Medicine Shelf Stuff

8/13/2019 Medicine Shelf Stuff

http://slidepdf.com/reader/full/medicine-shelf-stuff 1/15

Medicine Shelf Cardiovascular Derm Endo GI Heme Infectious Disease Oncology Pulm Renal / GU Rheum Miscellaneous

Cardiovascular

mksap 7, 17, 27

Pericarditis use an NSAID !efore steroids

Mocarditis !viral" no s"ecific treatment# use $CEi / other diuretic% treat li&e usual CH'(● )o "roven role for )*$IDs/steroids

Di# to$icit often atrial tachcardia %ith varia&le &lock

NS'(MI) +,ave inversions% *+de"ressions ,ith no * %aves

C+ADS2 for ,arfarin in $fi!- CH'% ++)% Age . 0% Dia!etes% Stro&e or +I$ h1 23 "ts# others 4 "t5(

● 6 or more 7 anticoagulate% 43 7 individuali8e% 9 7 don:t anticoagulate

In heart failure !sstolic")

● 'itrate the &eta &locker to the heart rate of the "atient;

● Spironolactone if )<H$ III/I=% !ut also need >=E' ?60% Cr ? 3(0% @ ? 0

● If pre#nant% avoid $CEi and use hdralaine - nitrates

In setting of cocaine use% don.t use an isolated &eta &locker/ ● leads to uno""osed al"harece"tor stimulation !y cocaine% increasing vascular tone% ,orsened

cardiovascular effect(

● Can use la&etolol 2com!ined al"ha and !eta!loc&er5

Chronic NSAID use can cause failure of antihpertensive meds 2raise AP !y decreasing sodium e1cretion;5(

$lso should discontinue if starting AC(i, etc(

pretest)

● If S'0el, an#ina !ut no si#nificant coronar arter disease% sus"ect Prinmetal.s 2r1 ,ith Ca0channel

&lockers5

● 'ach-&rad sndrome if sym"tomatic% pacemaker 2"revent synco"e from !rady5 B/ drugs for tachycardia

● a0flutter %ith 2)1 &lock can use metop to slo, ventricular rate● rd de#ree A0 &lock after an MI 0 tem"orary transcutaneous "acing# "ermanent if doesn:t resolve

● $t ris& for cardiac complications of non0cardiac sur#er) note that AGE is not involved!

○ +i#h0risk sur#er 2intra"eritoneal% intrathoracic% su"rainguinal vascular5

○ H1 of ischemic heart disease or C+3

○ H1 of sym"tomatic cere&rovascular disease

○ H1 of insulin therap for dia&etes

○ Serum Cr 4 256

+pertension

Classification

)ormal ? 439/9 )o treatment

Prehy"ertension 43946 / 99 2!oth5 >ifestyle modification

*tage I 4940 / 9 2either5 >ifestyle B drug

*tage II . 4F9 / 499 2either5 >ifestyle B 3 drugs

'reatment Goals

● 16-86 or less in general

● 16-96 if dia!etic% renal insufficiency



● 12:-7: if dia!etic% renal insufficiency% urine "rotein . 4g /3h

○ ;P control is <1 for sto""ing dia!etic &idney d8 "rogress 2more ,ell esta!lished than tight glc control5

Pre#nant = +'N- la&etalol and alpha methl0dopa are the !estevaluated for use(

S'0elev "ersisting long after an MI +hin& ventricular aneursm/

Aortic dissection-

re"air if ty"e A 2ascending5

may manage medically if ty"e ; 2transverse or descending5 use &eta &lockers to reduce shear stress

Scleroderma renal crisis- a/, mar&edly increased renin levels% so use short0actin# AC(i 2captopril"

>ipids● >D>) 4F9 or higher increases CHD ris&( Statins, then niacin, then &ile0acid0&indin# resins 2!ut they increase

+Gs;5

○ ? 166 !o"tional ?95 for CHD or CHD ris& euivalent(

○ ? 16 if 3 ris& factors# treat if . 4F9

○ ? 16 if . 3 ris& factors% !ut treat if . 469

○ ? 1@6 is O@ if 94 ris& factors(

● +D>) lo, if ? 60( Niacin is !est to raise

● 's- normal 430% high if . 309( Niacin good to lo,er% !ut usually ,t loss% diet% e1ercise if ? 099

● 'i!rates used if all the other stuff fails alone(

Derm

Acne treatment

● Early things to try- topical retinoid B/ topical anti&iotic# com!ination BCPs too

● If that fails- add oral anti&iotic 2tetracycline class5# ta&es F ,&s to ,or&

● Bral isoretinoin has 9J remission rate% !ut only for recalcitrant nodular acne# must have evidence of recent

negative "regnancy test% informed consent from "t% counseling re-teratogenicity

● )o role for corticosteroids 2can cause acne5 unless acne fulminans% a rare side effect of oral isoretinoin

