1. sigmoid

2. usually none. can have chronic constipation, abd pain, bowel changes

3. normal

4. barium enema is most sensitive

5. tx: high fiber diet is most important - bran powder, psyllium (metamucil) or methylcellulose (citrucel)

1. acute abd pain, fever, n/v, constipation or loose stools

2. PE: LLQ mass and tenderness, fever

3. CBC: leukocytosis

CT: wall thickening, diverticula, abscess, extraluminal air or contrast

4. tx: clear liquids

broad spectrum abx (amoxicillin or flagyl)

refer to GI

hospitalization if not beter w/in 3 days - surgery

1. Beck Depression Inventory, Hamilton Depression scale, patient health questionnaire

2. SSRIs: sertraline, fluoxetine, paroxetine, citalopram. take 2-6 weeks to take effect. must taper when coming off. give in AM due to stimulating effect.

1. irritative voiding sx (freqeuncy, urgency), hematuria, sx after sex

2. PE: afebrile, +/- suprapubic tenderness

3. tests: positive urine cultures

UA: leukocytes, RBCs, casts, pH change

4. tx: fluoroquinolones (Cipro) or Nitrofurantoin + lots of fluids - should see improvement in a few days

interstitial cystitis

can do urodynamic testing to assess bladder sensatin and compliance and detrusor instability

need to r/o UTI, STDs, bladder cancer

tx: no cure

hydrodistention (filling bladder wtih saline endoscopically) is sometimes helpful

amitriptyline is first line

CCB may provide relief

much greater risk for UTI when pregnant

8% are asymptomatic

20-40% will develop pyelo

2/3 due to e. coli

test all pts at every visit and tx even w/o sx

tx: macrobid, ampicillin, cephalexin -- NOT sulfonamides or fluorquinolones

pyelo

tx:

- mild: cipro or ofloxacin or bactrim

- severe: hospitalization with IV ampicillin AND gentamycin

emphasematous pyelo is a complication in dm

1. indications: acne, rosacea, h. pylori, syphilis, malaria, amebiasis, RMSF

2. contraindications: pregnancy, severe renal disease, breastfeeding, dermal erythema

3. precautions:

- can cause papilledema - need regular opthalmologic exams

- can be inactivated w/ calcium - do not take with milk

- inactivated by antacids/heart burn meds

- skin sensitivity - stay out of sun

- can cause lupus and hepatitis

- can stain teeth

1. sx: abrupt onset fever, tachypnea, SOB, non-productive cough -- most commonly in immunocompromised

2. PE: bibasilar crackles, tachypnea, tachycardia, cyanosis, fever, fatigue

3. xray: diffuse interstitial infiltration - miliary or patchy, focal consolidation, cavitary nodules, hilar adenopathy, cysts.

- Fiberoptic bronchoscopy with bronchoalveolar lavage is primary means of dx

4. tx: bactrim ASAP

BPH

exams: DRE, UA to r/o UTI, PSA

CT or US only if complications

tx:

- mild: watch and wait

- alpha blockers

- Finasteride (5alpha reductase inhibitor) - can cause sexual dysfunction

- surgery indications: urinary retention, cystic diverticula, recurrent UTI, recurrent gross hematuria, bladder stones, CKD

- surgical options: TURP, TULIP, TUNA

syphilis

exams:

- fluid expressed from lesions shows T. pallidum by immunofluorescence or dark field microscopy

- + RPR, VDRL, and FTA-ABS

tx: penicillin IM x1 for early

pencillin IM once a week x 3 weeks for later stages

- doxy or TCN are alternatives

- pregnancy: penicillin

treat anyone prophylactically who has been exposed bc it takes 3 mos to become serologically positive

secondary: generalized maculopapular rash, mucous membrane lesions/ulcers, weeping papules, generalized non-tender lymphadenopathy, fever, meningitis, heptaitis, osteitis, arthritis, iritis - positive serology

latent: no sx but positive serology -- can still be passed to fetus

tertiary: infiltrative tumors of skin, bones, and liver. aortic aneurysm and regurg. CNS d/o - meningovascular degeneration, paresthesias, shooting pains, abnormal reflexes, dementia, psychosis, argyll-robertson pupils

1. pale, edematous, mucosa-covered masses. can lead to nasal obstruction, diminished sense of smell

2. most common in pts with allergic rhinitis

3 Samter's triad - can lead to bronchospasm if aspirin is taken

4. tx: topical nasal corticosteroids for 1-3 mos +/- short course of oral steroids

- surgery for bigger polyps

- allergy medicine to tx underlying cause

Rosacea

tx: avoid exacerbating factors

wear sunscreen

local metronidazole is first line

topical clindamycin is second line

topical retinoids for maintanence

Systemic hearpy: TCN, minocycline, doxycycline

1. mets, nonseminomas (most common), seminomas

2. 5%

3. right

1. sx: painless testicular mass or enlargment (most common), heaviness of testicle, may have sx based on location of mets (back pain, cough, etc)

