygen - Assess respiratory status: Is the patient wheezing, stridorous or hoarse? Do they have burns in the mouth or nose? --> Intubate if yes - Give fluids per the Parkland formula
	Parkland Formula: What's it for? How do you calculate it?	Calculates the amount of IV fluids needed by a burn patient in a 24 hour period to keep them hemodynamically stable 4 ml * Wt in kg * percentage of body with a 2nd or 3rd degree burn Ex: 75 kg pt with 30% burns would need 9000 mL of normal saline or LR
	How does hypothermia kill you?	Arrhythmia
	Most important step in evaluation of hypothermia?	EKG: Look for "J waves of Osborn"
	Treatment of hypothermia	Secure airway Remove wet clothing and rewarm (blankets, warm IV fluids) EKG!! Monitor electrolytes, renal function and ABG
	How does treatment of electrical burns differ from thermal burns?	Most of the destruction is internal Monitor: renal function, myoglobin, acid base status, EKG Treat aggressively with IV fluids to prevent renal failure Tx: - ABCs - IV fluids - Pain control - Tetanus prophylaxis - If they have myoglobinuria, give IV fluids to maintain urine output at 1.5-2 cc/kg/hr
	What are extrapyramidal symptoms?	Tremor, torticollis, trismus, rigidity, dysphonia, dysphagia
	Describe anticholinergic effects	Sympathetic! Fever Skin flushing Dry mucous membranes Tachycardia Dilated pupils Urinary retention Psychosis
	What medications tend to cause anticholinergic side effects?	Antihistamines TCAs Scopolamine Antipsychotics Atropine
	Describe cholinergic effects	Parasympathetic! Diarrhea Urination Salivation Lacrimation Pupils constricted Bradycardia Bronchospasm
	What medications tend to produce cholinergic effects?	Organophosphates Pilocarpine Pyridostigmine
	Antidote to anticholinergics	Physostigmine
	When should you treat for rabies with an animal bite?	If: 1) Animal is wild 2) The animal is domestic, acts unusual and has a positive direct immunofluorescent antibody study performed on their brain following sacrifice *No tx is necessary if the animal is observed to be normal for 10 days
	What are the most common organisms in a human bite?	Polymicrobial - Aerobic gram positive i.e. strep - Eikenella
	What are the most common pathogens in cat bites?	Pasteurella Bartonella
	What are the most common pathogens in dog bites?	Alpha-hemolytic strep Staph aureus Pasteurella multocida Anaerobes
	What is the first choice of antibiotic for any human/cat/dog bite?	Amp/clavulanate
	When would you consider giving tetanus immunoglobulin?	Contaminated wound AND Patient had <3 doses of vaccine (or unknown) NB: Do not give if the pt has EVER completed vaccination i.e. even if it was >10 yrs ago
	When would you consider giving tetanus vaccine in the setting of a wound?	1) No vaccination 2) Unknown vaccination history 3) >10 years since completion of the 3 shots 4) Contaminated wound AND >5 years since vaccine
	Describe the rule of 9s in burns	Describes the percent body surface area involved: 9% per arm and head 18% per leg, front torso, back torso 1% for perineum NB: In children, the legs are 14% apiece and the head is 18%.
	When should a patient be referred to a burn center?	Partial thickness >25% BSA Full thickness >10% Burns to face, hands, feet, perineum or joints Electrical or circumferential burns
	When should you suspect acute angle glaucoma?	Red eye Fixed midpoint pupil** Rock-hard, painful eye Corneal haziness Haloes around lights Nausea/vomiting Headache
	How do you diagnose acute angle glaucoma?	Tonometry (IOP >30 mm Hg)
	Treatment for acute angle glaucoma	Pilocarpine drops Acetazolamide (reduces production of aqueous humor) IV Mannitol (osmotic diuretic) Latanoprost/travoprost (prostaglandin analogues) Timolol (topical beta blocker) Once resolved --> peripheral iridotomy to prevent recurrence
	When should you suspect retinal detachment?	Sudden loss of vision like "a curtain coming down" Floaters/flashers Painless Unlateral
	Treatment for retinal detachment	Immediate referral to ophtho Tilt head back Reattach with surgery, cryotherapy or injecting gas into the eye Last choice: Place band around the eye to get the retina close to the sclera
	Differential Diagnosis of Sudden, Unilateral, Painless Vision Loss	Retinal detachment Central Retinal Artery Occlusion Central Retinal Vein Occlusion Vitreous hemorrhage Optic neuritis Stroke/TIA
	When should you suspect central retinal artery occlusion?	Sudden, painless, unilateral vision loss Cherry red spot in the macula
	Treatment for central retinal artery occlusion	Mostly supportive Exception: In the case of temporal arteritis, give high dose steroids
	When should you suspect central retinal vein occlusion?	Sudden, painless, unilateral vision loss "Blood and thunder" appearance on exam Retinal hemorrhages Often in the setting of HTN, diabetes, glaucoma, and increased blood viscosity
	Treatment for central retinal vein occlusion	Basically none
	When should you suspect optic neuritis?	Unilateral vision loss May be sudden or subacute Usually painful, but not always NB: Consider in the setting of MS, Lyme disease, or tumor
	Ddx for sudden, unilateral, painful vision loss	Optic neuritis Closed angle glaucoma Migraine headache (consider with N/V, aura) Trauma
	Ddx for gradual vision loss	Cataracts Macular degeneration Open angle glaucoma Presbyopia Diabetic retinopathy Uveitis (consider in autoimmune settings) Papilledema Corneal infection (CMV retinitis, HSV keratitis, corneal ulcer) Direct insult to brain
	Exam Findings in Macular Degeneration	Yellow-white drusen in the macular area
	Exam Findings in Diabetic Retinopathy	Cotton wool spots Dot-blot hemorrhages Microaneurysms Neovascularization
	Exam Findings in Optic Neuritis	Blurred disc margins
	Exam Findings with hypertensive retinopathy	Arteriolar narrowing Copper/silver wiring Cotton-wool spots Optic nerve edema (if severe)
	How does a CN4 palsy present?	Patient cannot look down when their gaze is medial Often presents as diplopia when the pt walks down stairs
	How does a CN3 palsy present?	Eye is down and out Can only move laterally May have ptosis
	When should you suspect corneal abrasion?	Pain out of proportion to exam Photophobia Foreign body sensation Dx: Fluorescein staining
	Treatment for corneal abrasion	Topical broad spectrum antibiotics (gentamicin, bacitracin) Tetanus prophylaxis Oral pain meds NB: Do NOT patch if caused by contacts.
	Ddx of a red eye	Uveitis Glaucoma Conjunctivitis Abrasion
	Bacterial vs Viral vs Allergic Conjunctivitis: Presentation	Viral: Bilateral, watery discharge, irritated, preauricular lymphadenopathy Bacterial: Unilateral, purulent discharge, eyelids stuck together Allergic: Bilateral, intensely itchy, watery discharge, cobblestone papillae under upper lid, history of atopy
	Treatment for Allergic Conjunctivitis	Cool compresses Topical antihistamine/vasoconstrictors (naphazoline/pheniramine) Mass cell stabilizers (Cromolyn, olopatadine)
	Causative organisms in Bacterial Conjunctivitis	Staph Strep Neisseria gonorrhoeae Chlamydia trachomatis
	Treatment for Bacterial Conjunctivitis	Staph or strep: topical 10% sulfacetamide or aminoglycoside Gonorrhea: IV ceftriaxone AND topical erythromycin/tetracyline Chlamydia: Oral doxycycline or oral/topical erythromycin
	Treatment for Viral Conjunctivitis	Generally none
	DDx and Timing of Neonatal Conjunctivitis	Within 24 hours: chemical 2-5 days: Gonorrhea 5-14 days: Chlamydia
	Primary Survey for Trauma	Airway and cervical spine control Breathing with ventilation Circulation with hemorrhage control Disability (neuro) Exposure
	Primary Survey for Trauma: A	Airway and cervical spine control - Check patency of airway - Oxygen - Intubate or create a surgical airway, as indicated
	Indications for Intubation in Trauma	Impending airway compromise GCS <=8 Altered mental status Apnea Severe closed head injury
	When should you consider a surgical airway in trauma?	Significant maxillofacial injuries
	What are the most common pulmonary pathogens seen in cystic fibrosis?	Pseudomonas aeruginosa Staph aureus H. flu
	What is the preferred empiric antibiotic regimen in a CF patient with a pulmonary exacerbation?	Tobramycin AND Ticarcillin-clavulanate NB: Should cover staph, pseudomonas and H. flu. Single drug therapy is never appropriate in treatment of Pseudomonas.
	When should you suspect heparin-induced thrombocytopenia?	Heparin exposure for 5-14 days AND: - Thrombosis - Reduction in platelets >=50% - Necrosis at injection site - Anaphylactoid reaction after heparin
	How do you diagnose HIT?	Serotonin release assay
	Treatment for HIT	- Stop all heparin products (including Lovenox) - Serotonin release assay to confirm - Start alternative anticoagulation with direct thrombin inhibitor (argatroban, fondaparinux) - Start warfarin ONLY AFTER treatment with another anticoagulation AND recovery of platelet count >=150,000
	Why shouldn't you start warfarin immediately in HIT?	Dropping Protein C --> prothrombotic state
	What transient form of birth control has the lowest pregnancy rate?	Implantable or injectable contraceptives (<2-3%) NB: Compared to OCPs, condom, cervical cap, diaphragm and spermicide. Check where this stands compared with regard to IUD!
	A minor presents to your office and asks you not to tell his/her parents. What topics can you generally talk about without consent?	Mental health Contraceptives STDs Pregnancy Substance use
	How do you correct serum calcium for aberrant albumin?	For every decrease of 1 g/dL below 4, add 0.8 to the calcium. Example: Uncorrected Ca 10.0 with albumin of 2.0 --> Corrected Ca of 11.6
	What is the most common diagnosis with bilateral breast discharge?	Prolactinoma Dx: Order prolactin and TSH levels
	Most Common Cause of Unilateral Nipple Discharge	Nonbloody: Intraductal Papilloma Bloody: Cancer until proven otherwise
	When should you suspect intraductal papilloma?	Woman with unilateral, nonbloody nipple discharge NB: A palpable mass, bloody discharge or involvement of more than one duct makes it more likely to be cancer.
	Workup for Unilateral Nipple Discharge	Mammogram If negative --> Surgical duct excision If positive --> Biopsy
	Ddx for a Breast Mass	Cancer Fibroadenoma Intraductal papilloma Mastitis Fat Necrosis Fibrocystic breasts Abscess
	When should you suspect fibrocystic breasts?	Setting: 20-50 yo woman Presentation: Bilateral, nodular, painful breast lump(s) that vary with the menstrual cycle
	Treatment for fibrocystic breasts	OCPs
	When should you suspect fibroadenoma?	Setting: Young woman Presentation: Small, discrete, rubbery, unilateral, highly mobile mass. Usually slow growing.
	Treatment for fibroadenoma	Can observe. Surgery is curative but unnecessary. NB: 30% will spontaneously resolve, but recurrence is common.
	Janeway lesions	- Septic emboli --> nontender, hemmorhagic macules on the palms or soles - Indicative of infective endocarditis
	Osler nodes	- Characteristic of infectious endocarditis - Occur on finger pads
	What is phentolamine used for?	Mechanism: Vasodilation via alpha blockade Indications: - Hypertensive emergency due to pheochromocytoma or cocaine - Erectile dysfunction (injected into penis)
	Initial treatment for cocaine-induced MI?	- Nitrates (or CCB) - Oxygen - Aspirin - Benzodiazepine NB: If pt does not immediately improve, coronary angiography NB: Do NOT give beta blockers. Unopposed alpha activity may lead to worsened vasospasm.
	What is an appropriate nutrition goal (kcal and protein) for a patient with adequate baseline nutrition? i.e. not malnourished	30 kcal/kg/day with 1g/kg protein
	In a setting suggestive of MI, how many troponins are needed to rule out?	2, spaced 6 hours apart
	A patient on IV nutrition develops sudden hyperglycemia. What should you suspect?	Sepsis. Initiate an infection workup.
	What BUN/Cr ratio is suggestive of a prerenal etiology of AKI?	>20
	Describe the treatment paradigm for acute atrial fibrillation	1) Is the patient stable? If no --> urgent cardioversion 2) Rate control with a beta blocker (not in asthma) or calcium channel blocker (not in CHF or heart block) 3) Anticoagulate 4) If they don't spontaneously resolve w/in ~24 hours, cardiovert NB: Some sources suggest maintenance rate control with anticoagulation instead of cardioversion....
	What are the preferred agents for rate control in acute atrial fibrillation?	Calcium channel blockers: IV diltiazem, IV verapamil - Do NOT use in severe CHF or heart blocks Beta Blockers: IV metoprolol or IV propranolol - Do NOT use in asthma Others: amiodarone, digoxin (very slow onset)
	When should you suspect atrial fibrillation?	Setting: Patient with history of HTN, ischemia or cardiomyopathy Presentation: Palpitations, irregular pulse
	Work-up for acute afib	EKG --> telemetry for dx 1) Is the patient unstable? (SBP<90, AMS, CHF, chest pain) If yes --> Emergent cardioversion If no: - TEE - TSH and T4 - Electrolytes: K, Mg, Ca - Troponin, if indicated
	Preferred anticoagulation in acute atrial fibrillation	Dabigatran or Heparin bridge to warfarin
	Target INR in acute atrial fibrillation	2-3
	Describe the CHADS score: What's it for? How do you calculate it?	Used to determine anticoagulation in afib Congestive heart failure (1 pt) Hypertension (1 pt) Age 75 or older (1 pt) Diabetes (1 pt) Stroke or TIA (2 pt) Score 0 --> Aspirin Score 1 --> Aspirin or Warfarin Score 2 --> Warfarin or Dabigatra
	A mother with chronic Hep B gives birth. What should you do?	At birth: Hepatitis B immunoglobulin AND vaccine 1-2 mo: Hepatitis B vaccine booster 6 mo: Hepatitis B vaccine booster #2 Test serologies at 9-15 months
	Ddx for postpartum fever	7Ws: - Womb - emdomyometritis - Water - UTI - Wind - Pneumonia, atelectasis - Walking - DVT, PE - Wound - Incision, lacerations - Weaning- Breast engorgement, mastitis, breast abscess - Wonder drugs- Drug fever
	What are the indications for a C-section?	Maternal: - Prior C section with a vertical incision - Active genital herpes infection - Cervical cancer - Maternal death Fetal factors: - Malposition - Distress - Cord prolapse - Erythroblastosis fetalis Both: - Cephalopelvic disproportion - Placenta previa/placental abruption - Failed vaginal delivery
	When should you suspect 21-hydroxylase deficiency?	Setting: Newborn with ambiguous genitalia Presentation: - Salt wasting (hyponatremia) - Hyperkalemia - Hypotension - Elevated ACTH - Increased 17-hydroxyprogesterone - Hirsutism in adults NB: Due to congenital adrenal hyperplasia
	What are the three types of congenital adrenal hyperplasia?	21 hydroxylase deficiency (most common) 11 hydroxylase deficiency 17 hydroxylase deficiency
	Which patients in the ICU should get GI prophylaxis?	Coagulopathy or History of GI bleed in the last year or Ventilation for >48 hours or Two of the following: Sepsis, ICU stay >1 week, occult GI bleeding >6 days, glucocorticoids
	Preferred agents for ICU GI prophylaxis	Enteral: PPI (omeprazole) IV: H2 blocker (ranitidine)
	Preseptal (periorbital) cellulitis vs. Orbital (postseptal) cellulitis	Preseptal: Eyelid erythema, edema, tenderness, chemosis, fever and increased WBC - Treat with oral abx Orbital: Above sx PLUS ophthalmoplegia, visual acuity changes, diplopia, proptosis - Treat with broad-spectrum IV abx +/- surgery
	What are possible complications of orbital cellulitis?	Abcesses (orbit or brain) Cavernous sinus thrombosis Blindness
	When should you suspect PCP intoxication?	Agitation Restlessness Disorientation Hypertension Tachycardia Nystagmus ***
	Treatment for PCP intoxication	Low stimulation environment NB: Haldol or benzos can be used in the setting of aggression, seizures or agitation
	Good choices for treatment in a noncompliant schizophrenic	Haloperidol DECANOATE Injectable risperidone Injectable fluphenazine
	Recommended interval for feeding a newborn	Q2-3 hours. 4 hours is the absolute maximum.
