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220 Cards in this Set
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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
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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) |
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major complications of HYN
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coronary artery disease,
CHF with left ventricular hypertrophy stroke renal failure |
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cardiovascular complications due to HTN
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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 |
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eye changes due to HTN
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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
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intracerebral hemorrhage
stroke transient ischemi attackshypertensive encephalopathy nephrosclerosis- arteriosclerosis of afferent and efferent arterioles and glomerulus |
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kidney complications of HTN
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decreased GFR and dysfunction of tubules with eventual renal failure
nephrosclerosis- arteriosclerosis of afferent and efferent arterioloes and glomerulus |
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HTN and atherosclerosis
|
HTN accelerates atherosclerosis, leading to higher incidence of CAD as well as peripheral vascular disease and stroke
|
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Target organ dama of HTN
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Heart- LVH, MI, CHF
Brain- stroke , tia chronic kidney disease peripheral vascular disease retinopathy |
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normal bp
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<120/<80, no treatment
|
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prehypertension and treatment
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120-139/80-89, lifesyle modification
|
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stage I HTN and treatment
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140-159/ 90-99, lifestyle modification, drug therapy
|
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stage II HTN and treatment
|
>160/ >100
lifestyle modification drug therapy (2 drug combination for most) |
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diagnosis HTN
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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 |
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lab tests to evaluate target organ damage in HTN
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urinalysis, chemistry panel: serum K, creatinine, BUN
fasting glucose lipid panel ECG |
|
lifestyle changes in hypertension
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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 |
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Thiazide treatment of HTN
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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 |
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B blockers
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decrease HR and cardiac output and decrease renin release
|
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ACE inhibitors
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inhibit the renin- angiotensin- adlosterone system and inhibit bradykinin degradation
prefered in all diabetic patients because of their protective effect on kidneys |
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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 |
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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
|
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b blocker side effects
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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
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acute renal failure, hyperkalemia, dry cough, angioedema, skin rash, altered sense of tast, contraindicated in pregnancy
|
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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
|
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diabetes patients with HTN
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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
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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 |
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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
|
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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 |
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Leg reflexes
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Patella L4
Hamstring L5 Achilles or ankle- S1 |
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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 |
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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 |
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back pain treatment
|
NSAIDs, rest, analgesics
physical therapy steroid injections walk 20 minutes 3 times per day (inactivity is bad) if neurologic, MRI |
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causes of knee pain
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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 |
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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 |
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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 |
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complications of obstructive sleep apnea
|
hypoxia can lead to arrythmias
pulmonary hypertension and cor pulmonale systemic hypertension due to increased sympathetic tone |
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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
|
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diabetics eye exam time
|
every year, ophthalmologist performs annual funduscopic examination
|
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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 |