Family Medicine Shelf Review

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) • Most commonly reported hepatitis virus; always acute; fecal-oral • Early fecal shedding and less infectious once jaundiced Hepatitis B: • likelihood of transmission ↑with the level of HBV DNA in the serum • treat infant of a Hep B+ mom with Hep B Ig within 12 hrs of birth + vaccination (prevents 90% of infection) • all mothers should be screened for hepatitis B surface antigen • If Hep status of mother is unknown give baby vaccine and test mom; if mom is +, give baby Ig within 7 days. • adult at risk for Hep B immunize for Hep B if not immunized – sexually active persons with > 1 partner in the last 6 mo, persons seeking evaluation/treatment for a STD, current/recent IVDU, MSM, health care and public safety workers exposed to blood or body fluids, ESRD, HIV, chronic liver disease. • immunizations for an adult: 1 injection at time 0, another 1 - 2 mo later, a 3rd injection 4 - 6 mo after the 2nd • IgM anti-HBc early infection. • HBeAg replication. • anti-HBs exposure with immunity, recovery phase, or vaccination. • HBsAg either chronic infection or early infection. Hep C: • 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 doesn’t ↓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.

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. 4 .Varicella • immunization recommended for adults who have not had evidence of infection or immunization. regardless of age. the case is mild. with the exception of health care workers and pregnant women. and is not contagious. • 2 doses of vaccine are required.8 wks apart. should not be given before 12 mo • testing is not necessary in those with uncertain immunity. people receiving the vaccine may develop infection. . • US-born before 1980 are considered immune. • Rarely (1%).

Tdap: • tetanus-diphtheria 5-component acellular pertussis (Tdap) is recommended for adults 19 . 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 .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.

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 .

• If the patient is currently pregnant and nonimmune. inadvertent vaccination is not an indication for therapeutic abortion. she should be vaccinated early in the postpartum period .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.

• College students and military recruits are at risk . with a booster dose at age 16. • 2 doses of MCV4 are recommended for adolescents 11 through 18 years of age: the first dose at 11 or 12 years of age.Meningitis • Meningitis vaccination is indicated for those with functional asplenia or travelers to endemic areas.

immunodeficiency. and 12 to 15 months . functional asplenia. • pneumococcal polysaccharide vaccination if >65 yrs or <65 with chronic medical conditions – 2nd 5 yr revaccination in pts w/CKD. asplenia • PCV13: for infants and toddlers at 2. liver disease. residents of long-term care facilities.Pneumococcus • PPSV23: adult vaccination indications: chronic diseases. 4. 6.

attenuated influenza vaccine (LAIV) is 2 yrs – Do not give to immune-compromized or those around them • administer 2 doses (separated by 4 wks) to children 6 mo . • 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. or who were vaccinated for the 1st time during the previous influenza season. not for pregnant or immunocompromised adults • Inactivated is for everyone > 6 mo except those with egg allergies .Influenza • Vaccination is 30% . but only received 1 dose • Intranasal influenza should only be used in healthy adults < 50 and kids > 2 yrs.90% effective in preventing influenza or complications from influenza.8 yrs who are receiving the seasonal vaccine for the first time.

the vaccine should be given before a female becomes sexually active. • It is not recommended for use during pregnancy.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. • It can be administered when a patient has an abnormal Pap test or when a woman is breast-feeding. • People sexually active w/many partners should be immunized if they meet criteria • To be most effective. . • It can also be given when a patient is immunocompromised because of a disease or medication.

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 .

for the shelf exam.Lung Cancer • no screening improves mortality and no screening is recommended • Same true for many other cancers and illnesses. it probably doesn’t exist or isn’t used . if you haven’t heard of the screening tool.

Colorectal Cancer • screen with FOBT. or at 50. whichever is sooner • Recommend against screening > 85 yrs . screen 10 yrs before cancer was found in the family member. sigmoidoscopy. or colonoscopy in adults beginning at age 50 and continuing until age 75 • if family history.

and second degree relatives. – A combination of breast and ovarian cancer among first. – A first-degree relative with bilateral breast cancer. significant # of additional imaging procedures & biopsies were performed for women performing BSE recommend against the performance of BSE for women at average risk for breast cancer. – A male relative with breast cancer. 1 of whom was diagnosed when < age of 50.Breast Cancer • • • • • • • • Mammographic screening has been shown to ↓mortality from breast cancer.or second-degree relative with both breast and ovarian cancer at any age. . – A combo of 3 or more 1st or 2nd relatives w/breast cancer regardless of age at diagnosis. Screening before age 50 should be individualized. – A combo of 2 or more 1st or 2nd relatives w/ovarian cancer. – Ashkenazi Jewish women should be offered testing if any 1st relative (or 2 2nd degree on the same side) are diagnosed with breast or ovarian cancer. and take into account risks & preferences Do not do a mammogram if <30 yrs (do ultrasound) Biopsy all palpable masses in women >40 Persistent mass or bloody fluid after FNA excisional biopsy women between the age of 50 . High risk criteria: – 2 first-degree relatives with breast cancer. regardless of age at diagnosis – A first.74 should get screening mammograms every 2 years.

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

. if they are not at increased risk. whether or not they are pregnant. • The USPSTF recommends against routinely providing screening for chlamydial infection in women ages 25 and older.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 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 .

arterial thrombosis) – adverse reactions to anesthesia – gastrointestinal (ulcer disease. – require looking at the patients’ functional capacity to determine level of preoperative cardiac testing. respiratory failure) baseline CXR not indicated for surgery pts – thrombosis (peripheral venous thromboembolism. and sepsis) – cardiac (MI. ileus. decompensated CHF. superficial dermatologic surgery. or severe valvular disease. significant arrhythmias. – high anticipated blood loss and include aortic or peripheral vascular surgery. – Recent coronary revascularization is a risk for poor perioperative outcomes.Pre-op Evaluation • Potential surgical complications: – infectious (wound infections. and renal insufficiency. and include unstable coronary syndromes. atelectasis. cardiac arrest. High-risk procedures: risk of cardiac death greater than 5%. intrathoracic and intraperitoneal. noninvasive testing is recommended. cataract surgery. pneumonia. urinary tract infections. head and neck. bacterial endocarditis. a prior MI. and endoscopy. – In a patient with poor functional capacity. – generally do not require additional cardiac preoperative testing. stop smoking 8 weeks pre-op • • • • • . Guidelines for preoperative cardiac evaluation: – If a patient has no known heart disease. and prostate surgeries. – Intermediate clinical predictors: mild angina. pre-op evaluation of coronary arteries is necessary Discontinue NSAIDs/Aspirin 1 wk prior to surgery. exacerbation of existing psychiatric disease). – People with clinically important CAD should defer noncardiac procedures until 6 mo after revascularization – If surgery is necessary within 6 mo of revascularization. orthopedic. Moderate-risk procedures: risk of cardiac death between 1% and 5% – carotid endarterectomies. – Major clinical predictors require coronary artery evaluation prior to surgery. and complications of CHF) Most likely to be lethal – pulmonary (pneumonia. the evaluator should look at clinical predictors for heart disease. Low-risk procedures: risk of cardiac death less than 1% – breast surgery. hyperemesis) – psychologic (delirium. bronchitis. pulmonary edema. compensated CHF. DM.

Don’t memorize this .

colitis. Coli. pelvic thrombophlebitis Orthopedic surgery surgical site infection Neurosurgery meningitis. sulfa. PE >1 month: blood transfusion.000 BUN >15 Systemic manifestation such as chills and rigors Fever in first 24 hrs: preexisting infection. intraperitoneal leak. Klebsiella. Staph Epi. pseudomonas. vascular graft. pelvic abscess. bacteremia. MI. Ca accumulation in skeletal muscle leading to rigidity. gout. Wound (SSI). Wind (pneumonia). catheter-related infection. PE. and Dantrolene IV UTI risks: BPH. surgical trauma. give antipyretics.Post-Op Fever • • • • • • Five Ws: Water (UTI). Wonder drugs (drug fever) Drug Fever: resolution occurs with discontinuation of suspected drug. p. urethral catheter UTI bugs: E. soft tissue infection. B-lactams. after exposure to halothane or succinylcholine. device-related. device-related. DT. catheter-related. TSS. meds. abscess. metabolic acidosis. DVT – Atelectasis causes 90% of pulmonary complications of surgery – Suspect aspiration pneumonia in the elderly 1-4 weeks: SSI. spinal anesthesia. EtOH withdrawal. pneumonia. blood products. Walk (DVT). and amphotericin B Malignant hyperthermia: fever > 104. preexisting infection. heparin. 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. tachycardia. organ transplant-related. oxygen. Proteus. thrombophlebitis. pancreatitis. cooling blankets. meds. DVT • • • • • • • • • . malignant hyperthermia – Soft tissue wound infection often due to beta hemolytic strep or clostridium 1 day – 1 week fever: UTI. SSI. SSI. infective endocarditis. postpericardiotomy syndrome Cardiothoracic surgery pleural effusion Abdominal surgery ab abscess and pancreatitis OBGYN surgery endometritis.

• Cholera and typhus are not required immunizations for travelers. • Next most common: URI.70% of travelers. but who will be traveling to an area where polio is endemic. • A single inactivated polio vaccine (IPV) booster is recommended for adult travelers who have had primary polio immunization. • CDC does not recommend antibiotic chemoprophylaxis for diarrhea • Heart disease is the most common cause of death while traveling. • Yellow fever is the only legally required immunization (only for some countries).Travel Medicine • Traveler’s diarrhea is most common illness – 30% . malaria. viral syndromes. parasitic infections. • Hep A is the most common vaccine-preventable illness acquired by travelers. hepatitis. . and other more rare infections. but vaccination is not required. – 2nd most common (~ 25%) is accidents. skin conditions.

Equations: KNOW THEM
• 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 C

No Disease B D

Positive Test Negative Test

A

Read p. 296-302 in Step Up to Step 2 or the Biostat/Ethics chapter in whatever book you have

Alternative Medicine (+ random facts)
• • • • • • Gingko biloba - dementia Garlic - prevention of heart disease St. John’s wort - depression Saw palmetto - BPH Bee pollen - ↑energy, studies do not clearly indicate benefit. EtOH guidelines:
– nonpregnant women: no > 7/week, and no > 3/one occasion. – Men: no > 14/week and no > 4/one occasion. – patients > 65, no >1 drink/day.

• Atropine can decrease secretions and help the “death rattle.” • Ketorolac may help pain, lorazepam may help restlessness, haloperidol and thorazine may help agitation and hallucinations, both of which are also symptoms of impending death.

and face. – lesion is well-demarcated and annular with central clearing. arthritis.5% malathion lotion. & 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. then a hemorrhagic bulla with surrounding erythema and induration. Scabies: Sarcoptes scabiei burrow into intertriginous areas. If treatment fails second-line is 0. treated with streptomycin intramuscularly.Insect and Animal Bites • • 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 lesion—erythema chronicum migrans – early disseminated: lymphadenopahty. Tularemia: pain and ulceration at the bite site. and scaling of the periphery. Head lice: erythematous popular rash and nits on the hair follicles. hands. Tinea corporis: spread by close person-to-person contact (as in school wrestling). erythema. Fleas: bite the lower extremities. wrists. ankles. confirms diagnosis Bedbugs: infest unclothed areas—the neck. occur in clusters • • • • • • • • • • . Brown recluse spider: local pain and itching. Black widow: mild prick followed by pain at the bite site. – Ceftriaxone or cefotaxime and chloramphenicol are options. itching begins ~ 2 to 3 weeks after infestation – Treat: premethrin 1% and lindane. or areas where clothing is tight next to the skin -treat: oral ivermectin Chigger bites: linear pattern over wrists. – scraping the lesion and visualizing hyphae with microscopic examination. and legs. musculoskeletal pain.

antihistamine. – often produces infection with P multocida.3-0. anaerobs. observe in the hospital for 12-24 hrs Animal Bites: clean local wound with soap and water.scrap or brush off. eilenella. heomophilus.5 mL of 1:1000 epinephrine quickly and repeat in 10-15 minutes if needed. strep. 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. pasturella – Humans carry: staph. irrigate with saline. rapid removal is key Local reactions occur almost immediately and last for a few hours – Treat with ice. Local reactions occur as a result of toxic properties of venom. anaerobes . were as severe reactions are caused by allergic reaction to venom allergens Stingers should be removed promptly. – amoxicillin/clavulanic acid is treatment of choice if not hospitalized (5 days prevention.Insect and Animal Bites • • • • • • • • Cat Bite: hospitalization unless very superficial and does not appear infected. 10 days to treat) – Clindamycin + floroquinolone if allergic to penicillin. Bite wounds on the hands should never be closed primarily. 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.

Common Chronic Conditions
• KNOW THESE

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: destrucƟon of insulin producing pancreaƟc β cells; point mutaƟon 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 fats ketones DKA 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 syndrome blood 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
• Diabetic diagnostic criteria: – 2 Random glucose > 200 with classic symptoms (polydipsia, polyuria, polyphagia, frequent infections, weight loss) (easy but low specificity) – 2 Fasting glucose >125 – 2 hr plasma glucose >200 after 75 g glucose load (costly and time consuming) – HGA1c is now used as a diagnostic tool • 6.5 and above is considered diabetic • 5.7-6.4 is considered pre-diabetic – 1-hr GTT is used for pregnant women, with 3-hr GTT being used for those that are + – Urinalyses are highly specific, but have low sensitivity. – Fasting glucose is more accurate and is generally recommended. – C-peptide should be low in Type I DM – Other tests: fasting lipids, serum creatinine, UA, urine microalbumin:creatinine ratios, dilated eye exam, regular foot exams, EKG, TSH Treatment goals: HGA1c <6.5%, fasting blood sugar < 120, 2 hr post-prandial sugar <140; BP <130/80, LDL <70 (old recommendation said <100); pts should be immunized with pneumococcal vaccine and annual influenza

can ↓ Hb A 1C by 0. or CHF. tendency to gain weight & lose effectiveness over time. occurring in about 3% to 4 %. and slow onset of action. 3-5 hr duration Regular: short acting 30-50 min onset. reduces insulin levels. weight gain. 18-24 hr duration Glargine/Detemir: long acting 1 hr onset. 24 hr duration 40% . may have slight increase in LDL. 10% weight loss is a goal for most Metformin: – ↓glucose output during liver gluconeogenesis. remaining 50% . taken no more than 2 hr before meals because of rapid onset – useful if blood sugars vary at mealƟme. 5-8 hr duration NPH: intermediate 1-3 hr onset. 2% ↓in HGA1c. require 12 weeks to become fully effective – ↓insulin resistance and sensiƟze peripheral Ɵssues to insulin. risk of hypoglycemia. can lower HGA1c 1. Meglitinides: – short acting secretagogues that increase insulin secretion. – can ↓ HbA 1C by 1 . risk for hypoglycemia Thiazolidinediones: improve insulin sensitivity in muscle and adipose tissue. good choice for those with insulin insensiƟvity.Diabetes Management • • • • • • • Lispro/Aspart: rapid acting 15 min onset.5-2%. Other side effects include anemia & weight gain.5). 60-120 min peak. but postprandial sugars are high – should not be used in pts with hepatic dysfunction but safe in renal failure • • • . can ↓the insulin dosage by 30% . potentially helps wt loss. decrease in TG and increase in HDL. based on a preprandial glucose Diet and exercise: key components of type II DM treatment. – can be used as monotherapy. no peak. contraindicated in nursing mothers Sulfonylureas: insulin secreatagogues that sƟmulate beta cells in the pancreas to secrete insulin. 30-90 min peak. no potential for hypoglycemia. reduces TGs and LDL.50% of daily insulin should be Lantus. 7-15 hr peak. hepatic insufficiency. popular first line drug – side effects: renal insufficiency (contraindicated if Cr >1. – Edema is a common side effect. decrease hepatic gluconeogenesis and increased peripheral glucose utilization. with insulin or in combination with metformin.50%.5% -2% and are most valuable if fasting sugar is adequate. metabolized by the liver. improves insulin sensitivity in liver & muscle.60% is Lispro before each meal.2 %.

• ACE inhibitors are first choice for BP control indicated for DM pts with systolic BP > 100 mm Hg. • -GLP-1 – gut-derived incretin hormone that stimulates insulin & suppresses glucagon secretion. – ↓ risk of coronary events and are excellent in ↓LDL. the decrease is enough to get patients to goal.Diabetes Management & Complications Alpha glucosidase inhibitors – delay carb absorption by inhibiting alpha glucosidase in the small intestine which decreases postprandial hyperglycemia. and the condiƟon worsens with ↑Hb A 1C levels. or macro/macroalbuminuria despite maximal therapy. though K should be monitored as creatinine rises. – less effect on the triglyceride levels. contraindicated in ketoacidosis and hepaƟc disorders. They can ↑triglyceride levels and are generally not used in diabeƟcs. Diabetic retinopathy: • leading cause of blindness in the United States. • Bile acid resins sequester bile acids in the GI tract. and reduces appetite and food intake. – Providers do not need to wait to see microalbuminuria prior to initiating therapy. avoid if creatinine > 2. • Lifestyle changes: glucose control. • Glycemic control is dependent on the total caloric intake. but may ↑insulin resistance • Fibric acid derivaƟves ↓triglycerides and ↑HDL. ↑HDL.0 mg/dL. • Statins are drug of choice in treating hyperlipidemia in diabetes. • mild background abnormalities ↑vascular permeability & hemorrhage Proliferative changes • . Renal complications: • first indicaƟon of renal compromise is an ↑in GFR followed by microalbuminuria. but have minimal effects on LDL. and ↓LDL. can ↓the Hb A 1C by 0. weight loss. side effects are GI related. delays gastric emptying. but in many patients. • ACE inhibitors have been shown to ↓ESRD and death by 41% in DM.7% to 1%. • Niacin will ↓triglycerides. • risk ↑with length of Ɵme pt has had DM. not the type of calorie taken in. and decreased protein intake can help • Nephrology referral is indicated if creatinine is ↑. – can be used irrespective of creatinine 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 .

the total and LDL cholesterol each ↓. high HDL is considered a negative risk • For pts with known CAD or DM treatment goal for LDL cholesterol is <70 mg/dL. or triglycerides • AdopƟng an exercise program ↑HDL by up to 15 points. VLDL. • losing weight. HDL varies little • low HDL is the best predictor of an adverse outcome. • Smoking cessation increases HDL by 5 to 10 mg/dL. female <65). • EaƟng oat bran and decreasing life stress can ↓LDL.20% LDL treatment goal should be < 130 mg/dL. • If the risk is < 10% treatment goal should be < 160 mg/dL.10 points. age (>45 men. but does not affect LDL.Dyslipidemia 5 factors that determine LDL goal: smoking. • TG level is lowest in the fasƟng state and ↑by an ~ 50 mg/dL postprandially. >55 women). However. • If the risk is between 10% . • For a pt has no known CAD. but is not likely to ↑HDL. total & LDL cholesterol are ↑when fasƟng. a person can expect to ↑HDL by 5 . low HDL. 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. 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 • . • As TG level ↑. HTN. family history of premature CHD (male <55.

