Step Up to Medicine: Chapter 12 Ambulatory Medicine

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Most common causes of lower back pain?

1. Musculoligamentous strain
2. Degenerative disc disease
3. Facet arthritis

______ _ is the result of repetitive overhead motion. Patients complain of pain with active range of motion of the shoulder, and passive internal rotation and forward flexion at the shoulder

Subacromial bursitis

If dyspepsia of unknown cause by which H. pylori has been r/o - treatment?

EMPIRICALLY
1. Antacids including B2blocker, sucralfate, PPI
2. PPI if antacids FAIL
3. Endoscopy if PPI and antacids FAIL

Which treatment can be administered to patients suffering from "wet" ARMD?

RANIBIZUMAB by intraocular injection

HTN meds shown to decrease both MORTALITY and MORBIDITY

1. TZD
2. BB

Which drugs cause decreased hearing or OTOTOXICITY?

1. Vanc (great gram + coverage and MRSA)
2. Aminoglycosides (gram -) GNAT
-gentomycin, neomycin, amiktran, tobramycin
3. Loop diuretics (furosemide)
4. ASA
5. ETA (etharynic acid)
6. cisplatin
7. Quinidine

Unilateral periorbital pain (behind eye) associated with "burning" or "tearing" that is worse at night - lasts 30-90 min post 3 hours of sleep. Worse with OH and sleep:

Cluster headache

IBS is most commonly exacerbated by ____ and ______ to the intestinal lumen resulting in either (1) constipation or (2) diarrhea

stress and irritants

Predominates in females

Seven classes of treatment used for HTN

1. Thiazides = best initial choice in salt sensitive HTN; check serum K+ regularly (hypo K+) is exacerbated by elevated Na+ = HZTZ
2. BB = dec HR, dec CO, renin dec = metoprolol
3. ACEi = dec RAAS, dec BK degradion *cough = ramipril
4. ARBS = losartan = decreased RAAS; no cough
5. CCB = vasodilation and arteriolar vasculature = verapamil
6. alpha-blockers = decreased arteriolar resistance; good for BPH
7. Vasodilators = hydralazine/MINODIXIL

Treatment of OA

1. Nonpharmalogical treatment:
2. Pharmalogical treatment:
3. Surgical
4. Nutritional

Nonpharm - avoid excessive use of joint; wt loss; PT; swimming; use of cane or crutch

Pharm - acetominophen (bc OA is DG not inflammatory); corticosteroid injection (<4/year); VISCOSUPPLEMENTATION (3 injections of hyaluronic acid 1x/wk for 3 weeks

Surgical = total joint replacement - delay for as long as possible
Nutritional = glucosamine/condroitan sulfate

How might thick ascending loop diuretics (HCTZ) cause a change in lipids?

Elevated LDL
Elevated TOTAL cholesterol
Elevated TG (VLDL)

No fever, no blood in diarrhea infection

1. Rotavirus
2. Norwalk virus
3. Enterotoxic e. coli (ETEC)
4. Food poisoning (S. aureus within hours, c perfringens)

Type 2A and Type 2B hyperlipidemia:

IIA = elevated LDL = statins, niacin, cholestyramine
IIB = elevated LDL and VDL = statins, niacin, gemfibril

Amarosis fugax

Tests that should be ordered

Occurs subsequent to a thrombus that has erupted from an atherosclerotic lesion mainly from the carotid bifurcation. Results in a sudden transient loss of monocular vision that can lead to retinal ischemia

1. Test: carotid ultrasonography; cardiac workup (lipid profile ECG)

What are the RISK factors for HTN:

1. Age (elevated systolic/diastolic) BP
2. Gender (M>F)
3. African-Americans (Stroke; RF; HD)
4. Obesity
5. Family Hx
6. Inc sodium intake, elevated water retention
7. Alcohol (>2 oz.)/day inc HTN

Causes of cough (acute) v. causes of chronic cough

ACUTE: URI, pulmonary disease (pneumonia, COPD), pulmonary fibrosis, lung cancer, asthma, TB, CHF, pulmonary edema

Chronic cough: SMOKING, POST NASAL DRIP, GERD, ASNTHMA, ACEi

If constipation: order which labs?

HOW is obstruction ruled OUT?

Constipation: then must order:
1. TSH, Ca2+, CBC, electrolytes
2. IF suggestive by H&P = abdominal films and flexible sigmoidoscopy
3. Fecal examination = FISSURES, hemorrhoids, fecal impaction, masses

What neurlogical conditions can cause n/v?

elevated ICP, vestibular disturbance (vertigo), migraine headache

Emergency evaluation of headache

Step 1 = noncontrast CT scan rule out any type of bleed
Step 2 = if small bleed - missed by CT, need lumbar puncture

What is the classic TETRAD OF MULTIPLE MYELOMA:

Remember the pneumonic CRAB:

1. CALCIUM (Hypercalcemia)
2. RENAL IMPAIRMENT
3. ANEMIA
3. BONES (bone pain, lytic lesions, fractures)

IG antibodies or paraproteins produced by meloma cells collect in the gllomerluli causeing renal failure or MYEOLOMA KIDNEY.

