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220 Cards in this Set

  • Front
  • Back
Essential HTN
no identifiable cause
applies to more than 95% of cases of HTN
secondary HTN causes
Renal causes
renal artery stenosis- most common cause
chronic renal failure
polycystic kidneys

Endocrine causes
hyperaldosteronism
thyroid and parathyroid disease
cushing's syndrome
phechromocytoma
hyperthyroidism
acromegaly

Medications
oral contraceptives, decongestants
estrogen
appetite suppressants
chronic steroids
tricylic antidepressants
nosteroidal antiinflammatory drus (NSAIDS)

coarctation of the aorta
cocaine
sleep apnea
in young women, most common secondary cause of hypertension
birth control pills
hypertesion risk factors
AGE
gender- more common in men )gap narrows over age 60
race- twice as common in African American patients
obesity, sedentary lifestyle
family history
increased sodium intake-
alcohol- intake of more than 2 oz per day (8 oz of win, 24 oz of beer)
major complications of HYN
coronary artery disease,
CHF with left ventricular hypertrophy
stroke
renal failure
cardiovascular complications due to HTN
HTN is a major risk factor for CAD
CHF is a common end result of untreated HYN as LVH occurs
most deaths are due to MI or CHF
peripheral vascular disease
increased incidence of aortic dissection
eye changes due to HTN
early changes- arteriovenous nicking and cotton wool spots (infarction of the nerve layer in the retina
more serious disease- hemorrhages and exudates
Papilledema0 severely elevated BP
CNS complications of HTN
intracerebral hemorrhage
stroke
transient ischemi attackshypertensive encephalopathy
nephrosclerosis- arteriosclerosis of afferent and efferent arterioles and glomerulus
kidney complications of HTN
decreased GFR and dysfunction of tubules with eventual renal failure
nephrosclerosis- arteriosclerosis of afferent and efferent arterioloes and glomerulus
HTN and atherosclerosis
HTN accelerates atherosclerosis, leading to higher incidence of CAD as well as peripheral vascular disease and stroke
Target organ dama of HTN
Heart- LVH, MI, CHF
Brain- stroke , tia
chronic kidney disease
peripheral vascular disease
retinopathy
normal bp
<120/<80, no treatment
prehypertension and treatment
120-139/80-89, lifesyle modification
stage I HTN and treatment
140-159/ 90-99, lifestyle modification, drug therapy
stage II HTN and treatment
>160/ >100
lifestyle modification
drug therapy (2 drug combination for most)
diagnosis HTN
2 readings over a span of 4 or more weeks
site quietly for 5 min before measurement
amek sure no ingested caffeine or smoked cigarettes in past 30 min because both elevate BP temporarily
adequate sized cuff
lab tests to evaluate target organ damage in HTN
urinalysis, chemistry panel: serum K, creatinine, BUN
fasting glucose
lipid panel
ECG
lifestyle changes in hypertension
reduce saly intake <4g sodium/day
lose weight- weight loss lowers BP significantly
avoid excessive alcohol consumption- alcohol has pressor action
exercise regularly- regular aerobic exercise lowers BP
low saturated fat diet rich in fruits, veegetables and low fat dairy products. such a diet has shown to lower BP
stop unnecessary medications
stresss management practices
Thiazide treatment of HTN
Thiazide diuretics- best choirce in African - Americans because salt sensitive HTN
if african american has diabetes, ACE inhibitor is still initial choice agent
check serum potassium regularly due to hypokalemia
B blockers
decrease HR and cardiac output and decrease renin release
ACE inhibitors
inhibit the renin- angiotensin- adlosterone system and inhibit bradykinin degradation
prefered in all diabetic patients because of their protective effect on kidneys
angiotensin II receptor blockers
inhibit renin angiotension aldosterone system
recent studies- ARBs have same beneficial effects on kidney in diabetic patients as ACE inhibitors
calcium channel blockers
cause vasodilation of arteriolar vasculature
B blockers
work by decreasing arteriolar resistance
benefits patient with concurrent benign prostatic hyperplasia
vasodilators
hydralazine and minoxidil- not commonly used
given in combination with B blockers and diuretics to patients with refractory HTN
Before beginning antihypertensive treat, what test should you do?
a pregnancy test in reproductive age women becuase thiazides, ACE inhibitors, calcium channel blockers, and ARBs are contraindicated in pregnancy
B blockers and hydralazine are safe
HTN treatment
lower to <140/90 mmHg, with 135/85 mmHg the minimum goal in people with diabetes or renal insufficiency
ideal goal is <120/80
drug treatment is often lifelong
HTN treatment drugs of choice
initial choice- B blocker and thiazide diuretics have been shown to reduce mortaliy and morbidity
Ace inhibitors also a good choice , especially in diabetics
if pateient's resposne to one agent is not adequate, chnage to another first line agent of a different class before adding a second agent
any cardiovascular risk factors and comorbid conditions dramatically accelerates the risk from HTN- it should modify the treatment plan
thiazide side effects
hypokalemia, hyperuricemia, hyperglycemia, elevation of cholesterol and triglyceride levels, metabolic alkalosis, hyperuricemia, hypomagnesemia
b blocker side effects
bradycardia, bronchospasm, sleep disturbances, fatigue, depression, sedation, may increase Tg s and decrease HDL.
may mask hypoglycemic symptoms in diabetic patients on insulin
ace inhibitors
acute renal failure, hyperkalemia, dry cough, angioedema, skin rash, altered sense of tast, contraindicated in pregnancy
patient comes in with moderate to severe HTN, treatment
consider initiating therapy right away instead of waiting 1 to 2 months to confirm diagnosis and start treatment
diabetes patients with HTN
treat with ACE inhibitors and ARBs to decrease risk of new onset diabetes
yellow plaques on eyelids,
hard yellowish masses found on tendons
pancreatitis
hyperlipidemia

