Beruflich Dokumente
Kultur Dokumente
Stefanie Kreamer, MD
Hepatitis
Hep A:
vaccination indications: MSM, IVDUs, persons working with Hep A virus or infected primates, chronic liver disease,
persons that receive clotting factor concentrates. (these days all kids are vaccinated)
treat infant of a Hep B+ mom with Hep B Ig within 12 hrs of birth + vaccination (prevents 90% of infection)
If Hep status of mother is unknown give baby vaccine and test mom; if mom is +, give baby Ig within 7 days.
immunizations for an adult: 1 injection at time 0, another 1 - 2 mo later, a 3rd injection 4 - 6 mo after the 2nd
HBeAg replication.
screen for HCV infection in persons at high risk for infection AND one-time screening for HCV infection to adults
born between 1945 and 1965
H. Influenzae
Vaccines against Hib are 95% - 100% effective in
preventing invasive Hib disease.
vaccine doesnt rate of otitis media, as most cases
are caused by non-typeable H influ.
Adverse reactions are rare; no serious reactions
recorded; systemic reactions (fever, irritability) are
infrequent
most common side effects: mild fever, local redness,
swelling, or warmth
should not be administered before 6 wks, as immune
tolerance to the antigen may be induced.
Varicella
immunization recommended for adults who have not had evidence
of infection or immunization.
US-born before 1980 are considered immune, with the exception
of health care workers and pregnant women.
2 doses of vaccine are required, 4 - 8 wks apart, regardless of age;
should not be given before 12 mo
testing is not necessary in those with uncertain immunity; vaccine is
well-tolerated in those already immune
Non-immune pregnant women or immunocompromized should
not receive the vaccine until after delivery
household contacts of immunocompetent pregnant women do not
need to delay vaccination.
Rarely (1%), people receiving the vaccine may develop infection;
the case is mild, and is not contagious.
Tdap:
tetanus-diphtheria 5-component acellular pertussis (Tdap)
is recommended for adults 19 - 64 to replace the next
booster dose of tetanus
Tdap should be given to pts 65 yrs and older
should be administered regardless of the interval since the
most recent Td-containing vaccine.
Td booster every 10 yrs
Tetnus:
Clean, minor wound + vaccination within 10 yrs do nothing
Potentially contaminated wound + >5 yrs since vaccination
give booster
High risk wound + unimunized give tetanus Ig + vaccination
MMR
People born before 1957 do not need to be
vaccinated with MMR and are considered
immune
Contraindicated in neomycin allergy
Live attenuated vaccine
Not for pregnant or immunocompromized
patients
Wait 3 mo if blood or Ig products given
Rubella
mild self-limited illness, but during pregnancy can
result in fetal death or congenital defects
If a woman is rubella non-immune, vaccination
should not occur if pregnant or planning
pregnancy in next 4 wks
vaccine is contraindicated in pregnancy;
inadvertent vaccination is not an indication for
therapeutic abortion.
If the patient is currently pregnant and nonimmune, she should be vaccinated early in the
postpartum period
Meningitis
Meningitis vaccination is indicated for those
with functional asplenia or travelers to
endemic areas.
2 doses of MCV4 are recommended for
adolescents 11 through 18 years of age: the
first dose at 11 or 12 years of age, with a
booster dose at age 16.
College students and military recruits are at
risk
Pneumococcus
PPSV23: adult vaccination indications: chronic
diseases, functional asplenia, residents of
long-term care facilities.
pneumococcal polysaccharide vaccination if >65 yrs or
<65 with chronic medical conditions
2nd 5 yr revaccination in pts w/CKD, liver disease,
immunodeficiency, asplenia
Influenza
Vaccination is 30% - 90% effective in preventing influenza or
complications from influenza.
vaccination is recommended annually for kids 6 mo and older
minimum age for vaccination with the trivalent inactivated influenza
vaccine (TIV) is 6 months
minimum age for the live, attenuated influenza vaccine (LAIV) is 2 yrs
Do not give to immune-compromized or those around them
HPV
Recommended (not required) for all women and men 9-26 yrs
History of genital warts or abnormal Pap are not are not reasons to
avoid vaccination.
People sexually active w/many partners should be immunized if
they meet criteria
To be most effective, the vaccine should be given before a female
becomes sexually active.
It can be administered when a patient has an abnormal Pap test or
when a woman is breast-feeding.
It can also be given when a patient is immunocompromised
because of a disease or medication.
It is not recommended for use during pregnancy.
Herpes Zoster
vaccination recommended for those 60 or
older regardless of having had a prior episode
of herpes zoster
vaccination is not approved for persons
younger than 60
Lung Cancer
no screening improves mortality and no
screening is recommended
Same true for many other cancers and
illnesses- for the shelf exam, if you havent
heard of the screening tool, it probably
doesnt exist or isnt used
Colorectal Cancer
screen with FOBT, sigmoidoscopy, or
colonoscopy in adults beginning at age 50 and
continuing until age 75
if family history, screen 10 yrs before cancer
was found in the family member, or at 50,
whichever is sooner
Recommend against screening > 85 yrs
Breast Cancer
Prostate Cancer
There is evidence supporting DRE & PSA testing as a
screen, but concerns exist regarding false + tests and
any actual reduction in mortality that is gained from
doing the tests.
AAFP feels evidence is insufficient to recommend for or
against routine screening in men younger than 75
USPSTF: recommends against routine PSA screening
In patients who are interested in screening, physicians
should discuss potential benefits and harms
Cervical Cancer
Screen women age 21-65 via Pap smear cytology every 3
yrs OR every 5 yrs via cytology +HPV testing starting at 30
Recommend against screening in women under 21
AAFP says screening was low in previously screened women
after the age of 65 and USPSTF recommends against it
ACS recommends discontinuing screening at 70, but also
notes that a woman who has had 3 or more normal,
technically satisfactory Pap tests, and no abnormal Pap
tests in the last 10 yrs can safely stop
No screening in women who have had a hysterectomy with
cervix removal if no history of high grade lesion
AAA
one-time screening for AAA by ultrasonography
in men aged 65 to 75 who have ever smoked.
no recommendation for or against screening for
AAA in men aged 65 to 75 who have never
smoked.
recommends against routine screening for AAA in
women
GC/Chlamydia
screen for chlamydial infection in all sexually active women ages 24
and younger and in older women who are at increased risk.
The USPSTF recommends against routinely providing screening for
chlamydial infection in women ages 25 and older, whether or not
they are pregnant, if they are not at increased risk.
The USPSTF concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening for
chlamydial infection in men.
Depression
Screen for depression if accurate diagnosis/treatment/follow
up is available
Pre-op Evaluation
Dont
memorize
this
Post-Op Fever
Five Ws: Water (UTI), Wind (pneumonia), Wound (SSI), Walk (DVT), Wonder drugs (drug fever)
Drug Fever: resolution occurs with discontinuation of suspected drug; B-lactams, sulfa, heparin, and amphotericin B
Malignant hyperthermia: fever > 104, tachycardia, metabolic acidosis, Ca accumulation in skeletal muscle leading to rigidity;
after exposure to halothane or succinylcholine; give antipyretics, oxygen, cooling blankets, and Dantrolene IV
UTI risks: BPH, spinal anesthesia, urethral catheter
UTI bugs: E. Coli, Proteus, Klebsiella, Staph Epi, pseudomonas, Candida
Infection is most likely if 3 or more of the following are true:
Pre-op trauma ASA score >2 Onset on the second post-op day
WBC >10,000
BUN >15
Systemic manifestation such as chills and rigors
Fever in first 24 hrs: preexisting infection, bacteremia, intraperitoneal leak, soft tissue infection, TSS, surgical trauma, meds,
blood products, malignant hyperthermia
Soft tissue wound infection often due to beta hemolytic strep or clostridium
1 day 1 week fever: UTI, pneumonia, SSI, catheter-related infection, preexisting infection, MI, EtOH withdrawal, gout,
pancreatitis, PE, DVT
Atelectasis causes 90% of pulmonary complications of surgery
Suspect aspiration pneumonia in the elderly
1-4 weeks: SSI, thrombophlebitis, p. colitis, catheter-related, device-related, abscess, meds, DT, PE
>1 month: blood transfusion, organ transplant-related, infective endocarditis, SSI, device-related, vascular graft,
postpericardiotomy syndrome
Cardiothoracic surgery
pleural effusion
Abdominal surgery
ab abscess and pancreatitis
OBGYN surgery
endometritis, pelvic abscess, pelvic thrombophlebitis
Orthopedic surgery
surgical site infection
Neurosurgery
meningitis, DVT
Travel Medicine
Travelers diarrhea is most common illness
30% - 70% of travelers.
Yellow fever is the only legally required immunization (only for some
countries).
A single inactivated polio vaccine (IPV) booster is recommended for adult
travelers who have had primary polio immunization, but who will be
traveling to an area where polio is endemic.
Cholera and typhus are not required immunizations for travelers.
Hep A is the most common vaccine-preventable illness acquired by
travelers, but vaccination is not required.
Sensitivity: probability that a symptom is present given that the person has the disease. The
probability that the test is positive, given that the person is sick.
A/A+C
Specificity: probability that the symptom is not present given that a person does not have a
disease. The probability that the test is not positive, given that the person is not sick.
D/B+D
Positive predictive value: probability that a + test correctly identifies an individual who
actually has the disease.
A/A+B
Negative predictive value: probability that a - test correctly identifies an individual who does
not have the disease.
D/C+D
Disease
No Disease
Positive Test
Negative Test
Read p. 296-302 in Step Up to Step 2 or the Biostat/Ethics chapter in whatever book you have
Rocky Mountain spotted fever: red macules on peripheral extremities that become purpuric and confluent.
treat with chloramphenicol that continues 2 to 3 days after the pt is afebrile
Lyme disease: slowly spreading annular lesionerythema chronicum migrans
early disseminated: lymphadenopahty, musculoskeletal pain, arthritis, & pericarditis: treat with IV therapy
for 2 to 3 wk
Early localized can be treated with oral antibiotics (amoxicillin or doxycycline) for 14 to 21 days.
Ceftriaxone or cefotaxime and chloramphenicol are options.
Tularemia: pain and ulceration at the bite site; treated with streptomycin intramuscularly.
Brown recluse spider: local pain and itching, then a hemorrhagic bulla with surrounding erythema and induration.
Black widow: mild prick followed by pain at the bite site.
Head lice: erythematous popular rash and nits on the hair follicles; itching begins ~ 2 to 3 weeks after infestation
Treat: premethrin 1% and lindane; If treatment fails second-line is 0.5% malathion lotion.
Scabies: Sarcoptes scabiei burrow into intertriginous areas, wrists, or areas where clothing is tight next to the skin
-treat: oral ivermectin
Chigger bites: linear pattern over wrists, ankles, and legs.
Tinea corporis: spread by close person-to-person contact (as in school wrestling).
lesion is well-demarcated and annular with central clearing, erythema, and scaling of the periphery.
scraping the lesion and visualizing hyphae with microscopic examination, confirms diagnosis
Bedbugs: infest unclothed areasthe neck, hands, and face.
Fleas: bite the lower extremities; occur in clusters
Cat Bite: hospitalization unless very superficial and does not appear infected.
amoxicillin/clavulanic acid is treatment of choice if not hospitalized (5 days prevention, 10 days to treat)
Clindamycin + floroquinolone if allergic to penicillin.
Bite wounds on the hands should never be closed primarily.
often produces infection with P multocida.
Local reactions occur as a result of toxic properties of venom, were as severe reactions are caused by allergic
reaction to venom allergens
Stingers should be removed promptly- scrap or brush off; rapid removal is key
Local reactions occur almost immediately and last for a few hours
Treat with ice, antihistamine; give tetanus prophylaxis if not vaccinated
Large local reactions are IgE mediated and develop over 24-48 hrs
Treat with oral steroids and give tetanus prophylaxis
Anaphylaxis: give SQ or IM injection of 0.3-0.5 mL of 1:1000 epinephrine quickly and repeat in 10-15 minutes if
needed; observe in the hospital for 12-24 hrs
Animal Bites: clean local wound with soap and water, irrigate with saline, debridement of devitalized tissue;
tetanus vaccination
moderate-severe wounds from dog/cat/human seen early after injury and without active infection should
receive 3-5 days antibiotic prophylaxis (augmentin) where as complicated cellulitis should receive
antibiotics for 7-14 days
Cats and dogs carry: staph, strep, anaerobs, pasturella
Humans carry: staph, strep, heomophilus, eilenella, anaerobes
Diabetes
screen all > 45 yrs every 3 yrs; start earlier in people with risk factors
risks: family hx in a first-degree relative, HTN, obesity, high-risk ethnic groups, previous hx of
impaired glucose tolerance, abnormal lipids (TG,HDL), hx of GDM or a birth of a child > 9 lb.