Contact dermatitis treatment 2e(g( "oison ivy5

● Bral prednisone% ta"er over 36 ,&s% if severe or on face/nec&/intertriginous areas

● +o"ical corticosteroids can reduce erythema !ut not recommended on a!ove areas# also not if !listering

Psoriasis treatment- try topical corticosteroids 2med/high "otency% e(g( fluticasone5 first

to"ical vitamin D analogues 3nd line 2e1"ensive% don:t ,or& as ,ell5

U= thera"y 2!ut incr( ris& of *CC5% then methotre1ate% cyclo"hos"hamide% etc( if really refractory(

'elo#en effluvium hair loss after !ig stress# ,ill come !ac& reassure/Actinic keratosis) "redis"oses to SCC# don:t need to !1 Kust use topical :03/

arts- can use saliclic acid 2ta&es F43 ,&s5or crotherap if that fails

Smallpo$ vs chickenpo$)

Smallpo$) "alms L soles% face# lesions in same stage of develo"ment# more sic&N ,ith fever several days !efore

rash

Chickenpo$) trun&% lesions in various stages of develo"ment 2su"erficial% a""ear in cro"s5# less sic&%N fever ,ith

rash



Bnchomcosis) get cultures of nail !ed if sus"ected

● can treat ,ith ter&inafine 2to"ical5 or ste" u" to oral #riseofulvin, itraconaole

(ndo

mksap

● Aefore "rocedures ,ith I contrast 2"otentially ne"hroto1ic5% hold metformin● Bsteoporosis- AMD ? 025: or any fragility fracture;

● Bsteopenia- AMD !et,een 01 and 025:

● Bsteomalacia- vitamin D deficiency- lo, serum Ca% Phos# high al&"hos

● Na decreases !y 15@ for every increase in 166 in plasma #lucose 2hy"o)a in D@$5

● +poCa causes lon# *', hperCa causes short *'

pretest

● adrenal incidentaloma 4 1 cm- need to see if it:s functional measure "lasma metane"hrines% de1amethasone

su""ression test for cortisol

● Pa#et disease of !one- cortical thickenin# L fi!rous change and elevated alk0phos# treatment is

&isphosphonates

● M(N sndromes)

○ M(N 1 E pituitar, pancreatic, parathroid tumors

○ M(N 2a E M'C, pheo, parathroid

○ M(N 2& E M'C, pheo, Marfanoid% neuromas

Dia&etes Criteria● DM- 'AG . 12@% OG++ . 266 23hr5% random . 266 B s$

● Predia&etes- 'AG 166012:% OG++ 160188 23hr5

● Aasic treatment goal- ? 7F +&A1c

'hroid cancer-

G Papillar is most common% a/, radiation thera"y% ,ith good "rognosis 2s"reads lym"hatically5

G 3ollicular is 3 common% !ut ,orse "rognosis 2s"reads hematogenously5

G Medullar is 6% a/, ME) in 66J% !ut ,orse still

G Anaplastic is % a/, old "eo"le% ,orst "rognosis

+perPH>)

Remem!er hpothroidism can cause hperPH>/

Prolactinoma is most common% !ut don:t forget "regnancy

+1- DA0a#onist 2!romocri"tine% ca!ergoline5

Acrome#al- firstline is transsphenoidal resection# can use octreotide adKunctively / to shrin& tumor

I

mksap

+hin& il&ert.s if as1% unconKugated hy"er!iliru!inemia

Achalasia need an (D 2loo& for tumors% other stuff that can mimic5#



● +1- ca0channel &lockers vs "neumatic dilation, heller myotomy

I;S ,ith lots of diarrhea- R1 loperamide

Acute I &leed- lose ,hole !lood 2Hct doesn:t dro" right a,ay5(

● $fter re"air% can still trend do,n 2fluid redistri!utes into vascular s"ace5 ,ithout ne, !leed

Ascites chan#e in mental status or signs of infectionJ 'AP for S;P/

pretest

● Pancreatitis) !ad "rognosis ,ith a#e 4 ::, ;C 4 1@k, #lc 4 266, >D+ 4 66, AS' 4 2:6 2ranson5

○ )ote that amylase / li"ase are not "rognostic;

●

all&ladder d)

● Cholelithiasis- !iliary colic after eating% at night# gallstone ileus( lap chole if recurrent

● Cholecstitis) RU "ain B )/=% anore1ia% Mur"hy:s sign% lo, grade fever% leu&ocytosis(