	What is the rule of 2s?	Refers to characteristics of Meckel's diverticulum: - 2 feet proximal to the ileocecal valve - 2 types of ectopic tissue (pancreatic, gastric) - 2% of the population - 2x as likely in males - Usually presents by age 2 - 2 cm in diameter
	When should you suspect Meckel's diverticulum?	Setting: Child under the age of 2 with painless rectal bleeding or intussusception Dx: Tech-99 radionuclide scan ("Meckel scan") - Gold standard is a tissue biopsy
	Treatment for Meckel Diverticulum	- Stabilize with IV fluids +/- pRBCs as indicated - Surgical exploration
	When should you suspect subclinical hypothyroidism?	Setting: Asymptomatic patient Dx: TSH high, T4 normal
	When should you treat subclinical hypothyroidism?	Only if: - Abnormal lipid profile - Symptomatic - Presence of antithyroid peroxidase (anti-TPO) antibodies - Ovulatory or menstrual dysfunction - TSH >10
	Thyroid Screening	Controversial ATA: All pts >40 yo ACP: Women >50 yo with findings suggestive of thyroid disease
	What test is needed for definitive diagnosis of sickle cell?	Hemoglobin electrophoresis NB: Peripheral blood smear is supportive but not definitive
	When should you suspect mucormycosis?	Setting: Patient with DKA Presentation: Fever, facial flushing, maxillary pain and tenderness, nasal discharge, ophthalmoplegia, headache Dx: Biopsy
	Treatment for mucormycosis	Debride necrotic tissue IV amphotericin B NB: Mortality remains high even with aggressive tx.
	Which pap results constitute a high-grade squamous intraepithelial lesion (HSIL)?	Moderate dysplasia Severe dysplasia CIN 2-3 CIS
	What pap results constitute a low grade squamous intraepithelial lesion (LSIL)?	Mild dysplasia CIN 1 HPV-positive**
	Your pt has an ASCUS pap. Now what?	1) Repeat pap in 3-6 months with HPV DNA typing 2) Negative repeat --> routine screening Positive repeat --> colposcopy, ectocervical biopsies and endocervical curettage (ECC) NB: Do NOT perform an ECC in a pregnant patient. Also, if patient is not reliable, consider doing colposcopy upfront.
	Your patient has an abnormal Pap. Now what?	- Colposcopy, ectocervical biopsy and endocervical curettage - If not diagnostic, consider CKC NB: Do NOT do ECC in pregnant patients. If age <20 and it's not HSIL, repeat Pap in one year.
	Treatment for LSIL	- Observation - Follow-up Pap every 6 months
	Treatment for HSIL	HSIL=moderate or severe dysplasia, CIN 2-3 or CIS Dysplasia -->Colposcopy for diagnosis CIN 2-3 --> excision (LEEP) or ablation (CKC< last, cryotherapy) --> Pap in 6 months
	Treatment of choice for Pneumocystic pneumonia? What if the patient has a sulfa allergy?	IV trimethoprim-sulfamethaxazole (Bactrim) Sulfa allergy: - Mild to moderate pneumonia--> oral atovaquone -Moderate to severe pneumonia --> IV pentamidine
	When should you suspect Pneumocystic pneumonia?	Setting: Patient with defects in cell-mediated immunity i.e. HIV/AIDs Presentation: Insidious onset, low grade fever, cough ,dyspnea, tachypnea Imaging: Diffuse, BILATERAL, ground glass opacities
	Positive Psychotic Symptoms	Delusions (mostly bizarre) Disorganized speech or behavior Hallucinations Agitation
	Negative Psychotic Symptoms	Flattened affect Social withdrawal Anhedonia Apathy Poverty of thought
	What is needed for a diagnosis of schizophrenia?	POSITIVE psychotic symptoms Impairment of social or occupational function Duration >6 months
	What is the difference between schizophrenia, schizophreniform disorder and a brief psychotic disorder?	Mostly duration Schizophrenia: >6 months Schizophreniform disorder: 1-6 months Brief psychotic disorder: <1 month and resolves - Usually associated with a stressful life event
	A patient has peculiar thoughts/delusions without actual impairment of function. Ddx?	Delusional disorder: Delusions must be nonbizarre. Personality disorder i.e. schizotypal Substance abuse Temporal lobe epilepsy
	Treatment for psychosis	1) Decide whether to hospitalize! - Do so if paranoid or bizarre - Benzos for agitation - Antipsychotics for 6 months - Long term counseling - Consider long term antipsychotics only with repeat episodes
	Indications for an antipsychotic medication	Acute psychosis of any kind (schizophrenia, depression with psychotic features, mania, etc.) - Has immediate quieting effect - Delays relapse Sedation with benzos are contraindicated Movement disorders to suppress tics and vocalization
	Pros and Cons of High Potency Conventional Antipsychotics	Examples: Haldol, fluphenazine Pros: - Less sedating - Depot injections available - Fewer anticholinergic side effects - Less hypotension Cons: Greatest association with EPS
	Pros and Cons of Low Potency Conventional Anti-psychotics	Examples: Thioridazine, chlorpromazine Pros: Less association with EPS Cons: - Greater anticholinergic side effects - More sedation - More postural hypotension
	Pros and Cons of Atypical Antipsychotics	Examples: Olanzapine, risperidone, quetiapine, clozapine Pros: - Greater effect on negative symptoms - Little risk of EPS Cons: - Clozapine associated with agranulocytosis
	Thioridazine: Class, Side effects	Low potency conventional antipsychotic Side Effects: - Prolonged QT and arrhythmias - Long term retinal pigmentation (need eye exams!)
	Clozapine: Class, side effects, monitoring	Atypical antipsychotic - Use only in refractory but compliant patients Side Effects: - Agranulocytosis (1%) - Seizures - Virtually NO risk of movement disorders/EPS Monitoring: - Must get CBC before therapy and weekly thereafter
	Common reasons for antipsychotic noncompliance	Men: - Impotence - Inhibition of ejaculation Women: - Weight gain (hyperprolactinemia) - Galactorrhea - Amenorrhea
	Best medication choice for a schizophrenic with insomnia	Olanzapine Quetiapine Aripiprazole Ziprasidone
	Best medication choice for a schizophrenic with sedation	Risperidone
	Name the high potency conventional antipsychotics	Haloperidol Fluphenazine
	Name the low potency conventional antipsychotics	Thioridazine Chlorpromazine
	Name the atypical antipsychotics	Risperidone Quetiapine Olanzapine Clozapine Ziprasidone Aripiprazole (Abilify)
	When should you suspect akathisia?	Setting; Patient on antipsychotics for at least several weeks Presentation: - Whole body restlessness
	Treatment for akathisia	- Reduce dose of antipsychotic or - Switch to a newer antipsychotic Consider adding beta-blocker or benzo
	When should you suspect acute dystonia?	Setting: Younger person who recently started an antipsychotic Presentation: - Muscle spasms - Torticollis - Difficulty swallowing
	Treatment for acute dystonia	Reduce the dose of antipsychotic Add an anticholinergic - Benztropine - Benadryl - Trihexyphenidyl
	When should you suspect bradykinesia?	Setting: Older patient on antipsychotic medications Presentation: - Bradykinesia - Tremor - Rigidity - Other signs of parkinsonism
	Treatment for bradykinesia	Reduce dose of antipsychotics Add anticholinergic - Benztropine - Benadryl - Trihexyphenidyl
	When should you suspect tardive dyskinesia?	Setting: Patient on antipsychotics for at least months Presentation: - Repetitive, involuntary, purposeless movements such as lip smacking, tongue movements, grimacing, blinking NB: Can also be seen with long-term use of antiemetics (metoclopramide, prochlorperazine)
	Treatment for tardive dyskinesia	Stop older antipsychotic/dopamine antagonists Switch to a newer antipsychotic Consider benztropine NB: Symptoms often worsen after discontinuation of the offending drug!
	Anxiety Mimics	Hyperthyroidism Pheochromocytoma Excess cortisol Heart failure Arrhythmias Asthma/COPD Drugs: steroids, caffeine, amphetamines, cocaine, withdrawal from a depressant
	When should you suspect Panic Disorder?	REGULAR, brief attacks of intense anxiety Autonomic symptoms (tachycardia, tachypnea, sweating, etc.) No obvious precipitant or underlying psych illness
	Treatment for Panic Disorder	Cognitive behavioral therapy Relaxation training and desensitization Consider: SSRIs, benzos, imipramine MAOI
	When should you suspect OCD?	Obsessions: intrusive, anxiety provoking thoughts Compulsions: Behaviors that reduce the anxiety NB: Generally have insight i.e. they know that the behavior is unreasonable and excessive
	Treatment for OCD	CBT SSRIs or clomipramine
	When should you suspect acute stress disorder?	Setting: Patient who has experienced a LIFE THREATENING event within the last month Presentation: - Re-experiencing the event - Avoidance of stimuli associated with the event - Numbing of general responsiveness - Increased arousal: Hypervigilance, anxiety, sleep disturbances, emotional lability, impulsiveness NB: Symptoms must last <1 month and occur within 1 month of the event
	When should you suspect PTSD?	Setting: Patient who has experienced a LIFE THREATENING event Presentation: - Re-experiencing the event - Avoidance of stimuli associated with the event - Numbing of general responsiveness - Increased arousal: Hypervigilance, anxiety, sleep disturbances, emotional lability, impulsiveness NB: Symptoms last >1 month
	When should you suspect Generalized Anxiety Disorder?	Excessive, poorly controlled anxiety without any single focus Must occur DAILY for at least 6 months
	Treatment for Generalized Anxiety Disorder	Supportive psychotherapy Relaxation training Biofeedback Meds: SSRI, venlafaxine, buspirone, benzos short term
	When should you suspect cyclothymia?	Recurrent episodes of depressed mood and hypomania for at least 2 years
	Treatment for cyclothymia	Psychotherapy If function is impaired --> divalproex
	Indications for ECT	Major depression unresponsive to medications High risk for immediate suicide Contraindication to antidepressant medications Good response to ECT in the past
	Side Effects of Bupropion	Modest weight loss Seizures Tremor Fewer sexual side effects than other SSRIs
	Side Effects of Mirtazapine	i.e. Remeron Weight gain Sedation
	Classic side effect of trazodone	Sedation Priapism
	Antidepressants with sedative effects	Trazodone Doxepin (TCA) Mirtazapine (also an appetite stimulant) Amitriptyline
	Indications for divalproex	First-line choice for rapid-cycling bipolar When lithium is ineffective, not practical, contraindicated
	Significant side effects with carbamazepine	Sedation Agranulocytosis
	Maintenance therapy for bipolar	First choice: Lithium Second choice: Divalproex Third: Carbamazepine
	When should you suspect somatization disorder?	Multiple symptoms affecting multiple organs with no explanation Dx: Need 4 pain symptoms, 2 GI, 1 sexual, 1 pseudoneurologic NB: Symptoms are not produced intentionally or feigned
	Treatment for somatization disorder	Limit care to a single PCP Brief, monthly visits Limit diagnostic testing Psychotherapy
	When should you suspect conversion disorder?	At least one neurologic symptom that cannot be explained Usually have psychologic factors associated with onset Generally not concerned with the impairment
	Treatment of conversion disorder	Supportive patient-physician relationship Psychotherapy
	When should you suspect hypochondriasis?	- Pt belief that they have a SPECIFIC disease despite repeated negative work-up - Symptoms for at least 6 months - Reassurance by a physician doesn't help
	Treatment for hypochondriasis	Single provider Regular routine visits Psychotherapy
	What is the difference between factitious disorder and malingering?	Factitious Disorder: Pt generally presents to many doctors/hospitals, has a large body of medical knowledge and demands tx. Often it's more about the attention or there may be no clear motivation. Malingering: Obvious gain results from the faked sxs i.e. shelter, medications, disability
	Treatment for Factitious Disorder or Malingering	Supportive psychotherapy Minimize workup and tx
	When should you suspect anorexia nervosa?	Setting: Young person who is UNDERWEIGHT and amenorrheic Criteria: 1) Restriction of intake relative to requirements 2) Intense fear of gaining weight or becoming fat 3) Disturbance in the way in which one’s body weight or shape is experienced NB: Up to 50% of anorexa patients may purge
	Treatment for Anorexia Nervosa	1) Chem7 - If electrolytes are abnl --> hospitalize SSRI Consider olanzapine for weight gain Behavioral psychotherapy
	When should you consider bulimia nervosa?	Setting: Young person in NORMAL weight range with binge eating, purging, diuretic and/or enema use Presentation: - Painless parotid gland enlargement - Dental erosions - Electrolyte disturbances (hypokalemia, hypochloremia, metabolic alkalosis if puking, acidosis if laxatives)
	Criteria for Bulimia Nervosa	A.Recurrent episodes of binge eating. B.Recurrent inappropriate compensatory behaviors in order to prevent weight gain C.The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. D.Self-evaluation is unduly influenced by body shape and weight.