Type I: destrucTon of insulin producing pancreaTc cells; point mutaTon in HLA DQ with DR 3, 4
Islet cell antibodies are present for years prior to development of overt type I DM
Prone to metabolize fatsketonesDKA which is characterized by high serum acetone,
hyperglycemia, and anion gap metabolic acidosis
Type II: stronger familial predisposition; associated with obesity, metabolic syndrome,
hyperinsulinemia, HTN, HLD, hyperglycemia, central obesity
Prone to hyperosmolar states because of high blood sugar
Nonketotic hyperosmolar syndromeblood sugar becomes elevated approaching 1000
Gestational DM: more insulin in 3rd trimester; increased insulin resistance caused by elevated
chorionic somatomamotropin, progesterone, and estrogens
Prone to develop non-pregnancy related DM II
Risks: >25, native American, African American, Hispanic, south or east asian, pacific islander,
BMI >25, hx of glucose intolerance, history of GDM and DM in a first degree family member
Screen all women at 24-28 weeks
Treat with careful diet, and insulin when necessary
Diabetes Diagnosis
Diabetes Management
Lispro/Aspart: rapid acting15 min onset, 30-90 min peak, 3-5 hr duration
Regular: short acting30-50 min onset, 60-120 min peak, 5-8 hr duration
NPH: intermediate1-3 hr onset, 7-15 hr peak, 18-24 hr duration
Glargine/Detemir: long acting1 hr onset, no peak, 24 hr duration
40% - 50% of daily insulin should be Lantus, remaining 50% - 60% is Lispro before each meal, based on a preprandial glucose
Diet and exercise: key components of type II DM treatment; 10% weight loss is a goal for most
Metformin:
glucose output during liver gluconeogenesis; improves insulin sensitivity in liver & muscle; can lower HGA1c 1.5-2%; no
potential for hypoglycemia, reduces insulin levels, potentially helps wt loss, reduces TGs and LDL; popular first line drug
side effects: renal insufficiency (contraindicated if Cr >1.5), hepatic insufficiency, or CHF; contraindicated in nursing
mothers
Sulfonylureas: insulin secreatagogues that sTmulate beta cells in the pancreas to secrete insulin; 2% in HGA1c; tendency to
gain weight & lose effectiveness over time; risk for hypoglycemia
Thiazolidinediones: improve insulin sensitivity in muscle and adipose tissue; decrease hepatic gluconeogenesis and increased
peripheral glucose utilization; decrease in TG and increase in HDL; metabolized by the liver; may have slight increase in LDL,
weight gain, and slow onset of action; require 12 weeks to become fully effective
insulin resistance and sensiTze peripheral Tssues to insulin; good choice for those with insulin insensiTvity.
can be used as monotherapy, with insulin or in combination with metformin.
can HbA 1C by 1 - 2 %; can the insulin dosage by 30% - 50%.
Edema is a common side effect, occurring in about 3% to 4 %; Other side effects include anemia & weight gain.
Meglitinides:
short acting secretagogues that increase insulin secretion; taken no more than 2 hr before meals because of rapid onset
useful if blood sugars vary at mealTme; risk of hypoglycemia; can Hb A 1C by 0.5% -2% and are most valuable if fasting
sugar is adequate, but postprandial sugars are high
should not be used in pts with hepatic dysfunction but safe in renal failure
-GLP-1
gut-derived incretin hormone that stimulates insulin & suppresses glucagon secretion, delays gastric emptying, and reduces
appetite and food intake.
ACE inhibitors are first choice for BP controlindicated for DM pts with systolic BP > 100 mm Hg.
can be used irrespective of creatinine levels, though K should be monitored as creatinine rises.
Providers do not need to wait to see microalbuminuria prior to initiating therapy.
Niacin will triglycerides, HDL, and LDL, but may insulin resistance
Fibric acid derivaTves triglycerides and HDL, but have minimal eects on LDL.
Bile acid resins sequester bile acids in the GI tract. They can triglyceride levels and are generally not used in diabeTcs.
Glycemic control is dependent on the total caloric intake, not the type of calorie taken in.
Renal complications:
ACE inhibitors have been shown to ESRD and death by 41% in DM.
Lifestyle changes: glucose control, weight loss, and decreased protein intake can help
risk with length of Tme pt has had DM, and the condiTon worsens with Hb A 1C levels.
Lipid Screening
Men:
Screen if >35 if no risk factors
Screen beginning at 20 if CAD risk factors
Women:
Screen if > 45 if no risk factor
Screen beginning at 20 if CAD risk factors
Dyslipidemia
5 factors that determine LDL goal: smoking, HTN, low HDL, age (>45 men, >55 women), family history of
premature CHD (male <55, female <65); high HDL is considered a negative risk
For a pt has no known CAD, the 10-year risk for CAD should be estimated using a NCEP risk calculator
If the 10-year risk > 20% LDL treatment goal should be <100 mg/dL.
If the risk is between 10% - 20% LDL treatment goal should be < 130 mg/dL.
If the risk is < 10% treatment goal should be < 160 mg/dL.
Smoking cessation increases HDL by 5 to 10 mg/dL, but does not affect LDL, VLDL, or triglycerides
EaTng oat bran and decreasing life stress can LDL, but is not likely to HDL.
As TG level , the total and LDL cholesterol each ; total & LDL cholesterol are when fasTng. HDL
varies little
low HDL is the best predictor of an adverse outcome; However, high HDL does not guarantee immunity
from CAD
LDL <100 = optimal 100-129 = near optimal 130-159 = borderline high 160-189 = high >190 = very high
Total cholesterol: <200 = desirable 200-239= borderline high
240 or greater = high
HDL: <40 = low
60 or greater = high
Dyslipidemia Treatment
Fish oil:
high in omega-3 Fas and has been shown to be beneficial in lowering cholesterol; decreasing secretion of triglycerides by the liver.
Cholesterol absorption Blocker: Ezetemibe (Zetia):
cholesterol by interfering with the absorpTon of cholesterol in the gut.
LDL and TGs only modestly. When added to a low-dose statin, LDL as much as the max statin dose
Side effects: abdominal pain, diarrhea
Contraindications: hepatic insufficiency/active liver disease
Statins:
rosuvastatin is best at lowering LDL (25-50%); mild decrease in TGs
first line therapy to reduce LDL, coronary events, strokes, cardiac death, and mortality of all causes; must monitor liver enzymes
Decrease LDL; some increase in HDL and some decrease in TG
Side effects = myopathy, myalgia, increased liver enzymes
Contraindicated in liver disease or with other p450 inhibitors, cyclosporine, macrolids, antifungals
Bile acid sequestrants: cholestyramine, colestipol, colesevelam
Decrease LDL, increase HDL, no change in TG
Side effects = GI distress, constipation, decreased absorption
Contraindicated in dysbetalipoproteinemia or if TG > 400
Nicotinic acids: niacin
Increase HDL, some decrease in LDL and TGs, decreased mortality
Side effects: flushing, hyperglycemia, hyperuricemia, upper GI distress, hepatotoxicity; NSAIDs block flushing
Contraindications: liver disease, severe gout; caution with DM, PUD
Fibric Acids: Gemfibrozil, fenofibrate, clofibrate
Increase HDL, decrease LDL, decrease TGs
Side effects: dyspepsia, gallstones, myopathy
Contraindications: severe renal disease, severe hepatic disease
HTN
CVD risk double with each increase in blood pressure of 20/10 above 115/75
Diagnose: average of 2 BPs at 2 or more office visits
Normal: <120/<80
Pre-hypertension: 120-139/80-90
Stage I hypertension: 140-159/90-99
Stage II hypertension: >160/100
HTN
Obesity
Underweight <18.5
Normal 18.5-24.9
Overweight: 25-29.9
Obesity I: 30-34.9
Obesity II: 35-39.9
Extreme Obesity: >40
Increased body weight is a major risk factor for disease and premature death
Treatment: begin treatment if BMI > 25 or waist-hip ratio >.9 in men or >.85 in women
Dietary restriction, physical activity, behavior therapy only 20% of pts will lose 20 lb and maintain the weight loss for 2 years
<1% of obese pts have a secondary nonpsychiatric cause for their obesity.
Hypothyroidism and Cushing syndrome are important examples that can generally be detected by history and physical
Appetite suppressants can be amphetamines (carry a significant risk for abuse) or nonamphetamine.
Orlistat is a GI lipase inhibitor & boasts a 9% average weight loss, but a significant regain after discontinued.
Phentermine: noradrenergic agonist that allows its users to lose 3 to 4 kg > placebo, but regain is also common.
Sibutramine: mixed noradrenergic/serotonergic agonist w/5- 8% wt loss, but significant regain of wt once off
Roux-en-Y gastric bypass.
procedure can result in up to 50% loss of the initial weight in some studies.
Complications are common and occur with about 40% of the cases and nutritional deficiency is common
limited to those with a BMI >40 kg/m 2, or >35 kg/m 2 if there are obesity-related comorbidities present.
Metabolic Syndrome: insulin resistance characterized by abdominal obesity, dyslipidemia, elevated BP, and impaired fasting glucose
Waist > 102 cm in men, >88 cm in women
Triglycerides >150
HDL <40 in men and <50 in women
BP >130/85
Fasting glucose >110
Osteoporsis
Obesity is considered to be protecTve because of estrogen producTon, as long as the person is not sedentary.
deterioration of bone mass not associated w/other chronic illnesses or problems; imaging studies are diagnostic
Increased risk with age, tobacco, low body weight, Caucasian or Asian, family hx, low Ca, sedentary lifestyle
Plain radiographs are not sensiTve enough to diagnose osteoporosis unTl total density has by 50%.
DEXA scanning is most precise and is the test of choice.: T-score <-2.5 = osteoporosis; -1 to -2.5 = osteopenia
A T-score > 2.5 standard deviaJons below the mean (a score of 2.5 or lower) indicates osteoporosis.
Calcitonin directly inhibits osteoclastic bone resorption and is considered a reasonable treatment alternative for
pts in whom estrogen replacement therapy is not recommended; also produces an analgesic effect
Bisphosphonates work by binding to the bone surface and inhibiting osteoclastic activity.
Estrogen and selective estrogen receptor modulators (raloxifene or Evista) block the activity of cytokines.
Fluoride stimulates osteoblasts, but does not result in the formation of normal bone.
Osteoporosis: supplement 1200 mg Ca and 400-800 IU vit D daily; weight bearing exercise
Anemia
Urinary Incontinence
-Blockers inhibit bladder relaxation and therefore can cause both urinary leakage and urgency.
Stool impaction causative in up to 10% of pts with incontinence; disimpaction may restore continence.
Urge Incontinence:
anticholinergic medications are the drugs of choice -oxybutynin(Ditropan) and tolterodine (Detrol)
Functional incontinence:
limitation that does not allow the pt to void in the bathroom (bed rest, paralysis, dementia); not a urinary tract problem
Stress incontinence
loss of urine associated with intra-abdominal pressure(sneezing, coughing, laughing, exercising), more common in women
caused by urethral hypermobility resulting in weakness of the pelvic floor musculature (Q tip test)
overdistention of the bladder; loss of the ability to empty the bladder, usually due to neurogenic bladder (longstanding
diabetes, alcoholism, disk disease) or because of outlet obstruction (prostatic enlargement).
frequent or constant leakage of small amount, but occasionally a large amount of urine is lost without warning.
postvoid residual < 50 mL = normal. A postvoid residual > 200 mL = inadequate bladder emptying
Sexual Dysfunction
In pts with sex drive with no other complaints and no exam ndings, assessment of hormone status is indicated.
Testosterone levels should be checked in the morning, when they peak.
Free testosterone is a more accurate measure of androgen status, as it measures bioavailable testosterone.
-if low, workup should continue to get FSH, LH, PRL
-if FSH and LH are low, but PRL normal, diagnosis is pituitary or hypothalamic failure
-if FSH and LH are high, and PRL normal, diagnosis is testicular failure Prolactin (PRL)
-if FSH and LH are low and PRL is high, 40% chance of pituitary adenomaget CT or MRI
The TSH and prolactin levels may be indicated in the presence of other complaints or physical findings.
TCA & SSRIs sexual dysfunction.
Bupropion actually the orgasm threshold and is least likely to cause sexual dysfunction.
Premature ejaculation is the most common sexual dysfunction in men, affecting about 29% of the general population.
Fluoxetine raises the threshold for orgasm, making it an effective treatment option.
A penile brachial index can be performed to evaluate for significant vascular disease in patients with ED,
nocturnal penile tumescence evaluation would be done to eliminate psychologic factors that inhibit arousal
hypoactive sexual desire disorder Most commonly, this is a result of relationship problems, but growing evidence does
suggest androgen deficiency may play a role in some women.
Sexual aversion disorder is an extreme aversion to and avoidance of genital contact with a sexual partner.
Sexual arousal disorder refers to the inability to maintain an adequate physiologic sexual excitement response.
Dyspareunia refers to genital pain associated with intercourse.
Headache
Red Flag signs:
onset aZer age 50, sudden onset, in severity or frequency, signs of systemic disease, focal neuro
symptoms (except those consistent with a visual aura), papilledema, or a headache after trauma.
Cluster Headache:
Deep, excruciating pain for min-hours; peaks in 10-15 minutes and lasts 2 hrs w/o treatment
therapy is to provide relief from acute attacks, then to suppress headaches during the symptomatic period
Nifedipine has been shown to be effective, as has prednisone, indomethacin, and lithium.
Verapamil, lithium, divalproex, methysergide and prednisone may be used for prophylaxis
SQ or intranasal serotonin antagonists have been more efficacious. IV or IM ergotamine has been helpful
Tension Headaches:
episodes last from 30 min to several days, and headaches should occur < 15 times per month.
requires at least 2 of the following : Pressure/tightness, Bilateral, Mild to moderate, Not aggravated by
activity, There is generally no nausea, Either photophobia or phonophobia may be present, but not both.
Migraine Headache
Wheezing
Risk factors: fall or winter season, history of atopy, daycare, and passive smoke exposure.
Pneumonia causes 33% - 50% of wheezing children, and most are also caused by viruses as well.
Bronchiolitis causes < 5% of episodes of wheezing, but is important, especially in preterm infants.
Asthma is common in children, but is not diagnosed after one episode of wheezing.
Wheezing is commonly heard in patients with CHF.
Asthma:
In pts with known asthma a CXR is indicated if pt has fever, rhonchi, or sputum to r/o pneumonia.
Peak flows do not confirm diagnosis of asthma, but are useful to monitor the status of known lung
disease.
PFTs may be needed, but are usually done in a pulmonary laboratory.
Asthma
genetic component, but the strongest identified predisposing factor for its development is atopy.