most patients are asymptomatic
xanthelasma- tellow plaques on eyelids
xanthoma- hard yellowish masses found on tendons
pancreatitis can occur withs evere hypertriglyceridemia
Type I
exogenous hyperlipidemia
elevated chylomicrons
treat diet
Type IIa dislipidemia syndromes
familial hypercholesterolemia
LDL elevated
treat with
statins
niacin
cholestyramine
type IIb dyslipidemia
combined hyperlipopoteinemia
elevated LDL+ vLDL
treat with statins,
niacin
gemfibrozil
Type III
familial dysbetalipoproteinemia
IDL
treat with Gemfibrozil
Niacin
Type IV
Endogenous hyperlipidemia
Elevated VLDL
treat with
niacin
gemfibrozil
statins
type V
familial hypertriglyceridemia
VLDL+ chylomicrons
treat with niacin gemfibrozil
screening for lipid profile
all people every 5 years starting at age 20
earlier and mroe frequent sceening is recommended for a strong family history and /or obesity
secondary causes of hyperlipidemia
endocrine disorders- hypothyroidism, diabetes mellitus, cushing's syndrome
renal disorders- nephrotic syndrome, uremia,
chronic liver disease
medications- glucocoricoids, estrogen, thiazide diuretics, b blockers
pregnancy
risk factors for primaryhyperlipidemia
diet
Age- cholesterol levels increase with age until age 65
inactive lifestyle, abdominal obesity
family history of hyperlipidemia
gender- men
medications- Thiazides, B blockers, estrogens, corticosteroids and HIV protease inhibitors
genetic mutations- the most severe hyperlipidemias
LDL levels
levels above 160 mg/dL significantly increase CAD risk
accounts for two thirds of total cholesterol
CAD risk is primarily due to the LDL component
LDL measurement: LDL= total cholesterol- HDL- TG/5
total cholesterol
levels less than 200 mg/dL are desirable.
levels between 160-200 may still be associated with increased risk of CAD
risk of CAD increases sharply with above 240 mg/ DL
HDL
protective at least as strong as LDL effect
every 10 mg/dL increase, CAD risk decreases by 50%
Low HDL (<35 mg/ dL) is a major independent risk factor for CAD
high HDL (>60 mg/dL) is a negative risk factor - counteracts one risk factor
total cholesterol to HDL ratio
the lower the total cholesterol to HDL ratio, the lower the risk of CAD
ratio 5.0 is average risk
ratio of 10 doubles the risk
ratio of 20 triples the risk
ratio <4.5 is desirable
triglycerides
importance to CAD is controversial
ideal levels of total cholesterol, LDL, and triglycerides
total cholesterol <200
LDL < 130
triglycerides <125
diagnosis of hyperlipidemia
lipid screening- measures HDL and total cholesterol
if lipid screening is abnormal, do a full fasting lipid profile- includes TG levels and calculation of LDL levels
check laboratory tests to exclude secondary causes of hyperlipidemia0 TSH, LFTs, BUN, Cr, urinary proteins, glucose levels 9diabetes
treatment of hyperlipidemia
if patient has no established coronary heart disease, LDL is <130
if has established CHD or is diabetic , LDL target is <100 mg/dL
therapy for high LDL
dietary therap is initial measure. goods rich in omega-3 fatty acides are particularly beneficial
exercise and weight loss-reduce risk of CAD
drug therapy
drug therapy for hyperlipidemia
hmg coA reductase inhibitors
niacin
bile acid sequestrants
gemfibrozil
therapy for high TG levels
TG levels >500 mg/dL should be treated with medication
niacin- first line drug for hypertriglyceridemia
Gemfibrozil also lowers TGs effectively.
TG<500 can be managed with weight loss, diet, and exercise
statins and fibrates SE
can induce transient elevation in serum transmaminases. LFT s must be monitored
potency of HMG CoA reductase inhibitors in increasing order
fluvastatin<
lovastatin (Mevacor) and pravastatin (Pravachol)< simvastation (Zocor) and atorvastatin (lipitor).
HMG CoA reductas inhibitors (statins) effects
lower LDL levels- most potent
minimal effect on HDL and TG levels
HMG coa reductase inhibitors side effefects
monitor LFTs (monthly for the first 3 months, then every 3-6 months.
harmless elevation in muscle enzymes may occur (CPK)
niacin effects nad SE
lowers TG levels
lowers LDL levels
increases HDL levels
Flushing effect.
check LFTs and CPL levels as with statin drugs
bile acid-binding resins (cholestyramine, colestipol
lowers LDL increases TG levels
adverse GI side effects, poorly tolerated
fibrates (gemfibrozil
lowers VLDL and TG
increases HDL
GI side effects (mild)
mild abnormalities in LFTs
Gynecomastia, gallstones, weight gain, and myopathies
headache
pain is steady, aching, "viselike"
encircles the entire head
may be the intense around the neck or back of head
accompanied by tender muscles
tightness in posterior neck muscles
tension headache