.

severe gout. and mortality of all causes. myalgia. some decrease in LDL and TGs. When added to a low-dose statin. severe hepatic disease • • • • . decrease LDL. decreased mortality – Side effects: flushing. colesevelam – Decrease LDL. macrolids. diarrhea – Contraindications: hepatic insufficiency/active liver disease Statins: – rosuvastatin is best at lowering LDL (25-50%). hepatotoxicity. cyclosporine. increase HDL. gallstones. decrease TGs – Side effects: dyspepsia. constipation. coronary events. upper GI distress. colestipol. hyperuricemia. hyperglycemia. decreasing secretion of triglycerides by the liver. myopathy – Contraindications: severe renal disease. Cholesterol absorption Blocker: Ezetemibe (Zetia): – ↓cholesterol by interfering with the absorpƟon of cholesterol in the gut. NSAIDs block flushing – Contraindications: liver disease. strokes. mild decrease in TGs – first line therapy to reduce LDL. PUD Fibric Acids: Gemfibrozil.Dyslipidemia Treatment • • Fish oil: – high in omega-3 Fas and has been shown to be beneficial in lowering cholesterol. no change in TG – Side effects = GI distress. – ↓LDL and TGs only modestly. fenofibrate. some increase in HDL and some decrease in TG – Side effects = myopathy. ↓LDL as much as the max statin dose – Side effects: abdominal pain. caution with DM. antifungals Bile acid sequestrants: cholestyramine. must monitor liver enzymes – Decrease LDL. increased liver enzymes – Contraindicated in liver disease or with other p450 inhibitors. cardiac death. decreased absorption – Contraindicated in dysbetalipoproteinemia or if TG > 400 Nicotinic acids: niacin – Increase HDL. clofibrate – Increase HDL.

ARB. aldosterone antagonist Post-MI: ACE. CCB. diuretic. diuretic. aldosterone antagonist CKD: ACE. Hct. ARB.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 • • • • Initial testing: electrolytes. EKG Treatment goal: <140/90. ARB CVA prevention: ACE. no more than 2 EtOH drinks per day. UA. BB. BB High risk for CAD: ACE. Ca. diuretic . and <130/80 for those with DM or kidney disease Lifestyle Modifications: DASH diet (high K and high Ca). weight reduction Medication: thiazide diuretic is first line therapy in most settings – – – – – – DM: ACE. increased physical activity. CCB CHF: ACE. diuretic. BB. BB.

persons who are > 55 years or black. coarctation of aorta HTN in arms. β-blocker. ARB. renal artery stenosis ACE-inhibitor renal scan or renal MRA would evaluate this. but is low or normal in the legs. British Hypertension Society developed recommendations: persons < 55 years who are not black start an ACE inhibitor as first-line therapy (A). but are no longer considered ideal first-line therapy.HTN • • • • • • Weight reduction is most beneficial – systolic BP can ↓from up to 20 mm Hg for each 10 lb of weight lost. β-Blockers (B) can be used in this group. Dietary Na reducƟon. PROGRESS study found that ACEI and diuretic in combo are effective in preventing recurrent stroke. or CCB. • • • • • . ↑exercise and moderaƟon of EtOH can lower systolic BP < 10 mm Hg. not based on level of BP. Stage 2 hypertension: – 2-drug therapy is indicated most common is thiazide diuretic + ACE inhibitor. A DASH diet can ↓BP between 8 . low-dose diuretics are most effective first-line treatment for preventing CV morbidity & mortality. the first-line therapy is either a CCB (C) or a diuretic (D). Femoral pulsations are weak or absent.14 mm Hg. Correction should be considered if the gradient is > 20 mm Hg.

but significant regain of wt once off Roux-en-Y gastric bypass.9 Overweight: 25-29. • Phentermine: noradrenergic agonist that allows its users to lose 3 to 4 kg > placebo.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 >. • 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 2.5-24. elevated BP.8% wt loss. • 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. but a significant regain after discontinued.9 in men or >. • Medications do not demonstrate maintenance of weight loss once the discontinued.9 Obesity II: 35-39. or >35 kg/m 2 if there are obesity-related comorbidities present. dyslipidemia.85 in women • Dietary restriction. 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.9 – Obesity I: 30-34. • Orlistat is a GI lipase inhibitor & boasts a 9% average weight loss.5 Normal 18.Obesity – Underweight <18. and impaired fasting glucose • Waist > 102 cm in men. • Sibutramine: mixed noradrenergic/serotonergic agonist w/5. >88 cm in women • Triglycerides >150 • HDL <40 in men and <50 in women • BP >130/85 • Fasting glucose >110 . • procedure can result in up to 50% loss of the initial weight in some studies. but regain is also common. physical activity. Metabolic Syndrome: insulin resistance characterized by abdominal obesity.

• Hyperthyroidism is a common cause of accelerated bone loss. • Vitamin D increases absorption of calcium in the GI tract. • Weight-bearing acƟvity is known to ↓bone loss. -1 to -2. Primary osteoporosis • deterioration of bone mass not associated w/other chronic illnesses or problems. • Calcitonin directly inhibits osteoclastic bone resorption and is considered a reasonable treatment alternative for pts in whom estrogen replacement therapy is not recommended. ibandronate. or 60 if high risk • Plain radiographs are not sensiƟve enough to diagnose osteoporosis unƟl total density has ↓by 50%.5 standard deviaƟons below the mean (a score of −2. tobacco. • African Americans are less at risk than Caucasians or Asians.5 or lower) indicates osteoporosis. • DEXA scanning is most precise and is the test of choice. estrogen. • Estrogen and selective estrogen receptor modulators (raloxifene or Evista) block the activity of cytokines. risedronate.5 = osteoporosis. but does not result in the formation of normal bone.Osteoporsis • poor acquisition of bone mass or accelerated bone loss. imaging studies are diagnostic • Increased risk with age. PTH. low body weight. raloxifene . • Fluoride stimulates osteoblasts. Caucasian or Asian. calcitonin. weight bearing exercise • Treatments: bisphosphonates.5 = osteopenia • A T-score > 2. as long as the person is not sedentary. low Ca.: T-score <-2. alendronate. • Obesity is considered to be protecƟve because of ↑estrogen producƟon. also produces an analgesic effect • Bisphosphonates work by binding to the bone surface and inhibiting osteoclastic activity. • Osteoporosis: supplement 1200 mg Ca and 400-800 IU vit D daily. family hx. sedentary lifestyle • Dexa scan after age 65.

– Sideroblastic anemia: MCV would be normal. MCV < 80 microcytic Hemolysis decreased haptoglobin. increased LDH. – Prophylaxis for pain crises involves ensuring adequate oxygenation and hydration. high. treatment is parenteral vitamin B 12 replacement weekly for 1 month. B12 def: anemia. – Chronic analgesics and scheduled transfusions have not been shown to reduce pain crises. pallor. • • • . fatigue. Mediterranean. – found before age 6 in 90% of patients. increased unconjugated bilirubin microcytic: Fe deficiency. – thalassemia: RDW would be normal because the red cells are uniformly small. or low. wt loss. daily prophylaxis with penicillin until age 5. glossitis. neuro symptoms.Anemia • • • • Most common is Fe deficiency (Fe is absorbed in duodenum) MCV > 80 macrocytic. usually. with acute pain crises as most common presentation. – Immunize against streptococcal infection. anemia of chronic disease. – Increased methylmalonic acid and homocysteine Folate Def: increased homocysteine Sickle Cell: AR trait seen in African. but the red cells are dimorphic. or Asian heritage. sideroblastic anemias. – Iron deficiency: RDW would be ↑due to variaƟon in cell size. often with concurrent administration of folic acid. thalassemia.

Overflow incontinence: • overdistention of the bladder. not a urinary tract problem Stress incontinence • loss of urine associated with ↑intra-abdominal pressure(sneezing. • Pseudoephedrine has been shown to help stress incontinence. laughing. exercising).Urinary Incontinence • Symptomatic bacteruria may cause incontinence in the elderly • CCBs urinary retention. paralysis. • Hyperglycemia secondary incontinence because of polyuria • α-Blockers urethral sphincter relaxation and can cause urinary leakage • Stool impaction causative in up to 10% of pts with incontinence. but usually not leakage. disimpaction may restore continence. • detrusor hyperactivity strong urge followed by an involuntary loss of urine. dementia). • β-Blockers inhibit bladder relaxation and therefore can cause both urinary leakage and urgency. disk disease) or because of outlet obstruction (prostatic enlargement). usually due to neurogenic bladder (longstanding diabetes. but occasionally a large amount of urine is lost without warning. • 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. A postvoid residual > 200 mL = inadequate bladder emptying . Urge Incontinence: • most common type of incontinence in the elderly. loss of the ability to empty the bladder. alcoholism. • postvoid residual < 50 mL = normal. more common in women • caused by urethral hypermobility resulting in weakness of the pelvic floor musculature (Q tip test) • Kegel exercises are designed to strengthen the pelvic floor musculature. • frequent or constant leakage of small amount. • Diuretics ↑frequency and urgency. coughing.

Premature ejaculation is the most common sexual dysfunction in men. . -if low. making it an effective treatment option. PRL -if FSH and LH are low. Testosterone levels should be checked in the morning. when they peak. Dyspareunia refers to genital pain associated with intercourse. diagnosis is pituitary or hypothalamic failure -if FSH and LH are high. LH. as it measures bioavailable testosterone. A penile brachial index can be performed to evaluate for significant vascular disease in patients with ED. but PRL normal. and PRL normal. Sexual aversion disorder is an extreme aversion to and avoidance of genital contact with a sexual partner.Sexual Dysfunction • • • • • • • • • • • • • • • • • • In pts with ↓sex drive with no other complaints and no exam findings. TCA & SSRIs sexual dysfunction. but growing evidence does suggest androgen deficiency may play a role in some women. Free testosterone is a more accurate measure of androgen status. assessment of hormone status is indicated. Sexual arousal disorder refers to the inability to maintain an adequate physiologic sexual excitement response. affecting about 29% of the general population. nocturnal penile tumescence evaluation would be done to eliminate psychologic factors that inhibit arousal hypoactive sexual desire disorder Most commonly. workup should continue to get FSH. Fluoxetine raises the threshold for orgasm. this is a result of relationship problems. diagnosis is testicular failure Prolactin (PRL) -if FSH and LH are low and PRL is high. 40% chance of pituitary adenoma get CT or MRI The TSH and prolactin levels may be indicated in the presence of other complaints or physical findings. Bupropion actually ↓the orgasm threshold and is least likely to cause sexual dysfunction.

Cluster Headache: • Unilateral and orbital/temporal • Deep. . excruciating pain for min-hours. • trial of NSAIDs may be appropriate.Headache Red Flag signs: • onset aŌer age 50. Either photophobia or phonophobia may be present. ↑in severity or frequency. • pericranial muscle tenderness with bilateral bandlike distribution of pain • episodes last from 30 min to several days. and headaches should occur < 15 times per month. and lithium. Bilateral. lithium. methysergide and prednisone may be used for prophylaxis • SQ or intranasal serotonin antagonists have been more efficacious. • requires at least 2 of the following : Pressure/tightness. or a headache after trauma. as has prednisone. There is generally no nausea. • The mainstay of abortive treatment is oxygen and triptans • Verapamil. divalproex. focal neuro symptoms (except those consistent with a visual aura). but not both. signs of systemic disease. Mild to moderate. Not aggravated by activity. papilledema. peaks in 10-15 minutes and lasts 2 hrs w/o treatment • Associated with ipsilateral autonomic signs • More common in men • therapy is to provide relief from acute attacks. then to suppress headaches during the symptomatic period • Nifedipine has been shown to be effective. indomethacin. with follow-up if there is no improvement. sudden onset. IV or IM ergotamine has been helpful Tension Headaches: • most common of all headaches encountered in clinical practice.

worsening with activity. and are effective. Verapamil is the only CCB that studies show to have a prophylactic effect. increasing in severity and frequency. propranolol. photophobia. multiple attacks lasting for 4 hrs to 3 days. risk factors for HIV or cancer. post head trauma Prevention: amitriptyline. Abortive/Acute therapy: if attacks are less than 2-4 times/month Ergotamines and triptans goal of prophylactic migraine therapy is to reduce the frequency of headache by 50% use TCAs • • • • • • • • • . systemic illness signs. after age 50. focal neuro signs. divalproex sodium β-blockers are the most studied drug therapy. most frequent Classic migraine: headache with aura Need neuroimaging if rapidly increasing headache frequency. papilledema.Migraine Headache • • moderate to severe headache with a pulsating quality Signs/Symptoms: unilateral location. absence of history or physical exam findings that would cause headache Common migraine: headache without aura. phonophobia. focal neuro symptoms. lack of coordination. nausea and/or vomiting. awakened from sleep with headache Red Flag signs: sudden onset. timolol.

Acute viral respiratory tract infections cause up to 50% of wheezing episodes in children < 2 years – Risk factors: fall or winter season. • PFTs may be needed. and most are also caused by viruses as well. but is not diagnosed after one episode of wheezing. daycare. Asthma: • In pts with known asthma a CXR is indicated if pt has fever. • Treatment should begin with diuresis. but is important. glucose intolerance. . Pneumonia causes 33% . rhonchi. or sputum to r/o pneumonia.Wheezing • • • • • • first episode of wheezing get a chest x-ray. • Peak flows do not confirm diagnosis of asthma. and smoking. Asthma is common in children. especially in preterm infants. and passive smoke exposure. – Risk factors include HTN. Bronchiolitis causes < 5% of episodes of wheezing. but are usually done in a pulmonary laboratory. gold standard test is a 24-hour pH probe. GERD – – common cause of wheezing in the pediatric population.50% of wheezing children. Wheezing is commonly heard in patients with CHF. history of atopy. but are useful to monitor the status of known lung disease.

Night-time symptoms occur > 2x a month Moderate persistent: daily symptoms & use of short-acting inhaler. • Long-acting β-agonists do not impact airway inflammation and should not be used without a corticosteroid. • 50% . not diagnostic. with exacerbations that affect activity and may last for days. Cough is the only symptom in cough-variant asthma. with frequent exacerbations and night-time symptoms. and not all wheezing is asthma. sometimes affect usual activity. • Peak flow measurements parallel FEV 1 and are an easy and inexpensive way to monitor asthma control. or use additional medication). PFT is confirmatory. as life-threatening bronchospasm may occur. . Obesity is increasingly being recognized as a risk factor. most important component in the diagnosis of asthma is history. but should be used cautiously.100% of the pts personal best are in the “green zone. use of empiric antibiotics is not recommended.80% of personal best are “yellow zone. • A leukotriene receptor antagonist is a “second best” choice.” and indicate that the patient is doing well. and with night-time symptoms < 2x a month are classified as Mild persistent: symptoms > 2x a week but < 1x a day. Treatment: • Inhaled corticosteroids are preferred first-line agents for all pts with persistent asthma.” and are a warning to consider a step-up in therapy (review of medication technique. with brief exacerbations. However. • < 50% of the personal best are an indicator that the patient needs immediate medical attention. but not all asthma includes wheezing. Mild intermittent: symptoms < 2x a week. Night-time symptoms occur at least weekly. CXR is useful to rule-out other causes. Pts typically have recurrent episodes of wheezing. Severe persistent: continual symptoms that limit physical activities. but the strongest identified predisposing factor for its development is atopy. adherence. improves lung function and rescue inhaler use • Inhaled corticosteroids and leukotriene antagonists have replaced cromolyn in current asthma therapy. Provocative testing for the rare pt in whom the diagnosis is in question. • infections predispose to acute asthma exacerbations. and environmental control. • 80% .Asthma • • • • • • genetic component.

and COPD is not a steroid responsive disease. age. but no evidence exists to support their use chronically. only drug therapy shown to improve COPD progression is supplemental O2 in those patients that are hypoxemic. • . ciprofloxacin. ↓hospitalizaƟons. Theophylline is a fourth-line therapy for pts who do not achieve adequate symptom control oxygen is not indicated until there is significant evidence of hypoxemia. and height. assess the disease severity. Inhaled corticosteroids alone should not be first-line because pts receive more benefit from bronchodilators. – improve outcomes when treating acute exacerbations – azithromycin. Benefits of O2: longer survival. exercise tolerance.COPD • • • • • • • • • • • • sensitive measure to diagnose COPD is the FEV 1:FVC ratio. Antibiotics can be useful to treat infection & exacerbation. bonchodilators offer improvement in symptoms. and amoxicillin-clavulanate were found to be most effective spirometry is necessary to make the diagnosis. and beƩer quality of life. and overall health status most commonly prescribed bronchodilators are anticholinergic ipratripium bromide and beta agonists Ipratropium is preferred as first-line because of longer duration and absence of sympathomimetic effects. – normal if it is 70% or more of the predicted value based on the pts gender. Bronchodilators do not alter the course of decline in function. most important intervention in smokers with COPD is to encourage smoking cessation. and monitor response to treatment.