Patients with MM are at increase risk for infection 2/2 total decrease in function AB and leukopenia 2/2 bone marrow croading with malignant plasma cells. PARAPTOTEIN gap is a common finding in patients with MM. PARAPAROTEINS made by meyloma plasma cells contribute to the total serum protein count but not to the albumen concentration. So while normally there is a 3-4 gap betweeen total and albumin, the gap is HUGE in pateints with MM.

Acute infectious diarrhea: S AUREUS

ABD pain, n/v, diarrhea

No fever, no WBV
occurs within 24 hours and stops
exposed persons ill between 1-6 hours

What treatments are useful in PREVENTING OA?

1. Decreased alcohol and smoking
2. ERT for pero-postmenopausal women (look at hip, wrist, vertebral compression fracture. Elevated bone density by 2-3%
3. RALOXIFENE - selective ER modulater that acts as an estrogen AGONIST in some tissue and ANTAGONIST in others (BREAST/endometrial)

OF ALL TYPES OF HEADACHE TYPES, WHICH ARE BEST TREATED PROPHYLACTICALLY AND WITH WHICH AGENTS?

Cluster headaches:
1. Use verapamil (CCB) po #1
2. Ergotamine
3. Methylsergide
4. Lithium
5. Corticosteroids

How is sinusitis diagnosed

Treated?

Diagnosis: >8 day nasal congestion; purulent discharge/drainage from one of the turbintates; transillumination of maxillary sinuses; palpation of sinuses; imaging studies no indicated if ca-illness

Complications: mucocele, polyp; osteomyelitis of frontal bonest/maxilla, cavernos sinus thrombosos

How does narcolepsy differ from cataplexy?

What is the treatment?

Narcolepsy - variable penetrance of REM sleep, regulation resulting in excessive sleep during day with attacks that are involuntary and lasts several minutes

Cataplexy - loss of muscle tone that occurs with intense emotional stimulus (laruger/anger)

TREATMENT: METHYLPHENIDATE, RITALIN, PLANNED NAPS

GIARDIASIS (ACUTE NONBACTERIAL INFECTIONS CAUSING DIARRHEA)

Foul smelling, watery diarrhea, absominal bloating


(-) fever
(-) fecal leukocytes (5-7days)

Lifestype changes that can be made in patients with preHTN, stage I and stage II HTN?

1. Dec Na+ intake from 4g sodium/day to 3g sodium/day
2. Wt loss/central obesity *HLD/HTN/HM/INSULIN R (Metabolic syndrome)
3. Dec alcohol consumption because OH = pressor and thus acts like vasopressin to increase BP
4. Exercise
5. Decrease SAT FAT
6. Dec unecessary medications
7. Decrease stress

If pateint with ACUTE diarrhea with NO complications - treatment?
If patient with ACUTE diarrhea with complications - labs?
-IF POSITIVE - treatment:
-IF NEGATIVE - treatment:

If acute diarrhea and no complications - hydration, loperamide (OPIOD that rx diarrhea)

If acute diarrhea and complications -
1. Order CBC - look for anemia look at WBC elevation.
2. Stool sample for WBC increase
-Positive: stool culture and consider CDIFF
IF + = treat diff with Metronidazole
IF - = sigmoidoscopy with BIOPSY
-Negative: Symptomatic Rx

Essential hypertension v. secondary HTN

(1) Essential: non-identifiable cause but applies to > 95% of HTN cases
(2) Secondary: Identifiable cause
1. RAS
2. Endocrine crisis/causes
3. Medications
4. Coartation of the aorta
5. Cocaine
6. Sleep Apnea

What is the most common cause of "red" eye?

Conjunctivitis = most common cause due to inflammation of the transparent membrane that lines the inside of the eyes and globe (bulbar)

Acute bacterial infections: C PERFERINGENS

Diarrhea, crampy abd pain

negative fever, no WBC in fecal matter, lasts a few days

begins within 24 horus - good for treatment with of or for ingestions (CLINDAMYCIN, METRONIDAZOLE)

What are hemorrhoids? Two primary types?

Treatment:

Varicose veins of the anus and the rectum:
1. Internal-dilated submucosal veins of superior rectal plexus above the dentate line thus insenate area that is PAINLESS.
2. External-dilated veins from inferior plexus; distal to dendate line this in sensate area and PAINFUL

Treatment: SITZ bath, ice packs, bed rest, steroids (topical), rubberband ligation if internal or surgical removal

Who should receive:

1. Influenza vaccination
2. Pneumococcal vaccination:
3. Hep B
4. Tetanus

1. Adults > 50YO; Adults < 50YO with chronic Dz; HCW; pregnant women (2nd/3rd trimesters)

2. >65YO, SCA, adult chronic dz (first dose then 2nd dose in 5 years)

3. Everyone - primary (1 mo, 1-2 months, 6-12 months old); secondary is the boosters of 10 years.

What is the most common cause of visual imparitment in developed countries?

1. Diabetic retinopathy (<65YR)
2. ARMD (>65YO)
3. Cataracts
4. Glaucoma

Patients with conductive hearing loss have which type of clinical features?

Sensorineural hearing loss?

Decreased perception of sound (low f) BUT can hear loud noises well

difficulty hearing low noises, excerbation problem; can hear sounds but doesnt decipher words. More difficult with high f sounds (phone, doorbells, female voices). Tinnitis is present.