Obesity is increasingly being recognized as a risk factor.
most important component in the diagnosis of asthma is history.
Pts typically have recurrent episodes of wheezing, but not all asthma includes wheezing, and not all wheezing is asthma.
Cough is the only symptom in cough-variant asthma.
CXR is useful to rule-out other causes; PFT is confirmatory, not diagnostic; Provocative testing for the rare pt in whom the
diagnosis is in question, but should be used cautiously, as life-threatening bronchospasm may occur.
infections predispose to acute asthma exacerbations; However, use of empiric antibiotics is not recommended.
Peak flow measurements parallel FEV 1 and are an easy and inexpensive way to monitor asthma control.
80% - 100% of the pts personal best are in the green zone, and indicate that the patient is doing well.
50% - 80% of personal best are yellow zone, and are a warning to consider a step-up in therapy (review of medication
technique, adherence, and environmental control, or use additional medication).
< 50% of the personal best are an indicator that the patient needs immediate medical attention.
Mild intermittent: symptoms < 2x a week, with brief exacerbations, and with night-time symptoms < 2x a month are classified as
Mild persistent: symptoms > 2x a week but < 1x a day; sometimes affect usual activity. Night-time symptoms occur > 2x a month
Moderate persistent: daily symptoms & use of short-acting inhaler, with exacerbations that affect activity and may last for days.
Night-time symptoms occur at least weekly.
Severe persistent: continual symptoms that limit physical activities, with frequent exacerbations and night-time symptoms.
Treatment:
Inhaled corticosteroids are preferred first-line agents for all pts with persistent asthma.
Long-acting -agonists do not impact airway inflammation and should not be used without a corticosteroid.
A leukotriene receptor antagonist is a second best choice; improves lung function and rescue inhaler use
Inhaled corticosteroids and leukotriene antagonists have replaced cromolyn in current asthma therapy.
COPD
COPD
Asthma: presents earlier; may or may not be associated with smoking; episodic exacerbations with return to normal
function
COPD: presents midlife or later, long smoking history, slowly progressive; PFTs never return to normal.
Smoking associated with 90% of COPD cases
Non smoking causes = passive smoking, occupational exposures, alpha-1 antitrypsin deficiency
Baseline cough with white mucus, worsening dyspnea
Barrel chest, distant heart sounds, lung hyperinflation, flattened diaphragms on xray
CXR is normal until the disease is advanced
Primary diagnosis made by spirometry: FEV1/FVC < 0.7 fixed obstruction
FEV decreases by at least 50% by the time symptoms are present
Chronic Bronchitis: cough & sputum production on most days for at least 3 mo during at least 2 consecutive yrs
Emphysema: SOB caused by enlargement of respiratory bronchioles and alveoli caused by destruction of lung tissue
Management of Stable COPD: quit smoking, pneumococcal and influenza vaccination
Stage I: mild FEV1 >80%; give short acting bronchodilator (albuterol and ipratropium)
Stage II: moderate; FEV 1 30-50%; give long acting bronchodilator (salmeterol and tiotropium)
Stage III: severe: FEV1 30-50%; inhaled steroids reduce the frequency of exacerbations
Stage IV: very severe: FEV1<30% or <50% with hypoxemia (SaO2 <88%; PaO2 <55); steroids + O2
Management of Acute COPD: most commonly caused by viral/bacterial infections
Keep O2 > 90% or 60 mmHg
Short acting bronchodilators (beta agonist + anticholinergic)
Systemic steroids shorten the course of exacerbation and reduce risk of relapse
If increased sputum or purulent sputum, give antibiotics
Pneumococcus, H. influenze, M. caterrhalis, Klebsiella, Pseudomonas
Cough
Acute bronchitis:
antibiotics are not indicated for uncomplicated acute bronchitis, regardless of duration of the
cough. Antibiotics should be reserved for pts with significant COPD and CHF, those who are
very ill-appearing, or the elderly.
Pertussis:
Antibiotics do not alter the course unless initiated early in the illness; antibiotics do prevent
transmission and need for respiratory isolaTon from 4 wks to 1 wk and are therefore
recommended.
first-line is erythromycin x 14 days, or azithromycin x 5 days. Amoxicillin &
amoxicillin/clavulanate not effective.
Pain
Chronic pain recurrent or persistent pain lasting > 3 months; affects ~ 15% of the US population.
Nociceptive pain stems from tissue damage (such as arthritis and/or tumor).
Neuropathic pain is from sustained transmission of pain signals w/o ongoing tissue damage. It is
described as numbness (hypoesthesia), sensiTvity (hyperesthesia), pins & needles (paresthesia),
or severe from innocuous stimuli (allodynia).
NSAIDs are an excellent first-line medication for mild to moderate pain, especially w/ an
inflammatory component
Celecoxib (COX-2 inhibitor) may have better side effects, but is not first-line except in elderly or pts
who failed NSAIDs.
Tramadol: centrally acting synthetic opioid agonist that binds to -opioid receptors & inhibits
serotonin & norepinepherine reuptake. It should not be a first-line option.
TCAs like amitriptyline & anticonvulsants like gabapentin may work well in neuropathic pain, they
are less well-studied in nociceptive pain and therefore are not good first-line agents.
continued escalating opioid doses worsened analgesic response because NMDA receptors are
upregulated and lead to tolerance, while pain receptors become increasingly more sensitive to
stimuli.
In situations of tolerance, switch from one opioid to another, starting at half the equivalent dose of
the alternative med.
Fatigue
Mononucleosis: often mistaken for streptococcal pharyngitis.
symptoms of sore throat, fatigue, fever, and adenopathy.
If given ampicillin (and other penicillin derivatives), up to 100% may develop
rash
Sleep
Propranolol is known to cause nightmares
Hydrochlorothiazide can cause nocturia that inhibits sleep,
Alcohol causes excessive wakefulness, and allows people to fall asleep, but
interferes with the ability to stay asleep.
drugs of choice for transient sleep onset problems are zolpidem (Ambien)
or eszopiclone (Lunesta).
For sleep maintenance problems, zaleplon (Sonata) may be used.
Melatonin has been shown to help with adjustments to the sleep-wake
cycle (ie, jet lag, shift work).
Benadryl can cause excessive somnolence, and may help with sleep onset,
but not maintenance.
Good sleep hygiene:
wake up at a regular hour, exercise daily (not before bed), control sleep
environment, light snack before bed, limit/eliminate EtOH, caffeine & nicotine,
go to bed when sleepy, use bed for sleep & intimacy only, get out of bed if not
asleep in 15-30 min
Acute Conditions
These questions will be similar to your internal
medicine questions, but will focus more on
risk factors/prevention/follow-up
Acute GI conditions
Appendicitis:
Pain from an acute appendicitis usually starts in the periumbilical region before moving to the RLQ.
Only 22% of elderly patients with appendicitis present with classic symptoms, making the diagnosis more difficult.
Pancreatitis:
generally settles in the mid-epigastric region with radiation to the back and is associated with nausea and
vomiting.
Gallstones cause the majority of cases ; EtOH causes ~30% of the cases; 10 - 30% are idiopathic.
Less common causes: hyperCa, hyperlipidemia, trauma, medications, infections, and instrumentation (ERCP).
Ransons criteria assess the severity and prognosis of pancreatitis. On admission, 5 criteria are considered.
age > 55, WBC > 16,000/mm, glucose > 200 mg/dL, LDH > 350 IU/L, AST is > 250 U/L.
6 other criteria reect the development of complicaTons and include a in Hct > 10, BUN > 5 Ca < 8, PaO 2 <
60 mm Hg, base deficit > 4 mEq/L, and a fluid sequestration > 6 L.
Gallbladder pain is typically in the epigastric or right upper quadrant and radiates to the scapula.
Cholecystitis:
Sudden cessation of inspiration during deep palpation of RUQ is Murphy signsuggests acute cholecystitis
Choledocolithiasis:
usually performed in the setting of an acute cholecystitis with increased liver enzymes, amylase, or lipase.
Acute GI Conditions
Diverticulitis:
GI Conditions
IBS:
constipation, diarrhea, alternating; lower ab pain, particularly in LLQ, intermittent cramping; may
have mucus; may feel bloated
Rome Consensus Committee for IBS
symptoms for at least 12 wks (not necessarily consecutive) in the previous 12 months, and
pain that is characterized by 2 of the following 3: (1) relieved by defecation, (2) onset is
associated with a change in stool frequency, or (3) onset is associated with a change in the
form or appearance of stool.
Alarm features: fever, anemia, weight loss, hematochezia, melena, bloody diarrhea, family history
of colon cancer or IBD
Treat: antispasmodics (dicyclomine, homoscyamine), low dose TCAs, SSRI if depression or anxiety is
present; increased fiver intake; loperamide to reduce frequency of stools; tegaserod for
constipation; alosetron for diarrhea
Renal Calculi: Pain from renal calculi often radiates to the shoulder.
Symptoms begin acutely and are associated with typical viral syndrome symptoms.
Elevated ALT is more suggestive of gallstone pancreatitis and is less likely when alcohol or hypertriglyceridemia
symptoms occur after eating, and are improved when the patient does not eat.
Pyloric stenosis
weight loss, dehydration, and occasionally a palpable olive mass in the epigastric area.
GI Bleeding
Upper endoscopy is the best diagnostic testing option in the setting of an acute upper GI bleed.
Intussusception:
caused by the involution of one bowel segment into another bowel segment.
Meckel diverticulum:
2% of the population; male-to-female = 2:1; 2 ft from ileocecal valve; 2 in long. 2% of cases have complications.
Most are asymptomatic, but a common presentation is painless large-volume intestinal hemorrhage.
noninvasive diagnostic modality is the technetium scan, often called the Meckel scan.
Diverticulosis:
It is unusual to find the source of bleeding during colonoscopy; tagged RBC scan should be the next step
External Hemorrhoid:
When they thromboseacute pain and are hard and nodular on physical exam.
excision in the office w/local anesthesiaeliminates pain immediately and eliminates the risk of reoccurrence
Anal Fissure:
split in the anoderm of the anal canal. It generally occurs after the passage of a hard bowel movement.
After the BM, the patient may complain of an ache or spasm that resolves after a couple of hours.
Lower GI Bleeding
Clinical: weakness, fatigability, pallor, chest pain, dizziness, tachycardia, hypotension, orthostasis
Diagnostics: colonoscopy, angiography, technetium labeled or RBC scan, NG tube aspiration
Hemorrhoids: most common cause of lower GI bleeding
Dilated veins in the hemorrhoidal plexus; internal above dentate line
Cause: constipation, straining, pregnancy, prolonged sitting (truck drivers)
Externalpainful, irritable, palpable lump
Internalbleeding and prolapsed
Treat: high fiber diet, stool softeners, surgery only when necessary
Diverticular disease:
Usually asymptomatic, or may present with painless bleeding that stops spontaneously
If asymptomatic, treat with high fiber diet
DiverticulitisLLQ pain, fever, nausea, diarrhea, constipation; treat with bowel rest and Abx
IBD:
UC causes continuous inflammation of the large bowel; higher risk for colon cancer
Crohns causes focal inflammation anywhere n the GI tract
Both may have numerous extraintestinal manifestation
Treat: antidiarrheal meds, anti-inflammatory meds, immunosuppressive meds, colectomy
Colon Neoplasms:
Hyperplastic polyps are small, smooth growths of no prognostic significance
Adenomatous polyps are benign growths with malignant potential
Tubular, tubulovillous, villous
Larger polyps have higher risk of bleeding and becoming malignant
All patients >50 yrs with lower GI bleeding must be evaluated for colon cancer
Constipation
< 3 stools/week
Causes: hypothyroid, HyperCa, HypoK, scleroderma, DM, MS, PD, amyloidosis,
pregnancy, IBS, CCBs, carcotics, Anticholinergics, TCAs, diuretics, clonidine
Lab testing only indicated if: alarm symptoms present, medical disorder is likely, or
if no response to treatment.
Alarm symptoms: hematochezia, family hx of colon cancer, family hx of IBD,
positive FOBT, weight loss, or new onset of constipation in people > 50 years.
Bulk-forming agents (psyllium) is well-tolerated for chronic constipation
Osmotics like MgOH work well, but chronic use may cause hypermagnesemia.
Lactulose is another osmotic
Stimulant laxatives like bisacodyl work well in acute settings, but research is not
available to support their routine use
Enemas are usually the treatment of choice for impaction, but not chronic
constipation.
Lubiprostone is beneficial in the treatment of adults with chronic constipation, but
not as a first-line
Diarrhea
Acute Gastritis
Palpitations
Chest Pain
Differential: MI, Angina, Percarditis, Aortic Dissection, PE, PNX, PNA, bronchitis, costochondritis, muscular strain, GERD,
Esophageal spasm, cholelithiasis, anxiety, somatization, herpes zoster
ER studies: CBC, electrolytes, BUN/Cr, PT, PTT, INR, glucose, EKG, CXR, cardiac enzymes, tropinin T and I Q 6-10 hrs for 3
cycles, O2 sat
MONA- morphine, oxygen, nitroglycerin, aspirin
Morphine: decreases catecholamines which reduces myocardial O2 consumption
O2: may be discontinued after 6 hrs if saturation is normal
Nitroglycerin: give sublingually Q 5 min for 3 doses then advance to IV route
Aspirin: 325 mg to be chewed (clopidogrel if ASA allergy)
B-adrenergic antagonist: reduces myocardial damage and limits infarct size
ASA and heparin reduce risk of subsequent MI and cardiac death in pts with unstable angina
ACEI reduce short term mortality when started within 24 hrs of acute MI; prevents remodeling
Unstable angina + EKG changes give glycoprotein IIb/IIIa receptor inhibitor
EKG changes in MI: ST wave elevation/depression and/or T wave inversion; Q waves indicate cardiac pathology (necrosis)
Angina classifications:
Angina with unusually strenuous activity
Angina with more prolonged or slightly vigorous activity
Angina with usual daily activity
Angina at rest
Causes of MI: atherosclerosis and plaque rupture, cocaine induced spasm, aortic dissection, embolus
MI Clinical Presentation: pressure, squeezing, crushing, smothering, Levine sign, nausea, vomiting
Angina longer than 20-30 minutes is likely an MI
Secondary Treatment
Reduce or address risk factors: male >40, HTN, smoking, DM, cocaine, hyperlipidemia, LV hypertrophy, family hx,
chest trauma, postmenopausal, homocystinemia
Aspirin, nitrates and beta blockers have proven long term benefits
Statins decrease incidence of CV events; goal LDL is <70
HTN should be treated to reduce mobidity and mortality
Recommend minimum of 30 min exercise on most days with weight management
Chest Pain
Exercise ECG is most commonly used noninvasive procedure for evaluating whether the chest pain is due to angina.
