199 terms

Step Up to Medicine: Chapter 12 Ambulatory Medicine

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?
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

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
Remember the pneumonic CRAB:

1. CALCIUM (Hypercalcemia)
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)
Cluster headaches:
1. Use verapamil (CCB) po #1
2. Ergotamine
3. Methylsergide
4. Lithium
5. Corticosteroids
How is sinusitis diagnosed

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)

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?

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
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
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
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 + 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

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?
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?
Repetitive use of hands in certain professions
Pregnancy/Trauma to wrist
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
-watery diarrhea, nausea, abd pain
-NO fever
-<FEW days
-"self limiting" thus hydration

EHEC 0157H7
-bloody diarrhea pt appears sick
-pos fever
-pos WBC
-Hemolytic, uremic, syndrome, thrombolytic thrombocytopenia, purpura
Most common symptoms:
External hemorrhoids
Internal hemorrhoids
1. Saddle anesthesia
2. Major motor loss
3. Immunosuppression
4. Hx of CA
5. Bowel/Bladder incontinence
6, Night time pain
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?
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
IBS + constipation
Acute diarrhea secondary to SALMONELLA
Abdominal pain
diarrhea, bloody stool

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

Treatment: CIPRO
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;
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?

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

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:

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?

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

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
-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

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?
2. L5 ROOT
3. S1 ROOT
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
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?
a-methyl dopa

TZD (diuretics)
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
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
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
-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
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:

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?

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?
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?

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
How does AGE affect size of bladder? Incontinence?
1. Bladder size decreases
2. Earlier detrouser contractions
3. Postmenopausal GU atrophy
Acute diarrhea: SHIGELLA
Diarrhea, abdominal pain, tenesmus + n/v (feeling of constant urge to pass stool)
+ fever
-one week duration

Treatment: TMP-SMX - BACTRUM
Primary headache syndromes

Secondary headache syndromes
Primary: migraine, cluster, tension
Secondary: vascular (SUBDURAL, EPIDURAL, SUBARACHNOID hemorrhaging)
other: malig HTN, pseudo cerebri, pheochromocytoma
meds: nitrates, alochol, analgesics
infections: meningitis, herpes zoster
Timeline of migraine
1. Prodromal phase (30%) - prior to migraine
2. Headache = unilateral, thrombbing, lasts 4-72 hours and lasts days
Increased cholesterol with age until ~65YO; then ~2 mg/year

M>F until age of menopause THEN women > males
Statins act by?
Cholestyramine acts by?
FIbrates (gefibrozil) acts by?
1. HMG-CoA reductase: now chol form in liver
2. Binds to bile in the GI tract and doesnt allow for enterohepatic recirculation, reabsorption
3. Fibrates decreases in TH, BKing down into FFA by elevated LIPASE in ADIPOSE tissue
How might recurrent PNA results as a complication of GERD?
Due to recurrent pulmonary aspirations. Thus if aspirations on bronchoscopy reveal aspirates of gastric contents being lipid laden mceophages (by phagocytosis of fat) then DDX.
Most probable diagnosis instance where patient recalls a bending/twisting of back leading to "giving" way when lifting a heavy object:
Musculoligamentous strain
What is OSTEOPOROSIS and how can they be differentiated against that of OA and RA?
1. Dec in BONE MASS causing an INC in bone fracture due to decrease in bone mineral density
2. FAILURE to attain optimal peak bone mass b4 30YO or it is due to increased rate of bone resorption >> that of formation after peak mass.

Primary: (I) post menopausal females 51-75YO = loss of trabecular bone; vertebral compression; colles fracture common. (II) female v. male >70YO = loss of cortical and trabecular bone

Secondary: Cushings syndrome, LT heparin, hyperparathyroidism
Smoking cessation:
#1 behavioral
a. Nicotine patch - continue nicotine delivery without peaks/troughs
b. Patch is worn 16 hr / day and goes from 21 mg > 14 mg > 7 mg
c. Nicotine gum
d. Bupropirion (ZYBAN)
Questions to ask in woking up patient with history or CC of diarrhea?
1. Stool bloody or melanotic?
2. Other symptoms (pain, vomiting, ***fever)
3. Anyone else with history of illness
4. recent travel (r/o cholera/+- parasite)
5. Symptoms linked with foods (lactose = milk)
6. Medical problems
7. Recent change in medications (AB)
Viral URI: rhinorrhea, myalgia, headache, fever, dry cough
Bacterial URI: fever, cough, productive sputum
Propranolol is not recommended in patients with severe increase in lipids because?
Propranolol is a nonspecific B-b that increases triglycerides (VLDL) and decreases HDL.
How is hyperlipidemia diagnosed?
lipid screening:
1. TOTAL cholesterol
2. TG
3. HDL