Secondary causes of increased LIPIDs

1. Diabetes --> TEST: GLUCOSE levels
2. BUN/Cr --> urinary proteins (nephrotic syndrome0
3. CHRONIC LD --> LFT
4. Hypothyroidism --> TSH

Acute purulent medications - actual treatment medication for SINUSITIS

1. INitially - nasal spray AIDS drainage acoid smoke and environmental pollutants
2. Decongestants = pseduoephedrine/oxymetazol that facilitates drainages (use < 3days)
3. Antibiotics = amoxicillin, amoxiillin-clavulonic acid (augmentin), TMP-SMX (bactrum, levofluox, moxiflox, cefuroxime)
4. Antihistamines - use for patients with allergies "drying effect"
-loratidine/fexofenadine; chlophiramine

How is HTN diagnosed

Must be at least 2 readigns over a span of 4 or more weeks

NEUROMUSCULAR DISORDERS ASSOCIATED WITH CONSTIPATION

Parkinson's (BG)- treatment is to increase DA
Multiple sclerosis - treatment is to use IFN-B
CNS lesions - determine cause
scleroderma - AntiSSA/SSB
DM - autonomic neuropathy (also resulting in electrical dysfunction)

What is the proper method by which to physically examine the knee?

1. Look for distortions or contusions with abnormal bony prominences
2. Determine if EFFUSION present
3. Assess Mcmurray and apley tests for meniscal innjury
4. Determine ROM
5. Look at LCL/MCL
6. Assess ACL by Lachmans or anterior drawer
7. Joint line tenderness
8. Pateller grind test

Chronic diarrhea ex:

1. IBS
2. IBD
3. MEDS
4. Infection
5. Colon CA
6. DIverticulitis
7. Malabsorption syndrome (pacreatic AI, celiac, SB syndrome, ischemic bowel, laxative abuse

How is obstructive sleep apnea diagnosed?

Polysomnography (overnight sleep study)

SYmptoms: snoring-daytime sleepiness-change in mood-polycythemia-HTN-decreased O2 sat-hypoxemia

OSA apneic periods lasting 20-30 seconds in length - occur at the level of the oropharynx

Pain is steady, aching, tightband-like aroud the head but most generalized around neck and back of head +/- tender muscles

Tension headache

Acute infectious diarrhea:

If ROTA or NORWALKvirus:

Acute infectious diarrhea = myalgias, malaise, n/v

+/- fevers
no fecal leukocytes
treat symptomatically and hydration

Treatment of tension headaches

1. If depression induced = SSRI
2. If stress/anxiety = benzo
3. NSAIDS/Acetominophen/ASA if mild
4. If migranes, use different medications

Treatment of patients with IBS+diarrhea
Treatment of patients with IBS+constipation

IBS + diarrhea = LOPERAMIDE (Opiod), DIPHENYLOXYLATE
IBS + constipation = colace, psyllium, CISAPRIDE

How does sinusitis present?

Inflammation of paranasal sinus lining, often due to infection. Mucosal edema obstruction sinus opening (OSTIA) trapping sinus secreations.

HTN treatment preferred in pts with DM

ACEi preserved renal function

Diagnosis of osteoporosis =


Rx =

DEXA scan = GOLD standard
-perform at menopause
-bone samples from HIP/LUMBAR and compare with STD control which is that of "healthy" 30YO
-osteopenia will become osteoporosis

RULE OUT SECONDARY CAUSES: Calcium, phos, alk phos, TSH, PTH, CBC, VITAMIN D

What is the treatment regimen for strept throat?

1. Throat culture sent off (wait 24 hr results)
2. Rapid strept test to rule out GAS
3. Penicillin 10 days - covers all gram psitives - if allergic do erythromycin *MACROLIDE

Two types of hearing loss

1. Conductive hearing loss: lesion external/middle ear that interferes with mechanical reception or amplification (BC > AC)

2. Sensorineural hearing loss: CNVIII or cochlear lesion (AC > BC)

How are/is sinusitis classified?

Most common?

Acute bacterial sinusitis (usually will be: S. pneumo/H. Influ/Anaerobes)

Viral, fungal, allergic

Maxillary sinuses

Which tests (non-invasive) can be perfored for H. Pylori?

#1 UREASE breath test
1. If H. Pylori +, treat empirically with 3 Rx regimen
2. If negative, PUD is unlikely and patients either has GERN or nonulcer dyspepsia

Causes of SORE THROAT (4 MAIN)

1. VIRAL infection (ADV, Parainflu, RhinoV, EBV, HSV)
2 Tonsillitis
3. Strept throat (GAS)
4. Mononucleosis

When is a CBC ordered in patients with a cough?
PFT?
Bronchoscopy?

CBC with a cough when INFECTION is suspected
PFT with a cough when ASTHMA is suspected
BRONCH is a last resort if suspect a tumor, foreign body, or tracheal web

What associated conditions are seen with CARPEL TUNNEL SYNDROME?

Hypothyroidism
DM
Repetitive use of hands in certain professions
Activities
Pregnancy/Trauma to wrist
Acromegaly**

When is a CXR ordered in patients with cough?