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. flattened diaphragms on xray – CXR is normal until the disease is advanced – Primary diagnosis made by spirometry: FEV1/FVC < 0. PaO2 <55). distant heart sounds. alpha-1 antitrypsin deficiency – Baseline cough with white mucus. pneumococcal and influenza vaccination – Stage I: mild FEV1 >80%. give short acting bronchodilator (albuterol and ipratropium) – Stage II: moderate. give antibiotics • Pneumococcus. PFTs never return to normal. episodic exacerbations with return to normal function COPD: presents midlife or later. lung hyperinflation. may or may not be associated with smoking. inhaled steroids reduce the frequency of exacerbations – Stage IV: very severe: FEV1<30% or <50% with hypoxemia (SaO2 <88%. worsening dyspnea – Barrel chest. caterrhalis. occupational exposures. M. FEV 1 30-50%. long smoking history. give long acting bronchodilator (salmeterol and tiotropium) – Stage III: severe: FEV1 30-50%.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. slowly progressive. Klebsiella. – Smoking associated with 90% of COPD cases – Non smoking causes = passive smoking. H. influenze.COPD • • Asthma: presents earlier. Pseudomonas • • • • .

regardless of duration of the cough. nitrofurantoin cause cough Centrally acting cough suppresant codine. those who are very ill-appearing. and viral URI. . Amoxicillin & amoxicillin/clavulanate not effective. Acute bronchitis: – antibiotics are not indicated for uncomplicated acute bronchitis. or the elderly. and GERD acute: asthma exacerbation. pollutants). amiodarone. or azithromycin x 5 days. – first-line is erythromycin x 14 days. postnasal drainage. sinusitis with postnasal drip. smoking. irritants (smoke. dextromethrophan Chronic Bronchitis: – productive cough for at least 3 mo of the year for at least 2 consecutive years – most common cause of chronic cough in smokers. allergic rhinitis. Antibiotics should be reserved for pts with significant COPD and CHF.Cough • • • • • • • >8 wks = chronic common causes of chronic cough: asthma. acute bronchitis. ACEI. • Pertussis: – Antibiotics do not alter the course unless initiated early in the illness. aspiration. uncomplicated pneumonia. antibiotics do prevent transmission and ↓ need for respiratory isolaƟon from 4 wks to 1 wk and are therefore recommended.

Tramadol: centrally acting synthetic opioid agonist that binds to μ-opioid receptors & inhibits serotonin & norepinepherine reuptake. NSAIDs are an excellent first-line medication for mild to moderate pain. . TCAs like amitriptyline & anticonvulsants like gabapentin may work well in neuropathic pain. ↑sensiƟvity (hyperesthesia). In situations of tolerance. starting at half the equivalent dose of the alternative med. It should not be a first-line option. switch from one opioid to another. continued escalating opioid doses worsened analgesic response because NMDA receptors are upregulated and lead to tolerance. but is not first-line except in elderly or pts who failed NSAIDs. Neuropathic pain is from sustained transmission of pain signals w/o ongoing tissue damage. pins & needles (paresthesia). affects ~ 15% of the US population. Nociceptive pain stems from tissue damage (such as arthritis and/or tumor). while pain receptors become increasingly more sensitive to stimuli. or severe from innocuous stimuli (allodynia). especially w/ an inflammatory component Celecoxib (COX-2 inhibitor) may have better side effects. they are less well-studied in nociceptive pain and therefore are not good first-line agents. It is described as numbness (hypoesthesia).Pain • • • • • • • • • Chronic pain recurrent or persistent pain lasting > 3 months.

• Chronic fatigue syndrome & chronic idiopathic fatigue are distinct diagnoses that require > 6 months of symptoms. lack of sleep. • Depression is 1 of the most common diagnoses in pts w/fatigue. especially when denying weakness/hypersomnolence . endocrine imbalances. fatigue. and adenopathy. • 3 general categories of fatigue: physiologic. physical. or a defined physical stressor like pregnancy. up to 100% may develop rash • Fatigue </= 1 month is likely the result of a physical cause (infection. meds) • fatigue > 3 months is more likely related to psychologic factors (depression. anxiety. – symptoms of sore throat. or adjustment reactions). • Physiologic fatigue is because of overwork. CV disease. stress. anemia. – If given ampicillin (and other penicillin derivatives). fever.Fatigue • Mononucleosis: often mistaken for streptococcal pharyngitis. and psychologic.

• For sleep maintenance problems.Sleep • Propranolol is known to cause nightmares • Hydrochlorothiazide can cause nocturia that inhibits sleep. control sleep environment. • Good sleep hygiene: – wake up at a regular hour. zaleplon (Sonata) may be used. and may help with sleep onset. but not maintenance. • Melatonin has been shown to help with adjustments to the sleep-wake cycle (ie. and allows people to fall asleep. exercise daily (not before bed). • drugs of choice for transient sleep onset problems are zolpidem (Ambien) or eszopiclone (Lunesta). get out of bed if not asleep in 15-30 min . shift work). • Benadryl can cause excessive somnolence. but interferes with the ability to stay asleep. go to bed when sleepy. jet lag. limit/eliminate EtOH. caffeine & nicotine. use bed for sleep & intimacy only. light snack before bed. • Alcohol causes excessive wakefulness.

but will focus more on risk factors/prevention/follow-up .Acute Conditions • These questions will be similar to your internal medicine questions.

Cholecystitis: • Sudden cessation of inspiration during deep palpation of RUQ is Murphy sign suggests acute cholecystitis Choledocolithiasis: • ERCP is the gold standard for diagnosis and treatment of choledocholithiasis • usually performed in the setting of an acute cholecystitis with increased liver enzymes. • Gallstones cause the majority of cases .Acute GI conditions Appendicitis: • Pain from an acute appendicitis usually starts in the periumbilical region before moving to the RLQ. LDH > 350 IU/L.30% are idiopathic. glucose > 200 mg/dL. medications. • These are assessed during the first 48 hours of admission. • Ranson’s criteria assess the severity and prognosis of pancreatitis. EtOH causes ~30% of the cases. AST is > 250 U/L. amylase. base deficit > 4 mEq/L. BUN ↑> 5 Ca < 8. PaO 2 < 60 mm Hg. Pancreatitis: • generally settles in the mid-epigastric region with radiation to the back and is associated with nausea and vomiting. and a fluid sequestration > 6 L. 5 criteria are considered. WBC > 16. hyperlipidemia. infections. • Only 22% of elderly patients with appendicitis present with classic symptoms. – age > 55. or lipase. trauma. On admission. and instrumentation (ERCP). making the diagnosis more difficult. • 6 other criteria reflect the development of complicaƟons and include a ↓in Hct > 10.000/mm. Gallstones: • Gallbladder pain is typically in the epigastric or right upper quadrant and radiates to the scapula. 10 . . • Less common causes: hyperCa.

Pylori Gastritis: H2 blocker/PPI Dysmotility: metoclopramide Non-ulcer dyspepsia: avoid food/meals that aggravate . Cipro Bleeding generally stops on its own • • • • H.Acute GI Conditions • Diverticulitis: – – – – – CT abdomen is test of choice f/u with colonoscopy 6-8 wk after symptoms clear Meperidine for pian relief Outpt abx: amox/Clav. Pylori Gastritis: clarithro/amoxi/metronidazole + PPI Non H. TMP-SMX.

PUD management: CBC. GI bleeding. ab U/S. liver enzymes. pain a few hours after eating. EKG. progressive dysphagia. recurrent vomiting. chest xray. NSAIDs. personal or family history of PUD symptoms: epigastric pain improved with food. lipase. Pylori: corkscrew shaped gram negative bacillus causing most non-NSAID related ulcers – Associated with gastric cancer – Test for H. with use of NSAIDs the second most common H.pylori. pregnancy test Patients older than 50 with blood in the stool should undergo colonoscopy regardless of upper endoscopic findings • • • • • . family hx of cancer GERD is midepigastric and generally does not radiate. smoking. begin empiric therapy with PPI for 4-8 wks – Treatment: PPI + clarithromycin + amoxicillin Early endoscopy should be considered for pts with new-onset dyspepsia who are older than 55 yrs or who have symptoms that may be associated with upper GI malignancy – Alarm symptoms: weight loss.Peptic Ulcer Disease • • • • risk factors: H. Reflux can be appropriately diagnosed by medical history and by evaluating the response to treatment. gradual onset. amylase. Pylori by urea breath test or stool antigen testing – Serologic testing is very sensitive but cannot distinguish between active and treated infection – For those who test negative for H. nocturnal symptoms Infection with H pylori is the leading cause of PUD. Pylori.

alosetron for diarrhea • • Esophagus: Esophageal spasm is often referred higher in the chest. alternating. melena. diarrhea.GI Conditions IBS: • constipation. or (3) onset is associated with a change in the form or appearance of stool. Renal Calculi: Pain from renal calculi often radiates to the shoulder. . low dose TCAs. and pain that is characterized by 2 of the following 3: (1) relieved by defecation. particularly in LLQ. anemia. intermittent cramping. tegaserod for constipation. may have mucus. increased fiver intake. weight loss. loperamide to reduce frequency of stools. may feel bloated • Rome Consensus Committee for IBS – symptoms for at least 12 wks (not necessarily consecutive) in the previous 12 months. lower ab pain. SSRI if depression or anxiety is present. (2) onset is associated with a change in stool frequency. hematochezia. • Alarm features: fever. family history of colon cancer or IBD • Treat: antispasmodics (dicyclomine. bloody diarrhea. homoscyamine).

Viral gastroenteritis: • Norwalk virus. and occasionally a palpable olive mass in the epigastric area. uremia. nausea. vomiting. • Symptoms begin acutely and are associated with typical viral syndrome symptoms. ↑ICP (meningiƟs or space-occupying lesions) nausea after eating Gastroparesis and pancreatitis Cholelithiasis nausea. and may cause dizziness and headache. followed by the acute onset of distension. CBC is likely normal • Elevated ALT is more suggestive of gallstone pancreatitis and is less likely when alcohol or hypertriglyceridemia • acute onset of significant nausea. Psychogenic vomiting: suspected in pts who are able to maintain adequate nutrition despite chronic symptoms. vomiting.Nausea and Vomiting • • • • • • • • • Metoclopramide improve gastric motility. • elevated serum amylase and lipase. EtOH withdrawal. dehydration. Pancreatitis • likely due to gallstones or EtOH. seen during social stress or in pts with a past history of a psychiatric disorder. • usually identified before 7 weeks of age. and will resolve within 5 days. vomiting. Vestibular disorders nausea without any clear association with meals or time of day. ileus mild pain. and epigastric pain. • self-limited. • Oral rehydration is indicated as long as there are no signs of severe dehydration. RUQ ultrasound to identify stones in the gallbladder. can also cause diarrhea and extrapyramidal reactions phenothiazines (Compazine and Phenergan) cause drowsiness. Zofran is a serotonin receptor antagonist. and adenoviruses are common causes. reoviruses. and pain after eating fatty foods. and are improved when the patient does not eat. hyperactive bowel sounds nausea before eating in AM pregnancy. • symptoms occur after eating. . dry mouth. and dizziness. Pyloric stenosis • weight loss.

Meckel diverticulum: • most common cause of significant GI bleeding in children. • excruciating pain on defecation with blood found on the toilet paper. 2% of cases have complications. often called the Meckel scan. It generally occurs after the passage of a hard bowel movement.15% with colonic diverticulosis develop severe diverticular bleeding. 2 ft from ileocecal valve. • 2% of the population. • After the BM. but a common presentation is painless large-volume intestinal hemorrhage. • noninvasive diagnostic modality is the technetium scan. • excision in the office w/local anesthesia eliminates pain immediately and eliminates the risk of reoccurrence Anal Fissure: • split in the anoderm of the anal canal.GI Bleeding • Upper endoscopy is the best diagnostic testing option in the setting of an acute upper GI bleed. • Most are asymptomatic. . male-to-female = 2:1. • When they thrombose acute pain and are hard and nodular on physical exam. the patient may complain of an ache or spasm that resolves after a couple of hours. Intussusception: • 2nd most common cause of lower GI bleeding in children • caused by the involution of one bowel segment into another bowel segment. tagged RBC scan should be the next step External Hemorrhoid: • arising distal to the dentate line. Diverticulosis: • 5% . 2 in long. • It is unusual to find the source of bleeding during colonoscopy.

palpable lump – Internal bleeding and prolapsed – Treat: high fiber diet. fatigability. chest pain. technetium labeled or RBC scan. hypotension. dizziness. immunosuppressive meds. fever. or may present with painless bleeding that stops spontaneously – If asymptomatic. straining. internal above dentate line – Cause: constipation. orthostasis Diagnostics: colonoscopy. treat with high fiber diet – Diverticulitis LLQ pain. NG tube aspiration Hemorrhoids: most common cause of lower GI bleeding – Dilated veins in the hemorrhoidal plexus. smooth growths of no prognostic significance – Adenomatous polyps are benign growths with malignant potential • Tubular. constipation. diarrhea.Lower GI Bleeding • • • Clinical: weakness. angiography. irritable. pregnancy. pallor. higher risk for colon cancer – Crohn’s causes focal inflammation anywhere n the GI tract – Both may have numerous extraintestinal manifestation – Treat: antidiarrheal meds. tubulovillous. prolonged sitting (truck drivers) – External painful. 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 • • • . anti-inflammatory meds. colectomy Colon Neoplasms: – Hyperplastic polyps are small. treat with bowel rest and Abx IBD: – UC causes continuous inflammation of the large bowel. surgery only when necessary Diverticular disease: – Usually asymptomatic. tachycardia. nausea. stool softeners.

but chronic use may cause hypermagnesemia. positive FOBT. Anticholinergics. pregnancy. clonidine Lab testing only indicated if: alarm symptoms present.Constipation • • • • • • • • • < 3 stools/week Causes: hypothyroid. Alarm symptoms: hematochezia. Bulk-forming agents (psyllium) is well-tolerated for chronic constipation Osmotics like MgOH work well. Lubiprostone is beneficial in the treatment of adults with chronic constipation. HypoK. but not as a first-line . family hx of colon cancer. DM. amyloidosis. or new onset of constipation in people > 50 years. PD. HyperCa. – Lactulose is another osmotic Stimulant laxatives like bisacodyl work well in acute settings. weight loss. medical disorder is likely. MS. IBS. but research is not available to support their routine use Enemas are usually the treatment of choice for impaction. TCAs. diuretics. CCBs. carcotics. scleroderma. or if no response to treatment. but not chronic constipation. family hx of IBD.

rice. wheat. norfloxacin). alcohol. trimethoprim/sulfamethoxazole or azithromycin are acceptable alternatives. rotavirus is most frequent cause. Coli O157:H7.80% of acute infectious diarrhea. yogurt. don’t usually treat Shigella: give flouroquinolones or Bactrim E. – adults should eat potatoes. salads. – Dairy products. Norwalk virus: Contaminated water. or shellfish. . boiled vegetables. Enteric adenoviruses are the second most common type. Salmonella: raw or undercooked meat (poultry. and caffeine should be avoided.bloody diarrhea. bananas. eggs) . Giardiasis: more prevalent in children in daycare centers. noodles. ofloxacin. Rotavirus: in the winter months. HUS. and soup. Viral infections: 70% . hemorrhagic. TTP ETEC: most common cause of traveler’s diarrhea 1/3rd travelers to underdeveloped countries will get it – treat: fluoroquinolone (ciprofloxacin.Diarrhea • • • • • • • • • • Acute diarrhea: an ↑number or ↓consistency of stool lasƟng 14 days or less. and most cases occur between the 3 months and 2 years. crackers.

campylobacter. blood. Coli (12-14 hrs). children. or hep A Daycare shigella. . giardia. Chronic diarrhea more than 4 weeks Traveler’s Diarrhea: enterotoxigenic E. dehydration.Acute Gastritis • • • • • • • • • • • • • • • • • • Priority is to replace lost intravascular volume with IV NS Viral: low grade fever. C. elderly. coli Camper’s Diarrhea: Giardia Undercooked chicken salmonella or shigella Undercooked hamburger EHEC Mayonnaise/canned food S. Azithromycin 1 1000mg dose. immunocompromised Prevention: hand washing. severe ab pain. salmonella Raw seafood vibrio. keep children home from school. Histolytica Acute diarrhea less than 2 weeks. fatigue Rotavirus is most common in kids Norwalk is most common in adults bloody invasive E. Yersinia. Entamoeba histolytica leukocytes salmonella. >100. Shigella. E. EHEC and ETEC. headache. shigella. Rifaximin for noninvasive strains of E. achy Bacterial: fever. salmonella. E. Coli. rotavirus Symptoms: usually self limited. duration >48 hrs. headache. yersinia. clostridium (8-12 hrs). Coli .4. boiling water Treat: Cipro 500 mg BID for 1-2 days (except in kids or pregnant women). pasteurization. Diff. exceptions are profuse diarrhea. anorexia. refrigeration. N/V. aureus (6 hrs).

digoxin. hyperthyroid. QT syndrome Rhythm disorders: sinus bradycardia. VSD. hypovolemia. electrolyte disturbance. hypoglycemia. and likely normal ECG. Wolff-Parkinson. ventricular tachycardias – Long QT syndrome: autosomal dominant. fever. theophylline.Palpitations • • Important inquiries: caffeine. increased risk for ventricular arrhythmia and sudden cardiac death. MV prolapsed. stress. anemia. ephedra. stress test are also helpful Atrial fibrillation: rapid and irregular heart beat. reassurance/observation Ventricular premature beats random. diet pills. • • • • • • • • • • • . hypothyroid. beta agonists. adenosine – Most pts with a. QT >500msec is dangerous – PVC occurring at rest and disappearing with exercise is usually benign – Primary supraventricular rhythm disturbances responds to BBs and CCBs.White syndrome (preexcitation syndrome) ECG demonstrates a short PR interval and δ-waves. AV block. pulmonary disease. sick sinus syndrome. Echo. instantaneous beats. congenital. CHF. SVT. premature atrial contractions.fib will need warfarin anticoagulation Psychiatric causes: panic disorder Structural : cardiomyopathy. WPW. systolic ejection murmur (like aortic stenosis) worsening with Valsalva maneuver. cocaine. pheochromocytoma. sinus tachycardia. always consider coronary artery disease EKG is appropriate in all pts with palpitations. valsalva. ASD. restrictive/hypertrophic/dilated cardiomyopathy – Dilated cardiomyopathy is the most common cause of sudden cardiac death Noncardiac causes: anemia. described as a “flip-flopping” sensation. physical. more common in females. diuretics. episodic. phenothiazine If >50 yrs. caffeine. fluttering PSVT: rapid and regular. labs. PVCs. cold application to face. Hypertrophic cardiomyopathy can be associated with atrial fibrillation or ventricular tachycardia. tobacco. valvular disease. digoxin can be used – SVT can be treated with carotid sinus massage. pericarditis. MV prolapse. will have normal history. Holter monitor. vasovagal syncope Medications/drugs: EtOH.

squeezing. Angina. smoking. 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. Aortic Dissection. electrolytes. bronchitis. homocystinemia – Aspirin. CXR. chest trauma. 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. hyperlipidemia. PE. glucose. LV hypertrophy. family hx. vomiting – Angina longer than 20-30 minutes is likely an MI Secondary Treatment – Reduce or address risk factors: male >40.Chest Pain • • • Differential: MI. PNX. anxiety. aortic dissection. tropinin T and I Q 6-10 hrs for 3 cycles. cardiac enzymes. somatization. Percarditis. postmenopausal. crushing. smothering. 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 • • • • • . INR. O2 sat MONA. DM.morphine. cocaine induced spasm. embolus MI Clinical Presentation: pressure. HTN. oxygen. cholelithiasis. muscular strain. GERD. costochondritis. PTT. nitroglycerin. nitrates and beta blockers have proven long term benefits – Statins decrease incidence of CV events. nausea. herpes zoster ER studies: CBC. cocaine. PT. PNA. Esophageal spasm. 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. EKG. BUN/Cr. Levine sign.