then calculate the LDL
TOP causes of diarrhea in elderly and immunocompromised (HIV)
1. Cryptosporidium (parasite)
2. Mycobacterium avium intra (MAC)
3. Cyclospora
4. CMV
Pateint with RECURRENT INFECTIONs, PARAPROTEIN gap (total protein v. albumin level > 3-4 difference), and elevated CALCIUM, RENAL IMPAIRMENT, ANEMIA, and BONE PAIN should be readily thought to have?
What are the clinical features of SEVERE hyperlipidemia
1. Xanthomas - hard yellow masses on tendons, finger extensors achilles tendons, plantar tendons.
2. Xanthelasma - yellow plaques on eyelids
2. Pancreatitis if increase TG
What is the most common loss of vision in people > 65YO
ARMD - loss of central vision ebcause macula is affected
***scotoma, distortion, blurred vision with peripheral vision in tact.
Involuntary loss of urine in spurts only due to activities that increase intrabdominal pressure (cough, laugh, sneeze, exercise): ________

Stress incontinence

Kegel exercises
Use of pessary
Endocrine causes of secondary HTN
1. Pheochromocytoma
2. Hyperaldosteronism
3. Thyroid, PTH disease
4. Cushings (elevated cortisol due to primary site of tumor, dec CRH, dec ACTH, inc cortisol...dec immunity, dec inflammation, inc neutrophil release, inc gluconeogenesis, elevated BP by BR
5. Acromegaly
Types of Migranes Headaches
1. Migrane with AURA (15%) = "Classic"
-Bilateral homonymous scotoma
-Bright, flashing, crescent images (10-20 minutes)
2. Migrane without AURA (80%) - "Common"
3. Menstrual Migrane
-2 days before mensus d/t E2 withdrawal
4. Status migrainous > 72 hours of headache that resolves spontaneously
IF TG > 500 mg/dL, Rx:
IF TG < 500 mg /dL, Rx:
1. Niacin (dec TG, dec VLDL, elevated HDL)
2. Fibrates (dec VLDL, dec TG, inc HDL)

-gynecomastia, gallstones, weight gain, myopathies can result
How is the causality of sore throat done? Orders?
1. Throat culture = 24 hours (more accurate than rapid strept test)
2. Rapid strept test = results within 1 hour doesnt indicate between any other bacterium other than strept or a virus (this IF negative only rules out GAS but doesnt indicate whether or not it is bacteria or viral
3. Mononucleosis (spot test) = obtain heterophil monospot test. If still suspect mono, but monospot negative think CMV (HHV5) and not EBV HHV4
How is carpel tunnel syndrome treated?
1. Wrist splints (VOLAR CARPEL)
-worn at night during sleep to prevent wrist flex
3. LOCAL corticosteroids injection
4. Surgical release
-only if persistant and affects the DAILY life
Risks for erectile dysfunction
1. Atherosclerosis --> HTN #1
2. Smoking
3. Hyperlipidemia
4. DM

Medications: antiHTN
Hematologic = SCA
Alcohol abuse
Laboratory tests performed for ACUTE DIARRHEA
1. Stool WBC: if absent-no need to order cultures because its unlikely to grow pathogenic organisms. If present, send stool for culture OR cdiff assay or treat empirically with AB
2. Stool sample for OVA and PARASITES (test 3 samples)
3. Stool sample for CDIFF CULTURE
4. Stool sample for CDIFF toxin assay (do if patient recently treatment with AB)
5. Stool for giardia antigen - ELISA assay
6. Stool culture - low sensitivity only examines for shigella, salmonella, campylobactor. If patient has severe diarrhea, req hospital plus WBC.
What is the only FDA_approved drug for smoking cessation that can be used in conjunction with couseling and nicotine replacement therapy?
BUPROPION - which is an anti-depressant. LT use
Exudative versus nonexudative ARMD
Nonexudative - dry ARMD
-gradual onset
-atrophy of central retina
-yellow-white deposits of DRUSEN for deep to pigmented epithelium

Exudative/wet ARMD
-sudden onset
-severe loss
-leaks fluids into retina
-increases neovasculature
5 causes of urinary incontinence
1. Urge
2. Stress
3. Overflow reflex
4. Functional incontinence
5. Reflex
How is CERUMEN IMPACTION treated best?
1. Irrigation after several days of
a. Carbamide peroxide (DEBROX)
b. Triethanolamine (CERUMENEX)
What are the 2 reactions for lipid management that can induce transient elevation in serum transminases like ALT and AST?
Acute v. Chronic cough
Acute cough < 3 weeks
Chronic cough >3 weeks
VIral v. Bacterial infections
VIral: Rhinorrhea (V), Myalgia (V), Headache (V), Fever (B/V), COUGH (B/V)
Bacterial: Fever (B/V), Cough (B/V), Sputum (B)
Radiographic findings for OSTEOARTHRITIS