● Choledocholithiasis) a!ove B Kaundice(

● Cholan#itis- RU "ain% Kaundice% fever% !ad if se"tic shoc& B altered M*

● allstone pancreatitis- RU U/* as 4st diagnostic test% then la" cholecystectomy after sta!le 2lots of rela"se5(

(HCP if >'+s mar&edly a!normal or ductal dilitation

+eme

pretest

'ransfusion0related acute lun# inKur- $! in donor "lasma !ind to recipient ;C, leads to noncardio#enic

pulmonar edema 2e(g( day after a transfusion5

Inhi&itors- $! against certain factors(

● *us"ect if acuired coa#ulopath 2e(g( ,ith malignancy incl( lym"homa% autoimmune disorders% "ost"artum5

● D1 ,ith mi$in# stud 2deficiency ,ill correct% inhi!itor ,on:t5

>M+ . ,arfarin for "revention of recurrent venous throm!oem!olism in metastatic cancer

Anti0phospholipid A&s)

$/, lu"us% can !e idio"athic etc( Usually ,ith lu"us anticoagulant% anticardioli"in $!% or !oth(

Recurrent venous B arterial throm!i% throm!ocyto"enia% livedo reticularis

*ee lon# P''-P' ,hich is not corrected !y adding plasma5 R1 ,ith %arfarin to I)R 3(06(0

Anemias

Microctic Iron deficiencAnemia of chronic disease'halassemias 2'e normal/high% ferritin normal/high% +IAC normal% RDQ normal/high5

;eta0thal- mediterranean/middle east/Indian% less !eta chains( Hetero8ygote 7 milddisease# homo8ygote 7 thal maKor% elevated +&3% !ig time disease(

Alpha0thal- $frican$merican "atients% decrease in al"hachains( *ilent if 4 gene missing%mild disease if 3% +&+ disease if 6 2really sym"tomatic5

Sidero&lastic anemia- disorder of RAC 'e meta!olism hereditary or acuired 2drugs- chloram"henicol% I)H% EtOH# lead# neo"lasia5(

*ee increased serum 'e% ferritin# normal +IAC% rin#ed sidero&lasts in !one marro,( R1 !y removing offending agent# sometimes can use prido$ine



Normoctic Anemia of chronic disease 2most times is normocytic5Aplastic anemia-

idio"athic% radiation% meds 2chloram"henicol% car!ama8e"ine% sulfas5% viruses 2HP=% HC=%HA=% EA=% CM=% H=% HI=5% chemicals(

Deficiency in multiple lines( Get &one marro% &$

Macroctic ;12 deficiency 2"ernicious anemia% ileal disease% vegans% alcoholism5 anemia% sore tongue% neuro"athy 2su!acute com!ined5% can lead to dementia

Elevated methlmalonic acid, homocstine B MC= . 499% hperse#mented PMNs Do a Schillin# testL can r1 ,ith ;12 IM month3olate deficienc) smaller stores 26 mo5% green veggies

>i&e A43 ,ithout neuro s1

+emoltic anemias-

@PD) see +ein &odies004 &ite cells

Spheroctes, helmet cells- thin& e1travascular

Schistoctes) thin& intravascular 2traumaN5

Direct Coom&.s positive) thin& autoimmune hemoltic anemia

S I# is %arm 2,arm ,eather is Great5# e$travascular hemolysis 2s"lenomegaly5% a/, lym"homa% C>>%

malignancy% collagen vascular diseases 2*>E5% al"hamethyldo"a( #lucocorticoids can !e useful

S I#M is cold 2MMM cold ice cream;5 Intravascular hemolysis# idio"athic or secondary to infection2myco"lasma% mononucleosis5

Bsmotic fra#ilit- thin& hereditar spheroctosis

Dark urine thin& hemoglo!inuria 2intravascular hemolysis5

Infectious Disease

mksap-● Osteomyelitis- MHI is imaging modality of choice if uncertain a!out "resence of osteo

○ et a &one &$ to guide thera"y if you can "ro!e to !one / high sus"icion / d1 of osteo on MRI

● If murmur conduction a&normalities% thin& endocarditis B paravalvular a&scess

pretest)

● Providencia is a G)R that can cause U+Is in hos"itali8ed "ts

● ;lasto can cause chronic res"iratory s1 of infection% also skin lesions 2crusty% ulcerated% verrucous5 and/or

osteoltic &one lesions

SIHS, Sepsis, etc5

● SIHS- 3B of

○

' . 6(9 or ? 6F(9○ +H . 9

○ HH . 39/min or PCB2 ? 63 mm Hg

○ ;C . 43& or ? &% or . 49J !ands

● Sepsis ) SIHS B a confirmed infectious source

● Severe sepsis) Sepsis B or#an dsfunction, hpoperfusion, hpotension

● Septic shock) se"sisinduced hy"o"erfusion / hy"otension despite adeuate fluid resuscitation

oal0directed therap for sepsis- ,ithin F hrs% &ee" central venous B2sat 4 76F% resolve lactic acidosis