Myocardial stress imaging (scintigraphy , echo) is indicated if resting ECG makes an exercise ECG difficult to interpret
to confirm results of the exercise ECG or to localize the region of ischemia
to distinguish ischemic from infracted myocardium
to assess the completeness of revascularization following an intervention.
The electron beam CT can quantify coronary artery calcification, but is not helpful to evaluate angina.
Atypical Angina: pain that has the quality and characteristics of angina, or occurs with exertion, but not both.
chest heaviness not related to exertion or relieved by rest, or it pain with an atypical character (sharp or
stabbing) but predictably brought on by exercise and relieved by rest.
Anginal equivalent: other symptoms of cardiac ischemia (eg, dyspnea) that is predictably precipitated by exertion
and relieved by rest.
LV hypertrophy with strain, LBBB and ST-segment baseline abnormalities in the precordial leads abnormalities
should get a thallium ETT rather than standard exercise treadmill test
Poor prognostic signs in an ETTfailure to complete stage II of a Bruce protocol, failure to achieve a HR > 120
beats/min (off -blockers), onset of ST depression at a HR < 120 beats/min, ST depression > 2.0 mm, ST depression >
6 min into recovery, poor systolic BP response to exercise, angina or ventricular tachycardia with exercise and ST
depression in multiple leads.
Nitrates:
Tolerance is the most significant issue to consider when using nitrates for stable angina; develops rapidly with longacting nitrates
When using a patch, it is important to have intervals of 10 - 12 hrs w/o the patch to retain the effect.
D-Dimer
useful in determining the risk for a DVT or PE.
A low result has a high negative predictive
value for the presence of thrombus.
If the result were high, a confirmatory test
would be appropriate.
Pneumonia
infection of lung parenchyma; most common triggering mechanism is upper airway colonization
Clinical: age, cough with green sputum, fever with chills, exposure, egophany, dullness to percussion
Diagnosis: CXR is gold standard; cultures have low sensitivity
Absence of infiltrate does not rule out pneumonia
Community Acquired Pneumonia (non hospital pts):
Strep pneumo, H. influenza (esp in COPD pts), and M. Catarrhalis are most common focal, lobar infiltrates
Mycoplasma, Chlamydia & legionella cause atypical pneumonia; more in adolescent/young adult Bilateral diffuse infiltrates
Hospital Acquired Pneumonia
Risks are intubation, NG tube feeds, lung disease, multisystem failure
Pseudomonas, klebsiella, acinetobacter, gram+ cocci, staph aureus
Abruptly worseningpneumococcal pneumonia
Diarrhea + pneumonia legionellacan do urine antigen testing or direct fluorescent antibody
Postinfluenza pneumoniastaph aureus
Right lower lobe consolidationaspiration pneumonia
Pneumonia Severity Index: assigns pts a risk category based on age, comorbid illness, specific exam and lab; high risk includes
neoplastic disease, liver/renal disease, CHF, DM; physical bindings include tachypnea, fever, hypotension, tachycardia, AMS, low pH,
low Na, low Hct, low O2 sat, high glucose, high BUN, pleural effusion on xray
Low risk classes treated as outpatient; high risk as inpatient
Treat: fluoroquinolone or macrolide or beta-lactam for outpatient; IV beta lactam and IV macrolide for inpatient; get early follow up
with CXR in 5-7 days; treat for 72 hrs in an afebrile patient, but at least 2 weeks if complicated or atypical pneumonia
Complications: bacteremia, parapneumonic pleural effusion, empyema
Prevention:
Pneumococcal vaccine for all >65, and all other adults with chronic illness
Influenza vaccine
Acute Bronchitis
Inflammation of the tracheobronchial tree often in the
setting of a URI in the winter
Influenza, parainfluenza, adenovirus, rhinovirus,
mycoplasma, Chlamydia
CHF
CHF
NYHA functional classification:
Class II: pts have slight limitations; comfortable at rest; fatigue, palpitation, dyspnea, angina w/ordinary activity
Class III: patients are also comfortable at rest, but less-than-ordinary activity causes symptoms.
Class IV: patients have symptoms at rest and increased symptoms with even minor activity.
Dizziness
Vertigo rotational sensation, in which the room spins around the patient.
Orthostasis lightheadedness upon arising, common with orthostatic hypotension.
Presyncope feeling of impending faint.
Disequilibrium sensation of unsteadiness or loss of balance; pt often thinks
problem is in the feet
Light-headedness is often vaguely described as a floating sensation.
Dix-Hallpike maneuver is useful to distinguish central from peripheral causes of
vertigo.
peripheral vertigo latency time for onset of symptoms of vertigo or nystagmus is 3
- 10 sec; symptoms are severe; direction of the nystagmus is fixed; repeating the
maneuver lessens the symptoms.
central vertigo no latency to onset of symptoms, no lessening of symptoms with
repeat maneuvers, the direction of the nystagmus changes, and the symptoms are of
mild intensity.
antihistamines are first-line therapysuppress the vestibular end-organ receptors
and inhibit activation of the vagal response. Meclizine (Antivert), 25 mg Q 4-6 hrs and
diphenhydramine (Benadryl), 50 mg orally Q 4 - 6 hrs
ENT
Vestibular neuronitis
acute onset of severe vertigo lasting several days, with symptoms improving over several
weeks
ENT
Eye Conditions
Conjunctivitis
itching and bilateral symptoms are more specific for allergic conjunctivitis
Supportive treatment; topical antibiotics prevent bacterial superinfection, but no good evidence that it makes any impact.
eye drops for herpetic eye infections (corneal dendrites w/fluorescein staining); also use cold compresses
Bacterial conjunctivitis purulent discharge, pain, photophobia, and a gritty sensation of the eye.
MRSA conjunctivitis is treated with the same drugs used to treat MRSA in other parts of the body
Scleritis:
vision, deep boring eye pain, surrounding headache; associated w/autoimmune diseases like RA or Wegeners
Episcleritis: mild irritation, and is not as intense as the syndrome described above.
Corneal abrasion: associated with vision, intense pain, and tearing, but is associated with trauma.
Acute glaucoma: pain, vision, and redness, but the aected pupil is usually dilated.
Chalzion: sterile inflammation of meibomian gland; painful nodule
Blepharitis: inflammation of eyelids, loss of eyelashes, scaling
Dactrocystitis: occlusion of nasolacrimal duct
Subconjunctival hemorrhage: benign bleeding of small bessels, painless
Conjunctival hyperemia: diffuse erythema of conjunctiva
Iritis: photophobia, sluggish pupil, cloudy cornea, pain, pupillary constriction
Sinusitis
Allergic Rhinitis
IgE mediated response to extrinsic protein Mucus glands increase secretion, vasodilation, stimulation of sensory nerves
Symptoms: sneezing, itching, rhinorrhea, postnasal drip, congestion, anosmia, headache, earache, tearing, red eyes,
drowsiness
Exam: allergic shiners, nasal crease, allergic salute, swollen blue/gray turbinates; conjunctivitis, dennie-morgan liens,
cobble-stoning
Treat: H1 blockers, nasal decongestant, oral decongestant, intranasal steroids, oral steroids, cromolyn, LTRAs
Antihistamines: diphenhydramine, chlorpheniramine, hydroxyzine; side effects are dry mouth, dry eyes, blurred vision,
urinary retention; 2nd gen have less SE: loratadine, fexofenadine, cetirizine
Decongestants: constrict blood vessels; pseudoephedrine (-adrenoreceptor agonest); may cause tachycardia, tremors,
insomnia, rebound hyperemia, worsening of symptoms w/chronic use or discontinuation
Corticosteroid nasal spray: effective long term management; reduce inflammatory mediators
Oral corticosteroids: inhibit cell mediated immunity; long term steroid effects so only use short term
DesensiTzaTon therapy: test for specic anTgens; inject dilute anTgen & gradually concentraTon
Anaphylaxis: give aqueous epinephrine 1:1000 in 0.2-0.5 mL dose subQ or IM + IV fluids
Allergens may trigger asthma rapid acting B2 adrenergic agonist albuterol is mainstay treatment
Mild intermittent: <2/wk,<2/mo; no daily meds other than short acting B rescue inhaler
Mild Persistent: 3-6/wk; 3-4/mo; give low dose inhaled steroid
Moderate persistent: daily; >5/mo; give low/med inhaled steroid + long acting B agonist
Severe persistent: continual/frequent; give high dose inhaled steroid, long acting B agonist; corticosteroid
tablets/syrup if needed
Sore Throat
Pharyngitis
RSV, adenovirus, parainfluenza, rhinovirus
Herpangina tonsilar + palatal ulcerations; coxackie virus
Group A Strep rheumatic fever, GN, rare in children < 3
Viral: rhinorrhea, cough, low grade fever
Diphtheria gray membrane, tonsillitis, cervical lymph
Kawasaki < 5 yrs, strawberry tongue, fever, rash on
hands and feet
Monospot test positive after 5 days 3 weeks; IgM may
not be + for 2 weeks
Strep pneumo give 10 days of PNC or 1 IM injection
cause is multifactorial: familial factors, follicular keratinization, androgens, and Propionibacterium acnes.
Acne is not caused by dirt, chocolate, greasy foods or the presence or absence of any foods in the diet.
Topical agents are first line; topical retinoid + topical antibiotic 2nd line; add oral antibiotic if no improvement in 6 weeks
improvement occurs over a period of 2 - 5 months, and may take even longer for noninflamed comedones.
Topical retinoids applied in the evening, benzoyl peroxide & topical antibiotics (doxy) should be applied during the day
Isotretinoin indications: nodular acne, severe acne, moderate recalcitrant acne, resistant to other therapies
pregnancy must be prevented during its use.
tetracycline & isotretinoin cause pseudotumor cerebri, and should never be used together.
Rosacea:
Stage III- erythema is deep and persistent, telangiectases are dense, and there may be a solid appearing edema of the central part of
the face due to sebaceous Hyperplasia and lymphedema (rhinophyma and metophyma).
Management: topical metronidazole, antibiotics, and sodium sulfacetamide can work, but oral antibiotics are more effective than
topical. Minocycline or doxycycline are very effective first-line therapies.
Keratoacanthoma:
difficult to distinguish from basal cell cancers, nodular squamous cell cancers, or molluscum
For localized skin rashes, topical corticosteroids are appropriate therapeutic agent.
Topical pimecrolimus is effective for inverse psoriasis (perianal and genital regions) or on the face and ear canals
Oral retinoids & methotrexate treat generalized psoriasis, & help w/nails, but not first-line for localized rash
self-limited papulosquamous eruption; single herald patch (oval, slightly raised plaque with scale) followed in 1 - 2 wks with a
generalized eruption.
well-demarcated erythematous lesions that, when disrupted, develop a secondary golden crust.
responds well to topical antibiotics like mupirocin applied to the lesion and to the nares
Folliculitis:
Antiviral agents are more effective treating primary infections than recurrent infections.
Pulse dosing (treating at the first sign of outbreak) may shorten or reduce the severity of an eruption
Chronic suppression is best to frequency of symptomaTc recurrences and asymptomaTc viral shedding.
Acyclovir resistance is extremely rare. Valacyclovir & famciclovir have equal efficacy for cutaneous HSV
Genital herpes:
treat each outbreak (episodic therapy) at first sign of outbreak or use daily antiviral therapy to prevent (suppressive therapy)
Suppressive therapy does not alter the natural course of infection and is not associated with antiviral resistance
Herpes zoster:
AnTviral therapy is treatment of choice, and Tme for lesion healing and overall duraTon of pain if iniTated within 72 hours
In some cases, no benefit will occur if treatment starts after the 72 hour cutoff, but it should beinitiated regardless of time in pts >
50, those who are immunosuppressed, or those with eye involvement.
Systemic therapy is needed, but topical ketoconazole shampoo or selenium sulfide lotion may kill hair spores
Terbinafine, itraconazole, fluconazole, and ketoconazole can also be used. If fluconazole were to be used, the
treatment duration would only be for 3 to 4 weeks, not 4 to 8 weeks.
Tinea corporis/ringworm:
rough, red plaques with flaking that can affect the face, neck, upper trunk, and behind the knees.
Most patients have the onset of eczema in childhood, and onset after the age of 30 is very uncommon.
Molluscum contagiosum.
more common in white males, children in daycare/nursery (for kids it is not likely to be sexually transmitted)
can occur in immunocompetent pts, but in pts who are immunocompromised, they are numerous and larger.
Most resolve spontaneously within months, but they can be treated with cryotherapy, cautery, or curettage.