cause is unknown
worsens throughout the day
precipitatnts- anxiety, depression, and stress
can be easily confused with migraines
tension headache treatment
find causal factor
evaluate for depresssion and anxiety
stress reduction
NSAIDS, aacetaminophen, aspirin are standard treatment
if headache is severe, use migraine medications vecause probable a migraine.
emergency headache evaluation
obtain a noncontrast CT scan to rule out any intracranial bleed
lumbar puncture to find small bleeds.
middle aged man
excruciating periorbital pain (pain behind the eye)- almost always unilateral
deep, burrning, searing, or stabbing pain
ipsilateral lactimation, facial flushing, nasal stuffieness/ discharge
begins few hours after patient goes to bed
lasts 30 to 90 minutes
attacks occur nightly for 2 to 3 months then disappear
worse with alcohol and sleep
cluster headache
very rare- thought to be a variant of migraine
cluster headache subtypes
episoic cluster headaches- 90% of cases- last 2 to 3 months with remissions months to years later
chronic cluster headaches- 10% of cases- last 1 to 2 years, headaches do not remit
treatment for cluster headaches
acute attacks
sumatriptan (Imitrex) drug of choice
O2 inhalation is beneficial
combination sumatriptan and O2 is very effective
cluster headache prophylaxis
most responsive to prophylactive treatment
Verapamil taken daily is the drug of choice
ergotamine, methysergide, lithium, and corticosteroids are alternatives
cause reolution within 1 week
feels elation
excitability
increased appetite and craving for certain foods
depression irritability, sleepiness, and fatigue
24 hours later
severe throbbing unilateral headache lasting 4 to 72 hours
may last for days
pain aggravated by coughing, physical activity, and bending down
nausea and vomitting, photophobia, and increased sensitivity to smell.
migraine