Acute &acterial rhinosinusitis) duration . 4 ,&% ,orsening after initial im"rovement# ma1illary tenderness # "urulent

discharge # "oor res"onse to decongestents(

● R1 ,ith amo$icillin 2*tre" "neumo% H( flu5 for 016 das( $lternatives- +MP*MT% do1ycycline( @ee" it

narro,

PPD cutoffs-

4 1: lo% risk 2average "t5

4 16immi#rant from high ris& country ,/in : rs, ID, prisoners, health care ,or&ers% "ts ,ith silicosis% DM%chronic renal failure, leukemia / lmphoma% cancer of head/nec&% recent si#nificant %t loss% gastrectomy /

KeKunal !y"ass( $lso for healthy adolescents e1"osed to adults in high ris& category

4 :

hi#hest risk for develo"ing active ';) +I, immunosuppressed, "ts ,ith close contact to active ';, CH

c/, previous ';5

● $lso% if 4 : mm and you:re going to start someone on immunosu""ression 2"rednisone . 40 mg/d% etc5%IN+ $ 8 months for "ossi!le latent +A

Confusin# 0vir dru#s

● Ooster) 3amicclovir or valacclovir 2li&e acyclovir !ut !etter "harmaco&inetics% dosing schedule% efficacy5

● CM in immunosu""ressed- #anciclovir, val#anciclovir

A&$ pp$ for endocarditis)ho needs itJ

● NB' lo,ris& "ts- previous CA;% surgical re"air of ASD-SD-PDA% M= "rola"se ,ithout regurg% innocent

heart murmurs% "revious @a,asa&i:s or rheumatic fever ,/o valvular dysfunction% pacemakers - defi&rillators

● (S for hi#h0risk) prosthetic valves, previous endocarditis% com"l1 cyanotic heart diseases 2trans"osition of

great vessels% +et of 'allot5% surgically constructed systemic "ulmonary shunts / conduits

● (S for moderate0risk- most other congenital cardiac malformations% acuired valve dsf$n 2e(g( rheumatic

fever with valvular dsf$n5% +CM, MP with regurg and/or thic&ened leaflets% cardiac defects re"aired ,/in

last @ mo'pe of sur#er-

● Dental , respirator, I, , tonsillectomy / adenoidectomy% !ronchosco"y ,ith rigid !ronchosco"e%

eso"hageal stricture dilation% ERCP if "t has !iliary o!struction% intestinal or res"iratory mucosa surgery thin&

%hat could push &acteria into the &loodstreamJ

If pp$ indicated )

● Amo$icillin 2# orall 4 hr !efore "rocedure(

● $m"icillin 3g IM or I= 69 minutes !efore if can:t ta&e oral meds

● Clindamycin / a8ithromycin if allergic to PCn

● =ancomycin if moderateris&% PC) allergy% highris& GU/GI "rocedure 2a/, enteroccus5

Neuropretest

Cluster headache- use prednisone acutely% then taper over months( $lso tri"tans% O3 can hel" acutely

Hestless le#s- use "rami"re1ole% ro"inerole% or other direct dopamine a#onists

Chronic inflammator demelinatin# polneuropath 2CIDP5- "rogressive% symmetric "ro1imal / distal ,ea&ness in

all e1tremities% may have some num!ness L tingling too% develo" over several months# may "rogress or rela"se / remit(

Use immunosu""resive thera"y( Demyelinating neuro"athy 2li&e chronic GA*5(



Polcthemia vera- $ myelo"roliferative syndrome( hemato"oetic stem cells "roliferate . e1cessive

erythrocyte "roduction( Hy"erviscosity% throm!osis% !leeding% he"atos"lenomegaly% H+)( *ee elevated H;C,

+&, +ct !4:6" B/ throm!ocytosis% leu&ocytosis( Phle&otom to reduce Hct# consider hydro1yurea or I')al"ha

Melodsplastic sndromes) clonal# ineffective hemato"oesis% apoptosis of meloid precursors 7

panctopenia ,ith a NBHMA> or hpercellular marro% 2vs a"lastic anemia5( Can see +o%ell0Roll &odies%

!aso"hilic sti""ling% nucleated RACs% large% agranular "latelets( +1 is su""ortive( )eed AM+(

(ssential throm&octosis- throm!osis/"arado1ical !leeding 2defective f1n5( Plt . F99&( R1- anti"latelets

Melofi&rosis- fi!rosis of !one marro, 7 "ancyto"enia% e1tramedullary hemato"oesis( Massive s"lenomegaly(