Only when pulmonary cases is suspected!
-when hemoptysis expected, when chronic cough, when longterm COPD/lung CA

Tennis elbow versus Golfers elbow

Tennis elbow: lateral epicondylitis at elbow
-inflammation of extensor tendons of the forearm orginating from lateral epicondyle resulting from supination and pronation
-initial treatment: splinting forearm, physical therapy
-last resort: SURGERY

Golfers elbow: distal to medial epicondyle
-inflammation of the flexor tendons that is exacerbated by wrist flexion

Treatment of VIRAL conjunctivitis

-cold compress
-strict handwashing
-topical AB if suspect superinfection by a bacterial organism

Complications of HTN on the
1. Heart
2. Eyes
3. CNS
4. Kidney

1. Heart: htn is a mjor risk factor for CAD with angina and MI; CHF if no treatment of HTN because can lead to LVH; deaths due to MI or CHF; PVD; aortic dissection = HTN without atherosclerosis
2. Eyes: cotton wool spots, papilledema, AV nicking (loss of central vein d/t increased arterial wall thickening)
3. CNS: increased intracerebral hemorrhages; elevated stroke subtypes (TIA, ischemic stroke, lacunar stroke, HTN encephalopathy)
4. Kidney: Arteriolosclerosis of AFF or EFF arterioles and glomerulus called nephrosclerosis; dec GFR; dysfunction of tubules with renal failure

ETEC v. EHEC O157:H7

ETEC: (HL, HS)
-watery diarrhea, nausea, abd pain
-NO fever
-NO WBC
-<FEW days
-"self limiting" thus hydration

EHEC 0157H7
-bloody diarrhea pt appears sick
-pos fever
-pos WBC
-+HUS-TTP
-Hemolytic, uremic, syndrome, thrombolytic thrombocytopenia, purpura

Most common symptoms:
1. BRIGHT RED BLOOD PER RECTUM WITH RECTAL PROLAPSE
-IF PAINFUL?
-IF PAINLESS?

External hemorrhoids
Internal hemorrhoids

RED FLAG SIGNS/SYMPTOMS OF LOWER BACK PAIN

1. Saddle anesthesia
2. Major motor loss
3. Immunosuppression
4. Hx of CA
5. Bowel/Bladder incontinence
6, Night time pain
7. UNINTENTIONAL WEIGHT LOSS, FEVER

Most common cause of sensorineural hearing loss?

Presbycusis - gradual hearing loss secondary to age
1. Degeneration of sensory cells and nerve fibers at the base of the choclea
2. Marked with HIGH frequency hearing loss - then progresses to eventual low frequency hearing loss

Most common cause of secondary HTN in females?

OCP

Treatment of constipation:

1. DIET + BEHAVIORAL CHANGE: increase exercise, diet, fluid and fiber
2. Use enema (fleet) for temporary relief in patients with relieve from conservative therapy.
3. Surgery is obstruction

What is a Baker's cyst?

Intra-articular pathological cause that mimics DVT or thrombophlebitis

-seen in OA and RA
-treatment is actively mofifying diet and will resolve spontaneously

Treatment for chlamydial conjunctivitis

1. Adults and adolescents - ORAL TETRACYCLINE, DOXY, ERYTHRO for 14 days
2. Treat sexual partners for STD too

Tegaserod maleate (ZELNORM) is a _____ agonist used to treat IBS and _____ in females

Serotonin
IBS + constipation

Acute diarrhea secondary to SALMONELLA

Abdominal pain
diarrhea, bloody stool
n/v

fever, WBC, feval, resolves within one week , symptoms start 2-3 days post ingestion. Only treatment if immunocompromises or if enteric fever

Treatment: CIPRO

Causes of ACUTE DIARRHEA
1. Infections : ____>_______>_______
2. Medications: _______>_______
3. Malabsorption:
4. Ischemic bowel in patients with _______.

1. Viral > Bacterial (severe) > Parasite
2. Antibiotics associated diarrhea due to c. difficle toxin in 25% cases;
-AB>LAXATIVES>PROKINETICS (Cisapride), ANTACIDS, DIGITIALIS, COLCHICINE, ALCOHOL, MG containing, chemo treatment
2. Lactose intolerance; chrohns disease; celiac disease; CF patients
4. PVD

What is the most common transitional route of common cold v. s. aureus?

Hand-to-hand with the common cold
Nares with S. Aureus

Most common causes of acute diarrhea in < 4 weeks?

Most severe causes of acute diarrhea due to?

VIRAL infections: ROTAVIRUS, NORAWALK VIRUS

BACTERIAL infections: SHIGELLA, E. COLI, SALMONELLA, C. JEJUNI, C. PERFERINGENS, C. DIFFICILE

When are nasal steroids used for ACUTE sinusitis?

1. Fluticonasone
2. Beclomethasone

Use if sinusitis is seconary to allergic rhinitis (corticosteroid nasal spray to decrease inflammation

ACUTE SINUSITIS

Degenerative disc diseases: how does lumbar spinal stenosis differ?

Osteoarthritis: chronic low back pain, disk space narrowing, osteophytes causing nerve rootcompression and radiculopathy

LSS: narrowing of the spinal canal that can be aquired OR congenital with increased PAIN on activity and relieved by REST and SPINAL flexion because will increase the size of the canal

Majority of complications of OSA

1. Elevated PVR due to hypoxemia which can lead to pulmonary HTN and eventually COR pulmonale

2. Systemic HTN due to increase in sympathetic tone

Acute sinusitis v. Chronic sinusitis

Acute: nasal stuffiness, discharge, cough, sinus pain/pressure (worsens with percussion and leaning forward), 50% with fever

Chronic: nasal stuffiness, postnasal drip, pain/headache, 2-3 months, history of multiple sinus infection and at risk for infection with s auresu and gram - rods.