12 hrs w/o the patch to retain the effect. • Anginal equivalent: other symptoms of cardiac ischemia (eg. onset of ST depression at a HR < 120 beats/min. or occurs with exertion. Myocardial stress imaging (scintigraphy . 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 ETT failure to complete stage II of a Bruce protocol. ST depression > 6 min into recovery. but not both.60 beats/min.0 mm. . it is important to have intervals of 10 . poor systolic BP response to exercise. • The electron beam CT can quantify coronary artery calcification.Chest Pain • • Exercise ECG is most commonly used noninvasive procedure for evaluating whether the chest pain is due to angina. angina or ventricular tachycardia with exercise and ST depression in multiple leads. or it pain with an atypical character (sharp or stabbing) but predictably brought on by exercise and relieved by rest. dyspnea) that is predictably precipitated by exertion and relieved by rest. – chest heaviness not related to exertion or relieved by rest. • Headache and fatigue may be important side effects β-blockers: • all are equally effective in treating angina • dose should be adjusted to achieve a heart rate of 50 . failure to achieve a HR > 120 beats/min (off β-blockers). but is not helpful to evaluate angina. ST depression > 2. Nitrates: • Tolerance is the most significant issue to consider when using nitrates for stable angina. • Atypical Angina: pain that has the quality and characteristics of angina. 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. • LV hypertrophy with strain. develops rapidly with longacting nitrates • When using a patch.

a confirmatory test would be appropriate. • If the result were high. .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.

empyema Prevention: – Pneumococcal vaccine for all >65. gram+ cocci. Catarrhalis are most common focal. low Na. low pH. Chlamydia & legionella cause atypical pneumonia. egophany. lung disease. klebsiella. H. pleural effusion on xray – Low risk classes treated as outpatient. DM. get early follow up with CXR in 5-7 days. but at least 2 weeks if complicated or atypical pneumonia Complications: bacteremia.Pneumonia • • • • infection of lung parenchyma. high BUN. acinetobacter. IV beta lactam and IV macrolide for inpatient. low O2 sat. multisystem failure – Pseudomonas. specific exam and lab. exposure. parapneumonic pleural effusion. and all other adults with chronic illness – Influenza vaccine • • • • • • • • • . more in adolescent/young adult Bilateral diffuse infiltrates Hospital Acquired Pneumonia – Risks are intubation. CHF. hypotension. treat for 72 hrs in an afebrile patient. lobar infiltrates – Mycoplasma. AMS. high risk includes neoplastic disease. and M. influenza (esp in COPD pts). staph aureus Abruptly worsening pneumococcal pneumonia Diarrhea + pneumonia legionella can do urine antigen testing or direct fluorescent antibody Postinfluenza pneumonia staph aureus Right lower lobe consolidation aspiration pneumonia Pneumonia Severity Index: assigns pts a risk category based on age. most common triggering mechanism is upper airway colonization Clinical: age. fever with chills. dullness to percussion Diagnosis: CXR is gold standard. cough with green sputum. liver/renal disease. fever. NG tube feeds. high glucose. physical bindings include tachypnea. comorbid illness. low Hct. high risk as inpatient Treat: fluoroquinolone or macrolide or beta-lactam for outpatient. tachycardia. cultures have low sensitivity – Absence of infiltrate does not rule out pneumonia Community Acquired Pneumonia (non hospital pts): – Strep pneumo.

Chlamydia – No specific diagnostic criteria. bronchodilator therapy. mycoplasma. but most have cough productive of purulent sputum of variable color – Treatment: no antibiotics unless it is pertussis. adenovirus. rhinovirus.Acute Bronchitis – Inflammation of the tracheobronchial tree often in the setting of a URI in the winter • Influenza. parainfluenza. antitussives – Prolonged fever and consolidation pneumonia – Conjunctivitis and adenopathy adenoviral infection .

hepatojugular reflex. pulmonary edema Framingham Heart Study: – need 2 major criteria. weight gain. rales. pulmonary edema. hepatic ascites. orthopena. PND. ECHO is the gold standard diagnostic modality • • • • • • . pleural effusion. wheezing. tachypnea. survival is 3-5 yrs. – Minor criteria.5 kg over 5 days of treatment. nocturnal cough. cough. constipation. decrease pre/afterload Lung fluid overload often causes anxiety and distress due to oxygenation struggle activates sympathetic pathways & catecholamine response worse heart failure w/tachycardia &peripheral vascular resistance – Suppress these triggers with morphine sulfate which is an anxiolytic and vasodilator – Give diuretics. cardiomegaly. S3. PND. BNP > 500 pg/mL. rales. N/V. pleural effusion. tachycardia Elevated BNP and pr-BNP are sensitive and specific.PND. DOE. frothy sputum – Right sided: venous congestion.ankle edema. hepatomegaly. dilate pulmonary vessels. edema. wt loss of 4. S3 gallop. JVD. circulation time of 25 sec. fill. and eject blood Symptoms: dyspnea on exertion. anxiety. CVP >15. decreased VC. ACE and BB to decrease preload and afterload and reduce cardiac remodeling Systolic dysfunction: dilated LV with impaired contractility Diastolic dysfunction: normal LV.CHF • • • Leading diagnosis among hospitalized pts >65. JVD. ab pain. impaired ability to relax. Cheyne-Stokes respiration. hepatojugular reflex. fluid retention. DOE. decreased appetite. distension. bloating. cough with pink. First priority is optimize O2 exchange give O2 NC. splenomegaly – Left sided: pulmonary congestion. BNP < 80 pg/mL has a high (99%) negative predicative value and helps rule out CHF. orthopnea.

Avoid prolonged therapy Spironolactone is usually considered for NYHA class III or IV pts or those with a serum K level < 5. and verapamil. CCBs are contraindicated except for amlodipine. • • • • • • • • . – bisoprolol. metolazone can ↑diuresis in outpatient treatment of HF w/volume overload. and nicardipine) may worsen systolic dysfunction. comfortable at rest. hypotensive. hyperK. dyspnea. ACE inhibitors are first line (unless pregnant. renal stenosis/insufficiency).CHF NYHA functional classification: • Class I: patients have no limitation of activity. but not necessarily as a first-line agent. ↑quality of life. ↓hospitalizaƟons. and carvedilol can ↓symptoms. angina w/ordinary activity • Class III: patients are also comfortable at rest. – All pts with heart failure should be prescribed an ACE inhibitor unless they have a contraindication. but less-than-ordinary activity causes symptoms. • Class IV: patients have symptoms at rest and increased symptoms with even minor activity. ↑quality of life. weight reduction.IV – slow progression to heart failure among asymptomatic pts with LV systolic dysfunction. – β-Blockers inhibit the adverse effects of sympathetic nervous system activation in heart failure patients. β-Blockers are helpful. but does not ↓mortality. as can ARBs. fatigue. diltiazem. & ↓mortality in pts with NYHA class II . diltiazem. ACE inhibitors and ARBs do not have the same effects on the neurohormonal pathways involved in CHF an ARB added to an ACE inhibitor ↓hospitalizaƟon in pts with CHF.0 mmol/L. metoprolol. Some CCBs (nifedipine. • Class II: pts have slight limitations. and ↓mortality. • • discontinuing alcohol use has been shown to improve function significantly. beta blockers (in non-acute setting). Outpatient treatment: Na restriction. aldosterone antagonists can be used in advanced heart failure. Nitrates & hydralazine can be used in pts who do not tolerate ACE inhibitors. diuretics. ACE inhibitors ↓symptoms. palpitation.

the direction of the nystagmus changes. direction of the nystagmus is fixed. 50 mg orally Q 4 . Presyncope feeling of impending faint. and the symptoms are of mild intensity. central vertigo no latency to onset of symptoms. pt often thinks problem is in the feet Light-headedness is often vaguely described as a “floating” sensation. symptoms are severe. repeating the maneuver lessens the symptoms.10 sec. Dix-Hallpike maneuver is useful to distinguish central from peripheral causes of vertigo. Meclizine (Antivert). antihistamines are first-line therapy suppress the vestibular end-organ receptors and inhibit activation of the vagal response.6 hrs . no lessening of symptoms with repeat maneuvers.Dizziness • • • • • • • • • Vertigo rotational sensation. in which the room spins around the patient. Disequilibrium sensation of unsteadiness or loss of balance. Orthostasis lightheadedness upon arising. peripheral vertigo latency time for onset of symptoms of vertigo or nystagmus is 3 . 25 mg Q 4-6 hrs and diphenhydramine (Benadryl). common with orthostatic hypotension.

MS. destruction of hair cells. BPH. Meniere disease: endolymphatic hydrops increase pressure – Tinnitus. Vestibular neuronitis – acute onset of severe vertigo lasting several days. facial weakness. associated with nausea.ENT • • • • • • Peripheral vertigo: inflammation. and ataxia can occur. symptoms are constant and slowly progressive. hearing loss. hearing loss (low frequency) – attacks of vertigo lasting for several hrs. labrynthitis. Meniere’s. vomiting. and tinnitus – Treat with diuretics and salt restriction • Know the Rhine and weber test . vestubular neurotnitis. – vertigo. stimulation. with symptoms improving over several weeks Benign positional vertigo: dislodged otoliths in semicircular canals – symptoms with position changes only. acoustic neuroma Central vertigo: vascular insufficiency. brain tumor Acoustic neuroma – unilateral tinnitus and hearing loss.

stridor. H. by itself. fever. tinnitus. – First-line therapies: NSAIDs. tripod position. vertigo.Temporomandibular joint dysfunction: – common cause of referred otalgia. heat. Antibiotics not indicated for persistent effusions in the absence of acute otitis media. external ear canal with exudates & discharge. referral to the dentist if no improvement in 3-4 weeks. diminished hearing. M. – Purulent discharge in ear canal may indicate perforation – Effusions may take 3 mo to resolve. inflamed. give amoxicillin – opaque TM (purulent effusion). catarrhalis • Most resolve spontaneously though if prolonged or recurrent/severe. – middle ear infection seen in kids usually due to URI. absence of cough • Post-strep glomerulonephritis and rheumatic fever are possible complications • Treat with Penicillin for 10 days or cephalosporins if penicillin allergy – Infectious Mono: adenopathy & hepatosplenomegaly. PPV is near 90%. red TM • S. swollen. painful. tender cervical adenopathy. Otitis Media: – reddened TM. drooling. arcanobacterium are common in teens/young adults – GAS causes 15% of adult and 30% of pediatric cases. restrict from activity Epiglottitis: manage airway patency first. – Otic drops containing antibiotics and corticosteroids are very effective. ear pain. is not a sufficient finding to diagnose acute otitis media. pneumo. do a throat culture (gold standard) – GAS : abrupt onset of sore throat. – DM pts at risk for invasive external otitis (malignant) with pseudomonas surgical debridement and IV antibiotics – persistent otitis externa in an immunocompromised or diabetic should be referred for specialty evaluation. tonsillar and/or palatal petechiae. toxic ENT . impaired TM mobility When all 3 are present. the majority is viral – Mycoplasma. influ. diagnose with rapid antigen test • If rapid antigen test is negative. fever. – amoxicillin is first-line therapy External Otitis: – infection of external auditory canal. Pharyngitis: inflammation or irritation of the pharynx and/or tonsils. atypical lymphocytes in peripheral smear. Chlamydia. TM uninvolved – must protect from additional moisture and avoidance of further mechanical injury from scratching. mechanical soft diet. bulging TM.

pain. discharge. topical antibiotics prevent bacterial superinfection. associated w/autoimmune diseases like RA or Wegeners Episcleritis: mild irritation. and redness. and tearing. painless Conjunctival hyperemia: diffuse erythema of conjunctiva Iritis: photophobia. but no good evidence that it makes any impact. and is not as intense as the syndrome described above. surrounding headache. intense pain. also use cold compresses Bacterial conjunctivitis purulent discharge. • MRSA conjunctivitis is treated with the same drugs used to treat MRSA in other parts of the body Scleritis: • injection of the deeper scleral vessels.Eye Conditions Conjunctivitis • redness. sluggish pupil. painful nodule Blepharitis: inflammation of eyelids. but is associated with trauma. loss of eyelashes. • commonly caused by Streptococcus and Staphylococcus. ↑reports of conjuncƟviƟs caused by MRSA. photophobia. irritation. deep boring eye pain. Corneal abrasion: associated with ↓vision. or itching. tearing. • ↓vision. • topical corticosteroids are contraindicated Viral conjunctivitis a palpable preauricular lymph node is characteristic • eye drops for herpetic eye infections (corneal dendrites w/fluorescein staining). scaling Dactrocystitis: occlusion of nasolacrimal duct Subconjunctival hemorrhage: benign bleeding of small bessels. cloudy cornea. pain. and a “gritty” sensation of the eye. Chalzion: sterile inflammation of meibomian gland. not usually painful • itching and bilateral symptoms are more specific for allergic conjunctivitis • Adenovirus is most common virus (85%) • Supportive treatment. but the affected pupil is usually dilated. Acute glaucoma: pain. photophobia. ↓vision. pupillary constriction .

In pts with sinusitis confirmed by CT scan. & biphasic history (worsening of symptoms after an initial period of improvement) – S. purulent secretions in nasal cavity. & group A β-hemolytic strep • • • • • • Duration of illness < 7 days may be used as a negative diagnostic criterion. In pts clinically diagnosed with acute sinusitis. or bacteriology. – Others include H. . Sinus pain on palpation. lack of improvement w/decongestants. Bacterial: purulent rhinorrhea. tooth pain. Predisposing factors: viral URI and allergic rhinitis. there has been demonstrated efficacy of antibiotics amoxicillin is considered the drug of choice in most countries. x-rays are not diagnostically valuable. M.Sinusitis • • • inflammation of the mucosa of the para-nasal sinuses irrespective of the cause.catarrhalis. influenzae. Most with recurrent sinusitis have an underlying physiologic or anatomic abnormality that contributes to their problem. x-ray.pneumoniae is most common. no significant difference between antibiotics and placebo use.

stimulation of sensory nerves Symptoms: sneezing. side effects are dry mouth. intranasal steroids. hydroxyzine. allergic salute. red eyes. give low dose inhaled steroid – Moderate persistent: daily. conjunctivitis. worsening of symptoms w/chronic use or discontinuation Corticosteroid nasal spray: effective long term management. nasal decongestant. nasal crease. dennie-morgan liens. fexofenadine. cobble-stoning Treat: H1 blockers. corticosteroid tablets/syrup if needed . long term steroid effects so only use short term DesensiƟzaƟon therapy: test for specific anƟgens. itching. drowsiness Exam: allergic shiners.Allergic Rhinitis • • • • • • • • • • • IgE mediated response to extrinsic protein Mucus glands increase secretion. blurred vision. headache.2-0. long acting B agonist. 2nd gen have less SE: loratadine. tremors.<2/mo. cetirizine Decongestants: constrict blood vessels. rhinorrhea. oral steroids. swollen blue/gray turbinates. oral decongestant. insomnia. tearing. urinary retention. cromolyn. earache. pseudoephedrine (α-adrenoreceptor agonest). give low/med inhaled steroid + long acting B agonist – Severe persistent: continual/frequent. postnasal drip. may cause tachycardia. dry eyes. >5/mo. inject dilute anƟgen & gradually ↑concentraƟon Anaphylaxis: give aqueous epinephrine 1:1000 in 0. chlorpheniramine. 3-4/mo. LTRAs Antihistamines: diphenhydramine.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. reduce inflammatory mediators Oral corticosteroids: inhibit cell mediated immunity. congestion. vasodilation. no daily meds other than short acting B rescue inhaler – Mild Persistent: 3-6/wk. give high dose inhaled steroid. anosmia. rebound hyperemia.

tender anterior cervical adenopathy. a first-generation cephalosporin or macrolide. posterior cervical adenopathy infectious mononucleosis Fever. – first-line treatment is amoxicillin. lack of cough – most cost effective approach to pts who have all 4 criteria is to treat with antibiotics w/o laboratory testing. chills. and only supportive care is needed. and pain with swallowing. edema swollen uvula group A hemolytic streptococcal infection. as they do not develop complications from infection and are not important in the spread Laryngitis with pharyngitis is generally associated with a viral infection. myalgias. and a person with only 1 has 1%5% chance. Centor Criteria for adults is a method for determining the probability of group A β-hemolytic strep – 1 point is given for each of the: tonsillar exudates. the chance of having a strep is 40%-60%. – If someone has 3 criteria. In the penicillin-allergic pt. anterior adenopathy viral or bacterial pharyngitis.Sore Throat • • • • Palatal petechiae either a group A streptococcal infection or infectious mononucleosis. fever. 20% of school age kids are carriers of group A β-hemolytic Strep carriers do not need to be identified or treated. • • • .

rash on hands and feet • Monospot test positive after 5 days – 3 weeks. fever. cough. parainfluenza. strawberry tongue.Pharyngitis • • • • • • RSV. cervical lymph Kawasaki < 5 yrs. low grade fever Diphtheria gray membrane. coxackie virus Group A Strep rheumatic fever. rare in children < 3 Viral: rhinorrhea. IgM may not be + for 2 weeks • Strep pneumo give 10 days of PNC or 1 IM injection . adenovirus. tonsillitis. GN. rhinovirus Herpangina tonsilar + palatal ulcerations.