inherited disorder- autosomal dominant with incomplete penetrance
serotonin depletion plays major role
more common in women
types of migrain
migraine with aura- classic migraine. aura is usually visual- flashing lights, scotomata, visual distortions
migraine without aura- 85% of cases- common migraine
menstrual migrain- occurs between 2 days before menstruation and last day of menses linked to estrogen withdrawal
status migrainous- lasts over 72 hours and does not resolve spontaneously
things that provoke a migraine
hormonal alteration- menstruation
stress, anxierty
sleeping disturbances
drugs// foods
weather changes
treatment for migraine
if mild- NSAIDS or acetaminophen may be effective
if not effective use dihydroergotamine (DHE)or a triptan
if medications don't work, then patient does not have a migraine
DHE use and contraindications
a serotonin (5HT1) receptor agonist
highly effective in terminating pain of migrains
SE CAD, pregnancy, TIAs, PVD, sepsis
sumatriptan
use and contraindication
a more selective 5HT1 receptor agonist than DHE and other triptans
acts rapidly within 1 hour and is highly effective
should not be used more than once or twice a week
contra: CAD uncontrolled HTN, basilar artery migrain, hemiplegic migraine, use of MAOI, SSRI, or lithium
migraine prophylaxis
must be taken daily
avoid precipitants of the migraines
first line agents- TCAs amitriptyline and propanolo B blocker
second line- verapamil and valproic acid and methysergide
NSAIDS for menstrual migraines
migrain visual aura
classic presentation is a bilateral homonymous scotoma. bright flasshing crescent shaped images with jaffed edges often appear on a page, obscuring the underlting print. the aura lasts 10 to 20 minutes
mistaken for a migraine
rebound analgesic headaches
occur more frequently- every 1 to 2 days- than migraines
do not respond to migraine drugs
wean the patient from analgesics.
do not use narcotivs
classification of a cough
less than 3 weeks= acute
more than 3 weeks= chronic
benign cough- resolves in few weeks
otherwise, further investigation required
the most common cause of acute cough
upper respiratory infection (URI)
patient with a cough
suspected pulmonary cause-
suspected infectious cause-
what tests to order
pulmonary- CXR
infectious- CBC
patient with a cough
Test? Asthma
pulmonary function test
patient with a cough
test?
cancer, tumor, foreign body
bronchoscopy
what is post nasal drip
secretions from the nose drip back into the hypopharynx and stimulate mucosal receptors
treatment for postnasal drip
antihistamines/ decongestant
if have sinusitis too- give antibiotics
for allergic rhinitis- nonsedating long-acting anti-histamine like loratadine
antitussive medications
codeine
dextromethorphan
benzonatate(tessalon Perles) capsules
causes of chronic cough in adults
smoking #1
postnasal drip
GERD
asthma
distinguish between viral and bacterial cause of Upper respiratory infection
Common- fever and cough
Viral- rhinorrhea, myalgias, headache
bacterial- yellow sputum
fever, tachypnea, crackles, egophony, dulllness to percussion
Diagnosis and test?
pneumonia, CXR
cough lasting 1 to 2 weeks, with or without sputum
cough may last for 1 month or longer
treatment?
chest discomfor and shortness of breath
fever possible
acute bronchitis
virus is the most common cause
no antibiotics since viral
give cough suppresants like codeine
bronchodilators-relieve symptoms
rhinorrhea
soar throat
malaise
nonproductive cough
nasal congestion
Fever uncommon in adults
fever common in children
cause?
the common cold
the most common upper respiratory tract infection
virus- rhinovirus(50%), coronavirus
RSV, parainfluenza virus, adenovirus, coxsackie virus
common cold treatment
adequate hydration
rest
analgesics- aspirin, acetaminophen, ibuprofen- for malaise, headache, fever and aches
cough suppressnat- dextromethorphan, codeine
nasal decongestant spray- neo-synephrine
oral fist generation antihistamine for rhinorrhea/sneezing
inflammation and congestion of mucous membrances of nasal and sinus passages
common cold= acute rhinosinusitis
both bacterial sinusitis and the common cold (viral rhinosinusitis) have
sneezing/rhinorrhea
nasal discharge\
asal obstruction
and facial pain/headaches
influenza vs common cold
influenza
fever
headache,
myalgias
malaise much more pronounced
nasal stuffiness
purulent nasal discharge
cough
sinus pain or pressure
pain worsens with percussion or bending head down
fever in 50%
acute sinusitis
mosst common acute sinusitis
maxillary sinusitis
may mimic dental caries pain.
pain over cheeks
nasal congestion
postnasal discharge
pain and headache
symptoms present for 3 months
Dx? causes?
chronic sinusitis
strep pneumo,
haemophilus influenzae,anaerobes
if multiple sinus infections- staphylococcus aureus and gram-negative rods
causes of acute bacterial sinusitis
step pneumo
haemophilus influenzae
anaerobes
could be viral fungal or allergic as well
how to diagnose sinusitis
PE and tests
PE
purulent discharge from turbinates
perform transillumination of the maxillary sinus
palpate over sinus- tener

Imaging- severe
sinus radiographs
CT scan
treatments for acute sinusitis
saline nasal spray- drainage
avoid pollutants
decongestants- pseudoephedrine or oxymetazoline
Antibiotics
Antihistamines
nasal steroids
antibiotics for sinusitis
amoxicillin
amoxicillin-clavulanate,
TMP/ SMX
levofloxacin
moxifloxacin
cefuroxime
Antihistamines for sinusitis if allergic
Loratadine (clritin)
fexofenadine (allegra)
chlorpheniramine (Chlortrimeton)
antihistamines may have a drying affect that inccreases congestion
treatment for chronic sinusitis
broad spectrum penicillinase-resistant antibiotic
patient has a cold beyond 8-10 days and then cold improves, then worsens over the next few days
acute bacterial sinusitis- secondary bacterial infection after a primary viral illness
hoarse voice
cough may be present along with other URI symptoms
Dx? cause?
laryngitis- self limiting
viral in origin
moraxella catarrhalis
H influenzae
soar throat
causes?
viral most common cause
adenovirus, parainfluenza virus, rhinovirus, Epstein-Barr virus, herpes simplex