	When should you suspect body dysmorphic disorder?	Setting: Young person who is preoccupied with an imagined or slight defect in appearance, causing impairment
	Treatment for Body Dysmorphic Disorder	High doses of SSRIs
	Prognostic Factors in Schizophrenia	Signifies a poor prognosis: - Early age of onset - Negative symptoms - Poor premorbid functioning - Family history - Disorganized or deficit subtype
	When should you suspect intermittent explosive disorder?	Aggression out of proportion to the stressor - Generally, the patient does not have insight - May have a history of head trauma NB: Rule out drug use first
	Treatment for intermittent explosive disorder	SSRIs Mood stabilizers
	Your female patient is being abused by her husband. Do you report?	Reporting is not mandatory. Provide information about counseling and local shelters.
	Cluster A Personality Disorders	Paranoid Schizoid Schizotypal
	When should you suspect paranoid personality disorder?	Mistrustful, suspicious Emotionally cold or distant Often take legal action against people Example: Old man who accuses his neighbors of stealing his mail and conspiring against him
	When should you suspect schizoid personality disorder?	Detached, emotionally distant Absorbed in their own thoughts and feelings Example: Lighthouse keeper with no known contacts
	When should you suspect schizotypal personality disorder?	Discomfort with social relationships Eccentric, magical thinking Example: Man living in a small town selling magical, healing herbs for a living, guided by spirits
	Cluster B Personality Disorders	Histrionic Borderline Antisocial Narcissistic
	When should you suspect histrionic personality disorder?	Wants to be the center of attention Exaggerated behavior with shallow expression of emotions Use of physical appearance to draw attention
	When should you suspect Borderline Personality Disorder?	Splitting Mood swings Impulsivity Unstable relationships Intense anger if they feel abandoned
	When should you suspect Antisocial Personality Disorder?	Criminal acts Inabililty to conform to social mores Lack of remorse Aggressive
	When should you suspect Narcissistic Personality Disorder?	Grandiose sense of self Believes they're special and deserving of admiration Lack empathy Enraged when criticized
	Cluster C Personality Disorders	Avoidant Dependent Obsessive-Compulsive
	When should you suspect Avoidant Personality Disorder?	Desirous of affection and acceptance but socially inhibited Feel inadequate Hypersensitive to criticism Shy away from gatherings and new things
	When should you suspect Dependent Personality Disorder?	Submissive and clinging Need to be taken care of Feel inadequate and helpless
	When should you suspect Obsessive-Compulsive Personality Disorder?	Preoccupied with perfectionism and control Consumed by details Overconscientious Inflexible
	CAGE Screening: What's it for? How is it administered?	Have you ever: - Felt that you should Cut back? - Felt Annoyed by others who have criticized your drinking? - Felt Guilty about your drinking? - Needed an Eye-opener to steady nerves or alleviate a hangover? Two or more affirmative answers is suggestive
	Work-up in a patient with alcohol abuse	Tox screen for other substances (breath, blood and urine) Screen AST, ALT, GGT, LDH If there's any suggestion of IV drug use, add: - HIV - Hep B - Hep C - PPD
	Treatment for Acute Alcohol Intoxication	IV or IM thiamine Mg B12 Folate MVI Glucose Monitor for withdrawal - If concern --> chlordiazepoxide or diazepam NB: If the patient has a history of severe liver disease, use a short acting benzo (lorazepam or oxazepam)
	What drugs are available for treatment of alcohol dependence?	Naltrexone (NOT naloxone!) Acamprosate
	When should you suspect DTs?	Setting: Alcoholic who hasn't had a drink for 48-96 hours Presentation: - Hallucinations - Disorientation - Tachycardia - Hypertension - Low-grade fever - Agitation - Diaphoresis Classic scenario: Disorientation and hallucinations after 2 days in the hospital
	When should you suspect Wernicke-Korsakoff?	Setting: Chronic alcoholic Presentation: - Ataxia - Nystagmus - Amnesia with confabulation
	When should you suspect alcoholic hallucinosis?	Setting: Alcoholic 12-24 hours after their last drink Presentation: - Hallucinations (visual, auditory or tactile) - NO change in mental status
	Which drugs can cause withdrawal?	Alcohol Benzodiazepines Opiates Cocaine Amphetamines Barbituates
	Which drugs generally do not cause withdrawal?	PCP LSD Inhalants Hallucinogens Marijuana
	When should you suspect cocaine withdrawal?	Anxiety Tremors Headache Increased appetite Depression Risk of suicide
	Treatment for cocaine withdrawal	Antidepressants
	When should you suspect amphetamine withdrawal?	Anxiety Tremors Headache Increased appetite Depression Risk of suicide
	Treatment for amphetamine withdrawal?	Antidepressants
	When should you suspect LSD or mushrooms?	Hallucinations Impaired judgment Dissociative symptoms ("out of body") Panic Pupil Dilatation Tremors Incoordination Ideas of reference
	Treatment for LSD Intoxication	Talk them down Consider benzos or antipsychotics
	When should you suspect inhalant use?	Belligerence Apathy Assaultive Impaired judgment Blurred vision Stupor Coma
	Treatment for inhalant use	Consider antipsychotics if agitated
	When should you suspect opiate intoxication?	Respiratory depression Miosis Dysphoria Slurred speech Drowsiness
	When should you suspect opiate withdrawal?	Fever/chills Watery eyes and nose Abdominal cramps Muscle spasms Insomnia Yawning
	Treatment for opiate withdrawal	Clonidine Methadone
	When should you suspect PCP use?	Panic Assaultive Agitation Nystagmus Hypertension Seizures Hyperacusis
	Treatment for PCP use	Talk them down Support respiratory function Consider benzos, antipsychotics
	When should you suspect benzo or barbiturate use?	Inappropriate sexual or aggressive behavior Impaired memory Impaired concentration
	When should you suspect benzo or barbiturate withdrawal?	Autonomic hyperactivity (tachy) Tremor Insomnia Seizures Anxiety
	Treatment for benzo withdrawal	Long-acting barbiturates i.e. chlordiazepoxide, phenobarbital
	Drugs that cause sexual dysfunction	Beta blockers SSRIs a1-blockers Trazodone (priapism) Dopamine agonists (increased libido) Neuroleptics
	When should you suspect a paraphilia?	Causes impairment Lasts >6 months
	Treatment for paraphilias	Psychotherapy Aversive conditioning If severe, antiandrogen or SSRI to impair libido
	When should you suspect subarachnoid hemorrhage?	Sudden onset of "worst headache of their life" Stiff neck Photophobia Loss of consciousness (50%) Focal neurologic deficits (30%)
	Workup for Subarachnoid Hemorrhage	Noncontrast head CT If negative, LP (look for xanthochromia and RBCs)
	You have an elevated WBC on LP. How do you tell if it's due to infection or a traumatic tap?	Look at the WBC:RBC ratio Normal ratio: 1 WBC: 500 RBCs To be an infection, the number of WBCs should be higher than this
	Treatment for subarachnoid hemorrhage	Angiography to determine source of bleeding Embolize site of bleeding Consider PO nimodipine to reduce the risk of stroke secondary to vasospasm Blood pressure control NB: Shunt if hydrocephalus
	Name the different transfusion reactions	Acute hemolytic (ABO incompatibility) Febrile nonhemolytic reaction Urticarial reaction IgA Deficiency Minor blood group incompatibility Transfusion-related acute lung injury (TRALI)
	When should you suspect an acute hemolytic transfusion reaction?	Time Course: During the transfusion Presentation: - Hypotension - Dyspnea - Tachycardia - Dark urine - Chest, back and flank pain - Elevated LDH and bilirubin
	Treatment for Acute Hemolytic Transfusion Reaction (ABO incompatibility)	Stop transfusion IV fluids NB: Check for clerical error or blood mix-up.
	When should you suspect Transfusion-Related Acute Lung Injury (TRALI)?	Time Course: Within 6 hours of transfusion Presentation: - Acute shortness of breath following a transfusion - Fever - Hypotension - "White lung" on CXR
	Treatment for TRALI	Supportive care Oxygen Intubate, if indicated Will resolve spontaneously
	When should you suspect transfusion-related IgA deficiency?	Time Course: During the transfusion Presentation: - Anaphylaxis (hypotension, tachycardia, dyspnea)
	Treatment for IgA Deficiency	Stop transfusion ??? If the pt needs a transfusion in the future, use blood from an IgA deficient donor or washed RBCs
	When should you suspect a transfusion-related febrile non-hemolytic reaction?	Time Course: Within a few hours of transfusion Presentation: - Small rise in temperature - No evidence of hemolysis
	Treatment for transfusion febrile non-hemolytic reactions?	None needed In the future, use filtered blood to remove white cell antigens.
	When should you suspect minor blood group incompatibility?	Time course: Delayed Presentation: - Jaundice - Otherwise, largely asymptomatic
	Treatment for minor blood group incompatibility	No specific therapy NB: Due to minor incompatibilities in Kell, Duffy, Lewis or Kidd antigens.
	When should you suspect HELLP Syndrome?	Setting: Third trimester or postpartum woman Presentation: - Hemolysis - Elevated LFTS - Low platelets - RUQ or epigastric pain Complications: DIC, placental abruption, fetal demise, ascites, hepatic rupture
	Treatment for HELLP Syndrome	Immediate delivery IV mag sulfate, for seizure prophylaxis IV dexamethasone when plts <20k or <50k if you're doing a C section - Continue until plts >100,000 and liver fxn normalizes
	When should you suspect preeclampsia?	Setting: Young black woman with her first child Presentation: - Hypertension - Proteinuria - Swelling of hands/feet - Headache - Oliguria
	Mild vs Severe Preeclampsia	Mild: - BP>140/90 - Proteinuria 1+ or >300 mg/24 hours Severe: - BP>160/110 - Proteinuria 3+ or >5g/24 hours - HELLP - Oliguria (<500 ml/24 hrs) - Pulmonary edema
	Treatment for Mild Preeclampsia	#1: Is the pregnancy near term? - If so --> stabilize mother and deliver If premature: - Hydralazine or labetalol for hypertension - Mag sulfate for seizure prophylaxis - Bed rest - Hospitalize
	Treatment for severe preeclampsia	#1: Stabilize mother (anti-hypertensives, MgSO4) Deliver! NB: Continue mag for at least 12-24 hours after delivery
	When should you suspect magnesium toxicity?	Hyporeflexia Respiratory depression CNS depression Coma Death
	Risk factors for preeclampsia	First pregnancy Extremes in age Black Multiple gestation Hydatidiform mole Diabetes Chronic hypertension Chronic renal disease
	Workup for preeclampsia	CBC UA with urine protein Chem12 PT/INR, PTT LFTs NB: Hemoconcentration with lead to an elevation in Hgb, Hct, BUN, Cr and uric acid
	What is the blood pressure goal in preeclampsia?	140-150/90-100 NB: Reducing the pressure below this may reduce uteroplacental blood flow.
	Medications for Blood Pressure Control in Preeclampsia	Acute elevation: - IV hydralazine - IV labetalol Maintenance: - Methyldopa - B-blocker (may cause IUGR) NB: NEVER give thiazide diuretics or ACEIs.
	When should you suspect croup?	Age: 3 months-5 yrs Presentation: - Upper respiratory symptoms - Barking cough*** - Low grade fever - Inspiratory stridor - Tachypnea - Worse at night - Steeple sign on frontal neck x-ray
	Treatment of croup	Humidified oxygen PO dexamethasone Nebulized racemic epinephrine, if severe NB: Should resolve within 1 week. Rule out epiglottitis.
	Causative organisms in croup	Parainfluenza 1 or 3 Influenza A or B
	When should you suspect epiglottitis?	Setting: Sudden onset of symptoms in a 2-7 yo Presentation: - Muffled voice - Drooling - Dysphagia - High fever - No cough*** - Sitting in tripod position - Inspiratory stridor
	Causative organism in epiglottitis	H. influenzae B (less common d/t vaccination) S. pneumoniae S. aureus
	Treatment for epiglottitis	Hospitalize and send to OR Consult ENT and anesthesia Intubate IV ceftriaxone Steroids Once stabilized: - Neck x-ray (thumbprint sign) - Blood cultures - Scope in OR - Epiglottic swab culture
	When should you suspect bacterial tracheitis?	Setting: Child <3 yo with a recent viral upper resp. infection Presentation: - Brassy cough - Intermediate to high fever - Respiratory distress - NO drooling or dysphagia
	Workup for bacterial tracheitis	Blood cultures Throat cultures Laryngoscopy Chest x-ray (subglottic narrowing and ragged tracheal air column)
	Treatment for bacterial tracheitis	Secure airway, if indicated Antistaphylococcal antibiotics
	Causative organism in bacterial tracheitis	Staph aureus
	When should you suspect bronchiolitis?	Setting: Child under age 2 in fall or winter Presentation: - Mild URI - Fever - Paroxysmal wheezy cough - Dyspnea - Tachypnea - Prolonged expirations - Expiratory wheezing NB: Ball-valve obstruction of the small airways leads to overinflation
	Workup for brochiolitis	Clinic diagnosis CXR (hyperinflation with patchy atelectasis) Viral antigen testing of nasal secretions
	Causative organisms in brochiolitis	RSV (50%) Parainfluenza Adenovirus NB: Viral!!