and there may be a solid appearing edema of the central part of the face due to sebaceous Hyperplasia and lymphedema (rhinophyma and metophyma). topical retinoid + topical antibiotic 2nd line. severe acne. and may take even longer for noninflamed comedones. • tetracycline & isotretinoin cause pseudotumor cerebri. Minocycline or doxycycline are very effective first-line therapies.persistent erythema. Keratoacanthoma: • difficult to distinguish from basal cell cancers. • Management: topical metronidazole. add oral antibiotic if no improvement in 6 weeks • improvement occurs over a period of 2 .5 cm within a few weeks.erythema is deep and persistent.addition of papules and tiny pustules. but oral antibiotics are more effective than topical. chocolate. emotional stress. • Stage II . or molluscum • characterized by rapid growth. Psoriasis: • often has nail involvement in addition to skin • For localized skin rashes.5 months. & help w/nails. and sodium sulfacetamide can work. and Propionibacterium acnes. benzoyl peroxide & topical antibiotics (doxy) should be applied during the day • Isotretinoin indications: nodular acne. antibiotics. • Topical agents are first line. telangiectases are dense. • Stage III. • Topical pimecrolimus is effective for inverse psoriasis (perianal and genital regions) or on the face and ear canals • Oral retinoids & methotrexate treat generalized psoriasis. occlusion/pressure on the skin • Acne is not caused by dirt. generally with telangiectasia formation. greasy foods or the presence or absence of any foods in the diet. • Topical retinoids applied in the evening. moderate recalcitrant acne. resistant to other therapies – pregnancy must be prevented during its use. Rosacea: • Stage I. nodular squamous cell cancers. but not first-line for localized rash .Skin Rashes and Infections Acne: • cause is multifactorial: familial factors. • Contributory factors: certain medications. topical corticosteroids are appropriate therapeutic agent. androgens. and should never be used together. follicular keratinization. achieving a size of 2.

and includes antihistamines or corticosteroids to relieve itch. • Acyclovir resistance is extremely rare. slightly raised plaque with scale) followed in 1 . • Antiviral agents are more effective treating primary infections than recurrent infections. and ↓ Ɵme for lesion healing and ↓ overall duraƟon of pain if iniƟated within 72 hours • In some cases. Impetigo: • well-demarcated erythematous lesions that. 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 seems to reduce. . when disrupted. HSV: • topical antiviral therapy or oral antiviral therapy. no benefit will occur if treatment starts after the 72 hour cutoff. but it should beinitiated regardless of time in pts > 50. and recurrences are uncommon. or those with eye involvement. not eliminate. • 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 symptomaƟc recurrences and asymptomaƟc viral shedding. asymptomatic viral shedding. • Suppressive therapy does not alter the natural course of infection and is not associated with antiviral resistance Herpes zoster: • AnƟviral therapy is treatment of choice. single herald patch (oval. develop a secondary golden crust.2 wks with a generalized eruption. • The treatment is symptomatic. • spontaneously resolve in 6 to 12 weeks.Skin Rashes and Infections Pityriasis rosea: • self-limited papulosquamous eruption. • responds well to topical antibiotics like mupirocin applied to the lesion and to the nares Folliculitis: • infection is generally caused by Pseudomonas aeruginosa or Pseudomonas cepacia. those who are immunosuppressed. and therefore reassurance is all that is necessary. • condition is usually self-limited. • most cases are caused by S aureus followed by Strep.

• well-demarcated plaque with central scaling. and ketoconazole can also be used. lichenification • Steroids used for acute flares • Use emollients after bathing • Tacroliumus (and nonsteroidal immunomodulators) for short term treatment if severe • Most patients have the onset of eczema in childhood.Skin Rashes and Infections Tinea capitis. cautery. Molluscum contagiosum. • flexural surfaces are often involved. children in daycare/nursery (for kids it is not likely to be sexually transmitted) • poxvirus transmitted through direct skin-to-skin contact. upper trunk. but they can be treated with cryotherapy. red plaques with flaking that can affect the face. vesicles. itraconazole. • in adults and in the pubic region. • Most resolve spontaneously within months. neck. Tinea corporis/ringworm: • most commonly caused by Trichophyton rubrum. • more common in white males. they are sexually transmitted. pruritic. If fluconazole were to be used. scaling. and behind the knees. fluconazole. but in pts who are immunocompromised. the treatment duration would only be for 3 to 4 weeks. or curettage. not 4 to 8 weeks. and should be used for 4 to 8 weeks. . • Terbinafine. pruritus may be severe. they are numerous and larger. and onset after the age of 30 is very uncommon. but topical ketoconazole shampoo or selenium sulfide lotion may kill hair spores • Griseofulvin is treatment of choice. Atopic dermatitis/eczema • rough. • can occur in immunocompetent pts. crusting. • Papules. • Systemic therapy is needed.

if pathology indicates malignancy. well-defined borders Risk factors: family hx. rarely metastasize Squamous Cell Ca: higher rate of metastasis. immunocompromised Superficial spreading melanoma: – – – Most common type in both sexes Spreads superficially along the top layers of skin before penetrating into deep layers Superficial. uniform color. fair. ulcerated . most common in Hawaii Most common in African-Americans and Asians Found under the nails. <1 mm thick have low rate of metastasis Basal Cell Ca: most common. excise with 5 mm margin Tumor thickness is most important prognostic factor. palms of hands Invasive at the time of diagnosis. bleed easily. on the soles of feet. Most aggressive type • • • • • • • Lentigo Maligna: – – – – – Acral Lentiginous: Nodular: Treat: if any of the ABCDE signs are present. scaly. burn easily.Skin Cancer • • • Reassuring features: <6mm. radial growth phase is slower than the vertical phase Most often in the elderly on chronic. excise completely with 2-3 mm margin. symmetric. pearly papules w/central ulceration or telangectasias. sun-damaged skin Least common of the 4 types. irregularly shaped plaques/nodules w/raised borders. chronic exposure to toxic compounds.

ascending or descending stairs. Then. 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. start ROM exercises and strengthening • Younger pts may have ↑recurrence. • pain or ache over lateral knee that worsens with activity. symptomatic treatment Medial collateral ligament sprains: • occurs after valgus stress to a partially flexed knee. do exercise to increase ROM Iliotibial band syndrome: • most common cause of lateral knee pain in an athlete. but no joint swelling Ottawa ankle rules are a guide to use to determine if xray is indicated after ankle sprain. catching. or squatting or sitting for prolonged periods of time • Treatment is done primarily through strengthening the quadriceps muscles and hip rotators. • There is tenderness over the distal 6 cm of the tibia or fibula.Musculoskeletal shoulder dislocation pain management and relocation • keep immobilized for 7 -10 days to allow for capsular healing. internal rotators. running.” and immediate effusion while still able to bear weight. feeling of a “pop. • There is tenderness over the proximal fifth metatarsal. • treat with strengthening the hip abductors. Meniscal injuries: • locking. and on exam has pain and tightness over the IT band. . ACL tear: • twisting injury. • There is midfoot or navicular tenderness. pain over the medial aspect of the knee. and knee flexors is generally treatment for Patellofemoral pain syndrome: • diffuse knee pain and a positive patellar grind test. Films should be obtained if: • The pt is unable to walk four steps immediately after the injury and in the office. • commonly seen in athletes with repetitive knee flexion activities like distance runners and cyclists. but not necessary immediately • Rotator tendonitis discomfort w/abduction > 90. & surgical referral should be entertained. or giving way sensation. including the malleoli. sense of instability. pain with throwing motion • Adhesive capsulitis chronic pain and stiffness.

– high specificity. get C-spine radiograph cervical dystonia (torticollis) neck would be laterally flexed and rotated. – pt to bends head to the side & rotate head toward the side of pain while tester exerts downward pressure.Neck Pain • • • • • • • • • • Spondylosis or osteoarthritis Pain aggravated by movement. weakness. numbness. – Nonspecific mechanical pain should be considered if the maneuver results in neck discomfort only. Physical therapy. limited ROM chronic mechanical problems tenderness to palpation on examination. if there was absence of neck pain at the scene. 2. Canadian cervical spine rules help determine who should receive radiography: 1. 3. spinal stenosis: older individual with axial stiffness and paresthesias over several dermatomes (C7-T1). cervical collars. stretching. A no to any of the above would require radiography. Spurling test/neck compression test. if the pt was ambulatory at any time at the scene. ice/heat have all been used with some results evidence supporting those treatments is weaker than the evidence behind use of botulinim toxin. whiplash injury history of an acceleration injury. or paresthesias. dangerous mechanism (high speed motor vehicle accident) or numbness/tingling in extremities. gentle manipulation. – reproduces symptoms in the affected upper extremity in the case of nerve root injury. but low sensitivity for cervical radiculopathy. Is the pt able to voluntarily actively rotate the neck 45° to the left and right regardless of pain? A “no”to that question would require radiography. cervical nerve root irritation radiation of symptoms. Is there one high-risk factor? High-risk factors: age >65. and if there was absence of C-spine tenderness on examination. Is there one low-risk factor? Low-risk factors: simple rear-end collision. • • . worse after activities. associated with a dull ache. – CT scan is the best choice. A yes to any of the above requires radiography.

MRI is indicated for pain persisting > 6 wks despite normal radiographs and with no response to conservative therapy. Spondylolisthesis: anterior displacement of vertebrae in relation to the one below – most common cause of low back pain in patients < 26. Disk herniation associated with radiation and neurologic symptoms. • NSAIDs & muscle relaxants are effective for short-term symptomatic pain relief • Steroids can be considered in those who have failed NSAID therapy.Back Pain • • • • Inflammatory condiƟons produce ↑pain & sƟffness in the AM. Treatment: • maintain usual activities. • Back strain generally follows an inciting event. as dictated by pain. . • Low-dose TCAs can be useful in the treatment of chronic pain and do serve as adjuvants to other analgesics. mechanical disorders worsen during the day w/ activity. pain associated with movement. • prolonged bed rest & tracƟon have not been shown to be effecƟve in ↑return to usual activities sooner. especially athletes.

• Extra-articular manifestations: seen at any stage of disease • nodules occur anywhere (usually subcutaneously along pressure points). dry eyes. symmetric arthritis. achy pain • Gradual onset exacerbated by activity and decreasing with rest • Bony crepitus on passive ROM • Xray is normal at first. fatigue is common • Radiographic changes include erosions or decalcifications • Elevated ESR and CRP. anticytokines (infliximab. subchondral cysts. > 50% of the WBCs are PMNs. • Indications for joint replacement poorly controlled pain despite max therapy. thromobcytosis. and ↓mobility • Fluid aspirated is generally clear joint fluid with a WBC count of 2000/mm 3 to 10. malalignment. • symmetric swelling and tenderness are common. dyspnea. then develops bone sclerosis. +rheumatoid factor • gradual. involves hand joints. sulfasalazine. obesity. Rheumatoid Arthritis: • age 30-55 yrs. but it may spread to larger joints. and renal systems are rarely involved.Joints Osteoarthritis: • Osteoarthritis: age >65. pain is worse with activity and improved with rest. • pauciarticular. anemia. < 50% of the WBCs are PMNs. osteophytes • Heberden nodes (at the DIP joints) and Bouchard nodes (at the PIP joints). • In RA. with associated rheumatoid nodules. GI. etancercept). dull. • often mild swelling. history of trauma. or repetitive joint use. not as an extraarticular manifestation • Treat: NSAIDs. When a neuropathy is present. women>men. Crepitus is common. methotrexate . symptoms for >6 weeks • Morning stiffness Involves 3 or more joints. polyarticular and symmetric involvement of joints with morning stiffness that improves with activity • Hands and feet are usually involved first. deep. Cardiac.000/mm 3. low albumin. glucocorticoids. as is malalignment of the joint. or cough can all be seen. but warmth and an effusion are rare. • disease-modifying antirheumatic drugs (DMARDs) should be managed by rheumatologists and started early to avoid or delay joint deformity. it is generally because of a compression syndrome. while in osteoarthritis. vasculitis.

but they can precipitate a flare. glucocorticoids. strong neg birefringence on polarizing microscopy • Ca pyrophaosphate crystals: rode shaped. • Colchicine.000. • Corticosteroids can provide quick relief. rhomboid.000 with >90% neutrophils – Treat: Acute attack colchicine. NAID. thiazides abrupt in onset and monoarticular with pain at rest and with movement. staph. use UA to monitor therapy but not to diagnose acute attack – Monosodium urate crystals. but should be reserved if initial therapy fails. H. Aureus • HIV pneumococcal. after large meals. ESRD patients – Joint aspirate: WBC is 2000-60. strongly positive birefringence. limited range of motion. gram neg. any joint can be affected podagra. after trauma or surgery. • Septic joint: WBC: 100.an abrupt. another is a course of colchicine. – Serum uric acid may be normal or low during an acute gout attack. pneudomonas • Treat: drainage with IV antibiotics (Vancomycin if MRSA) . intense inflammation of the first MTP joint attacks often occur overnight. • glucose levels fluid aspirated from a knee with gout or pseudogout would be normal. • Allopurinol & probenecid are effective for prevention.Joint Pain Gout • • • • increased risk men. Influenzae • IVDU strep. fever • Steroid use S. Septic Joint: • infections of only 1 joint. weakly positive birefringence • Ca hydroxyapatite: cytoplasmic inclusions that are non-birefringent • Ca oxylate: bipryamidal. chronic probenecid or allopurinol • sed rate & C-reactive protein are both nonspecific. after an inciting event (excessive alcohol or a heavy meal). salmonella. high proportion of PMN leukocytes. <90% neutrophils. 1 tab Q 1-2 hrs until pain is controlled or side effects limit use (usual side effect is diarrhea). needle shaped. EtOH consumption. • crystals of pseudogout are rhomboid-shaped and demonstrate positive birefringement. • short course of NSAID is one standard therapy for gout. effusion.

and anterior talofibular ligament are most commonly injured (then CFL and PTFL) • Ottawa Ankle Rules aid decision about x-rays (adult pts. translation or palpable clunk of talus on tibia suggests tear • Squeeze test tests syndesmosis. pain with weight bearing. NSAID or acetaminophen for pain Shoulder: • Empty Can Test tests supraspinatus for rotator cuff injury or tear • External shoulder rotation tests infraspinatus/teres minor for rotator cuff injury or tear • Lift-off Test tests subscapularis for rotator cuff injury or tear • . isolated patella tenderness. more pain. inability to bear weight • Lateral ankle. loss of function. elevation.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. 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. loss of range of motion – Grade III: complete tear of ATFL and CFL with partial tear of PTFL. inability to flex knee to 90 degrees. normal mental status. tenderness of head of fibula. moderate joint instability. ice. swelling. syndesmotic injury if pain at anterior ankle joint • Lachman test excessive translation ofa ACL with no solid end point suggests tear • Anterior Drawer (knee) tests ACL tear • Valgus Stres tests MCL • Varus stress tests LCL • PRICE therapy: protection. compression. inability to bear weight for 4 steps • Anterior Drawer (ankle) tests anterior talofibular ligament for a tear • Inversion Stress test tests CFL. rest. bruising. significant joint instability.

history of vaginal discharge. • First treat with: voiding after intercourse. back pain Interstitial cystitis • chronic in nature and is generally not associated with back pain. based on presence of ulcerations and fissures in the bladder • When hematuria is present. back pain. • Dysuria without pyuria is common. interstitial cystitis should be suspected. Pyelonephritis: fever. • In postmenopausal years. atrophy is a usual cause. ask about a bladder irritant (caffeine & acidic foods are common). If symptoms reoccur after discontinuation. • 4 factors correlate with a diagnosis of acute bacterial cystitis: frequency. discontinuing diaphragm • if this treatment doesn’t work prophylaxis is indicated for women with frequent infections. acidification of urine. Dysuria • Vulvovaginitis is a common cause of dysuria. hematuria. • treat asymptomatic bacteriuria in pregnancy. but is associated with vaginal irritation or discharge. absent back pain. daily single-dose antibiotic prophylaxis for 3 . vaginal irritation • Women with any combination of the positive & negative symptoms have a more than 90% probability of a UTI.GU Infections Bacterial Cystitis: • Urine culture indicated when acute bacterial cystitis is suspected and urinalysis is inconclusive • classic symptoms + negative dipstick or microscopic evaluation culture will confirm diagnosis. If that does not ↓infecƟons. dysuria. • In younger women. treatment not indicated for other patients . • Single-dose postcoital anƟbioƟc. • 85% recurrent UTIs develop within 24 hours of sexual intercourse.6 months. • 4 factors ↓ likelihood of UTI: absent dysuria. Urethritis: gradual onset. it may need to continue for 1 to 2 years. • generally diagnosed through cystoscopy.

w/prostatitis Testicular torsion • emergent surgical referral. unless the diagnosis remains unclear. • prostate examination would reveal a boggy. • 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. • less commonly caused by Ureaplasma or Mycoplasma in this age group. and has pyuria. Prehn sign is +. hernias.gonorrhoeae or C. Acute prostatitis: • most commonly seen in 30-50-y/o men. only a 20% chance that the testicle can be saved. • This does not occur with testicular torsion.Male GU Epididymitis: • sexually active males due to retrograde spread of prostatitis or urethral secretions through the vas deferens. and back pain. • patient generally appears acutely ill. • monogamous men > 35 more commonly due to enteric gram-neg rods (Enterobacter) assoc. as after 12 hrs w/o treatment. and warm prostate. tender. generally found attached to the spermatic cord. • The cremasteric reflex and Prehn sign are positive in cases of epididymitis. or cancer. • No tests are necessary. urgency. . Spermatocele: • asymptomatic nodules. and symptoms include frequency. trachomatis. • sexually active men < 35 yrs usually associated w/urethritis & caused by N. orchitis.

• Treatment consists of topical azole applications or an oral one-time dose of fluconazole. with oral or topical clindamycin an acceptable alternative. • KOH preparation shows multiple hyphae. . • Recurrent yeast infections probably do not occur more frequently in diabetic or HIV +women. triangular cells with long tails. White plaques usually adhere to the vaginal wall. Bacterial Vaginosis: • Studded epithelial cells (clue cells) • treatment of choice is topical or oral metronidazole. but may be more difficult to eradicate in this population Trichomonas vaginalis: • strawberry cervix. slightly larger than WBC.Female GU Candidiasis: • vaginal itch with white “cheesy” exudate.

do not need to treat partners unless symptomatic Bacterial Vaginosis – Overgrowth of anaerobic bacteria and G. chronic ab pain.flouroquinolone for 14 days. pruritis. homogenous discharge. Vaginalis – Associated with many sexual partners. immunocompromized.5. treat partners PID: – Lower abdominal tenderness with adnexal and cervical motion tenderness. edematous. pH >4. hx of antibiotic use – Treat: 150 mg fluconozole single dose. ectopic pregnancy • • • • . clue cells on wet mount prep – Treat: oral and topical metronidazole or clindamycin. infertility. 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. elevated sed rate and CRP – Treat: if pregnant. erythema. Doxycyline 100 mg BID x 7 days for Chlamydia or single oral dose of azithromycin if compliance is a concern. pH 4-5.Vaginitis • Trichomonas vaginalis: – Motile. discharge. give cefotetan 2g IV – Complications: tuboovarian abscess. or ceftiraxone IM single dose. thinner green-yellow discharge with fishy odor. or severe disease. should get inpatient therapy. +KOH whiff test. fungal cultures not needed – Increased incidence in patients with DM. though not an STD – Thin. or 10-14 days if complicated. menopause – Treat: metronidazole 2g po in a single dose for patient and partner or 500mg BID x 1 week Vulvovaginal Candidiasis: – Thick. flagellated trichomonads and many WBCs. white discharge w/o odor. HIV. pregnancy. fever. frothy discharge with erythematous cervix – Incubation is 3-21 days after exposure – Risks: multiple sexual partners. KOH prep shows budding yeast or pseudohyphase. oral. if inpatient.