main concern- Group A strep
possible rheumatic fever
sore throat
cough
runny nose
bacterial or viral?
viral origin
sore throat tests?
throat culture-24 hours more accurate
rrapid strep test- 1 hour results, will not indicate if caused by bacteria other than strep or a virus
Monospot blood test for mononucleosis
sore throat treatment?
strep- penicillin for 10 days
viral- symptomatic treatment
mononucleosis-rest and acetaminophen
symptomatic treatment of sore throat
acetaminophen or ibuprofen
gargling with warm salt water
humidifier
sucking on lozenges , hard candy, flavored frozen desserts (popsicles)
epigastric symptoms including
heartburn,
indigestion
bloating
epigastric pain
dyspepsia
dyspepsia
tests?
endoscopy is the test of choice
test for H. Pylori
indications for endoscopy
don't test on all dyspepsia
indications:
patients with alarming symptoms
patients >45 years with new onset
vomiting, upper GI bleed
signs of Peptic ulcer disease
recurrent symptoms
treatment for dyspepsia
treat the cause
advise patient to :
avoid alcohol, caffeine
stop smoking
raise head of bed when sleeping
avoid eating before sleep
use antacids,
if antacids fail-- H2 blocker, proton pump inhibitor, sucralfate
heartburn, dyspepsia
restrosternal pain
regurgitation
waterbrash
cough
hoarseness, sore throat
feeling a lump in the throat
early satiety, postprandial nausea/vomiting.
gastroesophageal reflux disease (GERD)
waterbrash- reflex salivary hypersecretion
cough- due to aspirated material
dietary factors affecting GERD
chocolate, smoking, tobacco, coffee, high-fat foods-
they decrease Lower esophageal sphincter presure
Diagnostic test for GERD
don't do on typical cases
endoscopy with biopsy- test of choice
barium contrast study- only detects complications such as strictures and ulcerations but cannot diagnose GERD
24 hour pH monitoring- gold standard but unnecessary
eophageal manometry- use for motility disorder
complications of GERD
esophagitis
barrett's esophagus- squamous --> columnar
esophageal ulcer
peptic stricture- fibrotic rings that narrow
recurrent pneumonia
pitting of dental enamel
laryngitis, pharyngitis
most dyspepsia (90%) due to
Peptic ulcer disease
GERD
gastritis
nonulcer dyspepsia
nonulcer dyspepsia
diagnosis of exclusion
no specific cause
dyspepsia symptoms must be present at least 4 weeks
GERD followed by dysphagia or inability to swallow
peptic stricture
or
cancer or motility disorder
Patient with symptomatic GERD for 5 years
Barrett's esophagus
endoscopy with biopsy required
screen for cancer
periodic surveillance every 3 years
treatment for GERD
1. behavior modification-diet and antacids
2. add H2 blocker
3. switch to PPI
4. add promotility agent such as meoclopramide (dopamine blocker) or bethanechol (cholinergic agonist)
5. combination
6. antireflux surgery
GERD surgery
indications
types
outcome
indications
intractability- failure of medicine
respiratory problems due to reflux
severe esophageal injury

types
nissen fundoplication (for normal motility)
partial fundoplication (for poor esophageal motility)

outcome= excellent
diarrhea
causes?
viral- norwalk and rotavirus most common
bacteria
immunocompromised- mycobacterium avium-intracellulare, cryptosporidium, cyclospora, or CMV
acute diarrhea
time and causes?
lasts less than 3 weeks
Infections- viral most common
medications
malabsorption
ischemic bowel
intestinal tumors
chronic diarrhea
time and causes?
more than 4 weeks
Irritable Bowel syndrome- most common cause, diagnosis of exclusion
inflammatory bowel disease
medication
A lot of stuff
nausea, vomitting, diarrhea
food poisoning, viral gastroenteritis
fever, blood, and diarrhea
causes?
shigella
campylobacter
salmonella
enterohemorrhagic E.coli
no fever, no blood, diarrhea
viral infection-
rotavirus
norwalk virus
E. coli
staph aureus
clostridium perfringens
lab tests to assess diarrhea
CBC
stool sample- leukocytes not present, no culture. If leukocytes present, culture.
Measure ova and parasites
Measure c dificile toxins
colonoscopy/ flexible signoidoscopy- if cause cannot be identified
bacteria that cause diarrhea with fecal leukocytes and blood
shigella, salmonella, e. coli, campylovacter
electrolyte / acid-base abnormality in diarrhea
metabolic acidosis
hypokalemia
treatment for c difficile infection
metronidazole
treatment for blood, fever , and diarrhea
moderate to severe disease
5 day course of ciprofloxacin
loperamide, when give?
give with mild to moderate diarrhea.
not recommended for people with fever or blood in the stool
myalgias, malaise
headache
watery diarrhea
abdominal pain
nausea/ vomiting
low fever
acute viral gastroenteritis- rotavirus, norwalk virus
most common cause of acute diarrhea in US
fecal oral route
48-72hours
abdominal pain, diarrhea, nausea and vomiting
ate some foood and eggs
Salmonella
resolves within 1 week
no treatment except in immunocompromised
treat with ciprofloxacin
diarrhea, abdominal pain, tenesmus (a distressing but ineffectual urge to defecate or urinate)
nausea, vomitting
Shigella
resolves in 1 week
fecal oral route
treat with TMP/SMX (Bactrim)
Abdominal pain, nausea, and vomiting, diarrhea