'eardrop cells on PA*( Aone marro, as"irate 7 fi!rosis% dry ta"N if severe( Can pro#ress to AM> or die of

!leeding / infection(

Pulm

mksap

● $ smptomatic pneumothora$ !uys you a chest tu&e tension or not es"ecially if it:s &i#

● (ffusions-

○ 'horacentesis if free0flo%in#, . 16 mm in height 2get lat decu! CTR5

○ +hen chest tu&e if com"licated 2"us% Gramstain"ositive% "H ? 5

○ Other,ise manage ,ith I a&$ o&servation

pretest-

● ;iPAP can !e used in acute COPD or CH' e1acer!ation if acute CO3 retention 2may hel" "revent intu!ation5

!ut can:t use if not "rotecting air,ay(

● Asthma e$acer&ation- !ad sign if silent chest 2air,ay constriction so !ad that can:t generate ,hee8ing5( Good if

"ulsus "arado1icus ? 0 mm Hg

● P(- can have ,hee8ing 2asthma mimic5% !ut generally not &i&asilar rales 2suggest CH'% P)$5

● +pophosphatemia can result from intracellular shift in respirator acidosis

● PCP 2in HI=5 often has an elevated >D+

Spirometr-

● $!normal values if ? 9J "redicted

● 'E=4/'=C ? 9 7 o!structive lung disease

● D>CO decreased in em"hysema% I>D, normal in asthma% usually !ronchitis

>i#ht.s criteria for effusions- to !e an e$udate, need 4B of

● pleural - serum fluid protein ratio of 4 65:

● pleural - serum >D+ ratio of 4 65@% or

● pleural fluid >D+ . 3/6 of normal upper limit for serum >D+

A0a radient

P$O3 7 2 'iO3 2F9 55 2PaCO3 / 9(5 7 4092PaCO3 / 9(5 if on room air(

$a gradient 7 P$O3 PaO3( *hould !e ? 49# if elevated% thin& = mismatch / shunt / etc(

Henal -

Nephrotic sndrome- see urine sediment ,ith fatt casts# oval fat &odies can loo& li&e Maltese crosses



● Minimal chan#e glomerulo"athy is 4 in younger "ts# can develo" uic&ly 2over ,&s5% can !e triggered !y

infection / immune stimulus( H$ corticosteroids( )ormal microsco"y# foot "rocess effacement on EM(

*electively lose al&umin 2lose negative GAM charge5(

● Mem&ranous glomerulo"athy 4 in older "ts% usually ta&es longer to develo"( s"i&e and domeN ,ith su!e"i

de"osits% granular IM( caused !y drugs% infections% *>E% solid tumors

● 3SS- also ta&es longer to develo"# +I associated

● Amloidosis 2congo Red Multi"le myeloma% +A% R$5

● Dia&etic #lomerulonephropath- nonen8ymatic glycosylation of GAM# "ermea!ility / thic&ening of afferent

arterioles( GAM thic&ening% mesangial e1"ansion% @Q nodules(

● Mem&ranoproliferative) lo, C% associated ,ith HA=/HC=( 2May !e ne"hritic# anything "roliferativeN can !e

ne"hritic% anything mem!ranousN can !e ne"hrotic5

Nephritic syndromes

● I#A nephropath !erger d8% e1acer!ation durin# HI

● Post0strep N 0 after infection# H+)% "erior!ital edema( Resolves s"ontaneously( >um"y !um"yN glomeruli

,ith su!e"ithelial IC de"osition% granular I'(

● S>(0related) lo, C = C

● Hapidl pro#ressive - crescenteric- "oor "rognosis( oodpasture 2linear I'% males% hematuria% res"

involvement5 vs e#ener.s 2c$)C$5 vs MPA 2"$)C$5

Acid0&ase = compensationMeta&olic acidosis

● )ormal A) 43 Vremem!er- )a 2Cl B HCO65W

○ Is there a coe1isting $G and non$G meta!olic acidosis chec& the delta delta 2does the decrease in

!icar! from 3 eual the increase in the $G from 43 If so% it:s a sim"le $G met acidosis5

○ Calculate rine A VUrine )a B @ ClW to determine if )H !eing e1creted

■ H'A tpe 1, - &idney not e$cretin# acid a""ro"riately% so A positive

■ H'A tpe 2, diarrhea) &idney e1creting acid O@ 2R+$ ty"e 3 7 defect in !icar! rea!sor"tion5%

so A ne#ative● )ormal osmolar #ap ? 16 Vremem!er- 23 1 )a5 B 2glc / 45 B 2AU) / 3(5W5