	Treatment for brochiolitis	Supportive: - IV fluids - B-agonist nebulizer - Humidified oxygen Hospitalize if: - Severe tachypnea >60 rpm - Fever - Intercostal retractions
	When should you suspect viral pneumonia in a kid?	Setting: Age <5 Presentation: - URI symptoms - Low-grade fever - Tachypnea - CXR: Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing
	When should you suspect bacterial pneumonia in a child?	Setting: Age >5 Presentation: - High fever - Acute onset of shaking chills - Prominent cough - Pleuritic chest pain - Markedly diminished breath sounds - Dullness to percussion - CXR: Lobar consolidation
	When should you suspect a Chlamydia pneumonia in a child?	Chlamydia trachomatis Setting: Infant 1-3 months in age Presentation: - Insidious onset - Staccato cough - Peripheral eosinophilia - No fever or wheezing - Conjunctivitis at birth - CXR: Unilateral lower lobe interstitial changes that look worse than the patient's presentation
	Work-up for Pediatric Pneumonia	Chest x-ray Blood cultures CBC with diff IgM for mycoplasma/viral antigens NB: Do NOT get sputum cultures in children
	Treatment for Pediatric Pneumonia	Viral: Supportive. - If they deteriorate, give abx as they may be coinfected with bacteria. Chlamydia/Mycoplasma: Erythromycin or another macrolide Bacterial: - Outpatient: Amoxicillin, amoxicillin/clavulanate or cefuroxime - Inpatient: IV cefuroxime. Add vancomycin for Staph aureus
	Most common initial presentation of CF	Meconium ileus
	When should you suspect CF?	Meconium ileus Failure to thrive Steatorrhea Vitamin A, D, E and K deficiencies Rectal prolapse Persistent cough Infertility (absent vas deferens) Undescended testes
	How do you diagnose CF?	Elevated sweat chloride test (>60 meq/L) x 2, obtained on different days
	Inheritance Pattern in Cystic Fibrosis	Autosomal recessive
	When should you suspect enuresis?	Bedwetting after age 5-7 At least twice a week for at least 3 months NB: Rule out UTI
	Treatment for enuresis	1) Behavioral therapy - Sticker charts - Alarms If that fails --> TCAs, imipramine or desmopressin to reduce urine volume
	When is a family history of CAD significant?	Based on age. Male relatives< 55 yo Female relatives< 65 yo
	What does an S3 gallop represent?	Dilated left ventricle
	What does an S4 gallop represent?	Left ventricular hypertrophy
	Describe a mitral regurgitation murmur	Holosystolic
	What counts as a significant Q wave on EKG?	At least one little box wide or 1/3 of the entire QRS complex amplitude (height and depth)
	What does a significant Q wave signify?	Necrosis NB: Q waves are for life.
	Where should you look for an anterior infarct?	V1-V4
	Where should you look for an inferior infarct?	II, III and AVF
	Where should you look for a lateral infarct?	I, AVL
	Where should you look for a posterior infarct?	V1 and V2 Looks like an inverted anterior MI so look for large R waves and ST depression
	When should you suspect a bundle branch block?	Widened QRS (at least 3 small squares) R-R1
	Left vs Right Bundle Branch Block	Left: Usually in leads V5-V6 - R-R1 may appear as two peaks "on the same mountain" or as a flattened peak Right: Usually in leads V1-V2 - Usually has two distinct R-R1 peaks with what looks like an S in between
	Why do we care about LBBB in the setting of possible ischemia?	EKG diagnosis of MI is generally not valid in the presence of LBBB (Q waves hide in the qRS complex)
	What vessel is associated with a lateral MI?	Circumflex
	What vessel is associated with an anterior MI?	LAD
	What vessel is associated with a posterior infarction?	RCA or its branches
	What vessel is associated with an inferior MI?	Left or right coronary artery, depending on dominance NB: RCA more common
	What is the best test for reinfarction following an MI?	CK-MB NB: CK-MB returns to baseline within 1-2 days after infarction whereas troponin stays elevated for 1-2 weeks.
	What is the first cardiac enzyme to elevate in the setting of MI?	Myoglobin
	Absolute contraindications to exercise stress testing	Acute MI within the last 2-4 days Acute aortic dissection Recent PE Myocarditis, pericarditis or endocarditis Critical aortic stenosis Severe CHF Unstable angina
	Relative contraindications to exercise stress testing	Anything that causes baseline EKG changes: - LBBB - Digoxin - Paced rhythm - LVH HOCM High grade AV block
	When should you use a dipyridamole or adenosine stress test?	Patient can't exercise to a target heart rate of >85% of maximum Baseline EKG changes
	When should you NOT use a dipyridamole or adenosine stress test?	Severe asthma or COPD (can cause bronchospasm) Already on dipyridamole (Aggrenox for stroke prevention) Caffeine use in the last 24 hours (blocks adenosine) Second degree or higher heart block
	How do dipyridamole and adenoside stress the heart during a stress test?	Vasodilators They work preferentially on the normal coronaries leading to "steal."
	How does dobutamine stress the heart during an echo?	Inotrope, increases contractility and heart rate NB: Dobutamine is a beta agonist, so patients should be off of beta blockers on the day of the test.
	When should you consider a dobutamine stress echo?	Patient cannot exercise to >85% of maximum and they cannot have a vasodilator stress test Example: Paraplegic with bad COPD
	What conditions make an EKG essentially unreadable for ischemia?	LBBB Digoxin use Paced rhythm LVH Any baseline abnormality of the ST segment
	What is a thallium stress test good for?	Can localize non-perfused myocardium/infarcted tissue Can be helpful with baseline EKG abnormalities (LBBB,etc.)
	Definition of acute coronary syndrome	Purely clinical! Chest pain with features suggestive of ischemic disease
	First step in ACS	Morphine (if hypoxic) Oxygen Nitrates Aspirin (only part that reduces mortality) Then --> EKG, CXR, cardiac enzymes, labs
	In STEMI, when should PCI occur?	Within 90 minutes (sx onset/door to balloon time)
	Acute Treatment for STEMI	MONA PCI within 90 minutes Gp IIb/IIIa inhibitor in cath lab (IV) Heparin IV or LMWH subQ Plavix (clopidogrel) Statin Beta blocker* ACEI or ARB, if EF<40% *CCB if cannot tolerate BB due to bronchospasm
	Which intervention has the greatest efficacy in reducing mortality in STEMI?	PCI
	Post-MI, what medications should a standard patient go home on?	81 mg aspirin Beta blocker (reduces mortality) Clopidogrel or prasugrel Statin (atorvastatin) ACEI, if EF<40% Sublingual nitro prn
	Lifestyle modifications post-MI	LDL <100 BP< 140/90 Smoking cessation Exercise/cardiac rehab
	What should you do if cath is delayed in a STEMI patient?	Consider TPA
	Treatment for NSTEMI	MONA --> EKG, CXR, cardiac enzymes, labs Heparin Clopidogrel Beta blocker Statin NB: If the patient does not go for cath, do an echo at some point. Add ACEI if EF <45%.
	Differences between the treatment between STEMI and NSTEMI?	STEMI: PCI, Gp IIb/IIIa inhibitor, TPA - EF determined during cath NSTEMI: Get an echo if no cath
	Which therapies reduce mortality in ACS?	Aspirin Beta blocker Statin Clopidogrel or prasugrel ACEI or ARB (only if EF<40%)
	When is a calcium channel blocker (diltiazem, verapamil) used in ACS?	Intolerance to beta blockers (severe asthma) Cocaine-induced MI Prinzmetal's angina (coronary vasospasm) NB: CCB do NOT change mortality.
	When should you think about putting in a pacer post-MI?	AV blocks and severe brachycardia - Mobitz II - Third degree AV block - Bifascicular block - NEW LBBB - Symptomatic bradycardia or brady <40 regardless of symptoms
	When should you consider giving amiodarone post-MI?	Vtach with a pulse AND is hemodynamically stable NB: Vfib and pulseless vtach should be defibrillated. Unstable vtach with a pulse should be cardioverted.
	Post-MI Complications	Rhythm Changes: - Sinus bradycardia - AV block - Vfib/vtach Anatomic: - Free wall rupture - Septal rupture - Papillary muscle rupture Cardiogenic shock Fibrinous pericarditis
	Duke's Criteria: What are they for? How many do you need?	For diagnosing infective endocarditis Need: - 2 major - 1 major and 3 minor or - All 5 minor
	Roth spots	"White-centered" hemorrhages seen on the retina secondary to immune complex vasculitis Associated with infective endocarditis (not specific)
	Duke Criteria: Major Criteria	1) TWO positive blood cultures with: - Staph aureus - Viridans strep - Strep bovis/epidermis - Enterococci - Gram negative rods - Candida - HACEK organism 2) Abnormal echo - Intracardiac mass or vegetation - Abscess - New partial dehiscence of prosthetic valve
	HACEK organisms	Haemophilus aphrophilus/parainfluenzae Actinobacillus actinomycetemcomitans Cardiobacterium hominis Eikenella corrodens Kingella kingae
	Duke Criteria: Minor Criteria	1) Fever >38 F 2) Presence of risk factors (IVDU, structural heart disease, prosthetic valve, dental procedures, hx of endocarditis 3) Vascular FIndings (Janeway lesions, septic pulmonary infarcts, arterial emboli, mycotic aneurysm, conjunctival hemorrhage) 4) Immunological Findings (Roth spots, Osler nodes, glomerulonephritis) 5) Positive blood cx without meeting major criteria
	Risk factors for endocarditis	Structural heart disease Prosthetic heart valve IV drug use History of endocarditis Dental procedures that involve bleeding
	When should you suspect infective endocarditis?	Fever New or changed heart murmur Vascular findings: Janeway, splinter hemorrhages, mycotic aneurysm, pulmonary infarcts Immunologic findings: Osler nodes, Roth spots, glomerulonephritis
	Workup for suspected endocarditis	1) Blood cultures 2) If positive --> echo
	What is the most common organism in endocarditis in the setting of IV drug use?	Staph aureus
	Treatment in infective endocarditis	If any concern for MRSA: Vancomycin and gentamicin x 4-6 weeks If no concern for MRSA: Nafcillin and gentamicin x 4-6 weeks Consider valve replacement for anatomic defects NB: If strep bovis, also consider colonscopy to rule out colon pathology
	When should you consider valve replacement in infective endocarditis?	Anatomic Defects: - Valve rupture - Abscess - Prosthetic valve Fungal endocarditis Embolic Events once the patient is already on abx
	Who needs antibiotic prophylaxis for endocarditis?	High Risk Condition AND High Risk Procedure Conditions: - Prosthetic valve - Unrepaired cyanotic heart disease - Previous endocarditis - Transplant pt with valve disease Procedures: - Dental procedures that CAUSE BLEEDING - Respiratory tract surgery - Surgery of infected skin
	Antibiotic Prophylaxis for Endocarditis: Drug(s) of Choice	Amoxicillin PO Penicillin allergy: Clindamycin or clarithromycin
	When should you supect sinus bradycardia?	Setting: Post-MI Presentation: - BP<60 - Dyspnea - Chest pain - Hypotension - DIzziness
	Treatment for sinus bradycardia	1) Put in ICU and put on telemetry 2) Treat based on heart rate and symptoms 40-59 bpm and asymptomatic: Observe 40-59 bpm and symptomatic --> Atropine <40 bpm --> Atropine 3) If no response --> sedate with midazolam and place transcutaneous pacer pads 4) Transvenous or permanent pacer, if indicated
	When should you suspect first degree heart block?	PR interval >0.2 sec (one large square)
	Treatment for first degree heart block	Atropine
	When should you suspect Mobitz type I heart block?	PR interval gets progressively longer until a beat is dropped
	Treatment for Mobitz type I heart block	Can try atropine (still has partial AV transmission) Transcutaneous, transvenous or permanent pacer, as indicated
	When should you suspect Mobitz Type II heart block?	No change in PR interval QRS complexes are dropped intermittently
	Treatment for Mobitz Type II heart block	Sedation --> transcutaneous pads Consider transvenous or permanent pacer NB: Atropine is CONTRAINDICATED - Speeds up the SA node, which is not conducted
	When should you suspect 3rd degree heart block?	Complete AV dissociation Ventricular rate is often 20-40
	Treatment for 3rd heart block	Transcutaneous pacer --> permanent
	Time Course for Electrical Complications following MI	Usually first 24 hours
	Treatment for vfib	Defibrillate immediately
	Treatment for vtach	1) Assess pulse Pulseless --> Defibrillate 2) Assess blood pressure Unstable --> Synchronized cardioversion Stable --> Amiodarone
	Treatment for pulseless vtach	Defibrillation
	Treatment for vtach with a pulse but hemodynamically unstable	Synchronized cardioversion
	Treatment for hemodynamically stable vtach with a pulse	Amiodarone
	When should you suspect papillary muscle rupture?	Setting: 3-5 days after MI Presentation: - Hypotension - Acute mitral regurgitation --> holosystolic murmur - Dyspnea - Acute pulmonary edema - Cardiogenic shock (<90/65)
	Workup of papillary muscle rupture	Echo
	Treatment of papillary muscle rupture	Nitroprusside (vasodilator, reduces afterload) IABP (reduces afterload) Dobutamine or isoproterenol (inotrope) Call TCV for surgical repair!
	When should you suspect septal rupture?	Setting: 3-5 days after MI Presentation: - Hypotension - Cardiogenic shock (<90/65) - JVD
	Workup for septal rupture	Echo Right heart cath (saturation should increase from right atria to right ventricle d/t backflow)
	Treatment for septal rupture	Reduce afterload: - Nitroprusside - IABP Inotropic Support: - Dobutamine or isoproterenol Definitive Management: Call TCV!!
	When should you suspect myocardial wall rupture?	Setting: ~5 days after MI Presentation: - Cardiac tamponade - Muffled heart sounds - JVD - Pulsus paradoxus
	Workup for myocardial wall rupture	Echo
	Treatment for myocardial wall rupture	Immediate pericardiocentesis Transfuse Call TCV for repair!
	When is IABP contraindicated?	Aortic dissection Severe aortic regurgitation Severe peripheral vascular disease
	Right vs Left Cardiogenic Shock: Quick differentiation	1) Listen to lungs: If crackles --> probably left 2) JVD present? : If yes, probably right
	Empiric treatment for right cardiogenic shock	IV fluids
	Empiric treatment for left cardiogenic shock	Reduce afterload: nitroprusside, IABP Increase contractility: Isoproterenol NB: IV fluids are CONTRAINDICATED
	When should you suspect fibrinous pericarditis?	Setting: 7 days after MI Presentation: - Chest pain - Diffuse ST elevation on EKG - No bump in CK-MB (troponin is probably still elevated from MI)
	Treatment for fibrinous pericarditis	Aspirin
	How do ACEI and ARBs affect potassium?	They both cause HYPERkalemia.
	Treatment for stable angina	Aspirin (improves mortality) Metoprolol (improves mortality) ACEI or ARB (if EF <40%) Sublingual nitro prn Statin (if LDL >70-100) NB: Clopidogrel can be added if the patient cannot tolerate aspirin.
	When might you do a cath in the setting of stable angina?	To determine eligiblity for CABG
	CAD Equivalents	Diabetes CAD Peripheral arterial disease Symptomatic carotid disease
	Indications for CABG	Left main stenosis >70% Three vessel disease with >70% stenosis
	LDL goal in CAD	LDL <100 NB: Remember CAD equivalents!
	LDL goal with CAD and diabetes	<70 NB: Remember CAD equivalents!
	What is the most common side effect of statins?	Elevated transaminases
	Monitoring for statins	Get LFTs at baseline and again at 3 months NB: Don't stop the statin unless the transaminases are 3x the upper limit of normal
	Myalgias with a statin	Can be caused by rhabdomyolysis Stop the statin. Restart at a lower dose and increase slowly.
	Treatment for isolated elevated triglycerides	Gemfibrozil NB: Should not affect LDL or HDL
	Which statin should be used in HIV patients?	Pravastatin NB: It's not metabolized by the p450 enzymes, so it should not interact with antiretroviral therapy.