Womens health:

1. Breast CA - self examination versus mammogram

2. Cervial CA:

Self examination: Monthly self exam for all females greater than 20YO
Physicians exam: every 3 years until 40YO then every year > 40YO

Mammogram: every 1-2 years in females >/= 40YO; every year females >/= 50YO

Cervical CA: PAPsmear: within 1st three years of sex OR 21 YO
-if two consecutive years are (-) for cervical CA, then repeat every 3 years byt age 35, and repeat every 5 years by age 65

What is the most commonly injured ligament of ankle sprains:

Classification:
Diagnosis:
Treatment:

ATFL - anterior talofibular ligament

Class I: partial rupture
Class II: complete rupture of ATFL and partial rupture of CFL
Class III: complete rupture of BOTH ATFL and CFL
Diagnostics: Pt walks 4 steps at the time of injury; NO BONY tenderness over distal 6cm then do NOT order a xray.

Treatment: RICE and PT

Most definitive treatment for cataracts:

What is secondary sight?

SURGICAL REMOVAL IS BEST FOR CATARACTS - MOST DEFINITIVE WITH IMPLANTATION OF AN ARTIFICIAL INTRAOCULAR LENS

BECOME INCREASINGLY NEASIGHTED AND NO LONGER NEED READING GLASSES BECAUSE THE CATACT INCREASES REFRACTICE POWER OF THE LENS.

What are the two most common causes of nausea/vomiting?

1. Food poisoning (s. aureus, cdiff)
2. Viral gastroenteritis

Diff: pregnancy, metabolic (DKA, addisons uremia, hypercalcemia, hyperkalemia, hyperthyroid), GI (gastroenteritis, PUD, GERD, gastroparesis), acute MI, drugs, visceral change

What is the lab workup of "FATIGUE"

1. CBC to check for anemia
2. TSH to rule out hypothyroidism
3. Fasting glucose (DM)
4. BMP (electrolytes)
5. UA (BUN/Cr) renal disease
6. LFT (liver dz)

Labs to order for n/v?

Complications of severe LT vomiting?

Order: CBC, electrolytes, glucose, LFT, pregnancy test in FEMALES

-fluid/electrolyte abnormalities, dental caries, mallory weiss tears, metabolic alkalosis +hypokalemia, boerhaaves syndrome

Most common cause of acute bacterial diarrhea esp in children

C. Jejuni (comma shaped and oxidase positive)

Headache, bloody stool, fatigue followed by diarrhea and abd pain, + fever, +WBC fecally, < 1 week

Treatment: ERYTHROMYCIN (macrolide)

How often should a patient with BARRETTS esophagus be screened for ADENOCARCINOMA

Every 3 years - an EGD should be performed with BIOPSY to note DYSPLASTIC changes

How does HTN affect the heart?

1. Decreases SVR (thus increases afterload - rx with antibiotics)
2. Elevated LVH (concentric)
3. Decreased LV function
4. This results in dilation of the L ventricle and has signs/symptoms of heart failure

What normally causes laryngitis?

Symptoms: VIRAL in origin - if bacterial = 1. Morexella catarrhalis or 2. H. Influenza
Diagnosis: Hoarseness, cough (other URI), self limiting, rest voice until laryngitis resolves to avoid formation of vocal NODULES

Most common spinal tumor causing lower back pain, night pain?

Metastatic carcinoma
#1-breast
#2-lung
#3-prostate
#4-kidneys
#5-thyroid

PTBLK - P.T. Barnum loves kids

Treatment of sinusitis initially?

If symptoms persist > 2 weeks?

1. Decongestants = initial therapy (1-2 weeks)
2. XRAY films and penicillinase -R > 2 weeks then AB are appropriate
3. Consider ENT consult - because of anatomic difficulties - acute sinusitis takes a lont time to treat.

Laboratory findings of ALCOHOLISM

-anemia
-macrocytic
-microcytic
-LFTs (AST>ALT)
-HyperTG
-HyperURICEMIA
-hyPOcalcemia
-Thiamine def
-decreased testosterone

Treatment with: alcohol - join AA; DISULFIRAM, NALTREXONE (BENZO)

Treatment for withdrawal - BENZODIAZEPINES: DIAZEPAM #1

Which endocrine disorders are associated with constipation?

HYPOTHYROIDISM (bone maturation, brain maturation, basal metabolic rate and beta-adrenergic receptor

-HYPERCALCEMIA (BONES, MOANS, GROANS, STONES)
-HYPOKALEMIA
-UREMIA
-DEHYDRATION

What is NONULCERATIVE dyspepsia

Diagnosis of exclusion like AD in which appropriate tests (including endoscopy) reveal no specific cause

Must: (1) no ulcers (2) last > 4 weeks

Prophylactic treatment of migraines?

first line: TCAS (amytriptyline) or BB (propranolol - do not give if elevated lipids)
secondary: VERAPAMIL (CCB) and Valproic acid

What is the IDEAL VALUE for total cholesterol, LDL, TG?
What is the BORDERLINE VALUE for total cholesterol, LDL, TG?
What is the HIGH VALUE for total cholesterol, LDL, TG?