happened within 24 hours of eating ham, poultry, potato salad, and mayonnaise
Staphylococcus food poisoning
become ill within 1-6 hours
may be severe and require hospitalization
headache, fatigue
followed by diarrhea and abdominal pain
Campylobacter jejuni
most common cause of acute bacterial diarrhea
blood appears in stool in 50% of cases
treat with erythromycin
diarrhea
crampy abdominal pain is prominent
began within 24 hours of food
clostridium perfringens
watery diarrhea, nausea, abdominal pain
after eating food
enterotoxic E. coli
common in developing countries
travelers susceptible
bloody diarrhea
patient can appear very sick
fever
ate undercooked meat or raw milk
E coli 0157:H7
hemorrhagic colitis
hemolytic uremic syndrome and
thrombotic thrombocytopenic purpura
watery foul smelling diarrhea
abdominal bloating
giardiasis
treat with metronidizole
lasts 5-7 days
voluminous diarrhea
rice water stools
abdominal pain and vomiting
vibrio cholera
constipation tests
TSH,
CBC (colorectal cancer)
electrolytes
abdominal films- obstruction
rectal examination
treatment for constipation
increase physical activity
eat high-fiber foods
increase fluid intake
enema (injection of fluid into the anus)
diarrhea, constipation
cramping abdominal pain- mainly in sigmoid colon
bloating or abdominal distention
depression, anxiety, somatization
exacerbated by stress and irritants
Irritable Bowel Sydrome (IBS)
affects 10-15% of adults
need to be present 3 months to diagnose
treatment for irritable bowel syndrome
diarrhea- diphenoxylate, loperamide
constipation- colace, psyllium, cisapride
tegaserod maleate (Zelnorm)- serotonin agonist, NEW, works.
most common causes of nausea and vomiting
viral gastroenteritis-most common
food poisoning
treatment for nausea and vomiting
most causes are self limiting
identify the cause and treat it
if dehydrated, hospitalization
assess hydration-
fluid replacement with 1/2 NS iwith potassium replacement
for symptomatic relief of nausea and vomiting
prochlorperazine (compazine)
promethazine- phenergan
liquid diet- cleared quickly
avoid large meals
nasogastric suction
complications of chronic constipation
hemorrhoids
recal prolapse
anal fissures
fecal impaction
electrolyte abnormality after severe vomiting
metabolic alkalosis
hypokalemia
treatment for hemorrhoids
sitz baths
ice packs to anal area
bed rest
stool softeners to reduce strain
high-fiber, high fluid diet
topical steroids
rubber band ligation for internal hemorrhoids
surgery- hemorrhoidectomy
most common causes of low back pain
musculoligamentous strain
defenerative disc disease
facet arthritis
patientbent over to pick up a heavy object
back gave way
pain across lower back stopping at the knee
no nerve problems
musculoligamentous strain
paraspinal muscles around iliac crest/ lower lumbar
low back pain, stiffness
neurological problems
lumbar disc herniation
nucleus pulposus extrudes through annulus fibrosis
95% in L4-L5 or L5-S1
pain in back caused by activity
relieved by rest or spinal flexion
low back pain
sciatica
decreased ambulatory capacity
lumbar spinal stenosis
may be acquired or congenital
elderly patient
back pain
local radiation across back and around the trunk
rarely into the legs

diagnosis and treatment?
vertebral compression fracture
Kyphoplasty- injection of cement into vertebral body
night pain in the back
neoplasm
most common is metastatic carcinoma
classically do not involve the disc space
fever
back pain
involves the disc space
infection
vertebral osteomyelitis
bilateral sciatica
saddle anesthesia over buttocks/ perineum
low back pain
lower extremity weakness
bowel or bladder dysfunction
impotence, perianal anesthesia

diagnosis and test?
Cauda equina syndrome
after trauma or disc herniation
compresses S1, 2,3,4 nerve roots
emergency
do MRI--->surgery
factors causing back pain in disc herniation
coughing
sneezing
forward flexion- sitting, driving, lifting
pain on back extension-
pain worsens with standing or walking
relief with bending or sitting
spinal stenosis
lumbar disc herniation treatment
conservative care
only 10% require surgery
how to evaluate to nerve compression in lower back
straight leg raise
sensitive test for nerve compression
if L5 or S1 compressed, radicular pain is produced

contralateral leg pain is specific for herniated disc
Leg reflexes
Patella L4
Hamstring L5
Achilles or ankle- S1
Major segmental innervation of lower limb
hip flexion- L2
knee extension -L3
ankle dorsiflexion -L4 and L5
Great toe dorsiflexion- L5
Ankle plantar flexion- S1
Tests for low back pain
plain films not indicated
longer than 3-4 weeks, radiographs appropriate
if compression fracture, infection, or tumor, radiographs immediately
MRI if >3 months
back pain treatment
NSAIDs, rest, analgesics
physical therapy
steroid injections
walk 20 minutes 3 times per day (inactivity is bad)
if neurologic, MRI
causes of knee pain
osteoarthritis- most common
patellofemoral pain- very common cause of anterior knee pain
degeneration of meniscus
Rheumatoid arthritis
acute monoarticular arthritis
osteochondritis dissecans
Osgood-Schlatter disease
Backer's cyst
Patellar tendinitis (jumper's kneed)
knee pain
running and jumping sports
patellar tendinitis- jumper's knee
common cause of anterior knee pain
treatment- physical therapy
patient with rheumatoid disease or osteoarthritis with knee pain
pain/swelling
Baker's cyst
Rupture will cause pain and swelling
Ultrasound to diagnose
majority resolve spontaneously
lateral ankle ligaments
medial angle ligaments
LATERAL
anterior talofibular ligament (ATFL)- most commonly injured, at anterior tip of fibula
calcaneofibular ligament (CFL)
posterior talofibular ligament