○ If high% thin& methanol% ethylene glycol% iso"ro"yl alcohol% etc(

Meta&olic alkalosis

rine Cl ? 16 7 saline res"onsiveN )G suction% vomiting% diuretics% "osthy"erca"nia

rine Cl 4 16 E saline resistantN

S If AP elevated% thin& "rimary aldosteronism% Cushing:s% renal artery stenosis%

S If AP normal% thin& hy"omagnesemia% severe hy"o@% Aartter:s% )aHCO6% licorice

Compensation-

● Meta&olic acidosis- Qinter:s formula 24(0 1 HCO6 B B/ 35

● Meta&olic alkalosis- generally for every increase of 1 in &icar&, 65:01 increase in PCB2

● Others- see ta!le( Res"iratory acidosis is the only condition in ,hich "H can return to normal

Hespirator acidosis - alkalosis- e1"ected com"ensation

2note PCO3% HCO6 go in the same direction5

PCO3 'or every 49 unit change in PCO3% HCO6 should change !y(((

Acute res"iratory acidosis Increased B4

Chronic res"iratory acidosis Increased B6



Acute res"iratory alkalosis Decreased 3

Chronic res"iratory alkalosis Decreased 0

Contrast0induced nephropath-

● at ris& 7 volume depletion, C+3, DM, CD% multi"le myeloma

● reduce ris& !y a##ressive volume resuscitation 2)* or isoosmotic sodium !icar! sol:n5 if "t can handle it

3eNa-

In chronic kidne disease- 2a gross !ut useful oversim"lification5

Decreased "hos clearance leads to elevated "hos% ,hich inh!iits 4%30 OH=itD "roduction

(levated phosphate and lo% calcium result% ,hich increases P'+ production

Increased P'+ then leads to renal osteodstroph

Henal 'u&ular Acidosis-

'pe 1 !Distal"Can:t secrete HBat distal tu!ule

Can:t lo,er urine "H ? F

+po, hperCl, non0A met acidosis $lso increased Ca-PB e$cretion ric&ets /

osteomalacia% renal stones can result R1- Na+CB

'pe 2 !Pro$imal"Can:t rea!sor! HCO6at "ro1imal tu!ule

+po, hperCl, non0A met acidosis 'anconi:s% Qilson:s% other conditions No stones# no role for !icar! R1- restrict Na 2incr )aHCO6 rea!sor"tion at P+5

'pe !+poaldo orresistance"

Increased )a rea!sor"tion,ith decreased H/@secretion 2at distal tu!ule5

+P(H0A>(MIC 2only one5 Can acidify the urine "retty ,ell;

Hheum

mksap

● ;ursitis) a/, "ainful full el&o% fle$ion 2stretches !ursa tight5

● Crstalline - infectious snovitis- a/, "ain on any "assive Koint motion

● TPoppin#U B Koint line tenderness "ain on #oin# up - do%n stairs, %alkin# 7 meniscal tear

● out treatment-

○ Don:t use allopurinol in acute flares NSAIDs are first line% then colchicine

○ +ry to get serum uric acid do,n to ? @ m#-d> !y increasin# allopurinol if uric acid is still high

■ Hel"s dissolve tophi L other urate de"osits

■ since decreasing uric acid levels itself can induce a gouty attac&% keep colchicine on ,hile you

increase allo"urinol(

● +ereditar hemochromatosis- classically &rone dia&etesN !ut no, more often a/, arthropath, fati#ue,

impotence, a&normal >3's



● Polmal#ia rheumatica- Pain% morning stiffness in a$ial Koints, pro$imal musclesL no muscle ,ea&ness /

s,elling / "ain / ,armth / movement restriction( 9J have elevated (SH % usually 4 :6 rs old5 +reat ,ith

prednisone(

pretest

● S>( high dose corticosteroids if hemolytic anemia% throm!ocyto"enia% or glomerular disease develo"s

● 3eet-

○ Ankle s"rain vs !rea&- Otta,a rules- only need Tray if 1" can.t &ear %ei#ht right after inKury or 2"

point tenderness over medial or lateral malleolus(

○ Plantar fasciitis 0 runners% heel "ain at first steps or after sittin#% then goes a,ay# O@ at night

○ 'arsal tunnel syndrome posterior ti&ial nerve runs through# entra"ment leads to pain in ankle - heel,

num&ness of sole of foot at night

○ Metatarsal stress fracture) comes on suddenly% ,orse ,ith ,eight !earing% "oint tenderness% can have

normal Tray

○ Morton neuroma causes "ain% num!ness on !all of foot% made !etter !y ta&ing shoes off

>o%er &ack pain, &uttock pain

● Smptomatic treatment for nons"ecific >AP ,ith no ,arning signs

● Acute sciatica- use NSAIDs if no cauda euina% s"inal cord com"ression s1(

○ *urgery- s1 . F ,&s% "rogressive neuro deficits(○ Don:t MRI early lots of false "ositives