Ideal: <200; <130; <125
BRD: (200-240); 130-160; (125-250)
HI: >240; >160; >250

Treatment for acute migraine attacks:

1. If migraines mild, use nSAIDS or ACETOMINOPHEN

2. If migraines severe, use DHE = 5HT1R agonist - use if CAD, pregnancy, TIA, PVD, Sepsis

3. Sumatriptan (selevtice 5HTIR agonist) - rapid action (1 hr)
**do not take greater than 1x/week

What is the first line therapy for hypertriglyceridemia > 500 mg/dL?

NIACIN

NEUROLOGICAL EXAMINATIN
1. TESTS FOR L4 ROOT:
2. L5 ROOT
3. S1 ROOT
4. REFLEX

L4: Ankle dorsiflex; anteromedial LEG, plantar reflex
L5: dorsiflex ankle/great toe against R; sensation along lateral shin of injury
S1: plantar flex (gastroc), ankle DTR (achilles), sensation lateral foot/heel

Reflexes (L4 - patella; L5 - hamstring; S1 - ankle)

Type of headache that worsens throughout the day and can be ignited by:
1. Anxiety
2. Depression
3. Stress

Tension headache

Sudden urge to urinate followed by loss of large amounts of urine = _____ ______

How might this be managed:

Urge incontinence --> oxybutynin; TCA (imipramine); bladder retraining
-most common to pts with MS, stroke, dementia, illness or parkinson's

Electrolyte imbalances caused by diarrhea

1. Metabolic acidosis: elevated bicarb in fecal matter
2. HyPOkalemia: increased movement of ions into cells (H+) and increased movement of K+ out of cells as buffer but will get renally excreted

Type I hyperlipidemia treatment

Elevated chylomicrons thus treat diet (dec total FAT and total CHOL)

Differential to patients with IBS (possible)

1. Colorectal cancer - neoplasm
2. IBD - congenital
3. DRUGS
4. Mesenteric ischemia - vascular
5. Ischemic colitis
6. Giardia
7. Pseudoobstruction
8. Depression - psych
9. Somatization - psych
10. Volvulus, megacolon (BIGTIME WITH CDIFF)
11. Bacterial aggravation
12. Endometriosis

Treatment of the common cold?

-no fever; if present, suggests bacterial complication
-rhinorrhea, sore throat, malaise, nonproduction cough, nasal congestion
-common to have fever in children

Adequate hydration
-looses secretions and prevents airway OBS
-elevate FLUID intake and inhaling steam
-rest and analgesics (ASA/COX3; COXi)
-Cough suppressants and nasal spray/first generation antiH

Treatment of GERD

Phase I
Phase II
Phase III
Phase IV
Phase V
Phase VI

Phase I (initial) - behavioral modification (decrease caffiene, -OH, chocolate, coffee, fatty foods, OJ; sleep with upper body elevated, dec smoking

Phase II (add) - a H2 blockers (cimetidine/ranitidine) + behavioral modification
Phase III (switch) - to a PPI like omeprazole
Phase IV (add) - add promotility agent + PPI
-metoclopromide (DA blocker); bethanechol (ACh agonist) increases GI motility
Phase V: COMBO = H2B +promotility or PPI + promotility
Phase Vi: Surgery if cases are severe

Lumbar disc herniation

nucleus palposus extrudes through the annulus fibrosis and impingment of nerve root occurs causing RADICULOPATHY @ L4-L5, L5-S1

Screening for HTN =
Screening for HLD =

ALL adults > 18YO and older/middle age

Healthy adults >/= 20 YO - nonfasting Totalc and HDL
-look every 5 years
-if total C < 200 mg/dL and HDL > 35 mg/dL then repeat in 5 years
-if total C > 240 mg/dL and or risk factors with 200-240 mg/dL then get completr lipoprotein profile

"common cold" or acute rhinosinusitis

#1 URI (children>adults) - ADV, RSV
1. Primarily viral (coronavirus and rhinovirus)
2. Susceptibilty depends on pre-existing AB levels

identification of rhino v. corona is no important
-rhinovirus most common (~50%) with >100 antigenic serotypes so reinfection with another type is likely.

HTN medications that are safe in pregnant women?

SAFE:
a-methyl dopa
BB
hydralazine

UNSAFE:
ACEi and ARBS
TZD (diuretics)
CCB

What causes infectious conjunctivitis?

(1) VIRAL = MOST common form by adenovirus, recent URI with edema or eye that spreads to other eye. D/C watery. Treatment with STEROIDS.

(2) BACTERIAL = S. pneumonia ubt can be by gram (-) too. Irritation, hyperemia, tearing with spread to other eye in <2 days. EXUDATE AND CRUST positive. Treatment with BROAD SPECTRUM AB

(3) CHLAMYDIAL = (1) trachoma a, b, c - #1 WW due to conjunctival scarring
(2) inclusion conjunctiva (D-K)

Supraspinatous (rotator cuff tendinitis)

most common cause of shoulder pain due to impingement of greater tuberosity on the acromion with pain with overhead movement

Treatment: steroid injections and/or surgery to treat the acromioplasty

What causes overflow incontinence?