1. Bouchards nodes at the PIP
2. Herberdens nodes at the DIPs
Fever + blood in diarrhea

Salmonella (+/-) blood
C. Jejuni
What renal diseases are associated with HTN?
1. RAS = #1 cause of secondary HTN
3. Chronic renal failure
What is the treatment in patients with MILD OSA? Severe OSA?
Mild is (<20 apneic episodes) - wt loss, avoid alcohol/sedatives, avoid sleep supine

Severe - nasal CPAP that prevents occlusion of the upper airway; uvulopalatopharyngoplasty - removal of excess tissue; trachiostomy - last resort
If a patient presents with EROSIVE ESOPHAGITIS, what HIGH RISK complication can result?
Barretts esophagus
Treatment for osteoporosis
1. Bisphosphonates: risendronate, alendronate = decreases bone resorption by decreasing osteoclastic activity by bidning to hydroxyapatite and decrease risks of fractures
2. Calcium supplementation
3. Vitamin D supplementation
4. Calcitonin (nasal spray) - minimal LT benefit but useful ST
5. Weight bearing exercise
If sore throat caused by viral infection like
1. EBV
2. Other virals (rhinoV, ADV, ParaINF, EBV, HSV

1. Symptomatically
A. Mono - REST, ACETOMINPHEN/IBUprofen, dec ACTIVITY, increase risk SPLEEN
B. Viral - ACETOMINOPHEN, gargling warm salt water, humidifier, throat losengers
Tympanic membrane perforation:
Hx: Pain, conductive hearing loss, TINNITIS, ringing of the ear
PE: Bleeding from ear; clot in the meatus; visible tear in the membrane

90% heal spontaneously within 6 weeks; larger perforations req surgery
What is the treatment of cluster headaches
1. Acute: Sumatriptan (IMITREX) = #1; O2 inhalation
Pseudomembranous bacterium causing gray-like lesionson pharynx and is associated with bacteriophages that yeild organism infections?
C. Diptheria
How is COUGH treated?

If postnasal drip?
If nonspecific antitussive rx?
(1) Postnasal drip (PND) - first generation antihistamine decongestant prep

-IF ALLERGIC RHINITIS: consider nondrownsy, long acting oral ANTI- histamine (LORATADINE)

(2) Nonspecific antitussive medication - codeine, dextromethorphan, benzonatate (TESSALON PEARLS)
Which viral organisms are responsible for SORE throat
ADV= viral DNA
ParaINF = RNA virus (paramyxo)
Rhinovirus = RNA virus (picorna)
EBV = DNA virus (HHV4)
Carpel tunnel clinical features:

Numbness, pain/tingling in median nerve distribution that worsens at night with weakness and THENAR atrophy

*****TINELS SIGN = tap over median nerve at weist crease that will cause paresthesias in median nerve distribution

******PHALENS sign = palmer flex 1 min with median nerve distribution
4 major organs affected by HTN
1. HTN
4. CNS
Specific therapy for use in patients with infectious bacterial diarrhea
2. Treat underlying cause (meds/foods)
3. AB if infectious by 24 hours
-CIPRO (floroquinolone) 5 day course
-METRONIDAZOLE cdiff infection; redox reaction, absorbed by bacteria and reduces derredoxin and decreases pyruvate synthesis.
Acute bronchitis

#1 Cause:
#1 cause = VIRAL accounts for primary for that majority of inflammed bronchi
-lab tests are NOT indicated unless PNA suspected

symptoms: COUGH (+/-) sputum for 1-2 weeks; CHEST DISCOMFORT; SOB; fever (+/-)

Treatement: NO AB; viral infection --> treat symptomatically with cough suppressants and bronchodilators (anti-tussive medications (TESSALON PEARLS) and bronchodilators like albuterol/salmeteral XR
Treatment by bacterial conjunctivitis including gonococcal:
Acute: broad spectrum topical AB = erythromycin, ciprofloxacin, sulfacetamide
Hyperacute: rx gonococcal conjunctiva with 1x dose of Cephtriaxone IgIm
Which drugs can often mask HYPOGLYCEMIC symptoms in patients with DM?
BB because they decrease CO, HR and thus can mimic the symptpms of hypoglycemia