MEDIAL
deltoid ligament- not injured in classic inversion
classification of ankle sprains
Grade 1- partial rupture of ATFL
Grade 2- complete rupture of ATFL and partial rupture of SFL
Grade 3- complete rupture of both ATFL and CFL
when to use radiographs on ankle sprain

treatment?
if patient can walk 4 steps and no bony tenderness, don't need radiograph

RICE- rest, ice, compression, and elevation
rarely need surgery
shoulder pain,
subacromial
lateral aspect of the shoulder with arm abduction
over lateral deltoid
supraspinatus tendinitis- most common cause of shoulder pain
in elders and young people who lift or throw
pain in elbow
excessive supination/pronation
extensor tendons of forearm

diagnosis and treatment?
lateral epicondylitis at the elbow

splinting of the forarm- inital treatment
physical therapy
surgery is last resort
pain distal to medial epicondyle
exacerbated by wrist flexion
medial epicondylitis- golfer's elbow
overuse of flexor pronator muscle group
pain at the radial aspect of the wrist
pain radiates to elbow or into thumb

diagnosis, test, treat?
De Quervain's disease
inflammation of abductor pollicis longus and extensor pollicis brevis tendons
Finkelstein's test- clench thumb under fingers when making fist and ulnar deviate

treatment- thumb splint and NSAIDs
local cortisone injections
surgery- last resort
spongy bag of fluid over elbow

diagnosis and treatment
olecranon bursitis- swelling, effusion of olecranon bursa

treatment
conservative
drainage if infection
lateral hip pain
hip exquisitely painful on palpation

diagnosis and treatment?
trochanteric bursitis

treatment
NSAIDs and activity modification
local cortisone injections- excellent relief.
numbness, pain
tingling in median nerve distribution
worse at night
muscle weakness
thenar atrophy
Carpal tunnel syndrome

median nerve compression within the tight confines of the carpal tunnel
longstanding- atrophy of thenar muscles
tests for carpal tunnel
Tinel's sign- tap over median nerve at wrist crease
Phalen's test- palmar flexion of the wrist for 1 minute
Electromyography and nerve conduction velocity study for definitive diagnosis
treatment for carpal tunnel
wrist splints should be worn at night
NSAIDs
local corticosteroid injection
surgical release-very effective
joint pain- monoarticular
pain on movement
deep dull ache, relieved with rest
worsened with activity
stiffness in morning or after inactivity
limited range of motion
no erythema or warmth

test?
Osteoarthritis
weight bearing joints involved- hips, knees, and spine

plain radiographs
MRI of spine if indicated
what are Bouchard's nodes and Heberden's nodes?
Bouchard's- bony overgrowth and significant osteoarthritic changes at PIP joints
Heberden's- DIP joints
treatment of osteoarthritis
avoid use of joint
weight loss
physical therapy- swimming
canes or crutches

Pharm- acetaminophen- first line
inject corticosteroids
surgery for disaility

Nutritional- glucosamine and chondroitin sulfate
compression fractures in spine
kyphosis
lumbar lordosis
fracture forearm after fall
hip fracture
osteoporosis
Colles fracture- distal radius fracture- due to fall on outstretched hand
mostly postmenopausal women and elderly men
osteoporosis test?
DEXA scan-gold standard
very precise in measuring bone density
perform at menopause
take samples from hip and lumbar vertabrae
compare densities to 30 year old
osteoporosis treatment
bisphosphonates- decrease osteoclastic activity by binding hydroxyapatite
Alendronate- increases bone density by 5%
Calcium supplements
Vitamin D
Calcitonin- more short term benefit
Weight bearing exercise
Osteoporosis prevention
reduce smoking and alcohol
estrogen replacement
Raloxifene- Selective estrogen receptor modulator
Calcium supplementation
prevent injuries
PROOF trial
decreased vertebral fractures by 40%
increased bone density at lumbar vertabrae
no effect at the hip
snoring
daytime sleepiness due to disrupted nocturnal sleep
personality changes
decreased intellectual function
decreased libido
oxygen desaturation and hypoxemia
morning headaches

Diagnosis and Test?
Obstructive sleep apnea
Polysomnography- overnight sleep study
Obstructive sleep apnea treatment
mild to moderate OSA- <20 apneic episodes on polysomnogram
weight loss
avoid alcohol, sedatives
avoid supine position