1. neurogenic bladder (pts with DM with lower MN lesions)
2. medications (anti-cholinergics, alpha-agonists
3. obstruction to flow (BPH, prostate CA)

nocturnal wetting; loss of small amounts of urine but large post void (>100mL)

Potency of HMG-CoA reductasei?

Fluvastatin (lescol) < lovastatin (mevacor) < pravastatin (pravachol) < simvastatin (zolar) < atorvastatin (lipitor)

Least potent: fluvastatin < lovastatin < pravastatin < simvastatin < atorvastatin (lipitor): Most potent, most expensive

What is the treatment for laryngitis if VIRAL

SELF LIMITING

Causa Equina Syndrome

MEDICAL EMERGENCY (Compression of roots S1, S2, S3, S4 after spinal trauma/central lumbosacral disc herniations)

1. Bilateral sciatica and motor loss
2. Saddle anesthesia
3. Urinary frequency or urinary retention
4. Lower back pain
5. Impotence (lax anal canal) - loss of bowel control

Treatment for erectile dysfunction

Treatment underlying causes and address atherosclerotic risk factors

-hormone replacement
-SILDENAFIL CITRATE (viagra) - smooth muscle relaxation (30-60 min b4 sex) contraindicated in patients current taking nitrates because can result in severe hyPOtension and lead to syncopal episodes.
-intracavernosal injections of vasoactive substances.

What medications cause HTN?

1. OCP
2. Decongestants (pseudoephedrines)
3. Estrogens
4. Apetite suppressants
5. Chronic steroids
6. TCA
7. NSAIDS

WHen should an endoscopy be performed for dyspepsia diagnosis?

Yes to ENDO:
1. If esophageal stricture (PV syndrome)
2. If ulcer
3. If malignancy
4. If GERD

No to ENDO
1. DO not is weight loss/anemia/dysphasia
2. DO not if >45-50 if new onset
3. Do not if recurrent vomiting of upper GI bleeding hematemesis

Episodic cluster headache verusus chronic cluster headache

Episodic: 90% 2-3 mo duration remits mo-years
Chronic: 10% 1-2 years without remission

How is GERD diagnosed:

NO diagnostic tests needed to initiate therapy for typical-uncomplicated cases of GERD

If complicated, atypical-uncomplicated cases of GERD
1. Perform endoscopy + BIOPSY (anemia, wt loss, dysphasia present)
2. Upper GI series (contrast barium) - only helpful in identification of ulcers/strictures. NOT DIAGNOSTIC OF GERD
3. 24 hour pH monitoring

When is imaging for the lower back pain performed?

If symptoms do not respond to NSAIDS and rest within one month or if neurological sign erupts.

Treatment: INTIALLY: NSAIDS, REST, and narcotics or muscle relax

If neuro += MRI, if compression --> spine specialist
IF CHRONIC: PT, NSAIDS, EPIDURAL injectios as needed

What causes male v. female incontinence

Male = BPH, neurologic disease
Female = hormonal, pelvic floor dysfunction/laxity, uninhibited bladder contraction due to aging

Familial type V hyperlipidemia

Elevated VLDL (APO B100)
Elevated Chylo (ABO B48)

Treateent: Niacin,gemfibrates

Which medications can result in hyperlipidemia?

1. GLucocorticoids (the "hump" of excessive fat with urine)
2. Estrogens (elevated adipose)
3. TZD diurattics (elevated LDL, Total Chol, VLDL)
4. Bblockers with elevated TG (VLDL) and Decreased HDL

If GERD is severe and unresponsive to treatment, which should be performed?

1. Antireflux surgery
-intractibility
-respiratory problems due to aspirates
-esophageal injury (ulcer/hemorrhage/stricture/barretts)

A. Nissen fundoplication - done if normal esophageal motility
B. Partial fundoplication - when esophageal motility poor

WHich antihistamines are used best in patienst with ACUTE SINUSITIS?

What treatments can cause "drying" effect?

1. Loratidine (claritin) - 2nd generation antihistamine
2. Fexofenadine (Allegra)
3. Chlorpheramine (Chlortrimeton)

Drying effect of anti-histamines can sometimes make the secrtions thicker and can worsen congestion. IF this occurs, AVOID IT

Type IV hyperlipidemia

Elevated VLDL *endogenously)

Treatment with
1. Niacin
2. Gemfibrils
3. Statins

What is sciatica? What exacerbates this movement?

pain along sciatic nerve + positive neurological deficits

-exacerbated by forward flexion, sitting, driving, lifting, worsens leg pain

Colorectal screening/surveillance

1. average risk patients (>50YO without prior GI issues)
a. Fecal occult blood test every 1 YEAR + sigmoidoscopy 5 YEARS
b. Fecal occult blood test every 1 YEAR + colonoscopy 10 YEARS
2. moderate risk patients (single polyp)
a. If initial colonoscopy then repeat it in 3 YEARS
b. if OK then go colonoscopy every 5 YEARS
c. If family pos for CAC then do colonoscopy @ 40 YO or 10 years younger than youngest cause in family and repeat colonoscopy 3-5 years

3. high risk patients
a. IF HNPCC = do test at 21YO -if positive do colonoscopy 2 years until 40 YO then do annually