• Absolute contraindications to liver transplant portal vein thrombosis. and prothrombin time. HIV or hep B surface antigen +. bilirubin. extensive previous abdominal surgery. • labs showing acute hepatocellular injury AST. • ratio is generally greater than 2.0.Liver most important aspect of diagnosing alcoholic liver disease is the documentation of chronic alcohol abuse. LDH. a value rarely seen in other forms of liver disease • . and alkaline phos. malignancy. • Relative contraindications to liver transplant active alcoholism. • labs representing hepatic function (more suggestive of chronic disease) albumin. ALT. Alcoholic hepatitis: • disproportionate ↑of AST compared to ALT with both values usually being < 300 IU/L. or lack of patient understanding. severe medical illness. hepatobiliary sepsis. • Bleeding from varices is the most common cause of death in cirrhotic patients. and a lack of a personal support system.

Jaundice • childhood unconjugated hyperbilirubinemia hemolytic diseases (G6PD deficiency & spherocytosis). • CHF accounts for around 10% of jaundice in pts > 60. but only for 5% of jaundice in pts >60 yrs • Extrahepatic obstruction (gall stones. • obstruction is still considered likely after a negative ultrasound or CT scan. less common wilson disease. galactosemia • Viral hepatitis accounts for up to 75% of jaundice in pts < 30. and metastatic disease accounts for ~ 13% • obstruction suspected do ultrasound or CT scan • If dilated bile ducts. MRCP is a reasonable next option. • childhood conjugated hyperbilirubinemia viral hepatitis is most common. . Gilbert disease and Crigler-Najjar syndrome. • bile ducts not dilated but likelihood of obstruction is low. then ERCP or PTC. evaluate for hepatocellular/cholestatic liver disease. pancreatic cancer) accounts for > 60% of jaundice in pts > 60 yrs. strictures.

no further work up needed Hemolysis: unconjugated hyperbilirubinemia. lasts 4-6 weeks – No specific treatment. – Incubation 6 weeks – 6 months. 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. Acute symptoms are similar to hep a. level will increase during illness then recover. bile duct stones. malaise. self-limited. male-male sexual contact – Jaundice. drugs. strictures. tumors. often with anemia with red cell fragments or abnormalities Hepatitis A: fecal-oral transmission. Incubation for 2-8 weeks. 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. mostly unconjugaged Posthepatic Jaundice: obstruction to the flow of bile through bile ducts. fever. chronic Hep B pts may qualify for antiviral therapy – Vaccination is universally recommended Hepatitis C: most common cause of liver disease in the US. abdominal discomfort. contaminated food nad water.Jaundice • • • • • • Prehepatic Jaundice: hemolysis of RBCs which overwhelms the liver’s ability to conjugate and clear the bilirubin. 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 • • • . 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.

die primarily due to CVD. before reaching the need for dialysis. . and metabolic acidosis (↓plasma bicarbonate) occur in later stages of kidney disease. • Renal replacement therapy (transplant or dialysis) is indicated for severe renal insufficiency (GFR <15 mL/min). hyperP. hyperK. because they have less muscle mass. • ACE inhibitors help prevent the evolution of microalbuminuria to full blown proteinuria. • CKD higher risk for CVD. • hypoNa. • 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.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. • anemia generally appears when the GFR falls below 60 mL/min.

and retention enemas Anemia reduced EPO Edema low albumin state Hyaline casts long term damage to kidneys Chronic renal failure: GFR < 60 for 3 or more months. or diltiazem if needed – Reduce protein excretion to <500-1000 mg/d. no NSAIDs/aminoglycosides/radiocontrast – Keep BP < 130/80. 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 • . use ACE or ARB. GFR < 15 Causes: DM.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. treat infection.8-1. decrease in nephrons and function – Is a CVD risk factor ESRD: irreversible loss of kidney function. treat HTN. glomerulonephritis Diagnostics: – >30 mg microalbumin per gram CR – Renal imaging and microscopic evaluation of urine Management: hydration. or 60% of baseline – Restrict dietary protein to 0. HTN. plus beta blocker.0 mg/kg/day – LDL < 100. verapamil. insulin + glucose.

UTI • 20-40 yrs UTI. renal carcinoma. stone. stone. metronidazole. and urinary frequency and urgency. smoking. aluminum. rifampin. vaginal bleeding. phenytoin. textile. UTI. certain food dyes. Pseudohematuria: chemical agents. and sulfasalazine • Acute prostatitis and UTIs are usually associated with dysuria. • Stones are associated with pain.Hematuria Bladder Carcinoma: • Painless hematuria without other symptoms is the most common presentation • Risks: male. • Chronic prostatitis is associated with urinary symptoms as well. and reassurance • > 40 yrs w/hematuria and normal labs/pyelogram cystoscopy would be appropriate. trauma. but a normal IV pyelogram. aromatic amines often used in dye. paint. BPH . urine culture and cytology periodic monitoring. and rubber industries. neoplasm • >40 yrs bladder cancer. beets. chloroquine. foods. fever. • <20 yrs glomerulonephritis. blackberries. • <40 yrs with hematuria.

and metabolic disorders Interstitial nephritis: eosinophils in urine. irritative voiding symptoms. no routine screening necessary • Initial dispstick method should be confirmed by evaluation of urinary sediment – Malignancy risk factors: smoking. pelvic irradiation – Radiology: IVP for upper UT. trauma. erythrocyte casts. CT (may lead to contrast nephropathy. hx of UTI. hx of urologic disorder. BPH Gross hematuria worry about malignancy. dysmorphic RBCs Renal hematuria: associated with tubulointerstitial. infection. analgesic abuse. give Nacetylcysteine). always needs a work-up Microscopic hematuria usually asymptomatic. cystoscopy for lower UT – If negative work-up follow for 3 yrs . renovascular. >40 yrs. ultrasound. calculi. hx of gross hematuria. benzene/aromatic amine exposure. often caused by analgesics or other drugs Urologic hematuria: tumors.Hematuria • asymptomatic hematuria – – – – – – Glomerular Hematuria: associated with proteinuria.

• Unilateral edema lower extremity Doppler evaluation is indicated unless history of recent trauma/inflammation • Signs of inflammation/erythema cellulitis • chronic venous insufficiency knee-length elastic stockings.Edema • many medications cause peripheral edema as a side effect. antisympathetics. rales. JVD) get chest x-ray to rule in CHF. BBs. limit prolonged standing . corticosteroids. centrally acting agents. followed by an Echo. nephritic syndrome or ATN is the likely diagnosis. • check urinalysis If sediment is abnormal. • If ascites is present liver function studies are needed. rosiglitazone. leg elevation throughout the day. NSAIDs • Bilateral edema + signs/symptoms of CHF (dyspnea. – Anti-HTN (CCBs). hormones. direct vasodilators.

generally presents with enlargement of thyroid. and increased sweating all occur with less frequency. and clinical manifestations of a bacterial illness. but is nontender.Thyroid Hashimoto Thyroiditis • -most common cause of thyroiditis. – Neurofibromas would also be cold. a female gender. weight loss. Subclinical hypothyroidism is distinguished by an elevated TSH and a normal free T 4. anorexia. a swollen thyroid. • -TSH would be elevated. • -Risk for progression: presence of thyroid autoantibodies. Subacute lymphocytic thyroiditis acute increase in thyroid size is seen. • -Thyroid receptor antibodies are very specific and differentiate Graves disease from other causes of hyperthyroidism. and a TSH level > 10 mIU/L. tremor. and the free T 3 and T 4 would be low. . – If a nodule takes up radiotracer. showing diffuse uptake. Suppurative thyroiditis associated with fever. • -Once a thyroid nodule is found radionucleotide imaging. • -Invasive fibrous thyroiditis gradually increasing gland that is firm. old age. and often there is associated tenderness. then fatigue. “hot” nodules are more likely benign. it is generally nontender. • -Radionucleotide imaging is helpful in Graves. • -will progress to clinical hypothyroidism at a rate of 2% to 5% per year. – Therefore. it is termed a “hot” nodule. and most common cause of goiter in the US • -middle-aged women. – Colloidal cysts and tumors do not take up tracer and are “cold” nodules. Subacute granulomatous thyroiditis follows a viral illness and is also associated with a mildly painful gland. Hyperthyroidism: • -elevated levels of thyroid hormones • -tachycardia is most commonly reported symptom.

weight gain. upper eyelid retraction. elevated BP. weight loss. moist skin. malignancy irregular margins. <30 or >60. enlarged thyroid. and patchy uptake with overall reduced activity in thyroiditis • Treat: propylthiouracil (prevents peripheral conversion)and methimazole (inhibits organification). depressed affect – May be confused with Alzheimer’s in older patients – Most commonly due to Hashimoto thyroiditis – Low free thyroid levels.Hyperthyroid Graves Disease • Symptoms: warm. tachycardia. family hx – Functional adenomas are rarely malignant. low TSH. and/or B-blockers. microCa – Hyperfunctioning nodules are treated with surgery or ablation – Nonfunctioning nodules >1cm require biopsy (FNA) • Follicular cell malignancy cannot be distinguished from its benign equivalent – Malignant nodules thyroidectomy followed by radioactive ablation . confusion. slowed mentation. constipation. secondary hypothyroidism have low TSH – Treat with thyroid hormone replacement (Levothyroxine) • Nodular Thyroid Disease: – Increased malignancy in children. and high TSH. dry skin. ophthalmopathy. widened pulse-pressure • Thyroid storm: sudden release of thyroid hormone. autonomous thyroid nodule may also secrete thyroixine • Diagnosis: elevated free thyroxine. resting tremor. restlessness. hx of irradiation. fever. vasodilation. cold intolerance. radioactive iodine (ideal if not pregnant) – 40% who receive radioactive iodine become hypothyroid – Medication side effect is agranulocytosis • Hypothyroidism: – lethargy. sweating. T-99m scan shows diffuse hyperactivity with large uptake in Graves. psychoticlike behavior • Cause: IgG Abs bind to TSH receptors on thyroid gland gland hyperfunctioning. hair loss. vascular.

lithium. abdominal pain. avoid inactivity.25 dihydroxyvitami D3 (calcitriol) regulate Ca – Thyroid parafollicular cells make calcitonin to lower Ca levels through renal excretion and opposing osteoclast activation. renal. familial. reduced urinary excretion or increased PTH – Rhabdomyolysis Ca released from injured muscle – Adrenal insufficiency increased bone resorption and increased protein binding of Ca – Thyrotoxicosis increased bone resorption – Familial hypocalciuric hypercalcemia defect in Ca sensing receptor Treat: hydration. arrhythmias Common causes of hypercalcemia: – Primary hyperparathyroidism sporadic. extrarenal conversion of 25 OH D3 to calcitriol – Milk alkali syndrome excessive intake of Ca containing antacids – Medications thiazides. fatigue.Hypercalcemia • • Corrected serum Ca = (normal Albumin – Pt’s albumin) x 0. poor concentration. parathyroidectomy • • • . nausea.8 x serum Ca PTH. tumor secretes PTH-rP or via direct osteolysis – Hypervitaminosis A increased bone resorption – Immobilization increased risk when underlying disorder of high bone turnover (paget’s) – Hypervitaminosis D increased calcitriol leads to increased GI absorption of Ca and P – Granulomatous TB. calcitonin and 1. constipation. sarcoidosis. this excretes Ca and P – PTH promotes osteoclast activation. physical activity. coma. short QT. weakness. breast. squamous ca of head/neck. MEN I or II. usually due to an adenoma – Malignancy solid lung. vomiting. osteoporosis. pancreatitis. hodgkins. stupor. mobilizing Ca from bone and Ca resorption at the kidneys – PTH also increases calcitriol levels which promote Ca and P absorption from GI tract Symptoms: kidney stones. arthritis. bone pain. avoid thiazides. prostate. multiple myeloma.

CVA/TIA • • • First get a brain CT without contrast. crossed signs. use of anticoagulants. uncontrolled HTN • Risk of hemorrhage is 5% Prevention: quit smoking. and small vessel disease Stroke: sudden onset of focal neuro deficit. contralateral hemiparesis. prosthetic heart valves • • • . DM. indicated if >70% stenosis. aspirin – Carotid endarterectomy can reduce risk of stroke in pt with history of TIA/CVA and carotid artery stenosis. cardiomyopathy. contralateral impaired conjugate gaze – ACA foot and leg deficits with cognitive and personality changes – Vertibrobasilar motor or sensory loss in all 4 limbs. nicardipine. patient is not a candidate for thrombolytic therapy TIA: focal neuro deficit lasting less than 24 hrs. spatial neglect. ischemic stroke caused by MI and LV thrombus. antipyretic if febrile – Give anti-HTN if systolic >220 or diastolic >120. increased risk for subsequent stroke – Risk factors: HTN. hyperlipidemia – 95% are due to atherothromboembolism. rheumatic mitral valve disease. as well as blood sugar. or. electrolytes. LDL <100. smoking. dysphagia – Cerebellum ipsilateral limb ataxia and gait ataxia Initial treatment: supplemental oxygen. dysarthria. nystagmus. often less than 1 hr. sex. age. treat HTN as per JNC-7 guidelines. or for symptomatic patients with 50-70% stenosis • Warfarin anticoagulation is useful for pts with a. IV labetalol. lasting >24 hrs – MCA aphasia. cardiac monitor. race. cautiously treat HTN. disconjugate gaze.fib. MI. if pt is suitable for thrombolytic treatment. trauma. heart disease. tight diabetic control. 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. sensory loss. drug screen If more than 3 hrs since the attack. give anti-HTN to reduce systolic <185 and diastolic <110. renal function. cardiogenic embolism. reduce EtOH.

but persistence of blinking is called Myerson sign and is common among patients with PD. Essential tremor: • bilateral. Other therapies provide symptomatic relief only. Intention tremor: • Its amplitude will increase during visually guided movements. The blinking normally stops after 5 to 10 repeated taps. and do not modify disease progression.Tremor Parkinson Disease: • tremor is typically seen at rest and inhibited by movement • glabella tap reflex is tested by percussing the pts forehead orbicularis oculi muscle contracts causing both eyes to blink. . usually symmetric and either postural (elicited by holding the arm against gravity) or kinetic (more apparent during purposeful movement). • MAO B inhibitors (selegiline) ↓morbidity and mortality in PD and delay functional impairment and disease progression.

the clock drawing test. • ↓ability to recognize & draw complex figures is an early sign of problems. ADLs. low levels of education. • MMSE. • modest improvements in cognition. with or without concomitant use of an acetylcholinesterase inhibitor. 1% meets diagnostic criteria. • Social propriety and interpersonal skills often remain strikingly preserved until late in the illness.individuals with a first-degree relative with the disease are 4x more at risk • other risk factors: female gender. • 3 cholinesterase inhibitors for treatment: donepezil (Aricept). AMS • history of HTN think of multi-infarct dementia. Dementia. and global measurements of functioning. • abrupt onset of a mental status change is consistent with delirium. but disorientation may occur later in the illness. • ↓ metabolism of acetylcholinesterase. • narcotic excess pinpoint pupils • DTs dilated pupils and sympathetic outflow • EtOH withdrawl hyperalert confusion • Amphetamine withdrawal psychomotor slowing. Lewy Body Dementia: begins similarly to Alzheimers. rather than delirium (focal neurologic deficits and papilledema) • in dementia.Delerium. CV risk factors. • Remote memories are well-preserved initially. and the prevalence doubles every 5 years • Family hx is risk factor. or other brief screening tools may be most useful in the diagnosis. • donepezil modest clinical improvement but no difference in rate of institutionalization or progression • Pts with advanced disease have benefit from Memantine. • Difficulty with word-finding is also noted early. Alzheimer’s Disease: • ↑age is the strongest risk factor. behavior. thereby prolonging its action at cholinergic synapses. and a history of head trauma. By 65. galantamine (Reminyl). but pts develop complex visual hallucinations and spontaneous signs of parkinsonism . the level of consciousness is not clouded. as is loss of the ability to calculate. • Structural imaging is important to rule out other causes as well and may include either a CT scan or an MRI. • no labs to independently confirm a diagnosis of Alzheimer disease. & rivastigmine (Exelon). • they do not change the progression of neurodegeneration. ability to recall new information is lost early in the illness.

hypothyroidism. lewy body dementia. AIDS . neurosyphilis. chronic alcohol abuse. Rivastigmine Alzheimer’s dementia: Tacrine – must monitor liver enzymes Severe: Memantine • Vascular Dementia: multi-infarct dementia is the second most common cause of dementia – Symptoms related to amount and location of neuronal loss – Sudden onset and progresses in a stepwise fashion • Other illnesses associated with Dementia – Parkinson disease. sedative use. anticholinergic use. like the MMSE. normal pressure hydrocephalus. Galantamine. to confirm presence of dementia Depression in elderly can present with symptoms of memory disturbance = pseudodementia Hypothyroidism. B12 deficiency. B12 deficiency. and neurosyphilis can also present like Alzheimer’s Treatments: cholinesterase inhibitors • • • Mild-moderate: Donepezil. hypoNa.Dementia • Alzheimer’s Disease: most common cause of dementia – – – – – – Definitive diagnoses by neuritic plaques and neurofibrillary tangles on autopsy Gradual onset and progression of cognitive dysfunction in more than 1 area of mental function Should use a validated test.