○ Aut can get plain films in "ts . 09 2incr( ris& of malignancy% osteo"orotic fractors5

● Spinal stenosis- "ain on standin#, %alkin#% relieved !y sittin# - &endin# for%ard

○ NBHMA> A;I 2"seudoclaudication5

● >e# ischemia - claudication- occurs ,ith %alkin# !ut not ,ith Kust standing

○ A;I ? 658 often ,ith 426F decline %ith e$ercise

asculitis● 'emporal Arteritis-

○ .09% tem"oral aa / aorta / carotids% incr( ris& $o aneurysm% d1n(

○

Constitutional s1% H/$% visual im"airment% Ka, claudication% tenderness% "olymyalgia rheumatica○ E*R elevated% serial !1 of tem"oral aa

○ +reat- high dose steroids immediately% follo, E*R

● 'akaasu.s Arteritis-

○ <oung $sian ,omen% $o arch L !ranches% stenosis(

○ Decreased "eri"heral "ulses% AP arm vs leg different% arterial !ruits( Constitutional s1% ischemia% lim!

ischemia

○ +1- steroids% treat H+)% surgery / angio"lasty% !y"ass grafting

● Chur#0Strauss

○ Many organ s1( Constitutional findings% "rominent res"iratory tract findings 2asthma% dys"nea5% s&in

lesions 2palpa&le purpura5(

○ D1- A1 2lung/s&in5 ,ith eosinophils, P0ANCA(

○ Poor pro#nosis 20 yr survival 30J% card / "ulm com"lications5( +1 ,ith steroids 209J survival5

● e#ener.s

○ @idneys% u""er / lo,er res"iratory tract( *inusitis% !loody nasal discharge% oral ulcers 2"ainful5% "ulm s1

2cough% hemo"t% dys"nea5% glomerulone"hritis% conKunctivitis / scleritis% arthralgias / myalgias( PAN has

no lun# involvement(

○ CTR- nodules / infiltrates( Elevated E*R% normochromic normocytic anemia% c0ANCA in 9J% B/

throm!ocyto"enia% can confirm ,ith o"en lung !1( Poor pro#nosis 2most die ,/in 4 yr5(

○ +1 ,ith cclophosphamide, corticosteroids, can ha""en at any time(

● Polarteritis Nodosa



○ Medium0sied vessels% incl( nervous system% GI tract( $/, +;, +I% drug reactions( PM) invasion of

all layers% fi!rinoid necrosis% intimal "roliferation . reduced luminal area . ischemia% infarcts(

○ 'ever% ,ea&ness% ,t loss% myalgias/arthralgias% a&dominal pain( $lso H+)% mononeuritis multiple$,

livedo reticularis 2laceli&e% "ur"lish% lo,er e1tremities5

○ D1- !1% mesenteric angiogra"hy( (levated (SH, -0 p0ANCA( +est for fecal occult !lood

○ Prognosis "oor% im"roved ,ith treatment( corticosteroids L if severe% cclophosphamide

● ;echet.s Sndrome

○ $utoimmune% multisystem# cause un&no,n( oral, #enital ulcerations 2"ainful5% arthritis 2&nees/an&les5%

ees 2uveitis / o"tic neuritis% iritis% conKunctivitis5% CNS 2meningoence"halitis% intracranial H+)5% fever%

,t loss(

○ D1- !io"sy# +1- steroids hel"ful

● ;uer#er.s Disease 2+hrom!oangiitis O!literans5

○ <oung men% smoke ci#arettes( *mall/medium si8ed arteries / veins% arms / legs% can lead to #an#rene(

Ischemic claudication% cold / cyanotic% "ainful distal e1tremities% "aresthesias of distal e1tremities%

ulceration of digits( Smokin# cessation reduces "rogression(

● +persensitivit vasculitis

○ *mall vessel% hy"ersensitivity / drug r1n% infection% other stimulus( *&in- palpa&le purpura, macules,

vesicles% can !e "ainful( Constitutional s1% D1 ,ith !1 of tissue% good "rognosis(

Autoanti&odies = %hatnot

Primar &iliar cirrhosis $ntimitochondrial

+ashimoto.s $ntithroid pero$idase !'PB"$ntithro#lo&ulin2antimicrosomal% !ut can also see in Grave:s5

rave.s +hyroidstimulating $!