Skin Cancer
Lentigo Maligna:
Nodular:
Acral Lentiginous:
Treat: if any of the ABCDE signs are present, excise completely with 2-3 mm margin; if pathology
indicates malignancy, excise with 5 mm margin
Tumor thickness is most important prognostic factor; <1 mm thick have low rate of metastasis
Basal Cell Ca: most common; pearly papules w/central ulceration or telangectasias; rarely
metastasize
Squamous Cell Ca: higher rate of metastasis; irregularly shaped plaques/nodules w/raised
borders, bleed easily; scaly, ulcerated
Musculoskeletal
shoulder dislocation pain management and relocation
keep immobilized for 7 -10 days to allow for capsular healing. Then, start ROM exercises and strengthening
Younger pts may have recurrence, & surgical referral should be entertained, but not necessary immediately
Rotator tendonitis discomfort w/abduction > 90; pain with throwing motion
commonly seen in athletes with repetitive knee flexion activities like distance runners and cyclists.
pain or ache over lateral knee that worsens with activity, and on exam has pain and tightness over the IT band.
treat with strengthening the hip abductors, internal rotators, and knee flexors is generally treatment for
Patellofemoral pain syndrome:
diffuse knee pain and a positive patellar grind test; generally does not occur acutely or after injury
most common diagnosis for patients with anterior knee pain presenting to their PCP
pain is worse with walking, running, ascending or descending stairs, or squatting or sitting for prolonged periods of time
Treatment is done primarily through strengthening the quadriceps muscles and hip rotators.
ACL tear:
twisting injury, sense of instability, feeling of a pop, and immediate effusion while still able to bear weight.
Meniscal injuries:
occurs after valgus stress to a partially flexed knee; pain over the medial aspect of the knee, but no joint swelling
Ottawa ankle rules are a guide to use to determine if xray is indicated after ankle sprain. Films should be obtained if:
The pt is unable to walk four steps immediately after the injury and in the office.
There is tenderness over the distal 6 cm of the tibia or fibula, including the malleoli.
Neck Pain
Spondylosis or osteoarthritis Pain aggravated by movement, worse after activities, associated with a dull ache,
limited ROM
chronic mechanical problems tenderness to palpation on examination.
cervical nerve root irritation radiation of symptoms, weakness, numbness, or paresthesias.
whiplash injury history of an acceleration injury; get C-spine radiograph
cervical dystonia (torticollis) neck would be laterally flexed and rotated.
Physical therapy, stretching, gentle manipulation, cervical collars, ice/heat have all been used with some results
evidence supporting those treatments is weaker than the evidence behind use of botulinim toxin.
spinal stenosis: older individual with axial stiffness and paresthesias over several dermatomes (C7-T1).
CT scan is the best choice.
Canadian cervical spine rules help determine who should receive radiography:
1. Is there one high-risk factor? High-risk factors: age >65, dangerous mechanism (high speed motor vehicle
accident) or numbness/tingling in extremities. A yes to any of the above requires radiography.
2. Is there one low-risk factor? Low-risk factors: simple rear-end collision, if the pt was ambulatory at any time at
the scene, if there was absence of neck pain at the scene, and if there was absence of C-spine tenderness on
examination. A no to any of the above would require radiography.
3. Is the pt able to voluntarily actively rotate the neck 45 to the left and right regardless of pain? A noto that
question would require radiography.
Spurling test/neck compression test.
pt to bends head to the side & rotate head toward the side of pain while tester exerts downward pressure.
reproduces symptoms in the affected upper extremity in the case of nerve root injury.
high specificity, but low sensitivity for cervical radiculopathy.
Nonspecific mechanical pain should be considered if the maneuver results in neck discomfort only.
Back Pain
Back strain generally follows an inciting event; pain associated with movement.
Treatment:
maintain usual activities, as dictated by pain.
prolonged bed rest & tracJon have not been shown to be eecJve in return to
usual activities sooner.
NSAIDs & muscle relaxants are effective for short-term symptomatic pain relief
Steroids can be considered in those who have failed NSAID therapy.
Low-dose TCAs can be useful in the treatment of chronic pain and do serve as
adjuvants to other analgesics.
Joints
Osteoarthritis:
Osteoarthritis: age >65, history of trauma, obesity, or repetitive joint use; deep, dull, achy pain
Xray is normal at first, then develops bone sclerosis, subchondral cysts, osteophytes
Heberden nodes (at the DIP joints) and Bouchard nodes (at the PIP joints).
often mild swelling, but warmth and an effusion are rare; Crepitus is common, as is malalignment of the joint.
Indications for joint replacement poorly controlled pain despite max therapy, malalignment, and mobility
Fluid aspirated is generally clear joint fluid with a WBC count of 2000/mm 3 to 10,000/mm 3.
In RA, > 50% of the WBCs are PMNs, while in osteoarthritis, < 50% of the WBCs are PMNs.
Rheumatoid Arthritis:
Morning stiffness Involves 3 or more joints; involves hand joints; symmetric arthritis; fatigue is common
Elevated ESR and CRP, anemia, thromobcytosis, low albumin, +rheumatoid factor
gradual, polyarticular and symmetric involvement of joints with morning stiffness that improves with activity
Hands and feet are usually involved first, but it may spread to larger joints.
symmetric swelling and tenderness are common, with associated rheumatoid nodules.
disease-modifying antirheumatic drugs (DMARDs) should be managed by rheumatologists and started early to avoid or
delay joint deformity.
nodules occur anywhere (usually subcutaneously along pressure points), vasculitis, dry eyes, dyspnea, or cough can all be
seen. Cardiac, GI, and renal systems are rarely involved. When a neuropathy is present, it is generally because of a
compression syndrome, not as an extraarticular manifestation
Joint Pain
Gout
increased risk men, EtOH consumption, after large meals, after trauma or surgery, thiazides
abrupt in onset and monoarticular with pain at rest and with movement; any joint can be affected
podagra- an abrupt, intense inflammation of the first MTP joint
attacks often occur overnight, after an inciting event (excessive alcohol or a heavy meal).
Serum uric acid may be normal or low during an acute gout attack; use UA to monitor therapy but not to diagnose acute attack
Monosodium urate crystals, needle shaped, strong neg birefringence on polarizing microscopy
Ca pyrophaosphate crystals: rode shaped, rhomboid, weakly positive birefringence
Ca hydroxyapatite: cytoplasmic inclusions that are non-birefringent
Ca oxylate: bipryamidal, strongly positive birefringence; ESRD patients
Joint aspirate: WBC is 2000-60,000; <90% neutrophils; high proportion of PMN leukocytes.
Septic joint: WBC: 100,000 with >90% neutrophils
Treat: Acute attack
colchicine, NAID, glucocorticoids; chronic
probenecid or allopurinol
glucose levels fluid aspirated from a knee with gout or pseudogout would be normal.
short course of NSAID is one standard therapy for gout, another is a course of colchicine.
Colchicine, 1 tab Q 1-2 hrs until pain is controlled or side effects limit use (usual side effect is diarrhea).
Corticosteroids can provide quick relief, but should be reserved if initial therapy fails.
Allopurinol & probenecid are effective for prevention, but they can precipitate a flare.
Septic Joint:
Ankle Sprain
Most ankle sprains are the result of inversion of the plantar flexed ankle
Grade I: stretching of ATFL w/pain and swelling but no mechanical instability or functional loss
Grade II: partial tear of ATFL and stretching of CFL; more pain, swelling, bruising; moderate joint instability,
pain with weight bearing, loss of range of motion
Grade III: complete tear of ATFL and CFL with partial tear of PTFL; significant joint instability, loss of function,
inability to bear weight
Lateral ankle, and anterior talofibular ligament are most commonly injured (then CFL and PTFL)
Ottawa Ankle Rules aid decision about x-rays (adult pts, normal mental status, within 10 days of injury)
100% sensitivity in ruling out significant malleolar and midfoot fractures
Get x-ray if one of the following: >55 yrs, isolated patella tenderness; tenderness of head of fibula; inability
to flex knee to 90 degrees; inability to bear weight for 4 steps
Inversion Stress testtests CFL; translation or palpable clunk of talus on tibia suggests tear
Lachman testexcessive translation ofa ACL with no solid end point suggests tear
PRICE therapy: protection, rest, ice, compression, elevation; NSAID or acetaminophen for pain
Shoulder:
External shoulder rotationtests infraspinatus/teres minor for rotator cuff injury or tear
GU Infections
Bacterial Cystitis:
Urine culture indicated when acute bacterial cystitis is suspected and urinalysis is inconclusive
4 factors correlate with a diagnosis of acute bacterial cystitis: frequency, hematuria, dysuria, back pain.
4 factors likelihood of UTI: absent dysuria, absent back pain, history of vaginal discharge, vaginal irritation
Women with any combination of the positive & negative symptoms have a more than 90% probability of a UTI.
First treat with: voiding after intercourse, acidification of urine, discontinuing diaphragm
if this treatment doesnt workprophylaxis is indicated for women with frequent infections.
Single-dose postcoital anTbioTc. If that does not infecTons, daily single-dose antibiotic prophylaxis for 3 - 6
months. If symptoms reoccur after discontinuation, it may need to continue for 1 to 2 years.
Urethritis: gradual onset.
Pyelonephritis: fever, back pain
Interstitial cystitis
generally diagnosed through cystoscopy, based on presence of ulcerations and fissures in the bladder
Vulvovaginitis is a common cause of dysuria, but is associated with vaginal irritation or discharge.
In younger women, ask about a bladder irritant (caffeine & acidic foods are common).
treat asymptomatic bacteriuria in pregnancy; treatment not indicated for other patients
Male GU
Epididymitis:
sexually active males due to retrograde spread of prostatitis or urethral secretions through the vas deferens.
sexually active men < 35 yrsusually associated w/urethritis & caused by N.gonorrhoeae or C. trachomatis.
monogamous men > 35 more commonly due to enteric gram-neg rods (Enterobacter) assoc. w/prostatitis
Testicular torsion
emergent surgical referral, as after 12 hrs w/o treatment, only a 20% chance that the testicle can be saved.
absent cremasteric reflex (pinch or brush the inner thigh ipsilateral testicle retracts toward inguinal canal)
If pain is relieved upon elevation of the testicle when pt is supine, Prehn sign is +.
The cremasteric reflex and Prehn sign are positive in cases of epididymitis, hernias, orchitis, or cancer.
Spermatocele:
most commonly seen in 30-50-y/o men, and symptoms include frequency, urgency, and back pain.
Female GU
Candidiasis:
vaginal itch with white cheesy exudate. White plaques usually adhere to
the vaginal wall.
KOH preparation shows multiple hyphae.
Treatment consists of topical azole applications or an oral one-time dose
of fluconazole.
Recurrent yeast infections probably do not occur more frequently in
diabetic or HIV +women, but may be more difficult to eradicate in this
population
Trichomonas vaginalis:
strawberry cervix; triangular cells with long tails, slightly larger than WBC.
Bacterial Vaginosis:
Studded epithelial cells (clue cells)
treatment of choice is topical or oral metronidazole, with oral or topical
clindamycin an acceptable alternative.
Vaginitis
Trichomonas vaginalis:
Motile, flagellated trichomonads and many WBCs; thinner green-yellow discharge with fishy odor; frothy discharge with
erythematous cervix
Incubation is 3-21 days after exposure
Risks: multiple sexual partners, pregnancy, menopause
Treat: metronidazole 2g po in a single dose for patient and partner or 500mg BID x 1 week
Vulvovaginal Candidiasis:
Thick, white discharge w/o odor; pruritis, edematous, erythema; pH 4-5; KOH prep shows budding yeast or
pseudohyphase; fungal cultures not needed
Increased incidence in patients with DM, immunocompromized, hx of antibiotic use
Treat: 150 mg fluconozole single dose; or 10-14 days if complicated; do not need to treat partners unless symptomatic
Bacterial Vaginosis
Overgrowth of anaerobic bacteria and G. Vaginalis
Associated with many sexual partners, though not an STD
Thin, homogenous discharge, pH >4.5, +KOH whiff test, clue cells on wet mount prep
Treat: oral and topical metronidazole or clindamycin; treat pregnant women to decrease incidence of preterm delivery
Mucopurulent Cervictis:
50% of gonococcal infections and 70% of chlamydial infections are asymptomatic
Diagnosis: gold standard is culture of cervical discharge
Treat: 125 mg ceftriaxone IM for gonorrhea or 500 mg cipro; Doxycyline 100 mg BID x 7 days for Chlamydia or single oral
dose of azithromycin if compliance is a concern; treat partners
PID:
Lower abdominal tenderness with adnexal and cervical motion tenderness, fever, discharge, elevated sed rate and CRP
Treat: if pregnant, HIV, or severe disease, should get inpatient therapy; oral- flouroquinolone for 14 days, or ceftiraxone IM
single dose; if inpatient, give cefotetan 2g IV
Complications: tuboovarian abscess, chronic ab pain, infertility, ectopic pregnancy
Liver
most important aspect of diagnosing alcoholic liver disease is the documentation
of chronic alcohol abuse.
labs showing acute hepatocellular injury AST, ALT, LDH, and alkaline phos.
labs representing hepatic function (more suggestive of chronic disease)albumin,
bilirubin, and prothrombin time.
Bleeding from varices is the most common cause of death in cirrhotic patients.
Absolute contraindications to liver transplant portal vein thrombosis, severe
medical illness, malignancy, hepatobiliary sepsis, or lack of patient understanding.
Relative contraindications to liver transplant active alcoholism, HIV or hep B
surface antigen +, extensive previous abdominal surgery, and a lack of a personal
support system.