Severe OSA- >20 apeneic episodes
nasal continueous positive airway pressure-prefered therapy
urulopalatopharyngoplasty- removal of tissue
tracheostomy- last resort
sleep attacks at any time of day that last several minutes
loss of muscle tone that generally occurs with intense emotion
sleep paralysis
hallucinations

diagnosis and treatment
Narcolepsy
inherited REM sleep disorder
may cause car accidents
Cataplexy- loss of muscle tone

Treatment- methylphenidate (Ritalin)
planned naps
complications of obstructive sleep apnea
hypoxia can lead to arrythmias
pulmonary hypertension and cor pulmonale
systemic hypertension due to increased sympathetic tone
types of hearing loss
conductive hearing loss- external canal and middle ear
cerumen impactation- most common cause
exostoses- bony outgrowths of canal due to exposure to cold water
a lot

sensorineural hearing loss- lesions in cochlea or CN VIII
presbycusis- most common cause
elderly man is losing his hearing in both ears gradually
presbycusis- most common sensorineural hearing loss
degeneration of sensory cells and nerve fibers at base of cochlea
decreased perception of sound- especially low frequency sounds
can hear loud noises well

Rinne and weber and treatment??
conductive hearing loss
abnormal rinne test- bone conduction better than air conduction
Weber- sound lateralizes to affected side]

treat underlying cause
surgical techniques
difficulty hearing loud noises
can hear soundsk, has trouble deciphering words- poor speech discrimination
more difficulty with high-frequency sounds
tinnitus is often present

Rinne and weber and treatment??
sensorineural hearing loss
normal rinne
Weber- sound lateralizes to the unaffected side

treat underlying cause
hearing aids, cochlear implants
fatigue for more than 6 months
diminished short term memory,
muscle pain
sore throat
tender lymph nodes
unrefreshing sleep
headaches
chronic fatigue syndrome
most patients recover in 2 years
erectile dysfunction

risk factors
same risk factors as atherosclerosis
HTN, smoking, hyperlipidemia, diabetes
antihypertensives
sickle cell disease
pelvic surgery
alcohol abuse
low testosterone
congenital penile curvature
diagnostic tests for erectile dysfunction
CBC, chemistry panel, flucose, lipid
if normal erctions during sleep, a psychogenic cause is likely
if no erections during sleep, then organic cause
vascular testing
psychologic testing
CAGE questions
Cut down?
Annoyed? annoyed by criticism
Guilty?
Eye-opener? Morning drink to wake up.
quit drinking
tactile hallucinations, visual hallucinations,
confusion
sweating
tachycardia
elevated BP

treatment?
Delirium Tremens (DT)
20% mortality rate.
occurs in 5% of alcohol withdrawls

give benzodiazepines if withdrawl is present
high calorie, high carb, and multivamin diet.
alcohol drinker
nystagmus
ataxia
ophthalmoplegia
confustion
Wernicke's encephalopathy- reversible
thiamine deficiency

Korsakoff's psychosis- irreversible
alcohol induced amnestic disorder
confabulation and short term memory loss.
treatment for alcohol abuse
alcoholics anonymous is the best treatment
disulfiram (Antabuse)
naltrexone- reduces craving
benzodiazepines for withdrawal
smoking cessation treatment
nicotine patch- patient should not smoke while behavioral modification plus
wearing patch- MI
nicotine chewing gum
Bupropion
screening for hyperlipidemia

when
20 years old every five years measure cholesterol and HDL

in patients with risk of CAD, screen more frequently
colorectal cancer screening time
>50 years old
fecal blood test + flex sig every 5 years

or
fecal blood test+ colonoscopy every 10 years.
mammogram screen time
yearly mamograms after age 50
diabetics eye exam time
every year, ophthalmologist performs annual funduscopic examination
Influenza vaccine when

pneumococcal vaccine when
Influenza- Adults> 50 years, health care workers, prenancy

Pneumo- Adults >65 years, sickle cell,
one time dose
second dose after 5 years in high risk immunodeficiency
tetanus/ deptheria when

hep B vaccine when

hepatitis A vaccine when
Tetanus/diphtheria- Primary series for everyone- 1,1-2,6-12 months.
booster dose every 10 years

Hep B- primary series to infants- 0,1,6 months,
health care workers

Hep A- travelers to developing countries, patients with liver disease, HCV
given in two doses with 6 months in between
MMR

Varicella vaccine time

Shingles vaccine when
MMR- primary series, one or two dosees

Varicella- primary series in children, 2 doses 8weeks apart

shingles- adults >60 years of age
Polio vaccine time?

Meningococcus time?

Rabies time?

HPV time?
Polio- primary series in children

Neningo- military, all college students, asplenic individuals

Rabies- postexposure prophylaxis, high risk individuals

HPV- recommended for females.
Asplenic patients should receive which vaccines
Asplenic patients are vulnerable to encapsulated organismss
H. influenzae B (HiB) vaccine
meningococcal vaccine
pneumococcal vaccine