	Treatment for isolated low HDL	Niacin (nicotinamide) NB: Causes flushing and impaired glucose tolerance
	Treatment for Elevated LDL and Elevated Triglycerides	Fibrate: Fenofibrate or clofibrate
	Triglyceride Goal	<150
	HDL Goal	>40 in men >50 in women
	BP Goal: - Everyone - Diabetics - Diabetic Nephropathy (microalbuminuria)	Everyone: <140/90 Diabetics: <130/80 Diabetic Nephropathy: <125/75
	When should you suspect CHF?	DOE Edema Rales on lung exam Ascites JVD S3 gallop (pathologic over age 40) Orthopnea PND Fatigue
	What is the worst manifestation of CHF?	Acute pulmonary edema
	When should you suspect acute pumonary edema?	Acute, severe shortness of breath Rales on lung exam S3 gallop Orthopnea PND
	You suspect acute pulmonary edema. Now what?	Dx and Tx AT THE SAME TIME 1) Oxygen, nitrates, morphine, furosemide Put in the ICU Dx: - Chest x-ray - EKG - Pulsox (consider ABG) - Echo
	What do you expect on a CXR in CHF?	Pulmonary vascular congestion Cephalization of flow Cardiomegaly Effusions
	What medications should be given to a newborn at delivery?	1) 1% silver nitrate eye drops or 0.5% erythromycin ointment 2) 1 mg IM vitamin K
	Newborn: What needs to be done prior to discharge?	Hearing test Neonatal screening tests: - PKU - Galactosemia - Hypothyroidism
	When should neonatal screening tests be performed?	After 48 hours (More reliable at that time)
	When should you suspect Mongolian spots?	Setting: Newborn or very young child Presentation: - Blue/gray macules on posterior thighs or presacral back
	Treatment for Mongolian spots	Usually spontaneously resolve NB: Rule out abuse
	When should you suspect erythema toxicum?	setting: Newborn in first few days Presentation: Firm, yellow or white pustules/papules on an erythematous base - Usually peak on day 2 of life
	Treatment for erythemia toxicum	Usually self-limited
	When should you suspect a port wine stain (nevus flammeus)?	Setting: Child +/- Sturge Weber syndrome Presentation: Permanent, unilateral vascular malformation on head and neck
	Treatment for port wine stain	Pulsed laser therapy If associated with Sturge Weber: Also evaluate for glaucoma and give anticonvulsants
	When should you suspect Sturge Weber syndrome?	Port wine stain Seizures Mental retardation Glaucoma
	When should you suspect strawberry hemangioma?	Setting: Child under the age of ~5 Presentation: - Red, sharply demarcated, raised lesion - Appears in first two months of life --> rapidly expands - Usually involutes by age 5-9
	Treatment for strawberry hemangioma	Generally involutes on its own by age 5-9 Consider treating with steroids or pulsed laser if: - Large (can cause high output cardiac failure) - Deep and interfering with organ function
	A child presents with a preauricular pit. Now what?	Screen for hearing loss Do renal ultrasound for GU abnormalities
	A child presents with a coloboma. Now what?	Screen for CHARGE syndrome: - Coloboma - Heart defects - Atresia of the nasal choanae - growth Retardation - GU abnormalities - Ear abnormalities NB: Often have "deaf blindness"
	A child presents with aniridia. Now what?	Screen for Wilms - Abdominal ultrasound Q3 months until age 8
	When should you suspect branchial cleft cyst?	Neck mass lateral to midline May become infected
	Treatment for branchial cleft cysts	If asx, leave it alone. If infected --> antibiotics If large --> surgical removal
	When should you suspect a thyroglossal duct cyst?	Mass in midline Moves with swallowing or tongue protrusion May become infected
	Treatment for thyroglossal duct cyst	Thyroid function tests Thyroid scan (for thyroid ectopia) Then --> surgical removal
	When should you suspect omphalocele?	setting: Newborn. May be associated with trisomies 18, 13, 21. Presentation: - Abdominal defect WITH a sac - Through the umbilicus - Absent umbilical ring - May have polyhydramnios in utero
	Treatment for omphalocele	Immediate surgery Give TPN until healed Screen for trisomy 13, 18 and 21. NB: Small defects can be closed primarily. Large defects need a silastic "silo" to protect the bowel. Manually replace the bowel daily until closed (~1 week).
	When should you suspect gastroschisis?	Setting: Newborn Presentation: - Abdominal defect lateral to midline - NO sac - Associated with intestinal atresia
	Treatment for gastroschisis	Immediate surgery TPN for nutrition NB: Small defects can be closed primarily. Large defects need a silastic "silo" to protect the bowel. Manually replace the bowel daily until closed (~1 week).
	A child has an umbilical hernia. What screening should be done?	TSH, T4 (congenital hypothyroidism)
	A child has an undescended testis. Now what?	Do nothing until at least one year of age (80% will descend) Then: - B-hCG or testosterone injections or - orchidopexy (surgical removal)
	When should you suspect hypospadias?	Urethral opening UNDER the penis (ventral surface)
	When should you suspect epispadias?	Urethral opening on TOP of the penis (dorsal surface)
	A woman with diabetes has a baby. What might you expect in the infant?	Hypoglycemia Hypocalcemia Hypomagnesemia HYPERbilirubinemia Polycythemia Macrosomia --> birth trauma Cardiac abnormalities Small left colon and abdominal distension Increased risk longterm of developing DM and childhood obesity
	Workup for respiratory distress in a newborn	#1: Chest x-ray ABG Blood cultures Glucose CBC (anemia or polycythemia) Cranial ultrasound (hemorrhage) Exam for heart defects
	Initial treatment for a newborn in respiratory distress	Oxygen (keep SaO2 >95%) Consider empiric antibiotics NB: If high oxygen requirements, consider nasal CPAP to prevent barotrauma.
	When should you suspect Respiratory Distress Syndrome in a neonate?	Setting: Premature neonate Presentation: - Nasal grunting - Tachypnea - Intercostal retractions - Hypoxemia - Eventually hypercarbia and respiratory acidosis
	Workup for neonatal Respiratory Distress Syndrome	#1: Chest x-ray (ground glass, atelectasis, air bronchograms) Lecithin-sphingomyelin ratio on amniocentesis
	Treatment for neonatal Respiratory Distress Syndrome? What about prevention?	Oxygen Nasal CPAP Exogenous surfactant (decreases mortality) Prevention: - Prevent prematurity with tocolytics - Betamethasone at least 24 hours prior to delivery if <34 weeks
	Complications of neonatal Respiratory Distress Syndrome	Retinopathy of prematurity (secondary to hypoxemia) Bronchopulmonary dysplasia (prolonged high concentration O2) Intraventricular hemorrhage
	When should you suspect transient tachypnea of the newborn?	Setting: Term infant delivered by C section or rapid second stage of labor Presentation: - Tachypnea - Air trapping, fissure fluid and perihilar streaking on CXR
	Treatment for Transient Tachypnea of the Newborn	Oxygen support Usually resolves rapidly in 24-48 hours
	When should you suspect meconium aspiration?	Setting: Term infant with hyposia or fetal distress in utero Presentation: - Severe respiratory distress - Hypoxemia - CXR with patchy infiltrate, air trapping, flattening of the diaphragm
	Treatment for meconium aspiration	Airway suction of depressed infants immediately after delivery Positive pressure ventilation High frequency ventilation Nitric oxide therapy ECMO
	Complications of meconium aspiration	Air leak (pneumothorax, pneumomediastinum) Pulmonary hypertension Aspiration pneumonitis
	When should you suspect congenital diaphragmatic hernia?	Dyspnea at birth Loops of bowel in left chest Scaphoid abdomen Respiratory distress Pulmonary hypoplasia
	Treatment for congenital diaphragmatic hernia	Intubate with low-pressure ventilation Sedate NG suction Surgically repair after 3-4 days (for lung maturation)
	Ddx for meconium plugs	Small left colon (IODM) Hirschprung disease Cystic fibrosis Maternal drug abuse NB: Plugs are usually found in the lower colon.
	What should you be thinking about with meconium ileus?	Cystic fibrosis
	Workup for intestinal obstruction in a newborn	#1: Abdominal x-ray
	Treatment for meconium ileus	Gastrografin enema
	When should you suspect tracheoesophageal fistula?	Setting: Newborn Presentation: - Choking and gagging with first feeding - Respiratory distress - Aspiration pneumonia - Drooling - Infiltrates on lung x-ray
	How to diagnose tracheoesophageal fistula	Place an NG tube (will be coiled in the chest on CXR) NB: Remember to screen for other abnormalities (VACTERL syndrome)
	Ddx of the double bubble sign	Duodenal atresia Annular pancreas Malrotation Volvulus
	When should you suspect intestinal atresia?	Often premature and/or Down's syndrome Polyhydramnios in utero No respiratory distress Bilious vomiting Double bubble sign on chest w-ray
	Treatment for intestinal atresia	NG decompression Screen for other VACTERL abnormalities Surgical correction
	VACTERL Syndrome	Vertebral defects Anal atresia (imperforate anus) Cardiac abnormalities Tracheoesophageal fistula Esophageal atresia Radial and Renal abnormalities Limb Syndrome
	When should you suspect necrotizing enterocolitis?	Setting: Premature infant on formula feeds Presentation: - Low APGAR scores - Bloody stools - Apnea - Lethargy - Abdominal wall erythema and distension - Pneumatosis on abdominal x-ray
	Workup for NEC	Abdominal x-ray and/or ultrasound
	Treatment for necrotizing enterocolitis	STOP all feeds Decompress gut Broad spectrum antibiotics Evaluate for surgery
	When should you suspect Hirschprung disease?	Setting: Newborn Presentation: - Failure to pass meconium spontaneously - Voluminous stool passed after digital rectal exam
	Workup for Hirschprung's disease	#1: Rectal exam (looking for passage of voluminous stool afterward) Barium enema (proximal megacolon) Rectal biopsy (absent ganglionic cells)
	Treatment for Hirschprung's disease	Surgery
	When should you suspect kernicterus?	Setting: Jaundiced infant Presentation: - Elevated indirect bilirubin - Posturing - Hypotonia - Seizures - Choreoathetosis - Delayed motor skills - Sensorineural hearing loss
	Treatment for kernicterus	Immediate exchange transfusion
	When is neonatal hyperbilirubinemia pathologic?	- First day of life or after 2 weeks - >12 mg/dL in a term infant - Direct bilirubin > 2 mg/dL at any time - If it rises > 5 mg/dL/day
	Ddx of direct, conjugated hyperbilirubinemia in a neonate?	Sepsis TORCH infections TPN Hypothyroidism Galactosemia Tyrosinemia Cystic fibrosis Choledochal cyst
	Ddx of indirect (unconjugated) hyperbilirubinemia in a neonate?	Rh/ABO incompatibility Thalassemia minor Polycythemia Twin-twin transfusion Maternal-fetal transfusion Delayed cord IUGR IODM Spherocytosis Elliptocytosis G6PD deficiency Pyruvate kinase
	Ddx of Coombs-positive, indirect hyperbilirubinemia in a neonate?	Rh/ABO incompatibility Thalassemia minor NB: All other indirect hyperbilirubinemias are Coombs negative.