2. 20-35 y/o is most common

3. labs: HCG, AFP, and LDH are good markers

4. true dx cannot be made without orchiectomy

- any solid testicular mass should be sent to urology

5. tx: orchiectomy (usually curative), retroperitoneal radiation

- follow with tumor markers monthly, CXR and CT q 3 mon

1. STDs (chlamydia and gonorrhea - <40 y/o) and non-STDs (UTIs and prostatitis)

2. sx usually follow physical strain, trauma, or sex - FEVER + SCROTAL SWELLING, urethritis, cystitis, scrotal pain (may radiate to flank)

Prehn's sign: elevation of scrotum above pubic symphysis improves pain

3. CBC: leukocytosis w/ left shift

- culture urethra for GC/chlamydia

- UA to look for UTI

4. r/o testicular torsion

5. bed rest w/ scrotal elevation, treat causative pathogen for ~21 days

6. complications: epididymoorchitis, decreased fertility, abscess

1. def: swelling of testicles

2. most common cause: mumps - usually develops 7-10 days after parotitis

- can also cause after prostatitis or epididymitis, STDs, UTI, long term foley use

- can also be caused by lymphatic filariasis (elephanititis caused by W. bacrofti)

3. sx: fever, scrotal swelling, tender, swollen, heavy testicle, tender to touch, enlarged/tender prostate

4. tx: abx toward cause, anti-inflammatories, scrotal elevation, pain meds

varicocele

tx: varicolectomy, surgical ligation, percutaneous venographic embolization

more common on LEFT

GERD

**severity of sx is NOT correlated wtih amount of tissue damage**

workup: initially none, unless long standing or complications

- EGD

- barium esophagography

- esophageal pH testing

Barrett's Esophagus

tx: PPI long term - reduces risk of adenocarcinoma

- EGD every 3 years

Peptic stricture

tx: dilation with long term PPI

- eat smaller portions

- weight loss

- do not lay down three hours after eating

esophagitis

candida: fluconazole

cytomegalovirus: HAART

herpes: acyclovir

1. NSAIDs, KCl pills, quinidine, zalcitabine, zidovudine, iron, Vit C, abx

2. Sx: retrosternal cp, odynophagia, dysphagia

3. EGD: ulcers

4. tx: take pills w/ 4 oz water & remain upright for 30 min after ingestion

mallory-weiss syndrome

tx: transfusion and fluids. stop bleeding

eosinophilic esophagitis

tx: referral to allergist for testing, elminating food allergies

trial of PPI to exclude GERD

zenker diverticulum

workup: barium swallow

tx: symptomatic - upper esophageal myotomy + surgical diverticulectomy

1. size, present of red marks on endoscopy, severe liver disease, active alcohol use

2. tx: transfusion, stop bleeding

prophylaxis: beta blockers

achalasia

tx: botulinum injection, dilation, myotomy

other: empiric PPI, nitrates, CCB, muscle relaxers

1. sensory hearing loss

2. tx: avoid excessive noise and ototoxic agents, possibly oral antidepressants

3.pulsatile tinnitus: sounds like heartbeat in ears. caused usually by vascular abnormalities (aneurysm) - refer for MRA and venography

4. hyperacusis

1. vestibular

2. duration, associated sx, triggers

3. PE: ears, eye motion, nystagmus, cranial nerve eval, Romberg testing

4. horizontal nystagmus: periphearl lesion

meniere's syndrome

tx: low salt diet and diuretics (acetazolamide)

labyrinthitis

tx: antibiotics if fever

vestibular suppressants (diazepam or meclizine) for acute sx but should not be continued long term

benign paroxysmal positioning vertigo

tx: epley maneuver

vestibular neuronitis

tx: meclizine in acute phase

croup

tx: supportive care, corticosteroids

usually resolves in 3-4 days

RSV

dx based on nasal washings or else clinical

- usually everyone in the house has a cold but the baby has it worst

tx: supportive, may need O2

1. peanuts, raw carrot, apple, dried beans, popcorn, sunflower/watermelon seeds, small toys

- globular objects (hotdog) are the worst

2. more common in right main bronchus

3. sx:

- complete airway obstruction: sudden respiratory distress and inability to talk or cough