Causes of constipation

1. DIET
2. Medications (antipsycho); antidep; narcotic analgesics, IRON, CCB, ALUMINUM, Ca2+ - containing antacids, laxative abuse
3. IBS
4. Obstruction: CRC, stricture; fissures hemorrhoids
5. Ileus (pseudo obstructuion from that of GB or CF)
6. Endocrine
7. Neuromusclular - d/o

Fever, tachypnea (^RR), crackles, exophony on auscultation, dullness to percussion:

Dx:

PNA

Diagnostic of PEPTIC stricture secondary to GERD:

Confirmed by EGD
1. See fibrotic rings narrowing the lumen and obstructing the passage of food.
2. Presents with dysphasia, mimics esophageal cancer

Treatment - dilation of esophagus with LT PPI use (omeprezole)

Causes of reflex incontinence:

Spinal cord injury - MS, DM, tabes dorsalis, spinal cord complication, disc herniation

Which STD can yield a sore throat?

Gonococcal (N. Gono); gram - diplococci which response to glucose without maltose, no capsule.

Chlamydia trachomatis

When stratified squamous epithelium of the distal esophagus is replaced by columnar epithlium?

Diagnosis:
Inc risk of malignancy if DYSPLASTIC:

Barretts esophagus which can lead to dysphasia called - ADENOCARCINOMA

Up to 90% of cases involving epigastric pain are inclusive of:

1. PUD
2. Gerd
3. NONulcer dyspepsia (functional dyspepsia)
4. Gastritis

Other: Cholecystitis, biliary colic, malignancy, pancreatic disease

Treatment for chronic sinusitis?

1. Penicillinase-R Abiotic
--> Methicillin, Nafacillin

2. Refer to otolarynologist
--> +/- drainage

Leg pain on back extension that worsens wth standig and walking but relief with standing and sitting?

LSS

For alcoholism = WERNICKE's encephalopathy and korsakoffs psychosis

If alcoholic - must first administer thriamine then glucose to ensure DT treatment.

Wernickes is REVERSIBLE - thiamine deficiency that manifests with nystagmus, ataxia, apthalmoplegia, and confusion.

Korsakoffs psychosis is irreversible and caused by thismine deficiency and ST memory loss with confabulations.

How is elevated HTN that causes/d organ damage diagnosed?

1. UA
2. CHemistry panel (serum K+, BUN, Cr)
3. Fasting glucose (if diabetic, check microalbuminemia)
4. Lipid panel (see if HDL and elevated LDL --> atherosclerosis)
5. ECG (can tell you Hx of MI or stable v. unstable angina and can not change in LV and CHF.

What is dyspepsia?

Epigastric symptoms that are inclusive of heartburn "indigestion", bloating, pain or discomfort

HIGHLY common
confused with angina

Patients with "migraine headaches" for whom no medications work-likely diagnosis?

Rebound analgesic headaches. These occur more frequently

How is LDL calculated?

LDL = TotalC - HDL - (TG/5)

What is the most sensitive and specific test for GERD? THE GOLD STD:

24 hr pH monitoring in lower esophagus = most sensitive, gold standard, usually not necessary

36 YO patient presents to the clinic complaining of a pruritis eruption on his forearms. Denies fever, chills and maliase. PE shoes erythematous rash with occasional veiscles affecting both forearms. NO LAD is apprecirated. Vesicular fluid grows coagulase-negative staphlycocci. His only relevant history is recent owrk in the woods behind home chopping and transporting firewood. Which of the folowing is the most likely diagnosis?

HSV, S. aureus, S. Epidermidis, Supperative hidrasenitis, Contact dermatitis

Contact dermititis. Inflammatory skin condition caused by allergens like poison sumac, cosmetics and nickel. It presents days to weeks after exposure with an intensely pruritic erythematous rash with vesible at teh site of exposure. Secondary infection as a results of excessive scratching is possible and is suggested by pus filled vesicles that would hence test positive for a S. epidermidis infection. However this is generally an organism native to the skin that is generally non-pathogenic

Prehtn v. Stage I v. Stage II

Prehtn: no treatment/lifestyle modificcations (120-139/80-89)
Stage I: lifestyle modification + rx therapy (140-159/90-99)
Stage II: lifestyle + 2 drug therapy (>160/>100)

What is the first like therapy for HYPERGLYCERIDEMIA?

At what level of TG?

1. NIACIN

TG levels > 500 mg/dL

Which type of galucoma is commonly associated with severe abdominal pain, vomiting and headache?

CLOSED ANGLE glaucoma.

IF CHRONIC OPEN ANGLE - can use TOPICAL medications BB, a-agonist, CAi, PDE agonist ORRRR you can undergo laser or surgical treatment

ACUTE CLOSED ANGLE - emergency, MUST lower IOP; PILOCARPINE drops, IV ACETAZOLAMIDE and ORAL GLYCERINE are the top medications

HIP FLEXION --> NERVE ROOT =
KNEE EXTENSION --> NERVE ROOT =
ANKLE DORSIFLEXION --> NERVE ROOT =
GREAT TOE DORSIFLEX --> NERVE ROOT =
PLANTAR FLEXSION -->

L2
L3
L4/L5
L5
S1

How does AGE affect size of bladder? Incontinence?

1. Bladder size decreases
2. Earlier detrouser contractions
3. Postmenopausal GU atrophy

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