• Tilt table testing is recommended in pts with unexplained recurrent syncope if cardiac causes have been ruled out. carotid massage. orthostatic BP. especially if associated with other psychiatric symptoms (anxiety. • Psychiatric eval should be considered if the tilt table is normal. ECG. • Stress testing is indicated if there is high risk for. Echo. fear. ischemic disease. serum creatine kinase. depression. & evaluation of pulses should be done • Additional testing Holter monitor. or symptoms of. or dread).Syncope • Hct. ambulatory loop ECG. glucose. • Carotid Dopplers and MRI of the brain should be reserved for people with bruits or focal neurologic signs. • An abnormal result suggests vasovagal syncope. & tilt table testing yields a diagnosis in 5% of patients. .

thiazides are drugs of choice Stroke prevention: stroke incidence doubles with each 10 yrs.Geriatrics • Hearing screening: 1/3rd of those >65 and ½ of those >85 have some hearing loss. central auditory processing disorder • most common cause of hearing loss in the elderly. 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. macular degeneration. noise-induced hearing loss. shopping. dressing. age related sensorineural hearing loss associated with selective high frequency loss & difficulty with speech discrimination – Noise induced: tinnitus. eating. problems hearing background noise – Otosclerosis: autosomal dominant. cataract. greatest risks are HTN and a. toileting Vision screening: Snellen chart or Jaeger card is most sensitive and specific screening – Vision loss: presbyopia.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. continence. cerumen impaction. transferring from bed to chair. atrophy of cells in central macular region of retinal pigment epithelium. diabetic retinopathy – Age related macular degeneration is the leading cause of severe vision loss in elders. Zoster • • • • • • • • • • • . whispered voice test – Presbycusis. laundry – ADLs: bathing. 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. cleaning. DEXA scan if >65 Immunizations: >65 get annual influenza & 1 pneumococcal shot. booster of tetanus & diphtheria shot. managing $. cooking. taking meds. difficulty w/ speech discrimination. glaucoma. otosclerosis. telephone.

invasive cervical cancer. fever. intestinal isosporiasis. coccidiodomycosis. cervical dysplasia. disseminated/extrapulmonary histoplasmosis. ground glass appearance – Commonly seen with candidiasis. burkitt lymphoma. ITP. wasting syndrome Diagnosis: positive ELISA tests should be confirmed by western blot – HIV RNA levels. oral hairy leukoplakia. recurrent pneumonia. etrapulmonary crptococcus. mycobacterium TB. get PPD. most experience clinical latancy for 6-9 months after primary infection Category A: asymptomatic HIV. Kaposi sarcoma. Hep B and A vaccine should be given. dyspnea that worsen over a few days to weeks. PML. persistent generalized lymphadenopathy Category B: symptomatic conditions indicative of defect in cell mediated immunity – Bacillary angiomatosis. CMV. diarrhea. toxoplasmosis of brain. HIV encephalopathy. listeriosis. known as seroconversion syndrome. PCP.HIV/AIDS • PCP pneumonia is an AIDS defining illness in someone with HIV – Nonproductive cough. hypoxic – Bilateral interstitial infiltrates on xray. immunoblastic lymphoma. MAC. CD4 <200 with or w/o symptoms is considered a diagnosis of AIDS – Bronchi/trachea/lung/esophagus candidiasis. PID. HSV chronic ulcers/bronchitis/pneumonitis/esophagitis. fatigue. brian lymphoma. candidiasis. CD4 levels should be monitored – Do initial screen for STDs. recurrent salmonella septicemia. herpes zoster Category C: AIDS defining illnesses are present. low grade fever. myalgias. febrile. peripheral neuropathy. Kaposi sarcoma. tachypnic. Pap smear Treat: give annual influenza vaccine. intestinal cryptosporidiosis. wasting syndrome – Give prophylactic treatment with TMP-SMX in pts with CD4<200 Initial HIV exposure: nonspecific symptoms. offer pneumococcal vaccine if CD4 <200 – Live virus vaccines are contraindicated in HIB pts and their close contacts – Prophylaxis against PCP with TMP-SMX when CD4 <200 – MAC prophylaxis with azithromycin or clarithromycin if CD4<50 • • • • • • . primary HIV.

During this time. but it is generally not done because ganciclovir (the primary prophylactic agent) can cause neutropenia. . window period of several weeks .4 months between infection and seroconversion when tests may be negative. CMV prophylaxis can be instituted in those with CMV IgG positivity and with CD4 counts < 50 lymphocytes/mm 3. 5 mm is considered a positive test. herpes simplex and zoster is not generally done. plasma HIV RNA should be ordered. In HIV-infected individuals. Prophylaxis for fungal disease. corticosteroids improve course of pts with moderate to severe PCP with O2 sat < 90% or a PaO 2 < 65 mm Hg. 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.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. If there is strong clinical suspicion. More HIV infected women die of cervical cancer than from AIDS Pap testing every 6 months. but not have sufficient levels of antibodies to result in + tests. PCP: treatment of choice is TMPSMX for 3 weeks. pts may be viremic & infectious.

beneficence. self-sufficient. nonmaleficence. pregnant or a parent.Ethics – Emancipation: person younger than 18 petitions to be declared a legal adult • Live apart from parents. married. declared so by judicial system – Mature Minor/Judicial Bypass: minor may consent to receive care w/o parent consent if deemed mature by the judicial system – Ethical Principles: autonomy. justice . in the military.

then height. including hypothyroidism. palpable mass pyloric stenosis. ab distention. the majority of FTT is 2ndary to inadequate nutrition & a dietary history is most likely to reveal the cause. FTT & constitutional growth delay weight ↓first. breast-fed infants weight ↓relaƟve to peers aŌer 4 to 6 months. severe malnutrition.Growth Charts • • • • • • • • • • • • • • • • concern should be raised when a child drops > 2 %ile brackets on a growth curve and does not maintain at that area. is found in < 10% of cases of FTT. . get ultrasound familial short stature growth curve shows simultaneous changes in height and weight. FTT + diarrhea or melena inflammatory bowel disease may be considered. hypothyroidism height velocity slows first and may plateau before weight changes. Organic disease. and a hemoccult test would be necessary. ab pain. Hospital admission is indicated for FTT if: hypotension. foul-smelling stools lactose intolerance may be considered. Prealbumin is ↓in acute inflammaƟon and undernutrition and is therefore insensitive. bradycardia. IgA levels are sensitive to undernutrition and would be ↓in FTT. In the US. Albumin has a long half-life and is a poor indicator of recent undernutrition. FTT + diarrhea. lactose tolerance test FTT + projectile vomiting. but catches up aŌer 12 months. FTT + diarrhea and recurrent respiratory infections cystic fibrosis must be considered FTT + wet burps/emesis/cough get esophageal pH probe.

play simple games. runs. throws. knows first and last name 4 yrs: body parts. 1-3 words. stranger/separation anxiety 2 yr: walk up/down stairs. ties shoes. parallel play 3 yr: copies circle. refers to self by name. rolls prone to supine. bye-bye. 3 numbers. eye contact 2 mo: eyes to midline. ½ understood speech. transfers objects. skips. kicks ball. crawl. laughs/squeals. vocalizes. count 10 objects 6 yrs: draws person. head prone. recognizes strangers 9 mo: pincer grasp (10). identifies left and right • Strabismus: asymmetric light reflex. forward facing seat 20-40 lbs. tricycle. copies line. rolls over. regards hand 6 mo: sits unsupported. mama/dada. 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. responds to noise. recognizes parent 4 mo: eyes past midline. starts to explore 12 mo: walks. tells a story.Well Child Care • • • • • • FTT: weigh below 3rd-5th %. copies cross/square. completely understood. throws overhand. uses past tense. 1 step command. sentences. writes name. group play. 2-3 word phrases. cruises. refer to ophthalmologist . ¾ understood. dresses self. social smile. hops. 3 colors. booster seat until 4 ft/60 lbs Developmental Milestones: – – – – – – – – – – – 1 mo: reacts to pain. babbles. regards human face. pronouns. knows gender. social interaction 5 yrs: copies triangle. catches ball.

possible contrast study • Intussusceptions: intermittent severe pain with gradual and slow bowel telescoping. barium enema will be diagnostic and therapeutic • Pyloric stenosis: olive shaped mass palpable in the RUQ. get an upper GI series. surgery is treatment • Foreign bodies: flat disk batteries need immediate intervention. surgery consult. nonbilious vomiting after meals. peristaltic waves across upper abdomen. bilious vomiting and abdominal pain. currant jelly stools. most objects will come out in stool • Poisoning: another cause of vomiting and ab pain in children . sausage shaped mass. ab xrays. beaklike appearance of contrast medium. NG tube. projectile vomiting between 3-6 wks. bilious vomiting. mass if often at the ileocecal junction. GI contrast shows double track sign • Malrotation: 60% are less than one month.Abdominal/Vomiting Pain (Peds) • First steps: IV fluid hydration.

separation of growth plate with the femoral head being posteriorly displaced. obligate external rotation on passive flexion Septic Arthritis: monoarticular and associated with systemic signs. normal WBC. and widening of the femoral head. abducted.000 Legg-Calve-Perthes: avascular necrosis of the femoral head in children 4-8. usually because of pain during weight bearing SCFE: most common nontraumatic hip pathology in adolescents. treatment is conservative. more common in boys. and externally rotated. low grade or no fever. pain with internal rotation of the hip and overall ROM limited by pain. joint must be aspirated. or knee pain and limping. collapse. normal ESR. strep pyogenes. often after a viral infection. gradual onset of hip.Limping and Pain (Peds) • • Antalgic gait: when stance phase of gait is shortened. high risk of developing degenerative arthritis • • • • • . staph aureus.000 Toddler’s Fracture: spiral fracture of the tibia that results from twisting while the foot is planted. treat by surgically pinning the femoral head – Common in obese adolescent males – Pain with internal rotation of the hip. 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. flattening. thigh. purulent aspirate with WBC > 50. children lay with their hip flexed. GBS. yellow-clear aspirate with WBC < 10.

staph aureus. drooling. blood-streaked saliva. severe sore throat. drooling. dysphagia – Tripod position with neck hyperextended – Thumb sign on xray. dyspnea – Supplemental O2 and supportive care are the modes of treatment – Nebulized epinephrine. and includes rhinorrhea. CBC shows leukocytosis.Non-Asthma Wheezing (Peds) • • • Acute wheezing infectious or mechanical obstruction Chronic wheezing anomalies of tracheobronchial tree. beta hemolytic strep – Child looks toxic with fever. mycoplasma. cough. neutrophilia. unilateral wheezing. GERD. wheezing. wheezing. hoarseness. stridor – Parainfluenza. strep pneumo. esp infants 1-3 mo – RSV accounts for 70%. cyanosis. rhinovirus. vomiting. decreased breath sounds. ipratropium or corticosteroids may be helpful – RSV Ig can be given before RSV season for children younger than 2 born prematurely Croup: most common airway obstruction in children ages 6 mo – 6 yrs – Inflammation of the subglotting region that produces barking cough. enterovirus. may attempt opening the airway with head tilt • • • . nebulized epinephrine Epiglottitis: bacterial infection of supraglottic tissue usually in children younger than 5 yrs – H. CV disease. RSV. corticosteroids. high pitched sounds or no sounds during inhalation. the rest are parainfluenza. influenza viruses – Runny nose and low grade fever prodrome – Steeple sign on radiology – Give coolmist therapy. bandemia – Treat with airway management and antibiotics Foreign body airway obstruction: most common from 6mo – 3 yrs – Weak cough. immunologic disorder Bronchiolitis: most common cause of acute wheezing in children < 2yrs. choking. metapneumo – Diagnosis is clinical. inability to speak or cry. influenza. muffled speech. stridor – Do not to a blind finger sweep. adenovirus. irritability.

erythematous eruptions that feel like sandpaper. fever and mild respiratory symptoms that last for 5 days. rash often starts as an erythematous maculopapular eruption that progress to form petechiae. fatigue. elevated liver enzymes. hypotension. rheumatic fever. low WBCs. rash disappears in 1-2 days and no treatment is usually necessary Varicella: – fever and rash which develops in clusters. infects most children before age 3. expanding erythematous macule with a central clearing looking like a bully’s eye. glomerulonephritis. headache. treat with doxycycline Lyme Disease: – erythema migrans develops 3-30 days after infection. rash of scarlet fever starts 2 days after onset of sore throat. transmitted by tick. rash starts on upper trunk and spreads to the rest of the trunk and extremities. resulting in hydrops Group A Beta-Hemolytic Strep: – can cause strep pharyngitis. prophylaxis for close contacts with rifampin Rocky mountain spotted fever: – acute.Fever and Rash (Peds) • • Roseola: – HHV6. slapped cheek appearance. raised. meningeal irritation. may be given to fetus during pregnancy. confirmed with Tzanck smear or DNA probe. rash starts as confluent erythematous macules on the face and spares the nose and periorbital regions. rash lasts 2-4 days followed by lacy pruritis exanthema on the trunk and extremities lasting 1-2 weeks. treat with oral doxycycline • • • • • . confirm infection with rapid antigen testing or culture and treat with PCN Neisseria Meningitidis: – high fever. low platelets. rash is punctuate. the classic exanthema is a macular. strawberry tongue is common. exanthema is often papules or vesicles on an erythematous base. rash fades and desquamation occurs 4-5 days after the first appearance of rash. popular or petechial eruption that starts on the wrists and ankles. life-threatening infection caused by rickettsia rickettsii. altered mental status. crusted erosions. followed by an erythematous maculopapular rash that suddenly appears. myalgia. vesicles progress to shallow. acute fever. dewdrops on a rose petal. 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.

Enuresis alarms have been shown to be an effective treatment for nocturnal enuresis. frequency.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. chronic constipation. Non-monosymptomatic: bed-wetting associated w/urgency. If both parents. 40% likelihood child will be. straining. Secondary monosymptomatic enuresis: recurrence of bed-wetting after at least 6 months of nocturnal continence. Family history is important 1 parent enuretic. cause is unknown felt to be due to ↓producƟon of nocturnal ADH. 25% of 5-year-olds are enuretic. DDAVP can also be effective. associated with a maturational delay. but relapse rate is high once the medication is discontinued. Frequent nighttime wakening may be effective. encopresis . but compliance is a barrier to effectiveness. pain. 70% risk.

and reassurance – Outside puberty. Mastitis: occurs with nursing. serous. but diagnostic mammogram should be performed in 6 mo – BI-RADS 4 and 5 are suspicious for. physical. Mammograms: Up to 15% of breast cancers are mammographically silent. and is characterized by inflammation. – continue nursing. and if so. or if the mass reappears within 1 month. – BI-RADS classification 0 means that the test was incomplete. exam. – ↓caffeine and methylxanthines. Spontaneous. or using evening primrose oil may ↓symptoms – Cysts: range in size from 1 mm to > 1 cm in size. but biopsy is still necessary if the mass is palpable after aspiration. unilateral discharge is most suspicious for breast cancer. – may be asymptomatic or painful. or unilateral. and start antibiotic that covers streptococcal & staphylococcal infections. and routine screening can be conducted at usual intervals. if the fluid is bloody. assessment of hepatic. bilateral. – commonly occurs around puberty. and additional testing should be conducted ASAP – BI-RADS 1 & 2 mean that the mammogram is benign. – Sex hormones are only tested if progressive enlargement is noted. serosanguineous. well-circumscribed. and thyroid functions may help uncover a cause. cancer (respectively) and tissue diagnosis is needed Gynecomastia: benign enlargement of the male breast. palpable mass deserves further workup. Most cases resolve within 1 year. bloody. – BI-RADS 3 indicates the lesion is probably benign. requires only a history. renal. and highly suggestive of. even if the mammogram is negative do an ultrasound to determine if the mass is cystic or solid. and erythema in areas of the breast.Breast Changes • • • • • • • • Fibrocystic Changes: most common benign condition of the breast. or watery discharge deserves a workup as well. Fibroadenomas: rubbery. • . abnormality seen on a mammogram is classified using the breast imaging reporting and data system (BI-RADS). and freely mobile. nontender. Aspiration of the mass may be appropriate. and possible biopsy. smooth. edema.

persistent. HRT use.Breast Disease • • Breast cancer risks: family hx of breast cancer. or a lesion that recurs requires more evaluation. late age menopause. 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. nulliparity. cancer. first birth after age 30. duct ectasia. bilateral and related to menstrual cycle – Noncyclic mastalgia: unilateral and more common in postmenopausal – Nonmammary pain: pain not from the breast. severe pain can be treated with danazol Nipple Discharge: usually benign. infection – Pt should get mammogram – Treatment of most unilateral. associated with a mass. caffeine elimination. hyperprolactinemia. pregnancy • • • • • • . spontaneous or bloody nipple discharge is surgical excision of the terminal duct involved Galactorrhea: hypothyroidism. is more likely to represent a pathologic process – Most common non-benign causes are intraductal papilloma. stress reduction. a mass that doesn’t resolve. EtOH use Palpation of a new breast mass should prompt a FNA – Clear. pituitary adenoma. discharge that is spontaneous. bloody. medications. physical inactivity. primrose oil will help with breast pain. 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. from a single duct. early age menarche. but usually from the chest wall – Life style changes such as smoking cessation. obesity.

after ovulation. estrogen builds up the endometrial lining. endometrial biopsy. anovulatory bleeding is usually responsive to treatment with OCPs or progestin • • • • • • . 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 compacts the endometerium. nulliparity. weight loss Endometrial Cancer: risk factors are a history of anovulation. or unopposed exogenous estrogen – Work up: transvaginal ultrasound. if conception does not occur.Menstrual Cycle Irregularity • • • Normal menstruation: estrogen production by the ovaries is regulated by the hypothalamus and pituitary. 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. respectively PCOS clinical picture: obese. over age 35. use of tamoxifen. 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. hysteroscopy with D and C can be therapeutic If the work up for abnormal bleeding does not reveal malignancy. the corpus luteum produces progesterone. the production of progesterone abruptly decreases. exercise. 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. obesity.