- incomplete: choking/coughing accompanied by wheezing, gagging, may have periodic resolution of sx

work up: xray - NL in 15-30%

1. bronchiolitis

2. bronchiectasis

3. bronchitis

Mild intermittent: SABA

Mild persistent: low dose ICS, consider leukotriene antagonist, SABA prn

Moderate persistent: low-med dose ICS + LABA, SABA prn

Severe persistent: high dose ICS + LABA, SABA prn

cystic fibrosis

tx: chest percussion, exercise, postural drainage, abx as needed

prognosis: median survival 35 years

alpha 1 antitrypsin defienciency

tx: increase alpha-1 antitrypsin levels and avoid triggers that hurt breathing (smoke)

polyarteritis nodosa

tx: high dose oral prednisone

PMR

tx: oral prednisone

Giant Cell Arteritis/Temporal arteritis

dx via temporal artery bx

tx: oral prednisone

Wegener's granulomatosis

tx: prednisone and cyclophosphamide

henoch-schonlein purpura

need kidney bx

tx: prednisone

Kawasaki Disease

tx: IVIG and aspirin until pt is afebrile

1. dermatophyte infections - NYSTATIN WILL NOT WORK FOR THESE

tinea versicolor, capitus, corporis, pedis, cruris (jock itch)

2. yeast infections (candidiasis)

3. onychomycosis - oral to treat, topical to control

4. pityriasis rosacea

Tension Type Headache

tx: analgesia, relaxation techniques, amitriptyline

1. phases: prodrome, aura, headaceh, postdrome

2. s/s: n/v, sensitivity to light, sound, or movement

3. triggers: menstruation, glare, lights, sounds, hunger, stress, exertion, barometric pressure changes, lack of sleep, excess sleep, alcohol

4. diagnostic criteria:

a. 2 of the following: unilateral pain, throbbing pain, aggravated by movement, moderate/severe intensity

b. Plus one of the following: N/v, photophobia, phonophobia

c. high suspicion: aura

Treatment:

1. non-pharmacologic: avoid triggers, good sleep, manage env shifts, assess menstruation, weight loss, exercise, address mental health

2. pharmacologic - hsould be individualized:

a. NSAIDs

b. 5-HT receptor agonists for rapid relief:

- ergotamine, dihydroergotamine

- Triptans (sumatriptan/imitrex, rizatriptan/maxalt, zolmatriptan/zomig)

c. Dopamine receptor antagonists (add if NSAIDs and triptans fail)

- metoclopramide (reglan), prochlorperazine (compazine)

d. preventatives:

- for those with >5 attacks/month

- FIRST LINE: low dose amitriptyline, propanolol, topiramate, gabapentin, valproate

- Second line: methysergide, phenelzine

Cluster headache

workup: need to r/o pituitary tumor

tx:

1. acute attack: O2 at 10-12L/min for 15-20 min

sumatriptan SC/intranasal or zolmitraptan intranasal

NOT oral sumatriptan

2. preventative tx: prednisone taper

- ergotamine 1-2 hrs prior to attack

- verapamil is FIRST LINE for chronic/prolonged bouts

- lithium

1. definition: "false brain tumor" - due to high pressure in cranium due to accumulation of CSF. also known as idiopathic intracranial hypertension

- common in women aged 20-50

2. sx: HA, n/v, pulsating sounds in head, papilledema

3. risk factors: obesity, drugs (vit A, steroids, minocycline, levothyroxine), eclampsia

4. tx: weight loss, shunt placement, diuretics

5. complications: can cause vision loss - need ophthalmologic exams

1. killed virus, thimerasol

2. indications: everyone 6 months and older

- high risk: healthcare workers, young kids, pregnant women, immunocompromised, heart/lung/kidney dz, >65 y/o, close contacts of those <6 mos

3. flu season: october-may, february is peak

- protection begins 2 weeks after vaccination and lasts about a year

4. contraindications: egg or other vaccine allergies, previous rxn to flu vaccine, guillain-barre, moderate-severe current illness (wait til you're better)

5. risks: severe allergic rxn (very rare), soreness/redness/swelling at injection site, hoarseness/cough, red/sore/itchy eyes, fever, aches, HA, fatigue

1. NO thimerosol, live attenuated flu vaccine

2. indications: 2-49 y/o and NOT pregnant

3. contraindications: >50 y/o or <23 mos, children <5 w/ asthma, pregnancy, heart/lung/kidney/liver/blood disease, DM, seizure d/o, CP, HIV, cancer, close contacts of immunocompromised, long term ASA tx, egg allergy, guillain-barre syndrome, modrate-severe illness

4. risks:

- flu-like sx

1. early localized infection (stage 1): erythema migrans (bull's eye lesion) at site of bite

2. early disseminated infection (stage 2): days to weeks - secondary annular lesion, severe HA, neck stiffness, fever, chilss, MSK pain, arthralgia, malaise, fatigue, adenopathy, hepatitis, splenomegaly, neuro manifestations (lymphocytic pleocytosis in CSF), optic nerve involvement, cardiac manifestations, joint pain w/o swelling