Alcoholic hepatitis:
disproportionate of AST compared to ALT with both values usually being < 300
IU/L.
ratio is generally greater than 2.0, a value rarely seen in other forms of liver
disease
Jaundice
childhood unconjugated hyperbilirubinemia hemolytic diseases (G6PD
deficiency & spherocytosis), Gilbert disease and Crigler-Najjar syndrome.
childhood conjugated hyperbilirubinemiaviral hepatitis is most
common; less commonwilson disease, galactosemia
Viral hepatitis accounts for up to 75% of jaundice in pts < 30, but only for
5% of jaundice in pts >60 yrs
Extrahepatic obstruction (gall stones, strictures, pancreatic cancer)
accounts for > 60% of jaundice in pts > 60 yrs.
CHF accounts for around 10% of jaundice in pts > 60, and metastatic
disease accounts for ~ 13%
obstruction suspected
do ultrasound or CT scan
If dilated bile ducts, then ERCP or PTC.
bile ducts not dilated but likelihood of obstruction is low, evaluate for
hepatocellular/cholestatic liver disease.
obstruction is still considered likely after a negative ultrasound or CT
scan, MRCP is a reasonable next option.
Jaundice
Prehepatic Jaundice: hemolysis of RBCs which overwhelms the livers ability to conjugate and clear the bilirubin; mostly unconjugaged
Posthepatic Jaundice: obstruction to the flow of bile through bile ducts; bile duct stones, strictures, tumors; conjugated
Acute onset of painless jaundice in person > 50 yrs should be worked up for pancreatic cancer
Gilbert Syndrome: unconjugated hyperbilirubinemia
Congenital reduction of conjugation of bilirubin in the liver; level will increase during illness then recover; no further work up
needed
Hemolysis: unconjugated hyperbilirubinemia; often with anemia with red cell fragments or abnormalities
Hepatitis A: fecal-oral transmission; contaminated food nad water, drugs, male-male sexual contact
Jaundice, fever, malaise, abdominal discomfort; self-limited; Incubation for 2-8 weeks; lasts 4-6 weeks
No specific treatment; just supportive care and symptomatic treatment
Vaccine available for those who are high risk
Prophylaxis for close contacts with immunoglobulin injection
Hepatitis B: transmitted via contaminated blood or body fluids;
Incubation 6 weeks 6 months; Acute symptoms are similar to hep a, but chronic hep b is highly related to the age of the patient
HBsAg is present in acute and chronic
HBeAAg are more infectious
Anti-HBs is seen in resolved infections and in those vaccinated
Anti-HBcAg IgM is diagnostic of acute infection
Measurable HBsAg with negative anti-HBcAg IgM is diagnostic of chronic Hep B
Acute Hep B is treated supportively, chronic Hep B pts may qualify for antiviral therapy
Vaccination is universally recommended
Hepatitis C: most common cause of liver disease in the US; transmission via blood or body fluid
60-85% will develop chronic infection with measurable levels of RNA
Chronic Hep C can lead to cirrhosis and hepatocellular carcinoma
Treat with antiviral therapy using ribavirin or interferon
Alcohol Abuse: leads to conjugated hyperbilirubinemia by impairing bile acid secretion and uptake
AST is elevated more than ALT
Renal
most cases of chronic renal failure are caused by DM and HTN (60%)
serum creatinine can be normal in elderly people with chronic renal
insufficiency, because they have less muscle mass.
best indicator of the presence of renal failure is the GFR.
ability to concentrate and dilute urine is retained until the GFR falls < 30%
of normal.
hypoNa, hyperK, hyperP, and metabolic acidosis (plasma bicarbonate)
occur in later stages of kidney disease.
anemia generally appears when the GFR falls below 60 mL/min.
ACE inhibitors help prevent the evolution of microalbuminuria to full
blown proteinuria.
Renal replacement therapy (transplant or dialysis) is indicated for severe
renal insufficiency (GFR <15 mL/min).
CKD higher risk for CVD; die primarily due to CVD, before reaching the
need for dialysis.
Renal Failure
First must assess volume status and see if kidneys recover with IV fluids
Stage I: GFR 90-100
Stage II: GFR 60-89
Stage III: GFR 30-59
Stage IV: GFR 15-29
Stage V: GFR <15 or dialysis
Elevated K treat with sodium polystyrene sulfonate, insulin + glucose, and retention enemas
Anemiareduced EPO
Edemalow albumin state
Hyaline castslong term damage to kidneys
Chronic renal failure: GFR < 60 for 3 or more months; decrease in nephrons and function
Is a CVD risk factor
ESRD: irreversible loss of kidney function; GFR < 15
Causes: DM, HTN, glomerulonephritis
Diagnostics:
>30 mg microalbumin per gram CR
Renal imaging and microscopic evaluation of urine
Management: hydration, treat HTN, treat infection, no NSAIDs/aminoglycosides/radiocontrast
Keep BP < 130/80; use ACE or ARB, plus beta blocker, verapamil, or diltiazem if needed
Reduce protein excretion to <500-1000 mg/d, or 60% of baseline
Restrict dietary protein to 0.8-1.0 mg/kg/day
LDL < 100, and ideally <70
Treat volume overload with Na restriction and loop diuretics
Treat metabolic acidosis with sodium bicarb to maintain concentration of 22 mEq/L
Oral phosphate binders if GFR < 25-30
May treat with EPO before developing ESRD to reduce symptoms of anemia and CVD
Hematuria
Bladder Carcinoma:
Painless hematuria without other symptoms is the most common presentation
Risks: male, smoking, aromatic amines often used in dye, paint, aluminum, textile,
and rubber industries.
Pseudohematuria: chemical agents, foods, vaginal bleeding; beets, blackberries,
certain food dyes; chloroquine, metronidazole, phenytoin, rifampin, and
sulfasalazine
Acute prostatitis and UTIs are usually associated with dysuria, fever, and urinary
frequency and urgency.
Chronic prostatitis is associated with urinary symptoms as well.
Stones are associated with pain.
<40 yrs with hematuria, but a normal IV pyelogram, urine culture and
cytologyperiodic monitoring, and reassurance
> 40 yrs w/hematuria and normal labs/pyelogramcystoscopy would be
appropriate.
<20 yrs
glomerulonephritis, UTI
20-40 yrs
UTI, stone, trauma, neoplasm
>40 yrs
bladder cancer, stone, UTI, renal carcinoma, BPH
Hematuria
asymptomatic hematuria
Edema
many medications cause peripheral edema as a side effect.
Anti-HTN (CCBs), direct vasodilators, BBs, centrally acting agents,
antisympathetics, rosiglitazone, hormones, corticosteroids, NSAIDs
Thyroid
Hashimoto Thyroiditis
-most common cause of thyroiditis, and most common cause of goiter in the US
-middle-aged women, generally presents with enlargement of thyroid, and often there is associated tenderness.
-Risk for progression: presence of thyroid autoantibodies, old age, a female gender, and a TSH level > 10 mIU/L.
-Invasive fibrous thyroiditis gradually increasing gland that is firm, but is nontender.
Hyperthyroidism:
-tachycardia is most commonly reported symptom, then fatigue, weight loss, tremor, anorexia, and increased
sweating all occur with less frequency.
-Thyroid receptor antibodies are very specific and differentiate Graves disease from other causes of
hyperthyroidism.
Hyperthyroid
Graves Disease
Symptoms: warm, moist skin, sweating, vasodilation, resting tremor, enlarged thyroid, weight loss, tachycardia, upper eyelid
retraction, ophthalmopathy, elevated BP, widened pulse-pressure
Thyroid storm: sudden release of thyroid hormone; fever, confusion, restlessness, psychoticlike behavior
Cause: IgG Abs bind to TSH receptors on thyroid glandgland hyperfunctioning; autonomous thyroid nodule may also
secrete thyroixine
Diagnosis: elevated free thyroxine, low TSH; T-99m scan shows diffuse hyperactivity with large uptake in Graves, and
patchy uptake with overall reduced activity in thyroiditis
Treat: propylthiouracil (prevents peripheral conversion)and methimazole (inhibits organification), and/or B-blockers;
radioactive iodine (ideal if not pregnant)
40% who receive radioactive iodine become hypothyroid
Medication side effect is agranulocytosis
Hypothyroidism:
lethargy, weight gain, hair loss, dry skin, slowed mentation, constipation, cold intolerance, depressed affect
May be confused with Alzheimers in older patients
Most commonly due to Hashimoto thyroiditis
Low free thyroid levels, and high TSH; secondary hypothyroidism have low TSH
Treat with thyroid hormone replacement (Levothyroxine)
Hypercalcemia
CVA/TIA
First get a brain CT without contrast, as well as blood sugar, electrolytes, renal function, drug screen
If more than 3 hrs since the attack, patient is not a candidate for thrombolytic therapy
TIA: focal neuro deficit lasting less than 24 hrs, often less than 1 hr; increased risk for subsequent stroke
Risk factors: HTN, DM, age, sex, race, heart disease, smoking, hyperlipidemia
95% are due to atherothromboembolism, cardiogenic embolism, and small vessel disease
Stroke: sudden onset of focal neuro deficit, lasting >24 hrs
MCAaphasia, contralateral hemiparesis, sensory loss, spatial neglect, contralateral impaired conjugate gaze
ACAfoot and leg deficits with cognitive and personality changes
Vertibrobasilarmotor or sensory loss in all 4 limbs, crossed signs, disconjugate gaze, nystagmus, dysarthria,
dysphagia
Cerebellumipsilateral limb ataxia and gait ataxia
Initial treatment: supplemental oxygen, cardiac monitor, cautiously treat HTN, antipyretic if febrile
Give anti-HTN if systolic >220 or diastolic >120; or, if pt is suitable for thrombolytic treatment, give anti-HTN to
reduce systolic <185 and diastolic <110; IV labetalol, nicardipine, and sodium nitroprusside are often used
Pts with non-hemorrhagic stroke should get aspirin in the first 48 hrs
Give DVT prophylaxis if not getting tPA
Pts should get rtPA if they can be treated in the first 3 hrs
Contraindications: recent surgery, trauma, MI, use of anticoagulants, uncontrolled HTN
Risk of hemorrhage is 5%
Prevention: quit smoking, reduce EtOH, treat HTN as per JNC-7 guidelines, LDL <100, tight diabetic control, aspirin
Carotid endarterectomy can reduce risk of stroke in pt with history of TIA/CVA and carotid artery stenosis; indicated if
>70% stenosis, or for symptomatic patients with 50-70% stenosis
Warfarin anticoagulation is useful for pts with a.fib, ischemic stroke caused by MI and LV thrombus,
cardiomyopathy, rheumatic mitral valve disease, prosthetic heart valves
Tremor
Parkinson Disease:
tremor is typically seen at rest and inhibited by movement
glabella tap reflex is tested by percussing the pts foreheadorbicularis
oculi muscle contracts causing both eyes to blink. The blinking normally
stops after 5 to 10 repeated taps, but persistence of blinking is called
Myerson sign and is common among patients with PD.
MAO B inhibitors (selegiline) morbidity and mortality in PD and delay
functional impairment and disease progression. Other therapies provide
symptomatic relief only, and do not modify disease progression.
Essential tremor:
bilateral, usually symmetric and either postural (elicited by holding the
arm against gravity) or kinetic (more apparent during purposeful
movement).
Intention tremor:
Its amplitude will increase during visually guided movements.
history of HTN think of multi-infarct dementia, rather than delirium (focal neurologic deficits and papilledema)
in dementia, the level of consciousness is not clouded, but disorientation may occur later in the illness.
age is the strongest risk factor. By 65, 1% meets diagnostic criteria, and the prevalence doubles every 5 years
Family hx is risk factor- individuals with a first-degree relative with the disease are 4x more at risk
other risk factors: female gender, low levels of education, CV risk factors, and a history of head trauma.
Remote memories are well-preserved initially; ability to recall new information is lost early in the illness.
ability to recognize & draw complex figures is an early sign of problems, as is loss of the ability to calculate.
Social propriety and interpersonal skills often remain strikingly preserved until late in the illness.
Structural imaging is important to rule out other causes as well and may include either a CT scan or an MRI.
MMSE, the clock drawing test, or other brief screening tools may be most useful in the diagnosis.
3 cholinesterase inhibitors for treatment: donepezil (Aricept), galantamine (Reminyl), & rivastigmine (Exelon).
Pts with advanced disease have benefit from Memantine, with or without concomitant use of an acetylcholinesterase inhibitor.
Lewy Body Dementia: begins similarly to Alzheimers, but pts develop complex visual hallucinations and spontaneous signs of
parkinsonism
Dementia
Syncope
Hct, serum creatine kinase, glucose, ECG, carotid massage,
orthostatic BP, & evaluation of pulses should be done
Additional testing Holter monitor, Echo, ambulatory loop ECG, &
tilt table testing yields a diagnosis in 5% of patients.
Tilt table testing is recommended in pts with unexplained recurrent
syncope if cardiac causes have been ruled out.
An abnormal result suggests vasovagal syncope.
Psychiatric eval should be considered if the tilt table is normal,
especially if associated with other psychiatric symptoms (anxiety,
depression, fear, or dread).
Carotid Dopplers and MRI of the brain should be reserved for
people with bruits or focal neurologic signs.
Stress testing is indicated if there is high risk for, or symptoms of,
ischemic disease.