	Workup for neonatal hyperbilirubinemia	Total and direct bilirubin Blood type of infant and mother: ABO, Rh Direct Coombs CBC Reticulocyte count Blood smear (look for hemolysis) UA and culture if elevated direct (look for sepsis)
	Ddx of prolonged (>2 weeks) jaundice in a neonate	Direct: - Cholestasis Indirect: - Infection - Bilirubin conjugation abnormalities (Gilbert, Crigler-Najjar) - Hemolysis - Intrinsic red cell membrane or enzyme defects (G6PD, spherocytosis, pyruvate kinase
	Treatment for neonatal hyperbilirubinemia	When bilirubin >10-12 mg/dL --> phototherapy If phototherapy is ineffective or concern for kernicterus --> exchange transfusion
	How quickly should bilirubin decrease with phototherapy?	2 mg/dL every 4-6 hours
	What are the most likely causes of early and late sepsis in a neonate?	Early=Within the first 24 hour Early: Pneumonia Late: Bacteremia or meningitis
	Causative organisms in neonatal pneumonia	Group B Strep E. coli H. influenzae Listeria monocytogenes
	Causative organisms in neonatal meningitis/bacteremia	Staph aureus E. coli Klebsiella Pseudomonas
	Treatment for neonatal sepsis	If meningitis is possible: ampicillin and 3rd gen cephalosporin (NOT ceftriaxone) If there is no evidence of meningitis: ampicillin and an aminoglycoside (-mycin)
	Third Generation Cephalosporins	Ceftriaxone Cefotaxime Ceftazidime Cefpodoxime Cefixime Ceftibuten
	Aminoglycosides	Streptomycin Gentamicin Tobramycin Amikacin
	When should you suspect a TORCH infection?	Setting: Congenital infection Presentation: - IUGR - Hepatosplenomegaly - Jaundice - Mental retardation - Symptoms specific to individual infections
	TORCH Infections	Toxoplasmosis Other (syphilis, varicella) Rubella CMV Herpes
	When should you suspect congenital toxoplasmosis?	Hydrocephalus Intracranial calcifications Chorioretinitis
	Workup for a suspected TORCH infection	Review maternal history (sexual history, cats, etc) Physical exam CBC and platelets LFTs X-rays of long bones Eye evaluation Hearing evaluation Neuroimaging Consider LP
	Best diagnostic test for congenital toxoplasmosis	IgM against toxo
	When should you suspect congenital rubella?	Cataracts Deafness Heart defects Blueberry muffin spots (extramedullary hematopoesis)
	Best diagnostic test for congenital rubella	Maternal rubella immune status (unknown or negative) IgM against rubella
	When should you suspect congenital CMV?	Microcephaly Periventricular calcifications Thrombocytopenic petechiae Sensorineural hearing loss
	Best diagnostic test for congenital CMV	Urine or saliva CMV culture (if negative, no CMV) Serum IgM antibody
	When should you suspect congenital herpes?	First week: pneumonia and shock Second week: Skin vesicles and keratoconjunctivitis Third-Fourth Week: Acute meningoencephalitis
	Workup for congenital herpes	Initial: Tzanck smear/culture (If neg, does not rule out) Most specific: HSV PCR
	When should you suspect congenital syphilis?	Snuffles Desquamating rash of palms and soles Osteochondritis and periostitis
	Workup for congenital syphilis	Initial test: VDRL screening Most specific: IgM-FTA-ABS
	When should you suspect congenital varicella?	Neonatal pneumonia Limb hypoplasia Cutaneous scars Seizures Mental retardation
	Workup for congenital varicella	Initial: IgM serology Most specific: PCR of amniotic fluid
	When should you suspect neonatal seizures?	Subtle repetitive movements ie chewing, tongue thrusting, apnea, blinking Ocular deviation Jitteriness
	Workup for neonatal seizures	EEG (may be normal) Labs: CBC, lytes, Ca, Mg, phosphorus Glucose (especially in IODM) Amino acid assay and urine organic acids (errors in metabolism) Total cord blood IgM Urine culture Blood culture LP, if meningitis possible Ultrasound of head for hemorrhage (esp if premature)
	Ddx of neonatal seizures	Electrolyte abnormalities Hypoglycemia Inborn errors of metabolism Infection Intracranial hemorrhage
	Treatment for neonatal seizures	Phenobarbital Correct electrolyte abnormalities If seizures persist, phenytoin
	When should you suspect neonatal substance withdrawal?	Hyperactivity Irritability Restlessness Fever Diarrhea Tremors/jitters High-pitched crying Vomiting Nasal stuffiness Poor feeding Seizures Tachypnea
	Which drugs cause neonatal withdrawal in the first 48 hours?	Cocaine Heroin Alcohol Amphetamines
	Which drugs cause neonatal withdrawal after the first 48 hours?	Methadone (96 hours-2 weeks)
	Possible complications with an addicted mother: Neonatal? Prenatal?	Low birth weight IUGR Congenital abnormalities SIDS STDs Placental abruption Intraventicular hemorrhage (cocaine)
	Treatment for neonatal withdrawal	Generally opioids and phenobarbital
	Which drugs have teratogenic effects?	Anesthetics Barbituartes Mag sulfate Phenobarbital Sulfonamides NSAIDs ACEIs Isoretinoin Phenytoin DES Tetracycline Lithium Warfarin Valproate Carbamazepine
	Workup for Down's Syndrome	Hearing exam Echo (endocardial cushion defects) TSH High index of suspicion for: GI defects (duodenal atresia, fistula), ALL, early onset Alzheimer's
	When should you suspect Edwards Syndrome?	Low set- malformed ears Microcephaly Micrognathia Clenched hand Rocker bottom feet Hammer toe Omphalocele NB: Trisomy 18
	Workup for Edwards syndrome (Trisomy 18)	Echo Renal ultrasound (polycystic kidneys, ureter abnormalities) NB: Often die within first year
	When should you suspect Patau syndrome?	Defects of midface, eye and forebrain development Holoprosencephaly Microcephaly Microphthalmia Cleft lip/palate Single umbilical artery NB: Trisomy 13
	Workup for Patau Syndrome (Trisomy 13)	Echo Renal ultrasound (polycystic kidneys)
	What is WAGR Syndrome?	Wilms tumor Aniridia GU abnormalities mental Retardation
	When should you suspect Klinefelter Syndrome?	Usually present as male with: Low IQ Behavioral problems Slim with long limbs Gynecomastia NB: XXY
	Workup for Klinefelter's Syndrome?	Testosterone levels (hypogonadism, hypogenitalism) NB: Replace testosterone at 11-12 yo
	When should you suspect Turner Syndrome?	Female Small stature Gonadal dysgenesis Low IQ Congenital lymphedema Webbed posterior neck Broad chest with wide-spaced nipples NB: X0
	Workup for Turner Syndrome	Renal ultrasound (horseshoe kidney, double renal pelvis) Echo (coarctation, bicuspid aortic valve) TSH (hypothyroidism) NB: Consider replacement of estrogen, growth hormone and/or anabolic steroids
	When should you suspect Fragile X Syndrome?	Macrocephaly in childhood Large ears Large testes Elongated face Mental retardation ADHD
	When should you suspect Beckwith-Wiedemann Syndrome?	Multiorgan enlargement: - Macroglossia - Pancreatic beta cell hyperplasia (leads to hypoglycemia) - Large kidneys Neonatal polycythemia Hemihypertrophy
	Workup for Beckwith-Wiedemann Syndrome?	AFP and abdominal ultrasound Q6 mo until age 6 NB: Increased risk of Wilm's and hepatoblastoma
	When should you suspect Prader-Willi syndrome?	Morbid obesity Mental retardation Binge eating Small genitalia
	What is the genetic defect in Prader Willi?	Deletion of the PATERNAL 15q11q13
	When should you suspect Angelman Syndrome?	Mental retardation Inappropriate laughter Sparse or absent speech Ataxia Jerky movements Recurrent seizures (80%) NB: Deletion of MATERNAL 15q11q13
	When should you suspect Pierre Robin or Robin sequence?	Mandibular hypoplasia Cleft palate Tongue falls back --> high risk for airway obstruction
	First step in diagnosing abnormal growth	How does the height/length compare to the weight? Is it proportional?
	Growth Abnormalities: Ddx if weight gain is more affected than height	Basically anything that prevents use of calories Undernutrition Inadequate digestion Malabsorption (infection, celiac, CF, protein-losing enteropathy)
	Growth Abnormalities: Ddx when weight and height are proportional	Systemic illness: - Heart failure - Inflammatory bowel disease - JRA - Renal insufficiency - Hepatic insufficiency Genetic short stature Constitutional growth delay
	Growth Abnormalities: Ddx when height is affected more than weight	Growth hormone deficiency Thyroid hormone deficiency Skeletal dysplasia Excess cortisol
	Contraindications to breastfeeding	Absolute: - Chemo - Iodide - Lithium - Chloramphenicol - Nicotine - Alcohol Relative: - Meuroleptics - Sedatives - Metronidazole - Tetracycline - Sulfonamides - Steroids
	Newborn Reflexes	Moro Grasp Rooting Tonic neck (fencer reflex) NB: Appear at birth and should disappear by 4-6 months
	Parachute reflex	Extend arms when turned upside down Appears at 6-8 months and persists
	Milestones at 9 months	Pincer grasp Creeps and crawls Knows name
	Milestones at 12 months	Cruises 1+ words Plays ball
	Milestones at 15 months	Builds 3 cube tower Walks alone Makes lines and scribbles
	Milestones at 18 months	4 cube tower Walks down stairs 10 words Feeds self
	Milestones at 24 months	7 cube tower Runs well Goes up and down stairs Jumps with 2 feet Threads shoelaces Handles spoon 2-3 sentences
	Milestones at 3 years	Walks downstairs with alternating feet Tricycle Knows age and sex Understands taking turns
	Milestones at 4 years	Can hop on 1 foot Throws a ball overhead Tells stories Participates in group play
	First line treatment for uncomplicated otitis media in a child	Amoxicillin x 10 days
	Most common cause of acute diarrhea in an infant?	Rotavirus
	What organisms cause bloody diarrhea in a child?	Campylobacter Amoeba (E. histolytica) Shigella E Coli Salmonella
	Workup for acute diarrhea in a child	Ova and parasites Stool culture Enzyme immunoassays for viruses If concern for HUS: CBC, blood smear, Coombs, UA If recent antibiotics: C difficile toxin
	Initial therapy for acute diarrhea in a child	Hydration Fluid and electrolyte replacement Antibiotics only in specific cases NB: Do NOT use antidiarrheals in children
	Acute pediatric diarrhea: Do you give antibiotics in E. coli?	No! Especially in cases of E. coli 0157:H7, antibiotics increase the risk of HUS.
	Acute pediatric diarrhea: Do you give antibiotics in Shigella?	Yes, trimethoprim/sulfamethoxazole.
	Acute pediatric diarrhea: Do you give antibiotics in Campylobacter?	Maybe. Give erythromycin if severe or dysentery.
	Acute pediatric diarrhea: Do you give antibiotics in Salmonella?	Only if: - <3 months old - Toxic - Disseminated disease - Salmonella typhi Then, amoxicillin, ampicillin, trimethoprim/sulfamethoxazole or ceftriaxone
	Acute pediatric diarrhea: Do you give antibiotics in C. difficile?	Yes. Stop all other antibiotics first. Then, PO vancomycin or metronidazole.
	Acute pediatric diarrhea: Do you give antibiotics in amoebiasis?	Yes, metronidazole.
	Acute pediatric diarrhea: Do you give antibiotics with Giardia?	Yes, metronidazole.
	Acute pediatric diarrhea: Do you give antibiotics in cryptosporidium?	Yes, antiparasitics.
	When should you suspect hemolytic uremic syndrome?	Setting: Child 5-10 days after bloody diarrhea Presentation: - Pallor - Anemia - Weakness - Oliguria - Acute renal insufficiency
	Workup for HUS	CBC (anemic, elevated WBC, thrombocytopenia) Blood smear (burr cells, helmet cells, fragments) Coombs test (negative) UA (microscopic hematuria and proteinuria)
	Treatment for HUS	Supportive care Treat hypertension Dialysis, if indicated
	Benign causes of chronic diarrhea in children	Too much fruit juice Carbonated beverages Low fat intake NB: Weight and height should be normal. No fecal fat.
	Which infection can cause chronic malabsorption?	Giardia
	Workup for pediatric malabsorption	Fat: - Sudan black - 72 hour fecal fat - Serum trypsinogen Carbohydrate: - Clinitest screening - Breath hydrogen test (most specific) Protein: - Spot stool alpha-1 antitrypsin level Vitamins/Minerals: - Serum iron - Folate - Ca - zinc - Mg - B12, D, A
	When should you suspect celiac in a child?	Chronic diarrhea Failure to thrive Growth retardation Anorexia
	Workup for celiac	Antiendomysial antibodies Antigliadin antibodies Biopsy (most specific)
	When should you suspect GERD in a child?	Wheezing Apnea after feeds Recurrent spitting up
	Treatment for pediatric GERD	1) Change feeding technique and thicken feeds 2) H2 receptor blocker (ranitidine) 3) PPI or surgery only for severe cases and esophagitis
	When should you suspect pyloric stenosis?	Setting: 2-6 week old, first born, Caucasian male Presentation: - NONbilious vomiting - Hypochloremia - Metabolic alkalosis - Firm, mobile mass in epigastrium on exam
	Diagnostic test for pyloric stenosis	Abdominal ultrasound
	When should you suspect malrotation or volvulus?	Setting: Infant Presentation: - Bilious emesis - Recurrent abdominal pain - Acute small bowel obstruction
	Workup for suspected malrotation or volvulus	Abdominal ultrasound Barium enema Upper GI series
	When should you suspect intussusception?	Setting: Child <2 yo Presentation: - Currant jelly stools - Paroxysms of colicky abdominal pain - Lethargy - Fever - Shock NB: May have a history of GI infection, Meckel's, polyp, Henoch-Schlonlein purpura
	Workup for intussusception	Abdominal x-ray Air enema (diagnostic and therapeutic)
	Treatment for pediatric UTI	1) Amoxicillin or trimethoprim-sulfamethoxazole 2) Repeat urine culture 1 week after stopping abx to confirm sterile urine 3) Consider VUR workup in boys, febrile UTI, girl under 5 and girls >5 with their second UTI NB: Do NOT give quinolones to children under 16
	Which children should be screened for vesicoureteral reflux?	UTI and: - Male - Female under 5 - Female over 5 (second UTI) - Fever
	Workup for suspected vesicoureteral reflux	Voiding cystourethrogram Renal ultrasound
	What is the danger of vesicoureteral reflux?	Predisposition to pyelonephritis Renal scarring Reflux nephropathy (HTN, proteinuria, ESRD, impaired kidney growth)
	Treatment for vesicoureteral reflux	Antibiotic prophylaxis for one year after diagnosis Surgery if: breakthrough UTI, renal scarring, failure to resolve
	Antibiotics for prophylaxis in VUR	Amoxicillin Trimpethoprim-sulfamethoxazole Nitrofurantoin
	Treatment for pediatric pyelonephritis	IV ceftriaxone or Ampillin + gentamicin
	Age cut-off for tetracyline in children	Do NOT use in children under 7
	Age cut-off for quinolones in children	Do NOT use in children under 16 NB: ciprofloxacin, levofloxacin, etc.
	When should you suspect acute poststreptococcal glomerulonephritis?	Setting: 5-12 yo child a few weeks after strep or impetigo Presentation: - Hypertension - Edema - Hematuria
	Workup for acute poststreptococcal glomerulonephritis	Urinalysis: RBCs, RBC casts, protein, PMNs C3 (low) Throat culture Streptococcal antibody titer Anti-DNase antigen (most specific)
	Treatment for acute poststreptococcal glomerulonephritis	Treat the underlying infection: Penicillin - Erythromycin if pen-allergic Supportive care: Sodium restriction, diuresis, electrolyte management NB: Do NOT give antihypertensives or steroids
	Ddx for pediatric hematuria	Acute poststreptococcal glomerulonephritis IgA Nephrophathy (Berger's Disease) Alport Syndrome
	When should you suspect IgA Nephropathy (Berger's DIsease)?	Setting: Teenager or in 20-30s with a recent GI or upper respiratory infection Presentation: - Gross hematuria - Mild proteinuria - Hypertension - NORMAL C3***
	Treatment for IgA Nephropathy	Control blood pressure
	When should you suspect Alport Syndrome?	Setting: Young boy with positive family history of hearing loss and renal issues Presentation: - Hearing trouble - Asymptomatic microscopic hematuria - Intermittent gross hematuria after URIs - Eye abnormalities
	When should you suspect Polycystic Kidney DIsease (autosomal recessive type)?	Setting: Infant Presentation: - Bilateral flank masses - Hypoplasia - Hypertension - Oliguria - Acute renal failure
	Workup for Polycystic Kidney Disease	Renal ultrasound (cysts through medulla and cortex) Liver ultrasound (Fibrosis, bile duct proliferation)
	Treatment for Polycystic Kidney Disease (autosome recessive)	Dialysis Kidney Transplant
	Ddx for pediatric proteinuria	Orthostatic Transient: - Fever - Exercise - Dehydration - Cold exposure Glomerular or tubular disorders (more likely if >1 g/24 hours or associated with HTN, hematuria, etc.)
	When should you worry about pediatric proteinuria?	>1 g protein per 24 hours Associated with hypertension, hematuria or renal dysfunction
	What is orthostatic proteinuria?	Benign condition in school-aged children and teens Proteinuria is increased when UPRIGHT and normal when supine
	When should you suspect pediatric nephrotic syndrome?	Setting: Age 2-6 with a recent minor infection Presentation: - Edema - Proteinuria (>40 mg/m2/hour) - Hypoalbuminemia (<2.5 g/dL) - Hyperlipidemia - NORMAL C3 and C4***
	Treatment for pediatric nephrotic syndrome	Oral prednisone (several weeks) Supportive care (fluid and sodium restriction) Immunization against Pneumococcus and Varicella NB: If relapses occur on prednisone, try cyclophosphamide, cyclosporine, high dose pulsed methyprednisolone.