3. Late/persistent infection (Stage 3): months after onset - oligoarthritis in large joints, chronic neuro involvement with encephalopathy (mood, memory, sleep changes, peripheral neuropathy), acrodermatitis

4. Post-lyme syndrome/Chronic lyme disease: marked fatigue, severe HA, diffuse msk pain, painful/stiff joints, paresthesias, difficulty concentrating, sleep disturbance, no joint inflammation, normal neuro test -- SIMILAR TO CHRONIC FATIGUE/FIBROMYALGIA

serologic antibody test - neg for first few weeks of infection, does not disctinguish between active and inactive infx

- Punch bx of EM

- PCR of joint fluid

Testing/Treatment algorithm:

1. Pt wtih erythema migrans - abx w/o testing

2. Pt w/ oligoarthritis - abx if + serologic testing

3. Nonspecific sx - Nothing

1. organism: borrelia burgdorferi

2. Skin: doxy 14 days

disseminated: doxy 21 days

arthritis: doxy 30 days

3. 2nd line: amoxicillin, 3rd line: cefutoxime

NOT cephalexin

4. IV ceftriaxone if no response to oral, neuro or cardiac involvement

5. preventative: 200 mg doxy w/in 72 hr of tick bite

1. rickettsia rickettsii

2. Sx: classic triad of fever, HA, rash. malaise, myalgia, n/v, anorexia

- progresses to encephalitis (lethargy/confusion), cardiac arrythmias, pulmonary edema, GI bleed, renal failure, DIC, shock, death in 8-15 days

3. PE: macular rash on wrists and ankles then extremities and trunk that progresses to petechiae

4. Diagnostics: clinical if suspicion is high

Cutaneous punch bx is only test that is useful in acute illness

5. Tx: Doxy

- chloramphenicol if pregnant or allergy to doxy

1. Diagnostics: hx, elevated IgE, skin testing

2. tx:

- allergen avoidance

- oral antihistamines - fexofenadine, loratadine, desloradine, cetirizine, levocetirizine, olopatadine, bilastine, azelastine PLUS oral decongestant - pseduoephredrine - CI in narrow angle glaucoma, urinary retention, severe HTN, CAD, first trimester pregnancy

- alternatives: leukotriene receptor antagonist (CysLT1 blocker) - motelukast (singulair)

- topical alpha adrenergic agents (phenypephrine, oximetazoline)

- Nasal glucocorticoids: beclamethasone, flunisolide, traimcinolone, budesonide, fluticasone, mometasone

- cromolyn sodium nasal spray

- immunotherapy injections if required daily use of oral meds

- oral prednisone

pompholyx (vesiculobullous hand eczema)

workup: KOH prep to r/o bullous tinea

tx: topical corticosteroids

1. Sx: severe dyspnea, pink/frothy sputum, diaphoresis, cyanosis, dyspnea at rest, tachycardia, pulmonary rales/ronchi/wheezes in all lung fields

2. Workup:

- EKG (look for ischemia)

- Cardiac cath/angiography: for any pt w/o prior HF

- CXR: vascular redistribution, icreased interstitial markings, butterfly pattern, cardiomegaly

- Echo: look ate EF

- ABG: hypoxemia

3. Management

- O2 until PaO2 >60 mmHg

- Ensure adequate ventilation

- Morphine 2-8 mg IV q 2-4h

- IV diuretics furosemide or bumetanide

- Nitrates sublingual, topical, or IV

- INhaled beta-adrenergics or IV aminophylline

- May need oral ACE-I or diuretics on discharge

1. Definition: complex clinical syndrome in which heart is incapable of maintaining a cardiac output adequate to accommodate metabolic requirements and venous return

2. Causes: ischemic heart disease, HTN, cardiomyopathy, infx, toxins, valvular disease, arrythmias

3. sx: SOB, DOE, orthopnea, PNE, dyspnea at rest, chronic cough, noctuira, fatigue, exercise intolerance, fluid retention, edema, hepatic congestion, loss of appetite, nausea

4. PE: tachycardia, hypotension, reduced PP, cold extremities, diaphoresis, JVD, aortic stenosis,c rackles, wheezes, organomegaly, ascites, peripheral edema, parasternal lift, enlarged LV impulse, diminished heart sounds, S3/S4

5. Labs: anemia, elevated BNP

Xray: cardiomegaly, pulmonary congestion, interstitieal edema, pleural effusion

EKG: hypertrophy, arrhythmias, conduction disturbance

echo

cath lab: CAD - need for revascularization

6. Lifestyle modificiations: weight loss, smoking cessation, alcohol cessation, exercise

Meds: Digoxin, diuretics, ACE-I, BBs, aldosterone antagonists, ARBs

- may need resynchronization

7. prognosis: 50% 5 year mortality rate

Class 1: no sx with ordinary activity

Class 2: slight physical activity limitation

Class 3: marked limitation of physical activity

Class 4: Sx at rest, unable to carry out any physicial activity

Stage A: pts at high risk for developing HF but no structural d/o

Stage B: pts with structural d/o but no sx

Stage C: Pt with past or current sx AND structural d/o

Stad D: pt wtih end stage disease who requires special tx

1. Sx: precordial CP precipitated by stress/exertion and relieved by rest/nitrates. squeezing, tightness, burning, aching, indigestion