Geriatrics
Hearing screening: 1/3rd of those >65 and of those >85 have some hearing loss; whispered voice test
Presbycusis, noise-induced hearing loss, cerumen impaction, otosclerosis, central auditory processing disorder
most common cause of hearing loss in the elderly; age related sensorineural hearing loss associated with
selective high frequency loss & difficulty with speech discrimination
Noise induced: tinnitus, difficulty w/ speech discrimination, problems hearing background noise
Otosclerosis: autosomal dominant; progressive conductive hearing loss
CAPD: difficulty understanding spoken language but may be able to hear sounds well
25% of patients > 65 have impairments in IADL or ADLs
IADLs: transportation, shopping, cooking, telephone, managing $, taking meds, cleaning, laundry
ADLs: bathing, dressing, eating, transferring from bed to chair, continence, toileting
Vision screening: Snellen chart or Jaeger card is most sensitive and specific screening
Vision loss: presbyopia, macular degeneration, glaucoma, cataract, diabetic retinopathy
Age related macular degeneration is the leading cause of severe vision loss in elders; atrophy of cells in central
macular region of retinal pigment epithelium, resulting in loss of central vision
Cataract disease: most common cause of blindness worldwide
Fall Assessment: leading cause of nonfatal injury
Cognitive screening: prevalence of dementia doubles every 5 yrs after 60 Clock draw and three item recall
Depression screening: two question screen
Nutrition screening: serial weight measurements and inquiry about changing appetite
HTN screening: heart and CV disease are leading causes of death; thiazides are drugs of choice
Stroke prevention: stroke incidence doubles with each 10 yrs; greatest risks are HTN and a.fib
Cancer screening: colon and breast cancer screening until life expectancy is below 5-10 yrs
Osteoporosis screening: CaCO3 and Vit D reduce osteoporotic fractures; DEXA scan if >65
Immunizations: >65 get annual influenza & 1 pneumococcal shot; booster of tetanus & diphtheria shot; Zoster
HIV/AIDS
HIV
Health care workers should be tested for HIV ASAP after needle stick and therapy should be
initiated using at least 2 meds to which the source would unlikely be resistant.
window period of several weeks - 4 months between infection and seroconversion when tests may
be negative.
During this time, pts may be viremic & infectious, but not have sufficient levels of antibodies to
result in + tests.
If there is strong clinical suspicion, plasma HIV RNA should be ordered.
More HIV infected women die of cervical cancer than from AIDS
Pap testing every 6 months.
In HIV-infected individuals, 5 mm is considered a positive test.
Prophylaxis against MAC should be instituted once CD4 count drops < 75 to 100 lymphocytes/mm
Prophylaxis against PCP should be considered once CD4 count drops < 200 lymphocytes/mm 3.
Prophylaxis for fungal disease, herpes simplex and zoster is not generally done.
CMV prophylaxis can be instituted in those with CMV IgG positivity and with CD4 counts < 50
lymphocytes/mm 3, but it is generally not done because ganciclovir (the primary prophylactic
agent) can cause neutropenia.
PCP: treatment of choice is TMPSMX for 3 weeks.
corticosteroids improve course of pts with moderate to severe PCP with O2 sat < 90% or a PaO 2 <
65 mm Hg.
Ethics
Emancipation: person younger than 18 petitions
to be declared a legal adult
Live apart from parents, self-sufficient, married,
pregnant or a parent, in the military, declared so by
judicial system
Growth Charts
concern should be raised when a child drops > 2 %ile brackets on a growth curve and does not
maintain at that area.
In the US, the majority of FTT is 2ndary to inadequate nutrition & a dietary history is most likely to
reveal the cause.
Albumin has a long half-life and is a poor indicator of recent undernutrition.
Prealbumin is in acute inammaTon and undernutrition and is therefore insensitive.
Organic disease, including hypothyroidism, is found in < 10% of cases of FTT.
IgA levels are sensitive to undernutrition and would be in FTT.
FTT + diarrhea and recurrent respiratory infectionscystic fibrosis must be considered
FTT + wet burps/emesis/cough get esophageal pH probe.
FTT + diarrhea or melenainflammatory bowel disease may be considered, and a hemoccult test
would be necessary.
FTT + diarrhea, ab pain, foul-smelling stoolslactose intolerance may be considered; lactose
tolerance test
FTT + projectile vomiting, ab distention, palpable masspyloric stenosis; get ultrasound
familial short stature growth curve shows simultaneous changes in height and weight.
FTT & constitutional growth delayweight rst, then height.
hypothyroidismheight velocity slows first and may plateau before weight changes.
breast-fed infantsweight relaTve to peers aZer 4 to 6 months, but catches up aZer 12 months.
Hospital admission is indicated for FTT if: hypotension, bradycardia, severe malnutrition.
FTT: weigh below 3rd-5th %, or deceleration of growth across 2 major growth %iles in short time
All states require PKU and congenital hypothyroidism screening
Lead screening: once at 9-12 mo and once at age 2
Begin to measure blood pressure at age 3
Car seat rear facing until 20 lbs & 1 yr old; forward facing seat 20-40 lbs; booster seat until 4 ft/60
lbs
Developmental Milestones:
1 mo: reacts to pain, responds to noise, regards human face; eye contact
2 mo: eyes to midline, head prone, vocalizes, social smile, recognizes parent
4 mo: eyes past midline, rolls over, laughs/squeals, regards hand
6 mo: sits unsupported, transfers objects, rolls prone to supine, babbles, recognizes strangers
9 mo: pincer grasp (10), crawl, cruises, mama/dada, bye-bye, starts to explore
12 mo: walks, throws, 1-3 words, 1 step command, stranger/separation anxiety
2 yr: walk up/down stairs, copies line, runs, kicks ball, 2-3 word phrases, understood speech, refers to self
by name, pronouns, parallel play
3 yr: copies circle, tricycle, 3 numbers, sentences, understood, 3 colors, group play, play simple games,
knows gender, knows first and last name
4 yrs: body parts, copies cross/square, hops, throws overhand, completely understood, uses past tense, tells
a story, social interaction
5 yrs: copies triangle, catches ball, dresses self, writes name, count 10 objects
6 yrs: draws person, ties shoes, skips, identifies left and right
Antalgic gait: when stance phase of gait is shortened, usually because of pain during weight bearing
SCFE: most common nontraumatic hip pathology in adolescents; separation of growth plate with
the femoral head being posteriorly displaced; treat by surgically pinning the femoral head
Common in obese adolescent males
Pain with internal rotation of the hip; obligate external rotation on passive flexion
Septic Arthritis: monoarticular and associated with systemic signs; children lay with their hip
flexed, abducted, and externally rotated; joint must be aspirated; GBS, staph aureus, strep
pyogenes; purulent aspirate with WBC > 50,000
Toddlers Fracture: spiral fracture of the tibia that results from twisting while the foot is planted;
tibial tenderness and normal knee and upper leg
Congenital dysplasia of the hip: painless limp from the time the child learns to walk
Transient synovitis: self limited, often after a viral infection; low grade or no fever; normal WBC,
normal ESR; pain with internal rotation of the hip and overall ROM limited by pain; yellow-clear
aspirate with WBC < 10,000
Legg-Calve-Perthes: avascular necrosis of the femoral head in children 4-8; more common in boys;
gradual onset of hip, thigh, or knee pain and limping; collapse, flattening, and widening of the
femoral head; treatment is conservative; high risk of developing degenerative arthritis
Roseola:
HHV6, infects most children before age 3; fever and mild respiratory symptoms that last for 5 days, followed by an
erythematous maculopapular rash that suddenly appears; rash disappears in 1-2 days and no treatment is usually
necessary
Varicella:
fever and rash which develops in clusters; exanthema is often papules or vesicles on an erythematous base; dewdrops on
a rose petal; vesicles progress to shallow, crusted erosions; confirmed with Tzanck smear or DNA probe; antiviral therapy
may shorten disease course if given within 72 hrs of onset
Erythema Infectiousum:
parvovirus B19/fifth disease: infects children under 10 yrs in the winter and spring; rash starts as confluent erythematous
macules on the face and spares the nose and periorbital regions; slapped cheek appearance; rash lasts 2-4 days followed
by lacy pruritis exanthema on the trunk and extremities lasting 1-2 weeks; may be given to fetus during pregnancy,
resulting in hydrops
Group A Beta-Hemolytic Strep:
can cause strep pharyngitis, rheumatic fever, glomerulonephritis; rash of scarlet fever starts 2 days after onset of sore
throat; rash is punctuate, raised, erythematous eruptions that feel like sandpaper; rash starts on upper trunk and spreads
to the rest of the trunk and extremities; strawberry tongue is common; rash fades and desquamation occurs 4-5 days
after the first appearance of rash; confirm infection with rapid antigen testing or culture and treat with PCN
Neisseria Meningitidis:
high fever, hypotension, altered mental status, meningeal irritation; rash often starts as an erythematous maculopapular
eruption that progress to form petechiae; prophylaxis for close contacts with rifampin
Rocky mountain spotted fever:
acute, life-threatening infection caused by rickettsia rickettsii, transmitted by tick; acute fever, headache, myalgia, fatigue;
the classic exanthema is a macular, popular or petechial eruption that starts on the wrists and ankles; low WBCs, low
platelets, elevated liver enzymes; treat with doxycycline
Lyme Disease:
erythema migrans develops 3-30 days after infection; expanding erythematous macule with a central clearing looking like
a bullys eye; treat with oral doxycycline
Childhood Enuresis
spontaneous nocturnal voiding into bed/clothes at least 2x/week for 3 consecutive months in a
child who is at least 5 yr
Primary monosymptomatic enuresis: bed-wetting w/o history of nocturnal continence & no other
symptoms.
cause is unknownfelt to be due to producTon of nocturnal ADH.
associated with a maturational delay; 25% of 5-year-olds are enuretic.
Family history is important1 parent enuretic, 40% likelihood child will be. If both parents, 70%
risk.
Enuresis alarms have been shown to be an effective treatment for nocturnal enuresis.
Frequent nighttime wakening may be effective, but compliance is a barrier to effectiveness.
DDAVP can also be effective, but relapse rate is high once the medication is discontinued.
Secondary monosymptomatic enuresis: recurrence of bed-wetting after at least 6 months of
nocturnal continence.
Non-monosymptomatic: bed-wetting associated w/urgency, frequency, straining, pain, chronic
constipation, encopresis
Breast Changes
Breast Disease
Breast cancer risks: family hx of breast cancer, early age menarche, late age menopause, nulliparity, first birth after age 30,
HRT use, obesity, physical inactivity, EtOH use
Palpation of a new breast mass should prompt a FNA
Clear, yellow or green fluid that results in complete resolution is diagnostic of a benign cyst and pt can follow up in 4-6
wks to evaluate for recurrence of the lesion
Bloody fluid, a mass that doesnt resolve, or a lesion that recurs requires more evaluation;
Diagnostic mammography is the next test
Ultrasound can be used to determine if the lesion is solid or fluid filled and can assist with aspirating cystic lesions
Masses found to be solid or complex should be biopsied
Core needle biopsies are done using ultrasound or mammographic guidance
Breast pain: not a common presentation of breast cancer
Cyclic mastalgia: diffuse, bilateral and related to menstrual cycle
Noncyclic mastalgia: unilateral and more common in postmenopausal
Nonmammary pain: pain not from the breast, but usually from the chest wall
Life style changes such as smoking cessation, caffeine elimination, stress reduction, primrose oil will help with breast
pain; severe pain can be treated with danazol
Nipple Discharge: usually benign; discharge that is spontaneous, persistent, bloody, from a single duct, associated with a
mass, is more likely to represent a pathologic process
Most common non-benign causes are intraductal papilloma, duct ectasia, cancer, infection
Pt should get mammogram
Treatment of most unilateral, spontaneous or bloody nipple discharge is surgical excision of the terminal duct involved
Galactorrhea: hypothyroidism, hyperprolactinemia, pituitary adenoma, medications, pregnancy
Normal menstruation: estrogen production by the ovaries is regulated by the hypothalamus and pituitary; estrogen builds up
the endometrial lining; after ovulation, the corpus luteum produces progesterone, which compacts the endometerium; if
conception does not occur, the production of progesterone abruptly decreases, resulting in sloughing of endometrium
Amenorrhea: absence of menstrual bleeding for 6 or more months w/o pregnancy
Menometororrhagia: heavy menstrual flow or prolonged duration of flow at irregular intervals
Abnormal bleeding with irregular cycles is known as dysfunctional uterine bleeding and implies an abnormality with
the hypothalamic-pituitary-ovarian axis
This is more common shortly after menarche and only require watchful waiting at that time
Continuous estrogen stimulation can lead to endometrial hyperplasia and carcinoma which may present as irregular
uterine bleeding
Menorrhagia: excessive menstrual flow, or prolonged duration >7 days at regular intervals
Ovulation is occurring
Leiomyomata (fibroids) are a common cause of this problem
If volume of menstrual bleeding is reduced but there is regular ovulation, think about asherman syndrome, which is
scarring of the uterine cavity caused by trauma from uterine curettage
Metrorrhagia: bleeding occurring at irregular intervals
Poly/oligo menorrhea: cycles < 21 or >35 days apart, respectively
PCOS clinical picture: obese, hirsute woman with ongoing weight gain and irregular menses
Insulin resistance and androgen excess with anovulatory menstrual cycles
Can induce menstruation by giving progesterone or OCPs
Treat with lifestyle modification- diet, exercise, weight loss
Endometrial Cancer: risk factors are a history of anovulation, obesity, nulliparity, over age 35, use of tamoxifen, or
unopposed exogenous estrogen
Work up: transvaginal ultrasound, endometrial biopsy; hysteroscopy with D and C can be therapeutic
If the work up for abnormal bleeding does not reveal malignancy, anovulatory bleeding is usually responsive to treatment
with OCPs or progestin
No menses at 16 in presence of normal secondary sex characteristics; no menses at 14 in the absence of secondary sex traits
usually the result of a genetic or anatomic abnormality (gonadal dysgenesis, Turner syndrome)
amenorrhea + testosterone & DHEA-S CT of adrenal glands & ultrasound of ovaries to rule out neoplasm.
Primary amenorrhea w/normal secondary sex characteristics & normal initial labs progestin challenge test.
-inadequate GnRH stimulation; history of head trauma, shock, infiltrative processes, pituitary adenoma, or craniopharyngioma.