S>( ANA 2sensitive% not s"ecific5$ntidsDNA L antiSM 2s"ecific% not sensitive5$ntissD)$ 2not as good5

Dru#0induced S>( $ntihistone

Hheumatoid arthritis Hheumatoid factor 2antiIgG5 not s"ecific% also not too sensitiveAnti0CCP 2s"ecific5

e#ener.s c0ANCA

Polarteritis nodosa p0ANCA

Mi$ed connective tissue d antiHNP

Scleroderma $ntiSC> 76 2antitopoisomerase I" diffuse d8 2s&in lesions "ro1 to

el!o,# e(g(% CRE*+ doesn:t give you s&in changes on chest5% rapid "rog($nticentromere mostly limited / CH(S' syndrome

SKo#ren.s $)$ B/ R'$ntiHo !SS0A", anti>a !SS0;" in 909J 2not too sensitive52+reatment o"tions include pilocarpine"

Mositides $ntiRo01 2antitR)$ synthetase5 !oth "oly L dermato

a/, disease activit fever% mechanic:s hands% I>D% arthritis%refractory to treatment



li&e Chlamydia a!ove( Also opt0out +I testin# for "retty much ever&od

Pap smear Start at age 21 or %ithin ears of startin# intercourse Qhile in 26s% 2 rs# ,hile in 6s, rs 2if 6 in a ro, have !een normal5 Can sto" if hsterectom for noncancer reasons L no lon#er have cervi$

Can sto" if over @: and normal Paps in a ro%# if ne, se1ual "artner after age F0%restart Pa"s 6 yrs

>ots of HP= "ositivity in adolescents 39 and younger so if >SI>% schedule a 12 month

follo%0up and only refer for co"osco"y if hi#h #rade SI> or #reater on re"eat 2lots clearthe infection on their o,n5(

Mammo#ram Old recs- Qomen 9B get mammo#rams 102 rs% then earl after a#e :6Ne% recs) Get mammogram 2rs starting at a#e :6

$lso "hysician e1am 6 yrs until 9% then yearly thereafter

';

$ny!ody at ris& for develo"ing latent or active +A 2see PPD recs a!ove5 Persons living in congregant settings 2prisons, #roup homes, homeless shelters,

nursin# homes"

Persons routinely e1"osed to +A 2health care %orkers" Persons ,ho are immunosu""ressed !+I, transplant pts"

accines

Pneumova$ (lderl 24 @: -o" or hi#h0risk adults 2as"lenic% nursing home5(

● If initial vaccine given !efore age F0% give &ooster : rs later

'D-D'aP

;ooster ever 16 ears If in the 180@ a#e ran#e, give 'DaP as ne1t !ooster instead of +D( =accinate health care %orkers ,ho haven:t had +DaP and had their last +D !ooster . 3

yrs ago

+P $ll females a#es 802@

+erpes Ooster Adults 4 @6 -o

Menin#ococcal $dults ,ith asplenia 2anatomical or functional5 or complement deficienciesColle#e students in 4st year dorms, militar recruits

+; +i#h risk 2health care ,or&ers% hemodialysis "ts% reci"ients of clotting factors% highris& se1ual!ehavior% travelers to endemic areas% I=DU% household contacts of HA= carriers% "ersons ininstitutions for mental retardation5

+A 'ravelers and "eo"le ,ith chronic liver d, +C

MMH >ive vaccine "rimary series in &ids( Give to unvaccinated "eo"le(

aricella >ive vaccine "rimary series in &ids( Give to adults% adolescents ,ho have never had

chic&en"o1% close contacts of immunocom"romised "ts% PEP in susce"ti!le

Polio Primary series in &ids( Don:t give to unvaccinated adults unless they:re going to travel to

endemic areas(

Influen8a don:t !e afraid to tac& on some olsetamavir if "t ,ith ris& factors 2e(g(% COPD5 has e1"osure to virus 2e(g(%

daugther has flu5 in addition to I= &illed vaccine



Pain control- if using PCA, ma&e sure to &olus morphine 4st 2PC$ for maintenence# doses are small L ,ould ta&e along time to get to thera"eutic level5(

A#e0related macular de#eneration- yello,ish drusens

advise to stop smokin#, consume antio$idants !AC(", see opththalmolo#ist

Meta&olic sndrome- -: of a&dominal o&esit 2,aist . 60in in '% 9in in M5% hper's 2.4095% lo% +D> 2?09 in '%?9 in M5% ;P . 469/0% insulin resistance 2fasting glucose . 44955 Note that LDLs not involved

omens. health initiative- Estrogen B "rogesterone 2H+5 in healthy "ostmeno"ausal ,omen . increase in &reast cancer over 0 yrs H+ hel"s "revent osteoporotic fractures !ut no &enefit for coronar heart disease ,as found If using H+% use it short0term in healthy "erimeno"ausal ,omen

Medicine Shelf Stuff

Documents

Transcript of Medicine Shelf Stuff