- "Levign's sign": fist over chest, pain behind sternum and to the left, can radiate to shoulder/back/jaw

2. precipitating events: meals, excitement, cold, morning, exercise

3. PE: elevated BP, gallop, systolic murmur, arrythmias

4. workup:

- Get troponin and CK-MB to r/o MI

- EKG: usually normal, may have reversible ST elevation

- Stress test: inducible ischemia

5. tx: nitro sublingual, B-blockers, CCBs, aspirin/clopidogrel

1. Sx: CP at rest or with minimal exertion

2. PE: nausea, dyspnea, diaphoresis, syncope

3. CK, CKMB, troponins, EKG: dynamic ST changes

4. Tx: bed rest and O2, antigoagulation and aspirin/clopdiegrel, nitro, BB, CCB, statins

MI

workup:

- CK, CKMB, troponin elevated

- EKG: ST elevation or LBBB, peaked T's, Q waves

tx:

- IMMEDIATE REPERFUSION - PCI w/in 90 min or thrombolysis w/in 30 min

- Meds: Aspirin or clopidegrel, BBs, nitrates, ACE-I, ARB, antiarrhythmics, CCB

Prevention: BB and anti-platelets

acute angle-closure glaucoma

workup: IOP >50 mmHg

tx:CONTROL IOP

- 500 mg IV acetazolamide x1 then 250mg PO QID

- if no response, 1-2g/kg diuretics

after pressure has fallen:

- 4% pilocarpine 1 drop q 15 min x 1 hr then QID to reverse angle closure

Definitive tx: laser or surgical iridotomy to BOTH eyes

1. Sx: early - none. insidious progressive bilateral loss of peripheral vision resulting in TUNNEL VISION with preserved visual acuity

2. PE: pathologic cupping and palor of optic discs, persistent elevation of IOP

3. Diagnostic requirements: consistent and reporducible abnormalities in 2 of 3 parameters - optic disk, visual field, and IOP. Cup:disk ratio of >0.5 or assymetry of cup: disk ratio of 0.2 or more

4. Tx:

- First line: prostaglandin analogs (iatanoprost 0.005%, bimatoprost 0.03%, and travoprost 0.004% qHS)

- Can add topical beta adrenergic bloers (timolol, cartelol, levobunolol, metipranolol)

- Laser or surgical traveculectomy

5. Prevention: everyone >40 y/o should have IOP assessed every 2-5 years. Annually if DM or fx hx of glaucoma

macular degeneration

amaurosis fugax

botulism

cataracts

giant cell arteritis

ischemic optic neuropathy

optic neuritis

pseudotumor cerebri

refractive errors

retinal artery occlusion

retinal detachment

thyroid disease

uveitis

vitreous hemorrhage

1. peripheral vertigo

2. central vertigo

1. workup: audiogram, electronystagmography (ENG) or videonystagmography (VNG), caloric stimulation, MRI, vestibular evoked myogenic potentials (VEMP)

2. DDX: external ophthalmoplegia, seizure, systemic d/o, anticonvulsant/antibiotic/hypnotic/analgesia/tranqualizing drugs/alcohol side effect

Meniere's syndrome

tx: low salt + diuretics (acetazolamide)

- refractory cases: intratympanic corticosteroid injection, endolymphatic sac decompression, vestibular ablation

labirinthitis

tx: abx

vestibular suppressants during acute phase

Benign paroxysmal positioning vertigo

tx: epley maneuvers, brandt-daroff exercises

vestibular neuronitits

tx: supportive care + diazepam or meclizine

traumatic vertigo

tx: supportive care and vestibular suppressants

perilymphatic fistula

tx: middle ear exploration and windown sealing w/ tissue graft

Cervical vertigo

tx: neck movement exercises

superior semicircular canal dehiscence

tx: surgical sealing

anaphylaxis

tx: epinephrine

Sx: uncontrolled bing eating at least 2 days/week for 3 mos followed by inappropriate behavior to prevent gaining weight (vomiting, laxatives, diuretics, fasting, excessive exercise)

PE: menstruation usually preserved, premorbid obesity, gastric dilation, pancreatitis, poor dentition, pharyngitis, esophagitis, aspiration of vomited material, electrolyte abn, dehydration, dry mouth, burst blood vessels in eyes, "pouch-like mouth" from swollen salivary glands

workup:

- dental exam: gingivitis, decreased tooth enamel

- Chem-20 test: electrolte imbalance, dehydration

tx: fluoxetine/SSRI, refer to psych

Sx: disturbed body image, 15% below normal body weight, absence of 3 consecutive menses, fear of weight gain, loss of control over food intake, refusal to exceed minimum normal weight

predisposing factors: adolescence/young adult females, parents overly concerned with slimness/physical fitness

PE: severe emaciation, cold intolerance, constipation, amenorrhea, dry/scaly skin, lanugo, parotid gland enlargment, edema

Labs: anemia, leukopenia, electrolyte abn, elevated BUN/Cr, depressed LH/FSH, elevated cholesterol

Tx: restore nl body weight and reduce psych factors

supportive

behavioral therapy

family therapy

TCAs, SSRIs, lithium

Severe malnutrition: enteral/parenteral nutrition, hemodynamic stabilization

REFER to psych

Pneumocystic jirovecii pneumonia

dx via sputum induction or bronchoalveolar lavage with wright-geisma stain

tx:

FIRST LINE: oral bactrim

second line: clinda/primaquine

Mycobacterium tuberculosis

Tx: rifampin

Histoplasmosis

tx: life long itraconazole

aspergillosis

tx: oral prednisone and intraconazole

weight loss and mild-mod physical activity

NSAIDS - acetaminophen

Interarticular injections: triamcinolone, corticosteroids, sodium hyaluronate

Surgery

refer to orthopedics for osteophyte formation or functional impairment

When: T scores below -2.5

Prevention: protein, calcium, vit D

- weight bearing physical activity

- Avoid Etoh and smoking

- Estrogen therapy

- SERMs (raloxifene)

Vit D supplement 800-2000 IU daily

Calcium citrate 0.4 g daily

Calcium carbonate 1-1.5g daily

Bisphosphonates (osteoclast inhibitors) - alendronate, risendronate, zoledronic acid (IV), pamidronate (IV)

Teriparatide - PTH analog w/ Ca and Vit D to increase bone density

Calcitonin nasal spray

Denosumab - inhibits osteoclasts

Sx: Hx of smoking, exacerbation of sx beyond normal day to day variation, chronic cough, dyspnea, sputum production, rhonchi, decreased breath sounds, sob, clubbing

PE: airflow obstruction, hyperventilation, mucus, recurrent URI/pneumonia

tests: spironmetry, PFT, EKG (tachy)

CXR: peribronchial and vascular markings, hyperinflation, flattened diaphragms,

CT and Echo can be done

SINGLE MOST IMPORTANT: smoking cessation.

- Best to use two methods: nicotine replacement, buproprion, varenicline (nicotine agonist)

- O2 therapy 15 hr/day

- INhaled bronchodilators (anticholinergic) - sx improvement only - ipratroprium

- corticosteroids

- theophylline (4th line)

- Abx for acute exacerbation - macrolides, cipro, augmentin

- pulmonary rehab - aerobic exercise

- Surgery: lung transplant, lung volume reduction, bullectomy

alopecia areata

causes: autoimmune conditions (hashimoto's, pernicious anemia, addison's disease, vitiligo)

tx: systemic corticosteroids, topical anthralin or tazarotene, diphencyprone, squaric acid, dibutylester

Wernicke-Korsakoff Syndrome (alcoholic encephalopathy)

tx: parenteral thiamine 50-100 mg/d IV x 3 day then orally 5-10 mg/d

Refer to neurology

sx: localized erythema wtih induration and purulent drainage

folliculitis, furuncle, carbuncles

deep abscesses

necrotizing fasciitis

tests: cultures of wound - gram + cocci clusters

- blood culture if signs of systemic infx

tx: I&D

- oral abx: dicloxacillin, cephalexin (Keflex), clindamycin, doxy, minocycline, bactrim, linezolid

- If fever: IV nafcillin, oxacillin, cefazolin, VANC, daptomycin, linezolid, tigecycline, telavancin

Sx: vague GI discomfort, pelvic pressure/pain, bloating, palpable mass w/ ascites. may be asymptomatic

Tests: pelvic exam, Serum Ca 125 (>35 is likely to be malignant), transvaginal US

Tx: surgical eval by GYN oncologist

- abd hysterectomy, bilateral salpinoophorectomy with omentectomy and selective lymphadenectomy

- post op chemo in advanced disease

simple ovarian cyst/benign functional cyst

resolve spontaneously

repeat transvaginal US if it doesn not go away

Sx: abn uterine bleeding/vaginal d/c

visible cervical lesion

metorrhagia (breakthrough bleeding/spotting)

post-coital spotting

cervical ulceration

bloody/purulent/odorous/non-pruritic d/c

can lead to bladder and rectal dysfunction and pain

tests: vaginal cytology (PAP), cervical bx and endocervical curettage or conization for staging, abdominal and pelvic CT, PET, or MRI