Polycystic ovarian syndrome:
-androgen excess, and symptoms include irregular or absent menses, hirsutism, acne, and virilization
Constitutional delay of puberty: common in boys; uncommon in girls, clinically very hard to distinguish from other more common causes.
Secondary Amenorrhea:
Polycystic ovarian syndrome is common and is responsible for ~ 30% of the cases of secondary amenorrhea.
Anovulatory Bleeding:
caused by continuous unopposed endometrial estrogen stimulation; progesterone from the corpus luteum is not secreted
most common cause of dysfunctional uterine bleeding in women < 20, accounting for ~ 95% of cases.
Postmenopausal Bleeding: needs an endometrial biopsy to rule out endometrial cancer.
ASCUS repeat in 4 - 6 months & 1 year, HPV testing, or colposcopy. If the HPV
testing is negative, the pt is low risk for cancer, and Pap can be repeated in 1 year.
ASCUS + HPV testing is positive colposcopy (if over 33 yrs) or wait for infection
to clear (if under 33 yrs)
ASCUS, HPV testing unavailable colopscopy or repeat the Pap smear in 4 -6 mo.
If repeat Pap has results of ASCUS or higher, a colposcopy should be performed.
If the repeat is normal, Pap should be repeated again in 4-6 mo. If next repeat Pap
is negative, frequency of testing can return to normal.
If you perform a colposcopy and no CIN is found, Pap should be repeated in 12 mo
and the frequency of testing can return to normal.
If patient is postmenopausal and not taking estrogen, Pap can be repeated 1 wk
after a course of vaginal estrogen (4 wks). If the smear remains abnormal,
colposcopy can be considered.
ASCUS, favoring LSILcolposcopy.
atypical glandular cells (AGUS) colposcopy, or endometrial biopsy if the atypical
cells are of endometrial origin
Pelvic Pain
Ovarian cysts:
unilateral dull pain that can become diffuse and severe if the cyst ruptures.
smooth mobile adnexal mass with peritoneal signs if the cyst ruptures.
PID:
fever, vaginal discharge, dysuria; gradual in onset and bilateral.
Treatment should provide coverage for N.gonorrhoeae, C.trachomatis, anaerobes, and enteric
gram-neg rods ceftriaxone 250 mg IM + doxycycline 100 mg BID for 14 days with or w/o
metronidazole 500 mg BID for 14 days.
Inpatient treatment w/parenteral antibiotics for pregnant women, pts with severe illness with fever
& vomiting, and where surgical emergencies cant be ruled out; may be necessary for those who
fail outpatient regimen
Ectopic pregnancy:
pain is colicky, and may radiate to the shoulder if there is a significant hemoperitoneum.
Nausea, a symptom of pregnancy, is a diagnostic clue.
Ovarian Mass
80 % of ovarian masses in girls < 15 years are malignant.
any adnexal mass should be evaluated by transvaginal ultrasound and referral for surgical removal.
In many women of childbearing years, adnexal masses are commonly cysts.
If the pain is not acute or recurrent, palpable cysts < 6 cm may be monitored with repeat pelvic
exam.
OCPs
may cause small in BP; risk with age. Once disconTnued, BP usually returns to normal within 3 months.
androgenic (hair growth, male pattern baldness, nausea) & estrogenic (nausea, breast tenderness, fluid retention).
Weight gain is thought to be common, but multiple studies have failed to show it to be statistically significant
side effect most cited as the reason for stopping use is irregular bleedingcommon in first 3 mo
3x risk of venous thromboembolism.
protective effect against ovarian cancer and endometrial cancer.
If an active pill is missed, and no intercourse has occurred in 5 days, 2 pills should be taken immediately & a
backup method used for 7 days. If intercourse occurred in the previous 5 days, emergency contraception should
be used immediately & pills restarted the following day. A backup method should be used for 5 days.
Progestin-only pills:
ovulation suppression, cervical mucus thickening, endometrium alteration, & tubal transport inhibition.
effectiveness of this method is dependent on consistency of use.
no hormone-free period with these pills, and they should be taken every day.
do not risk for thromboembolism, and the WHO has reported this to be safe for women with a history of
VTE, PE, DM, obesity, or HTN.
Nursing women can use this pill, but there is FDA approval for use in others as well.
OCPs containing estrogen and progestin components are contraindicated in smokers > 35 yrs, because of risk of
thromboembolic events.
An intravaginal ring or transdermal patch that releases estrogen & progestin is contraindicated in smokers > 35
Women who use IUDs are at higher risk for acquiring a STD and developing PID as compared to women who use
barrier or other hormonal birth control methods, and patients should be screened carefully
Contraceptives
Hormonal contraceptives
Contraindicated if >35 and a smoker, thromboembolic disease, cerebral vascular disease, coronary occlusion,
impaired liver function, breast cancer, abnormal vaginal bleeding, congenital hyperlipidemia
OCPs offer significant protection against ovarian cancer, endometrial cancer, Fe deficiency anemia, PID, and
fibrocystic breast disease
Minipill reduces cervical mucus and causes it to thicken
Emergency Contraception
should be used within 72 hrs of intercourse, well
before implantation (5-7 days after intercourse).
limited hormonal exposure, and have not been
shown to increase the risk of VTE, stroke, or MI.
no medical contraindications
do not disrupt an already implanted pregnancy
and do not cause birth defects.
Progestin ECPs prevent 85% of expected
pregnancies, and combined ECPs prevent 75%
L&D
ROM: visualize fluid, pH >6.5 in vaginal fluid on Nitrazine paper, ferning on air-dried microscope slide
First stage of labor: onset of labor until cervix is completely dilated
Latent phase- contractions become stronger, longer lasting more coordinated
Active phase- starts at 3-4 cm of cervical dilation and goes at 1.2-1.5 cm / hr
Second Stage of labor: from complete cervical dilation until delivery of the fetus
Normally lasts less than 2 hrs in nulliparous, and <1 hr in parous
Third stage of labor: after delivery of baby and ends with delivery of the placenta; <30 minutes
Progress of labor is determined by: Power, passenger, pelvis
Fetal Heart Rate: normal is 110-160
Bradycardia: maternal hypothermia, meds, heart block, fetal distress
Tachycardia: maternal fever
Acceleration: increase in HR >15 beats/min for >15 sec reassuring
Deceleration: early coincides with contraction/increased vagal tone by compression of the fetal head; late
decels are after contractions and show uteroplacental insufficiency/maternal hypotension, epidural
anesthesia, oxytocin, HTN, DM; variable decels are due to umbilical cord compression during contractions
Cardinal Movements: Flexion, Internal Rotation, extension, external rotation
Variability:
Decreased in sleep, CNS depressants, neuro abnormality, prematurity, acidemia
GBS:
Penicillin in labor; alternatives- ampicilin, cephalothin, erythromycin, clindamycin, vancomycin
Prenatal Care
First prenatal visit: CBC, HBsAg, HIV, RPR, UA, UC, rubella, blood type, Rh, Pap, GC/Chlam
Naegeles rule: subtract 3 mo and add 7 days to first day of LMP
Follow-up visits every 4 weeks until 28 wks, then every 2 weeks from 28-36 wks, then every week
Ultrasound not required if uncomplicated; accurate within 1 wks in 1st tri; 2 wks in 2nd tri; 3 wks in 3rd
Radiation exposure: risk for baby only if >5 rads (dental xray is 0.00017 rads)
Folic acid: low risk women should take 500 micrograms; 1mg if high risk; 4mg if previous child with NTD
Use methyldopa and CCB to treat HTN; avoid ACE, ARB, thiazide in first 2 trimesters
Trisomy screening: ideally between 16-18 wks
Triple screen: 65% sen; 95% sp- tests hCG, estriol, AFP
Quadruple screen: adds inhibin; 80% sen
Amniocentesis: 15 weeks; 0.5% risk of spontaneous abortion
CVS: 10-12 wks; 1-1.5% risk of spontaneous abortion; may be associated with limb defects
Gestational DM: screen at 24-28 wks with 1hr glucose challenge
If >135, do 3 hr GTT
28 weeks: repeat RPR, Hb/Hct, give RhoGAM if necessary
GBS: screen at 35-37 wks via swab of lower vagina, perineal area, rectum
Give intrapartum Abx if positive, or if previously positive in past pregnancy
Flu and tetanus toxoid can be given during pregnancy; varicella and rubella not during pregnancy
Assumption of Fetal Maturity
Heart tones documented for 20 wks by nonelectonic fetoscope, or 30 wks by Doppler
36 wks since positive bHCG
US measurement of crown rump length at 6-11 wks supports gestational age of 39 wks
US at 12-20 wks confirms gestational age of 39 wks
Postpartum Care
Psych
PTSD
Antidepressants can ameliorate symptoms; sertraline & paroxetine have FDA indications for treatment.
Alprazolam can be used, but there is significant concern for dependency problems.
Anorexia + Bulemia:
Both disorders involve self-evaluation that is unduly influenced by body weight and/or shape.
binge eating or purging are characteristics of bulimia; there is a binge eating/purging subtype of anorexia
Both bulimics and binge eating/purging subtypes of anorexics may use diuretics, enemas, and laxatives.
bulimics sense a lack of control over eating during binging; anorexics often feel a strong sense of control.
ADHD:
In adults, ADHD may be more subtle, and symptoms may changeDeficits in executive function tend to be more salient (poor
organization or time management) and hyperactivity may be replaced by restlessness.
hyperactivity and impulsivity tend to peak between the ages of 6 and 10, inattention remains relatively stable through the lifespan of
the illness.
Hyperactivity is the most problematic feature for children with ADHD because it tends to be most disruptive and socially unacceptable.
treating ADHD in adolescents actually the risk of substance abuse when compared to children not treated.
Oppositional behavior and conduct disorders may be comorbid, but are not necessarily features of ADHD.
Nefazodone should not be used in patients with liver disease.
Hypertension is a relative contraindication to venlafaxine.
Patients experiencing hypersomnia and motor retardation should avoid nefazodone and mirtazapine.
Patients who report agitation and insomnia should avoid bupropion and venlafaxine.
Mirtazapine and tricyclic antidepressants are less preferred for patients with obesity.
Bupropion is contraindicated for patients with seizure disorder.
Depression
At least 5 of the following for a 2 week period: depressed mood/loss of interest or pleasure plus:
weight change, sleep change, psychomotor change, fatigue/loss of energy, worthlessness,
decreased concentration, suicidal thoughts
Causes clinically significant distress or impairment of functioning; not due to another cause
Also consider- hypothyroidism, anemia, EtOH, sedatives, narcotics, cocaine, steroids
Depressed pts with CVD have a greater chance of dying of a heart attack
Treat: pharmacotherapy with psychotherapy is most effective
SSRI: increase serotonin by blocking presynaptic reuptake; takes 4-6 weeks before therapy works;
side effects are sexual dysfunction, weight gain, GI disturbance, fatigue, agitation
SNRI: act on serotonin at low doses and NE at high doses; second line if SSRIs fail
TCA: affect reuptake of NE and serotonin; side effects of sedation, dry mouth, dry eyes, urinary
retention, weight gain, sexual disturbance, potentially fatal in overdose
MAOIs: increase serotonin and NE released during nerve stimulation; need tyramine restricted diet
to avoid hypertensive crisis
Buproprion: contraindicated in seizure disorder or eating disorders; no sexual side effects
Trazodone: side effect of priapism; good to use as a sleep aid
Elevated GGT is shown to be more sensitive than an elevated MCV, ALT, or AST.
specificity is low; it is in nonEtOH liver disease, DM, pancreatitis, hyperthyroidism, HF, & anticonvulsant use.
ratio of AST:ALT may help distinguish between alcohol and nonalcoholrelated liver diseases
Ethyl glucuronide (EtG) urine test detects recent EtOH consumption, but says nothing about the level of
consumption or abuse. Its value is in the monitoring of those patients who are committed to abstinence.
An MCV is 96% specic for alcohol abuse with a 63% predicTve value.
Naltrexone: helpful for both opiate addiction and alcohol addiction; saturates opiate receptor sites and leaves
them unavailable for opiate attachment.
For EtOH abuse, naltrexone works by the reinforcing eect of EtOH (not allowing pts to become drunk)
Disulfiram: negative reaction to ingested alcohol, regardless of the form; flushing, nausea, and vomiting; alcohol in
cough medicines, mouthwashes, and other forms must be avoided
Acamprosat: most effective at reducing EtOH relapse.; affects both GABA and glutamine neurotransmission with
greater and longer lasting effects than naltrexone
Cocaine:
cocaine withdrawal extreme fatigue and significant depression. Relapse is common during the crash
Opiates:
withdrawal is not life-threatening in otherwise healthy adults, but can cause severe discomfort.
Restlessness & irritability occur later, with bone pain, nausea, diarrhea, abdominal cramping, and mood lability.
Smoking
Family Violence
physical violence, sexual, intimidation, emotional,
psychological, economic control, isolation from others
Look for numerous bruises of varying ages,
metaphyseal corner fractures, cigarette burns
Do a full x-ray bone scan and ophthalmologic exam
All elder and child abuse must be reported.
Child abuse not reported by a physician is a crime
A spiral fracture of the tibia is known as a toddlers
fracture and is a common injury
(low yield)
Medications with high first pass hepatic clearance may be
particularly susceptible to adverse events caused by alterations
in hepatic metabolism
CYP1A2: induced by tobacco; drugs that depend on 1A2 are
theophylline and imipramine
CYP2C9, 2D6, 2C19 have evidence of genetic polymorphism and
different individuals have different rates of metabolism
2E1: alcohol effects this isoenzyme; can produce a hepatotoxic
metabolite of acetaminophen
Probenecid decreases renal excretion of penicillin, resulting in
an increased level and therapeutic effect
Creatinine clearance: (140 age ) x (ideal body weight in kg) (
0.85 for women) / 72 x serum creatinine