	Possible complications of nephrotic syndrome	SBP Other infections Clots
	When should you suspect congenital adrenal hyperplasia?	Setting: Infant Presentation: - Vomiting - Dehydration - Salt wasting - Hyponatremia - Hypoglycemia - Hyperkalemia - Ambiguous genitalia (females)
	Diagnostic test for congenital adrenal hyperplasia	17-OH progesterone (increased in CAH) NB: More definitive if performed before and after an IV bolus of ACTH
	When should you suspect Kawasaki disease?	Setting: Child <5 yo Presentation: - Fever for >=5 days AND (4 of the 5): - Bilateral conjunctivitis without exudate - Intraoral erythema, strawberry tongue, cracked lips - Nonvesicular rash - Erythema/swelling of hands and feet with desquamation - Nonsuppurative cervical lymphadenitis
	Workup for Kawasaki Disease	CLINICAL diagnosis ESR/CRP (4-8 weeks) CBC (plts increase in weeks 2-3) Echo and EKG (baseline, 2-3 weeks and 6-8 weeks)
	Treatment for Kawasaki Disease	IVIG High dose aspirin Add warfarin if platelet count is very high
	Complications of Kawasaki Disease	Early myocarditis Pericarditis Coronary artery aneurysms (2nd-3rd week) Thrombosis
	When should you suspect Henoch Schonlein Purpura?	Setting: 2-8 yo with a recent upper respiratory illness Presentation: - Palpable purpura on legs and buttocks - Fever - Abdominal pain - Arthritis - Glomerulonephritis/nephrosis - Intussusception
	Workup for Henoch Schonlein Purpura?	CLINICAL diagnosis Supportive: - CBC (platelets up, WBC up, anemia) - ESR (up) - Anticardiolipin or antiphospholipid antibodies - UA: RBCs, WBCs, casts, albumin - Skin biopsy (IgA and C3 deposits)
	Treatment for Henoch Schonlein Purpura	Supportive: - Steroids for GI and renal complications - Aspirin if positive anticardiolipin or antiphospholipid antibodies
	Is anemia ever physiologic in children?	Yes. Term infants: Hgb nadir of 9-1 mg/dL at 12 weeks Premature infants: Hgb nadir 7-9 mg/dL at 3-6 weeks
	Treatment for pediatric iron deficiency anemia	Oral ferrous salts Limit cow's milk Continue iron replacement for 8 weeks after lab values normalize to replete bone marrow
	When should you suspect pediatric lead poisoning?	Hyperactivity Mental lethargy Aggression Learning disability Impaired growth Constipation
	Workup for lead poisoning	CBC with MCV (microcytic, hypochromic anemia) Blood smear (basophilic stippling) Blood lead level (<10 mcg/dL is ok) X-rays of long bones (lead lines)
	Treatment for pediatric lead poisoning	If >=15 mcg/dL --> refer to department of health If >45 mcg --> start chelation
	Diagnostic criteria for NF1	2 or more of the following: - First degree relative with NF1 - >6 cafe-au-lait spots of 5 mm (if children) or 15 mm (if adult) - >2 neurofibromas - Lisch nodules - Optic glioma - Bone dysplasia - Axillary freckling
	Workup for a new pediatric diagnosis of NF1	Ophthalmology consult (Lisch nodules, optic glioma) Derm consult NB: MRI not technically needed until there are eye or CNS abnormalities.
	What gastric abnormality is associated with Mallory-Weiss tears?	Hiatal hernia (40-100%)
	Treatment for acute seizure	ABCs and stabilize Put in IVs Workup: Glucose, CBC, lytes, calcium, urine tox screen If still seizing --> benzos (1st line) or barbiturate (2nd)
	Most common pathogen in adult viral meningitis	Herpes simplex virus
	Most common pathogens in pediatric viral meningitis	Enterovirus Arbovirus (more common in rural areas bc zoonoses)
	When should you suspect nonallergic rhinitis?	Setting: > age 20 Presentation: - Onset after age 20 - Nasal Blockage - Rhinorrhea - Postnasal drip - No clear trigger - year long symptoms
	Treatment for nonallergic rhinitis	Intranasal glucocorticoids (fluticasone) or Intranasal antihistamines (azelastine)
	When should you suspect allergic rhinitis?	Presents before age 20 Predominant eye symptoms Sneezing Nasal congestion Can usually identify a trigger Atopy Normal or blue nasal mucosa with pallor and occasional polyps
	Treatment for allergic rhinitis	Allergen avoidance Intranasal glucocorticoids
	Additional treatment for patients on long term steroids	Long term= Greater than 3 months or greater than 6 months if dose is <10 mg/day Baseline DEXA and then yearly Calcium and Vitamin D Add bisphoshonate only if risk of osteoporosis is very high
	How would you screen for HIV? What if the exposure was very recent?	Typical: ELISA --> Western blot for confirmation Recent exposure: HIV RNA PCR or p24 antigen NB: PCR can also be used when ELISA is negative or indeterminate.
	Workup for a suspected HIV exposure	Antibody testing at 1st visit (ELISA) Repeat at 6, 12 and 24 weeks
	What does an HIV ELISA test for?	Antibodies So it will be negative if the patient hasn't seroconverted
	How often should CD4 count and HIV load be measured in an HIV patient?	Q3-4 months
	Criteria for brain death	1) Irreversible absence of cerebral and brainstem reflexes 2) Absence of respiratory drive off the ventilator for a duration sufficient to produce hypercarbic drive (pCO2 50-60 or 10-20 minutes) 3) Body temp below 34 C 4) EEG isoelectric for 30 minutes at maximal gain 5) At least 24 hours observation in adults with anoxic brain damage with a negative drug screen NB: May still have purely spinal reflexes
	How do you diagnose C diff colitis?	1) Stool studies: PCR or EIA (PCR is more sensitive) 2) If negative and high clinical suspicion --> limited scope NB: Look for pseudomembranous colitis PCR looks for the toxin gene. EIA looks for the toxin itself.
	Which antibiotics are more likely to result in C diff?	Fluoroquinolones! Enhanced spectrum penicillins Cephalosporins Clindamycin
	First Generation Cephalosporins	Cefazolin Cephalexin Cefadroxil Cephalothin NB: Good for MSSA and strep
	What conditions can be associated with carpal tunnel?	Hypothyroidism Wrist trauma Diabetes End stage renal disease RA Pregnancy Obesity Fibromyalgia
	Treatment for Barrett's Esophagus	Dependent on whether there's dysplasia No dysplasia --> Yearly endoscopy Mild dysplasia -->Endoscopy Q6mo High grade dysplasia --> resection or ablation
	Modifiable risk factors in osteoporosis	Stop smoking (if >= 1 ppd) Calcium + vitamin D Stop heparin Stop steroids Consider raloxifene.......be careful
	Primitive idealization	Defence mechanism where a pt views another person as perfect and cannot tolerate evidence to the contrary
	Compensation (psych)	Defence mechanism Pt overemphasizes achieves in one area bc of failures in another
	Projection	Defense mechanism Pt attributes thoughts or desires to another person, especially those that are socially unacceptable
	Reaction Formation	Defense mechanism Reaction to stress by substituting thoughts, behaviors or feelings that are the exact opposite Example: Gay man acting like a homophobe
	What kind of therapy works best in borderline patients?	Dialectical behavior therapy NB: Works on behavior modification and skill building
	What is interpersonal therapy?	Short term therapy that works well in depression Focuses on relationships, reducing conflicts and building social support
	A tubular adenoma is found on colonoscopy. Now what?	Colonoscopy in 5 years
	A hyperplastic polyp is found on colonoscopy. Now what?	No change in screening. Colonoscopy in 10 yrs.
	Four adenomas are found on colonoscopy. Now what?	Colonscopy in 3 years NB: Indicated for 3-10 adenomas, any adenoma >1 cm, villous features or high grade dysplasia
	A polyp with high grade dysplasia is found on colonoscopy. Now what?	Colonoscopy in 3 years. NB: Indicated for 3-10 adenomas, any adenoma >1 cm, villous features or high grade dysplasia
	Do you ever need colon cancer screening more than every 3 years?	Only if: 1) Large (>2) sessile polyp that was removed piecemeal [2-6 mo] 2) Polyp with adenocarcinoma in situ and at least 2 mm margin [2-6 mo] 3) Patients with Familial Adenomatous Polpyposis [yearly beginning at 12] 4) HNPCC [yearly beginning at 25]
	Workup in fibromyalgia	Clinical diagnosis but should rule out other etiologies TSH, T4 CBC ESR CK
	Which blood pressure meds can be used in bipolar disorder?	Lithium is exclusively renally excreted, so be aware of kidney function! Amlodipine NB: Avoid furosemide, thiazides, ACEI and ARBs
	When should you suspect Vitamin D deficiency?	Setting: Gastric bypass or other malabsorption Presentation: - Bone pain or resorption - Low phos - Calcium may be normal due to bone resorption - Hyperparathyroidism NB: Measure serum 25-hydroxy vitamin D to diagnose.
	Treatment for pelvic inflammatory disease	Severe: IV abx only, cover gonorrhea and chlamydia - Doxycycline and cefoxitin or - Doxycycline and ceftriaxone Mild to moderate: Can consider PO or IM - Cover same bugs
	Antibiotics to treat gonorrhea	IM ceftriaxone (3rd gen) PO cefixime (3rd gen) IV cefoxitin (2nd gen)
	Antibiotics for chlamydia	PO azithromycin PO doxycycline
	What does mitral valve prolapse sound like?	Midsystolic click followed by a late systolic murmur
	When should you suspect acute cholangitis?	Charcot's triad: Fever, jaundice, RUQ pain Elevated direct bilirubin Elevated alk phos AST/ALT pretty normal
	Workup for acute cholangitis	LFTs CBC Admit! Blood cultures Once controlled --> ERCP
	Treatment for acute cholangitis	Admit! Strict vital sign monitoring Antibiotics (after blood cultures) IV fluids Once controlled, elective ERCP +/- biliary decompression
	When should you suspect iron deficiency anemia?	Microcytic Hypochromic Anisocytosis Ferritin usually <15 NB: Anemia of chronic disease usually has normal or elevated ferritin (acute phase reactant).
	Pt has a high hemoglobin. How do you screen for polycythemia vera?	Serum erythropoetin level - LOW in polycythemia vera - Elevated in compensatory polycythemia NB: JAK2 can be used as a confirmatory test for PV
	Workup of polycythemia	CBC Serum erythropoetin level Carboxyhemoglobin (to rule out CO poisoning) Pulsox Consider sleep study if no obvious other etiology
	When should you suspect transverse myelitis?	Setting: Recent URI Presentation: - Rapidly progressive lower extremity weakness - Sensory loss - Urinary retension - Dull back pain - Initial hypotonia and hyporeflexia -->spasticity later NB: Rule out compressive lesions
	When should you suspect temporal arteritis?	Tenderness of temporal area Jaw claudication Headache
	Workup for temporal arteritis	ESR Temporal artery biopsy
	Treatment for temporal arteritis	Emergent steroids NB: Generally high dose prednisone for several weeks
	When should you suspect pseudotumor cerebri?	Setting: Obese young woman Presentation: - Headache - Double vision (CN6 palsy) - Visual field loss - Pulsatile tinnitus - Papilledema - Normal imaging
	Workup for pseudotumor cerebri	LP with opening pressure (markedly elevated)
	Treatment for pseudotumor cerebri	Weight loss Acetazolamide Refractory --> shunt or optic nerve sheath fenestration
	When should you image a headache?	Sudden or severe Onset after age 40 Focal neurological findings
	Treatment for migraines	Abortive therapy: sumatriptan or ergotamine If >=4 headaches per month, add prophylaxis: - First choice: Propranolol - Alternatives: CCB, TCA or SSRI
	Abortive therapies for migraines	#1) Propranolol Calcium channel blockers Tricyclic antidepressants SSRIs
	When should a patient with migraine headaches receive prophylaxis?	At least 4 headaches per month
	When should you suspect cluster headaches?	Setting: Man Presentation: - Exclusively unilateral - Redness and tearing of eye - Runny nose
	Treatment for cluster headaches	Abortive: Triptan, 100% oxygen or steroids Prophylaxis: - CCB (verapamil)
	When should you suspect BPPV?	Vertigo, provoked by certain positions or maneuvers NO ataxia NO tinnitus NO hearing loss Positive Dix-Hallpike maneuver
	Treatment for BPPV	Particle repositioning maneuvers (Epley, Semont) Meclizine
	When should you suspect vestibular neuritis?	Vertigo unrelated to position NO hearing loss NO tinnitus
	Treatment for vestibular neuritis	Meclizine
	When should you suspect labyrinthitis?	Acute vertigo Hearing loss Tinnitus
	Treatment for labyrinthitis	Self-limited Meclizine
	When should you suspect Meniere's?	Chronic, remitting and relapsing Vertigo Hearing loss Tinnitus
	Treatment for Meniere's	Setting: Middle aged Salt restriction Diuretics
	When should you suspect acoustic neuroma?	Setting: Patient with NF2 (bilateral) Presentation: - Vertigo - Hearing loss - Tinnitus - Ataxia** - May knock out CN 5 and/or 7, depending on size
	When should you suspect Wernicke-Korsakoff Syndrome?	Setting: Chronic alcoholic Presentation: - Confusion with confabulation - Ataxia - Memory loss - Gaze palsy/ophthalmoplegia - Nystagmus
	Workup for Wernicke-Korsakoff	Head CT B12 level TSH, T4 RPR or VDRL for syphilis
	Treatment for Wernicke-Korsakoff	Thiamine, then glucose NB: Load with IV thiamine then PO
	When should you suspect Alzheimer's?	Setting: Older patient Presentation: - Slowly progressive loss of memory - No focal deficits - Eventually develop apathy and imprecise speech - Diffuse symmetrical atrophy on CT/MRI
	Workup for memory loss	Head CT (not MRI) B12 level TSH, T4 RPR or VDRL (rule out neurosyphilis)
	Treatments for Alzheimer's	Anticholinesterase meds (donepezil, rivastigmine, galantamine) Memantine NB: No benefit to combinations.
	When should you suspect frontotemporal dementia?	- Personality and behavior change first --> memory - Focal atrophy of the frontotemporal lobes on imaging - No movement disorder
	Treatment of frontotemporal dementia	Anticholinesterase meds (donepezil, galantamine, rivastigmine) Memantine NB: Doesn't respond as well as Alzheimer's
	When should you suspect Creutzfeldt-Jakob?	Setting: Older patients (younger than in Alzheimers) Presentation: - Rapidly progressive dementia - Myoclonus
	Workup for Creutzfeld-Jakob	EEG (abnormal) MRI (normal) 14-3-3 protein on CSF NB: If 14-3-3 is negative, need brain biopsy!