Plan:

1. CIS:

- Done childbearing: total hysterectomy

- Wish to retain uterus: cervical conization or ablation of lesions w/ cryo or laser, Paps q 3 mos x 1 year then 6 mos for another year

2. Invasive carcinoma:

- Microinvasive (IA1): extra fascial hysterectomy

- Stage IA2, IB1, and IIA: radical hysterectomy w/ radiation and chemo

- Stagest IB2, IIB, III, and IV: radiation plus cisplatin-based chemo

HPV types 16 & 18

25-40 y/o

Gardasil and Cervarix

Megaloblastic: Vit B12 deficiency, folate deficiency

Non-megaloblastic: myelodysplasia, chemo, liver disease, reticulocytosis, myxedema

Sx: pain, burning, tingling, over distribution of median nerve - PLAMAR surface of thumb, index and long fingers, radial half of ring finger

- aching radiates to forearm and shoulder, neck, chest

- sx worst at night

- exacerbated by manual activity, volar flexion/dorsiflexion of wrist

- weakness or thenar atrophy

Diagnostic Tests:

- PE: two point discrimination, identify different textures of cloth, Tinel/Phalen's sign, carpal compression test

- Electromyography

- Segmental sensory and motor conduction delay

Treatment:

- modify hand activity

- wrist cock up splint for 2-6 weeks

- NSAIDs

- refer to specialty - corticosteroid injections, surgery

B12 deficiency (Serum B12 <170 pg/ml)

Tx: IM B12 daily for 1 week, weekly for 1 month, monthly for life

- oral B12 doesn't absorb well

- CNS s/s are reversible if <6 mo

Facts: deficiency doesn't develop until 3 years after B12 absorption ceases

- gastrectomy eleminates intrisic factor with prevents absorption of B12

Normal aging: Lower levels of physical activity, decline in lean body mass, reduced taste, reduced stomach compliance, reduced protein turnover, reduced testosterone

Sx: 5% weight loss in one month of 10% in 6 mos.

- recent change in life circumstances

- depression

- reduced cognition

- poor wound healing

PE: loss of subcu fat, impaired muscle function, muscle wasting, loss of bone mass, immune dysfunction, anemia

Workup: CBC, CMP, UA, CXR, DEXA, dental exam, mini nutritional assessment

DDX: cancer, dehydration, reduced access to food (poverty)

Plan: Supportive, individualized tx

- liberal diet, nutritional supplements between meals

- Consider transition to palliative/hospice care

- Tube feeding does NOT prolong life in those w/ dementia

urge incontinence

Plan:

- Bladder training is cornerstone

- Kegels

- Drugs: tolterodine, oxybutynin are first line

- second line: fesoterodine, darifenacin, solifenacin

Surgery: interstim implantation (electrical stimulation of pelvic muscles), botox injections in detrusor

Stress incontinence

Plan:

- Bladder training + Kegels

- Avoid caffeine

- Vaginal cone/pessary

- Surgery: sling procedure (75-80% cure rate)

Overflow incontinence

Plan: address underlying pathology

- augmented voiding techniques - double voiding, applying suprapubic pressure

- intermittent or indwelling catheter

1. 50% of women

2. most common kind: mixed urge/stress

3. Risks: older, white, childbirth, obesity, medical comorbidities, frailty, atrophy of bladder/pelvic muscles, neuro degeneration

4. PE findings: Positive cough test. Get good hx.

5. Tests: UA, BUN/Cr, Glucose, B12, post void residual urine volume (PVR), Cystoscopy/urodynamic testing (referral)

6. Ddx: Medications SE, MS, prostatitis, spinal cord problem, UTI, urianry obstruction, uterine prolapse, vaginitis

7. General tx: avoid alcohol, caffiene, chocolate, acidic foods, spicy foods, sweeteners

RUQ (right hypochondriatic): biliary disease, hepatitis, renal colic

Epigastric: MI, PUD, biliary disease

LUQ (left hypochondriatic): splenic injury, renal colic

Right lumbar: diverticulitis, renal colic

Left lumbar: diverticulitis, renal colic

Umbilical/hypogastric: IBD, bowel obstruction/ischemia, appendicitis, AAA, IBS, DKA, gastroenteritis

Right iliac: appy, ovarian disease, PID, ectopic

Left iliac: ovarian disease, PID, ectopic

Renal colic/kidney stone

workup: US/CT

tx: NSAIDs, double fluid intake

Surgery: extracorporal shock wave tx, surgical removal

splenic infarct/rupture

tx: emergency surgery

PUD

workup: EGD w/ h pylori bx

Tx:

- Triple therapy: PPI BID, Clarythromycin BID, Amoxicillin (or flagyl) BID

- Quadruple therapy: PPI BID, Bismuth subsalicylate QID, TCN QID, Flagyl QID or TID

pancreatitis

workup: CT w/ contrast

tx:

appy

tx:

surgery

- IV cefoxitin or cefotetan post op OR bactrim

Bowel obstruction

tx: surgery, aggressive rehydration, & IV broad spectrum abx (cefoxitin or ampicillin-sulfabactam)

Mesenteric ischemia/infarct

Direct angiography is gold standard

tx: emergent revascularization, broad spectrum IV abx

AAA

emergency surgery

IBS

tx: elminate triggers

- anticholinergics (dicyclomine, hyoscyamine)

- tricyclic antidepressants (amitriptylline, nortriptylline)

- diarrhea control: loperamide, diphenoxylate, cholestyramine

- constipation control: fiber, psyllium, osmotic laxatives (lactulose)

Up and Go test: have them stand from sitting position and walk 10 feet, turn around, and walk back and sit down. Should be <10 sec. >30 sec means they need assistance

- Station romberg test, strength testing

Plan:

- Modify risk factors

- Orthostatic hypotension - hand clenching, raise head of bed, d/c high risk meds

- D/C sedating meds

- Look at drug interactions

- Make appropraite changes to home - grab bars, etc

- balance training

- Arm/leg strength training

Definition: constellation of metabolic abn that confer increased risk of CVD and DM

Diagnostic Features:

1. central obesity: Men waist >102 cm/40 in, Women waist >88 cm/34.5 in

2. Hypertriglyceridemia >150 mg/dl or on trigs med

3. HDL: Men <40, Women <50 or on HDL med

4. HTN: >130/>85 or on BP med

5. Fasting glucose >100 or previous dx of DM

Workup:

- Lipid panel

- Fasting glucose

- BP

- LFT

DDX: NAFL, Hyperuricemia, PCOS, OSA

Plan:

- Lifestyle modifications

- Bariatric surgery

- Statins, fibrates, BP meds, Metformin

1. 95-99% essential

2. Usually asymptomatic. Most frequent sx is HA. Acute HTN could cause somnolence

3. PE:

- Retinas: narrowing of arterial diameter to <50% of venous diameter, copper wire appearance, exudates, hemorrhages, papilledema

- Heart: L ventricular heave indicates long standing hypertroping, Presystolic S4 gallop

- Pulses: femoral delay suggests coarctation of aorta, diminished/absent peripheral pulses indicate atherosclerosis

4. Workup: CBC, UA (renal function), fasting glucose, lipid panel, serum uric acid, electrolytes, aldosterone/renin ratio

5. Goals: <130/80 for DM

<140/90 for everyone else

Primary aldosteronism

Pheo

Thyroid disease

Hyperparathyroid

Cushing's

CKD

Acute renal failure

Renovascular disease

Coarctation of aorta

OSA

obesity

Drugs

Lifestyle:

- DASH diet: fruits, veggies, lowfat dairy, low sat fat

- Gradually increase activity

- Smoking cessation

- weight loss

- Reduce etOH

- reduce salt

Definition: perception of abnormal noises

Persistent: usually SNHL

Intermittent high pitched: usually normal

Pulsatile: usually vascular - do MRA and venography

Staccato tinnitus: middle ear spasm/myoclonus

Tx:

1. avoid loud noises and ototoxic agents

2. masking w/ music or hearing aids

3. oral antidepressants

4. IV antiarrhythmics for immediate relief only

1. vestibular disease

2. Either sensation of motion when there is none or exaggerated sense of motion in response to a given bodily movement - spinning, sense of tumbling, falling backward, 'earthquake'

3. PE: romberg, nystagmus, gait evaluation

- peripheral lesions: horizontal nystagmus

1. Meniere's (Endolymphatic Hydrops)

2. Labyrinthitis

3. Positioning vertigo

4. vestibular neuronitis

1. Conductive HL

2. Sensory HL

3. Neural HL

1. whispered voice test

2. Weber

3. rinne

4. audiometric assessment

Normal: 0-20 dB

Mild: 20-40 dB

Moderate: 40-60 dB

Severe: 60-80 dB

Profound: >80 dB

Small: Wegener's, microscopic polyangiitis

Medium: polyarteritis nodosa

Large: PMR/GCA

porphyria cutanea tarda

tx: avoid trigger, stop alochol, phlebotomy, antimalrials

c. diff

hemorrhagic e. coli

salmonella

campylobacter

yersinia

Shigella

e. coli

entamoba histolytica

dehydration

grossly bloody

fever >38.5/101.3

>48 hr w/o improvement

recent abx use

new community outbreak

severe abd pain in >50 y/o

>70 y/o

immunocompromised

dysentery: cipro, bactrim, or doxy

giardia: metronidazole