accounting for ~ 95% of cases. Hypothalamic failure: anorexia nervosa. clinically very hard to distinguish from other more common causes. no menses at 14 in the absence of secondary sex traits • usually the result of a genetic or anatomic abnormality (gonadal dysgenesis. infiltrative processes. Postmenopausal Bleeding: needs an endometrial biopsy to rule out endometrial cancer. Turner syndrome) • amenorrhea + ↑testosterone & DHEA-S CT of adrenal glands & ultrasound of ovaries to rule out neoplasm. pituitary adenoma. and symptoms include irregular or absent menses. Secondary Amenorrhea: • Pregnancy is the most common cause • Polycystic ovarian syndrome is common and is responsible for ~ 30% of the cases of secondary amenorrhea. history of head trauma. acne. chronic or systemic illness. • No withdrawal bleeding after estrogen-progestin challenge outflow obstruction or anatomic defect. • -androgen excess. generally associated with normal breast development. or craniopharyngioma. progesterone from the corpus luteum is not secreted • most common cause of dysfunctional uterine bleeding in women < 20. hirsutism. severe stress suppression of hypothalamic GnRH Pituitary failure • -inadequate GnRH stimulation.Menstrual Cycle Irregularity Primary amenorrhea: • No menses at 16 in presence of normal secondary sex characteristics. excessive exercise. Anovulatory Bleeding: • caused by continuous unopposed endometrial estrogen stimulation. Polycystic ovarian syndrome: • -primary amenorrhea. uncommon in girls. • When no withdrawal bleeding either inadequate estrogen production or outflow tract obstruction. and virilization Constitutional delay of puberty: common in boys. • Primary amenorrhea w/normal secondary sex characteristics & normal initial labs progestin challenge test. . shock.

and Pap can be repeated in 1 year. Pap can be repeated 1 wk after a course of vaginal estrogen (4 wks). atypical glandular cells (AGUS) colposcopy. If next repeat Pap is negative. frequency of testing can return to normal.6 months & 1 year. HPV testing. If the repeat is normal. If patient is postmenopausal and not taking estrogen. ASCUS. ASCUS + HPV testing is positive colposcopy (if over 33 yrs) or wait for infection to clear (if under 33 yrs) ASCUS. colposcopy can be considered.Pap Smear Results • • • • • • • • • ASCUS repeat in 4 . If the smear remains abnormal. HPV testing unavailable colopscopy or repeat the Pap smear in 4 -6 mo. or endometrial biopsy if the atypical cells are of endometrial origin . If repeat Pap has results of ASCUS or higher. Pap should be repeated in 12 mo and the frequency of testing can return to normal. a colposcopy should be performed. If you perform a colposcopy and no CIN is found. the pt is low risk for cancer. favoring LSIL colposcopy. If the HPV testing is negative. Pap should be repeated again in 4-6 mo. or colposcopy.

and where surgical emergencies can’t be ruled out. is a diagnostic clue. • In many women of childbearing years. • Inpatient treatment w/parenteral antibiotics for pregnant women. dysuria. a symptom of pregnancy. 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. • smooth mobile adnexal mass with peritoneal signs if the cyst ruptures. may be necessary for those who fail outpatient regimen Ectopic pregnancy: • pain is colicky. pts with severe illness with fever & vomiting. • any adnexal mass should be evaluated by transvaginal ultrasound and referral for surgical removal. • Treatment should provide coverage for N. anaerobes. and may radiate to the shoulder if there is a significant hemoperitoneum. gradual in onset and bilateral. palpable cysts < 6 cm may be monitored with repeat pelvic exam. Ovarian Mass • 80 % of ovarian masses in girls < 15 years are malignant. vaginal discharge.trachomatis. C.Pelvic Pain Ovarian cysts: • unilateral dull pain that can become diffuse and severe if the cyst ruptures. • Nausea. . adnexal masses are commonly cysts.gonorrhoeae. PID: • fever. • If the pain is not acute or recurrent.

– do not ↑risk for thromboembolism. BP usually returns to normal within 3 months. male pattern baldness. nausea) & estrogenic (nausea. and patients should be screened carefully • • • • . because of ↑risk of thromboembolic events. but there is FDA approval for use in others as well. 2 pills should be taken immediately & a backup method used for 7 days. obesity. Progestin-only pills: – ovulation suppression. androgenic (hair growth. 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. Once disconƟnued. endometrium alteration. fluid retention). If intercourse occurred in the previous 5 days. A backup method should be used for 5 days. risk ↑with age. or HTN. If an active pill is missed. & tubal transport inhibition. – effectiveness of this method is dependent on consistency of use. cervical mucus thickening. breast tenderness. OCPs containing estrogen and progestin components are contraindicated in smokers > 35 yrs. PE. emergency contraception should be used immediately & pills restarted the following day. DM. – Nursing women can use this pill. but multiple studies have failed to show it to be statistically significant side effect most cited as the reason for stopping use is irregular bleeding common in first 3 mo 3x risk of venous thromboembolism. – no hormone-free period with these pills. and they should be taken every day. protective effect against ovarian cancer and endometrial cancer.OCPs • • • • • • • may cause small ↑in BP. Weight gain is thought to be common. and no intercourse has occurred in 5 days. and the WHO has reported this to be safe for women with a history of VTE.

complications include perforation. septic abortion. congenital hyperlipidemia OCPs offer significant protection against ovarian cancer. PID. and fibrocystic breast disease Minipill reduces cervical mucus and causes it to thicken • • • • • • • • • Depo-Provera: injectable progestine every 14 weeks Transdermal: similar to OCPs Intravaginal Ring Spermicide used alone: when used with a condom. cervical mucus changes Emergency contraception: high doses of COPS within 72 hrs decrease pregnancy risk by 74%. recommended for women in mutually monogamous relationships. breast cancer. ectopic pregnancy Natural Family Planning: measure basal body temp. Fe deficiency anemia. endometrial cancer. abnormal vaginal bleeding. HIV. high risk of PID. impaired liver function.Contraceptives • Hormonal contraceptives – – – Contraindicated if >35 and a smoker. coronary occlusion. failure rate is similar to OCPs Condoms: effective at preventing STDs Diaphragm: spermicide must be placed inside the diaphragm for it to be effective. inhibits transport of sperm through mucus and uterus. PID. pregnancy. mifepristone is effective after 72 hrs. anatomically distorted uterine cavity. leave for 6 hrs IUD: alters the uterine and tubal fluids. contraindicated if recent/recurrent endometritis. thromboembolic disease. 2 oral doses of levonorgestrel (plan b) . or STD. cerebral vascular disease.

• limited hormonal exposure. • no medical contraindications • do not disrupt an already implanted pregnancy and do not cause birth defects. and combined ECPs prevent 75% . or MI.Emergency Contraception • should be used within 72 hrs of intercourse. and have not been shown to increase the risk of VTE. • Progestin ECPs prevent 85% of expected pregnancies. stroke. well before implantation (5-7 days after intercourse).

HTN. vancomycin • • • • • • • . heart block. neuro abnormality. erythromycin. epidural anesthesia.5 in vaginal fluid on Nitrazine paper. and <1 hr in parous Third stage of labor: after delivery of baby and ends with delivery of the placenta. longer lasting more coordinated – Active phase. ferning on air-dried microscope slide First stage of labor: onset of labor until cervix is completely dilated – Latent phase. DM. external rotation Variability: – Decreased in sleep. oxytocin. CNS depressants. <30 minutes Progress of labor is determined by: Power. pelvis Fetal Heart Rate: normal is 110-160 – Bradycardia: maternal hypothermia.5 cm / hr Second Stage of labor: from complete cervical dilation until delivery of the fetus – Normally lasts less than 2 hrs in nulliparous.2-1.ampicilin. acidemia GBS: – Penicillin in labor. cephalothin.starts at 3-4 cm of cervical dilation and goes at 1. extension. prematurity. passenger. meds. late decels are after contractions and show uteroplacental insufficiency/maternal hypotension. pH >6. variable decels are due to umbilical cord compression during contractions Cardinal Movements: Flexion. clindamycin.L&D • • ROM: visualize fluid. alternatives. 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. Internal Rotation.contractions become stronger.

00017 rads) Folic acid: low risk women should take 500 micrograms. 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 • • • • • • • . UA. 1-1. estriol. 3 wks in 3rd Radiation exposure: risk for baby only if >5 rads (dental xray is 0. Hb/Hct. blood type. Pap.Prenatal Care • • • • • • • • First prenatal visit: CBC. 4mg if previous child with NTD Use methyldopa and CCB to treat HTN. 1mg if high risk. accurate within 1 wks in 1st tri. give RhoGAM if necessary GBS: screen at 35-37 wks via swab of lower vagina. UC. Rh. AFP – Quadruple screen: adds inhibin. 2 wks in 2nd tri. 80% sen Amniocentesis: 15 weeks. then every week Ultrasound not required if uncomplicated. thiazide in first 2 trimesters Trisomy screening: ideally between 16-18 wks – Triple screen: 65% sen. RPR. 95% sp. HBsAg. varicella and rubella not during pregnancy Assumption of Fetal Maturity – Heart tones documented for 20 wks by nonelectonic fetoscope. GC/Chlam Naegele’s rule: subtract 3 mo and add 7 days to first day of LMP Follow-up visits every 4 weeks until 28 wks. ARB. perineal area.tests hCG. then every 2 weeks from 28-36 wks. HIV. rectum – Give intrapartum Abx if positive. avoid ACE.5% risk of spontaneous abortion CVS: 10-12 wks. or if previously positive in past pregnancy Flu and tetanus toxoid can be given during pregnancy. rubella. 0. may be associated with limb defects Gestational DM: screen at 24-28 wks with 1hr glucose challenge – If >135.5% risk of spontaneous abortion. do 3 hr GTT 28 weeks: repeat RPR.

coagulopathy – Uterine atony is most common cause give IV oxytocin and do bimanual massage • Methylergonovine is 2nd line but contraindicated in HTN • Prostaglandin F2alpha is third line. lacerations/inversion. emotional lability – Postpartum depression: onset within 4 weeks of delivery and seen up to a year later • Same symptoms as major depression. retained placenta. reduced ovarian and breast cancer. wound infections. active herpes. but contraindicated in asthma Fever: – Often a sign of endometritis treat with broad spectrum antibiotics – UTI. high recurrence rate in future pregnancies • Treat with SSRIs – Postpartum Psychosis: manic or delusional behavior within a few days to weeks of delivery • • . convenience. acute/active Hep B – Breast feeding women should use the progestin-only minipill for hormonal contraception In women not breast-feeding. atelectasis. VTE Mood disorders – Maternity blues: develop in the first week and resolve by 10th day postpartum • Tearfulness. faster weight loss. menstruation begins by the 3rd postpartum month Breast engorgement occurs 1-3 days after delivery Hemorrhage: – Early if within 24 hrs of delivery. sadness.Postpartum Care • • • • • • Postpartum= 6-12 weeks after delivery of placenta Breast feeding benefits: rapid return of uterine tone. reduced bleeding. low cost Breast feeding contraindications: HIV. late if >24hrs – 6 weeks after delivery – Most commonly caused by uterine atony.

• Hyperactivity is the most problematic feature for children with ADHD because it tends to be most disruptive and socially unacceptable. but are not necessarily features of ADHD. Mirtazapine and tricyclic antidepressants are less preferred for patients with obesity.Psych PTSD • reexperiencing a traumatic event. inattention remains relatively stable through the lifespan of the illness. • hyperactivity and impulsivity tend to peak between the ages of 6 and 10. • Alcohol and drugs are commonly used by the patient to self-treat. sertraline & paroxetine have FDA indications for treatment. . • Alprazolam can be used. • bulimics sense a lack of control over eating during binging. • Oppositional behavior and conduct disorders may be comorbid. Patients experiencing hypersomnia and motor retardation should avoid nefazodone and mirtazapine. Bupropion is contraindicated for patients with seizure disorder. and symptoms may change Deficits in executive function tend to be more salient (poor organization or time management) and hyperactivity may be replaced by restlessness. enemas. Patients who report agitation and insomnia should avoid bupropion and venlafaxine. ADHD: • 50% to 75% of kids will continue to exhibit symptoms into adulthood. Anorexia + Bulemia: • Both disorders involve self-evaluation that is unduly influenced by body weight and/or shape. Hypertension is a relative contraindication to venlafaxine. anorexics often feel a strong sense of control. • Antidepressants can ameliorate symptoms. • Both engage in inappropriate behaviors to prevent weight gain. Nefazodone should not be used in patients with liver disease. • binge eating or purging are characteristics of bulimia. • In adults. there is a binge eating/purging subtype of anorexia • Both bulimics and binge eating/purging subtypes of anorexics may use diuretics. ADHD may be more subtle. and laxatives. • treating ADHD in adolescents actually ↓the risk of substance abuse when compared to children not treated. but there is significant concern for dependency problems.

fatigue. dry mouth. inadequate duration of therapy. or inadequate dosing Treat at least 6-9 months after first episode of depression • • • • • • SSRI: increase serotonin by blocking presynaptic reuptake. no sexual side effects Trazodone: side effect of priapism. suicidal thoughts Causes clinically significant distress or impairment of functioning. decreased concentration.Depression • • • • • At least 5 of the following for a 2 week period: depressed mood/loss of interest or pleasure plus: weight change. takes 4-6 weeks before therapy works. weight gain. cocaine. agitation SNRI: act on serotonin at low doses and NE at high doses.hypothyroidism. second line if SSRIs fail TCA: affect reuptake of NE and serotonin. psychomotor change. need tyramine restricted diet to avoid hypertensive crisis Buproprion: contraindicated in seizure disorder or eating disorders. side effects of sedation. EtOH. GI disturbance. sedatives. side effects are sexual dysfunction. anemia. sexual disturbance. worthlessness. narcotics. sleep change. good to use as a sleep aid . steroids Depressed pts with CVD have a greater chance of dying of a heart attack Treat: pharmacotherapy with psychotherapy is most effective – – Treatment failure is usually due to medication noncompliance. urinary retention. weight gain. not due to another cause Also consider. potentially fatal in overdose MAOIs: increase serotonin and NE released during nerve stimulation. fatigue/loss of energy. dry eyes.

sympathetic hyperactivity – Benzodiazepines are the drug of choice for managing EtOH withdrawal Intervention: 5-10 min discussion with Dr. palpitations. can lead to significant reduction in risky drinking • • • • • • • . Important social. Persistent desire or unsuccessful efforts to cut down or control. Great deal of time spent in activities necessary to obtain substance or recover from effects. 1 shot spirits Substance induced depression: depression arises in association with EtOH intoxication or withdrawal – Antidepressant medication is likely to be ineffective.Alcohol and Substance Abuse • • • Tolerance: increased amount or diminished effect Withdrawal: withdrawal syndrome or need of substance to avoid withdrawal symptoms Dependence: Substance taken in larger amounts or over more time than intended. 77-96% specific for answering 2 or more with “yes” At-Risk Drinking: men age 65 or younger with >4 standard drinks in a day or <14 in a week. 1 5 oz glass of wine. tremor. recurrent use in physically hazardous situations. legal problems. anxiety. agitation. if not harmful. GI upset. Use is continued despite knowledge of having a persistent or recurrent problem caused by it Substance abuse: if patient does not meet criteria for substance dependence and one or more of the following are evident failure to fulfill major role obligations. sweating – Seizures can occur with in 6-48 hrs – Hallucinations can occur within 12-48 hrs – DTs occur within 48-72 hrs. depressed mood.hallucination. consider other causes of depression EtOH withdrawal: tremulousness. insomnia. continued use despite persistent or recurrent social/interpersonal problems caused or made worse by the substance CAGE: Cut down? Annoyed? Guilty? Eye-opener? – 72-91% sensitive. men>65 and all women with >3 drinks in a day or >7 in a week Standard Drink: 14 g EtOH: 1 12 oz beer. sleeplessness. recreational activities given up or reduced because of substance. occupational. to a pt with EtOH problem – If symptoms persist >4 wks after EtOH discontinuation.

hyperthyroidism. • specificity is low. mouthwashes. • Early symptoms: lacrimation. Relapse is common during the crash Opiates: • withdrawal is not life-threatening in otherwise healthy adults. • For EtOH abuse. but can cause severe discomfort. and other forms must be avoided • Acamprosat: most effective at reducing EtOH relapse. HF. regardless of the form. • ratio of AST:ALT may help distinguish between alcohol and nonalcoholrelated liver diseases • Ethyl glucuronide (EtG) urine test detects recent EtOH consumption.Alcohol and Substance Abuse EtOH: • Elevated GGT is shown to be more sensitive than an elevated MCV. • An ↑MCV is 96% specific for alcohol abuse with a 63% predicƟve value.. and vomiting. it is ↑in nonEtOH liver disease. rhinorrhea. & anticonvulsant use. with bone pain. alcohol in cough medicines. flushing. naltrexone works by ↓the reinforcing effect of EtOH (not allowing pts to become drunk) • Disulfiram: negative reaction to ingested alcohol. and diaphoresis. pancreatitis. yawning. abdominal cramping. nausea. or AST. but says nothing about the level of consumption or abuse. ALT. and mood lability. nausea. . • Naltrexone: helpful for both opiate addiction and alcohol addiction. DM. • Restlessness & irritability occur later. • cocaine withdrawal extreme fatigue and significant depression. affects both GABA and glutamine neurotransmission with greater and longer lasting effects than naltrexone Cocaine: • Stopping cocaine use does not produce a significant physiologic withdrawal. diarrhea. saturates opiate receptor sites and leaves them unavailable for opiate attachment. Its value is in the monitoring of those patients who are committed to abstinence. • Intoxication with cocaine does produce elevated HR and BP.

It is safe in persons with seizure disorders.Smoking • 5As approach to tobacco use and cessation – Ask about tobacco use – Advise to quit through clear personalized message – Assess willingness to quit – Assist to quit – Arrange follow-up and support Buproprion: blocks uptake of norepinephrine and/or dopamine. and therefore can be taken while a person is still smoking. side effects include nausea. MAO use. or seizure disorder. • • • • • . contraindicated in patients with eating disorders. Varenicline: selective nicotinic receptor partial agonist. use for 7-12 wks Nicotine-replacement therapy increases the chance that a smoker will quit. insomnia. and abnormal dreams. Varenicline is taken for 1 week before the quit date. start meds 1-2 wks before quite date.

isolation from others – Look for numerous bruises of varying ages. economic control. – Child abuse not reported by a physician is a crime – A spiral fracture of the tibia is known as a toddler’s fracture and is a common injury . cigarette burns – Do a full x-ray bone scan and ophthalmologic exam – All elder and child abuse must be reported. sexual. intimidation. emotional. psychological. metaphyseal corner fractures.Family Violence – physical violence.

85 for women) / 72 x serum creatinine .Adverse Drug Reactions and Interactions (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. 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. 2D6. 2C19 have evidence of genetic polymorphism and different individuals have different rates of metabolism – 2E1: alcohol effects this isoenzyme. drugs that depend on 1A2 are theophylline and imipramine – CYP2C9.

Master your semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master your semester with Scribd & The New York Times

Cancel anytime.