	What is Lewy Body dementia?	Parkinson's disease + dementia i.e. will have a gait disorder.
	When should you suspect normal pressure hydrocephalus?	Setting: Old men Presentation: - Urinary incontinence - Dementia - Wide-based gait/ataxia
	Workup for normal pressure hydrocephalus	Head CT (hydrocephalus) LP (normal opening pressure)
	Treatment of normal pressure hydrocephalus	Shunt
	When should you suspect Huntington's?	Setting: 30ish with a family history Presentation: - Dementia - Personality changes - Chorea
	Workup for Huntington's	Genetic testing NB: Autosomal dominant
	When should you suspect MS?	Setting: Young woman from the northern latitudes Presentation: Multiple CNS abnormalities at different times: - Optic neuritis - Bladder atony - Motor and sensory issues Fatigue Hyperreflexia Spasticity Scanning speech Depression Periventricular plaques on MRI (Dawson's fingers)
	Workup for MS	MRI LP (oligoclonal bands) Visual evoked potentials (delayed conduction) NB: Do NOT order CT. Useless.
	Treatment for MS	Initial: Prednisone/methylprednisolone to speed resolution of acute exacerbations Disease modifiers: - Beta interferon** - Glatiramer - Mitoxantrone - Natalizumab (causes PML) Symptom management: - Amantadine for fatigue - Baclofen or tizanidine for spasticity
	When should you suspect Parkinson's?	Setting: Older Presentation: - Resting tremor - Slow, "festinating" gait - Orthostasis - "Cogwheel" rigidity - Micrographia - Hypomimia (underreactive face)
	Treatment for Parkinson's	#1: Mild or severe? Mild: - Anticholinergic (benztropine or hydroxyzine) if <60 - Amantadine if >60 Severe: - Levodopa/carbidopa - Dopamine agonists (pramipexole, ropinirole, cabergoline) Adjuncts: - COMT inhibitors (tolcapone, entacapone) boost dopamine agents - MAOIs (selegine, rasagiline) - Deep brain stimulation
	Treatment for levodopa psychosis	Quetiapine
	When should you suspect essential tremor?	Tremor both with intention and at rest
	Treatment for essential tremor	Propranolol
	Workup for new onset seizure	Sodium Calcium Glucose O2 Creatinine Magnesium Head CT --> MRI if negative Urine tox screen If no etiology found, then --> EEG Neurology consult***
	Treatment for status epilepticus (CCS style)	1) Lorazepam --> move clock 10-20 min 2) If seizure persists, fosphenytoin --> move 10-20 min 3) If seizure persists, phenobarbital --> 10-20 minutes 4) If seizure persists, general anesthesia (pentobarbital, thiopental, midazolam, propofol)
	When should you treat a single seizure for epilepsy?	Strong family history of seizures Abnormal EEG Status epilepticus that required benzos to stop Non-correctable etiology i.e. tumor
	Treatment for absence seizures	Ethosuximide
	Treatment for petit mal seizures	Ethosuximide
	First line drugs in epilepsy	Valproic acid Levetiracetam Carbamazepine Phenytoin Lamotrigine (causes Stevens-Johnson and skin rxns) NB: All equally effective. Do NOT give valproate in pregnancy!
	Second line drugs in epilepsy	Gabapentin Phenobarbital
	When should you suspect encephalitis?	Fever Confusion NO meningismus or photophobia
	Most common pathogen in adult encephalitis	Herpes
	Workup in encephalitis	Head CT CSF PCR for HSV
	Treatment for adult encephalitis	Acyclovir If resistant -->foscarnet
	When should you suspect brain abscess?	Fever Headache Ring-enhancing lesion on CT NB: Consider HIV status
	Treatment for brain abscess	#1: HIV status Negative: Brain biopsy Positive: Empirically treat for toxo with pyrimethamine and sulfadiazine x 2 weeks --> reimage with CT
	When should you suspect progressive multifocal leukoencephalopathy?	Setting: HIV positive patient Presentation: - Brain lesions without ring enhancement or mass effect
	Treatment for PML	Nothing specific Raise CD4 count
	When should you suspect neurocysticercosis?	Setting: Mexican with a seizure Presentation: - Seizures - Multiple small cystic lesions on CT (may be calcified)
	Treatment for neurocysticercosis	Are the lesions calcified or active? Active: Albendazole - Give steroids to prevent a reaction to the dying parasites
	When should a head CT be performed before an LP?	History of CNS disease Focal neurologic deficit Papilledema Seizures AMS Significant delay in ability to perform an LP
	Workup for suspected meningitis	Do they have any signs of hydrocephalus? Yes --> Blood cultures, abx, head CT No --> LP and blood cultures, abx
	What should you look for in an LP for meningitis?	Gram stain Protein (if normal --> NOT bacterial) Glucose (<60% of serum for bacterial) CSF cell count (thousands of neutrophils if bacterial) Culture
	Gram positive diplococci in CSF	Pneumococcus
	Gram negative diplococci in CSF	Neisseria
	Gram negative, pleomorphic coccobacilli	Haemophilus
	Gram positive bacilli in CSF	Listeria
	What is the best initial test for meningitis?	CSF cell count NB: Thousands of neutrophils = bacterial meningitis until proven otherwise
	What do you expect in the CSF with bacterial meningitis?	Elevated protein Positive gram stain (does not rule out if neg) Glucose <60% of serum Elevated cell count
	When should you suspect cryptococcal meningitis?	Setting: HIV positive patient with CD4 <100 Presentation: - Slower onset - Meningeal signs may be more subtle or asynchronous
	Diagnostic test(s) for cryptococcal meningitis	India ink (on gram stain) Cryptococcal antigen (CSF)
	A lesion affects CN 3 and/or 4? Where is it?	Midbrain
	A lesions affects CN 5-8. Where is it?	Pons
	A lesion affects CN 9-12. Where is it?	Medulla
	Third Generation Cephalosporins	Ceftriaxone Cefotaxime Ceftazidime Cefpodoxime Cefixime Ceftibuten NB: Ceftazidime has Pseudomonal activity. All 3rd gen have an association with C diff.
	Treatment for cryptococccal meningitis	Amphotericin and 5-flucytosine Follow with PO fluconazole - Continue until CD4 rises above 100
	Empiric treatment for bacterial meningitis	IV ceftriaxone Vancomycin Ampicillin (covers Listeria) Dexamethasone NB: Dex can be stopped later if it's not S. pneumoniae
	When should you suspect Lyme Disease?	Setting: Recent outdoor activity, camping, hiking Presentation: Stage 1 - Target lesion, fever, joint pain, muscle pain, LAD Stage 2 - Myocarditis, AV block, Bell's palsy, peripheral neuropathy, meningitis Stage 3: Arthritis, Chronic neurologic symptoms
	Treatment for Lyme meningitis	IV ceftriaxone or Penicillin
	Diagnostic test for Lyme Disease	Western blot or PCR
	Treatment for Lyme Disease (no CNS or CV sx)	Doxycycline or Amoxicillin
	When should you suspect Rocky Mountain Spotted Fever?	Setting: Hiker, camper Presentation: - Fever - headache - Malaise - Rash starting on the wrists and ankles and moves inward
	Diagnostic test for Rocky Mountain Spotted Fever	Serology for R. ricketsii NB: Must start tx empirically before this comes back
	Treatment for Rocky Mountain Spotted Fever	Doxycycline
	When should you suspect TB meningitis?	Setting: Immigrant, history of lung TB Presentation: - Very slow onset - Very high CSF protein level - Positive AFB culture (<10%)
	Treatment for TB meningitis	Same as lung TB + steroids Rifampin Isoniazid Ethambutol Pyrazinamide
	When should you suspect viral meningitis?	CSF: - Lymphocytes predominance - Normal glucose - Normal protein NB: Diagnosis of exclusion
	When should you suspect Neisseria meningitis?	Setting: Young person, teenager, military, asplenic Presentation: - Meningismus - Petechial rash***
	Treatment for N. meningitidis meningitis?	Empiric ceftriaxone and vancomycin Put in respiratory isolation Treat close contacts with rifampin *** NB: Medical staff do NOT count as close contacts. Ciprofloxacin or ceftriaxone can also be used prophylactically.
	When should you suspect Listeria meningitis?	Setting: Elderly, neonates, HIV, asplenic, immunocomprised
	When should you get a head CT in trauma?	LOC AMS
	CT findings with subdural hematoma	Crescent shaped collection
	Ct findings with a cerebral contusion	Bruising (intraparenchymal)
	CT findings with epidural hematoma	Lens shaped collection
	Treatment for concussion	Nothing specific
	Treatment for cerebral contusion	Admit for observation Most get no additional treatment
	Treatment for subdural and epidural hematomas	Small: Let it resorb Large; Evacuate
	Treatment for a large intracranial hemorrhage with mass effect	Mannitol Intubation/hyperventilation to pCO2 of 25-30 Evacuate
	When should you suspect subarachnoid hemorrhage?	Sudden, severe headache Photophobia Stiff neck LOC (50%) NO fever Focal neurologic deficits (30%)
	Workup for subarachnoid hemorrhage	Noncontrast head CT - Negative --> LP - Positive is diagnostic Do angiography to determine site of bleeding
	Treatment for subarachnoid hemorrhage	Hydrocephalus? - If yes, --> shunt Angiography to determine site of bleeding Embolize PO nimodipine to prevent vasospasm and stroke
	When should you suspect syringomelia?	Loss of sensation (pain and temperature) in the upper extremities bilaterally Capelike distribution (neck, shoulders, arms)
	When should you suspect spinal epidural abscess?	Back pain Tenderness Fever
	Treatment for spinal epidural abscess	Dx: MRI Antibiotics against staph (oxacillin, nafcillin) Decompress, if large
	When should you suspect spinal stenosis?	Leg pain on walking Pulses intact Pain is worse when walking downhill, better when leaning forward
	When should you suspect an anteiror spinal artery infarction?	Loss of all sensation exception proprioception and vibration
	When should you suspect Brown-Sequard Syndrome?	Setting: Trauma to the spine Presentation: - Loss of ipsilateral proprioception and vibration - Loss of contralateral pain and temperature
	When should you suspect ALS?	Upper motor neuron signs? - Hyperreflexia - Babinski - Spasticity - Weakness Lower Motor Neuron signs: - Muscle wasting - Fasciculations - Weakness
	Treatment for ALS	Riluzole NB: Blocks accumulation of glutamate
	Treatment for diabetic neuropathy	Gabapentin Pregabalin Last choice: TCA
	Treatment for carpal tunnel	1) Splint 2) If sx persist, steroid injxn 3) If sx persist, surgery
	What should you suspect radial nerve palsy?	"Saturday night palsy" Wrist drop
	When should you suspect peroneal nerve palsy?	Setting: Wearing high boots Presentation: - Foot drop - Inability to evert foot
	When should you suspect Bell's Palsy?	Presentation: - Hemifacial paralysis, upper and lower - Loss of taste on anterior 2/3 of tongue - Hyperacusis - Inability to close eye
	Treatment for Bell's Palsy	Steroids
	When should you suspect reflex sympathetic dystrophy?	Setting: Previous injury to the extremity Presentation: - Extreme pain resulting from light touch - Burning quality
	Treatment for Reflex Sympathetic Dystrophy	NSAIDs Gabapentin Consider nerve block Extreme cases: surgical sympathectomy
	Treatment for restless leg syndrome	Ropinirole or Pramipexole
	When should you suspect Guillain Barre?	Setting: Antecedent infection several weeks before Presentation: - Bilateral, symmetric leg weakness (ascending) - Loss of deep tendon reflexes (areflexia) - Elevated CSF protein withOUT cells - Mild sensory changes - Eventually CN involvement, respiratory compromise
	Treatment for Guillain Barre	Admit! Peak inspiratory pressure (predicts respiratory failure) IVIG or plasmapheresis - Check IgA levels before giving IVIG NB: Do NOT use steroids!
	Workup for Guillain Barre	Peak inspiratory level (spirometry) LP (elevated CSF protein after first 48 hours) ESR CBC Lyme titer (to rule out) Nerve conduction study (shows demyelination)
	When should you suspect myasthenia gravis?	Setting: middle-aged woman or older man Presentation: - Weakness and fatiguability of muscles - Ptosis/diplopia - Dysarthria - Dysphagia - Respiratory failure
	Workup of myasthenia gravis	Anti-acetylcholine receptor antibodies Tensilon test (edrophonium chloride) --> improved strength
	Treatment for myasthenia gravis	Pyridostigmine or neostigmine Refractory and <60 yo --> thymectomy Refractory --> Prednisone, azathioprine or cyclosporine
	When should you suspect an ACA stroke?	Profound lower extremity weakness Mild upper extremity weakness Personality changes Urinary incontinence
	When should you suspect MCA stroke?	Profound arm weakness Aphasia Apraxia/neglect Eyes deviate toward lesion Contralateral homonymous hemianopsia with macular sparing
	When should you suspect PCA stroke?	Inability to recognize faces
	When should you suspect vertebrobasilar artery stroke?	Vertigo Nausea/vomiting "Drop attack" Vertical nystagmus Dysarthria Ataxia Labile blood pressure
	When should you suspect PICA stroke?	Ipsilateral face Contralateral body Vertigo Horner's Syndrome
	Treatment for ischemic stroke	1)Noncontrast head CT 2) Thrombolytics (if <3 hrs since onset and not contraindicated) 3) Aspirin or clopidogrel or aspirin/dipyridamole 4) Look for etiology: Echo, carotid duplex, EKG/Holter monitor - If <50 without risk factors, add ESR, RPR or VDRL, ANA, ds-DNA, Protein C, protein S, factor V Leiden mutation, antiphospholipid abx On Discharge: Manage BP (<130/80), glucose and lipids (LDL<100)
	Absolute contraindications to thrombolytics	History of hemorrhagic stroke Intracranial mass Surgery within 6 weeks Bleedign disorder Traumatic CPR within 3 weeks Suspicion of aortic dissection Stroke in the last year Brain injury or surgery in last 6 months
	Cervical Cancer Screening	Start at age 21 Paps every 2-3 years Stop at age 65
	Colon Cancer Screening	General population: - Start at 50 - Colonoscopy every 10 yrs 1st degree relative: - Age 40 or 10 yrs before dx HNPCC: - Start at age 25 - Colonsocopy every 1-2 years
	Criterica for HNPCC	3 family members 2 generations 1 before age 50

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