ABIM
Patient's shoulder is passively abducted to 90 degrees in forward flexion and then is maximally internally rotated with thumb pointing down. Examiner applies downward pressure at wrist or elbow while patient resists. Positive test: Weakness
"Empty can" Positive test: Weakness (suggests supraspinatus tendon tear)
Antiretroviral therapy for HIV usually comprises of
"backbone" of two nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) plus a third agent, which may be a boosted protease inhibitor, or a nonnucleoside reverse transcriptase inhibitor, or an integrase inhibitor.
TIMI Risk Score for Non-ST-Elevation Acute Coronary Syndromes
(1) Age ≥65 years (2) ≥3 Traditional CAD risk factorsa (3) Documented CAD with ≥50% diameter stenosis (4) ST-segment deviation (5) ≥2 Anginal episodes in the past 24 hours (6) Aspirin use in the past week (7) Elevated cardiac biomarkers (creatine kinase MB or troponin) ------------- 0-2 Low risk 3-4 Intermediate risk 5-7 High risk
Infective endocarditis prophylaxis for dental procedures is currently recommended for patients with
(1) a prosthetic cardiac valve; (2) prosthetic material used for cardiac valve repair, including annuloplasty rings and chords; (3) a previous episode of infective endocarditis; (4) congenital heart disease, including unrepaired cyanotic congenital heart disease, a completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, and repaired congenital heart disease with residual defects; or (5) valvulopathy following cardiac transplantation.
Repeat colonoscopy in 3 years is indicated in the following 4 scenarios
(1) an adenoma 10 mm or larger, (2) three to ten adenomas, (3) an adenoma with a villous component (such as a tubulovillous or villous adenoma), or (4) an adenoma with high-grade dysplasia
Hepatorenal syndrome diagnostic criteria consist of
(1) an increase in the serum creatinine level to greater than 1.5 mg/dL (132.6 µmol/L) over days to weeks, (2) lack of response to an albumin challenge of 1 g/kg/d for 2 days, and (3) the absence of shock, nephrotoxic drugs, active urine sediment, proteinuria greater than 500 mg/d, and ultrasound evidence of parenchymal kidney disease or obstruction.
Indications for O2 in COPD
(1) arterial PO2 less than or equal to 55 mm Hg or oxygen saturation less than or equal to 88% breathing ambient air and/or (2) if there is evidence of pulmonary hypertension, peripheral edema suggesting right-sided heart failure, or polycythemia, in combination with arterial PO2 less than or equal to 59 mm Hg or oxygen saturation less than or equal to 89% breathing ambient air.
Oxygen therapy for COPD
(1) arterial PO2 less than or equal to 55 mm Hg (7.3 kPa) or oxygen saturation less than or equal to 88% breathing ambient air, with or without hypercapnia; and/or (2) if there is evidence of pulmonary hypertension: peripheral edema suggesting right-sided heart failure polycythemia in combination with an arterial PO2 less than or equal to 59 mm Hg (7.8 kPa) or oxygen saturation less than or equal to 89% breathing ambient air.
Long-term oxygen therapy is indicated if patients with COPD meet 1 of the 2 following criteria:
(1) chronic respiratory failure and/or severe resting hypoxemia, defined as an arterial PO2 less than or equal to 55 mm Hg (7.3 kPa) or oxygen saturation less than or equal to 88% breathing ambient air, with or without hypercapnia; and/or (2) if there is evidence of pulmonary hypertension, peripheral edema suggesting right-sided heart failure, or polycythemia, in combination with an arterial PO2 less than 60 mm Hg (8.0 kPa) or oxygen saturation less than 88% breathing ambient air.
Centor Criteria
(1) fever, (2) absence of cough, (3) tonsillar exudates, (4) tender anterior cervical lymphadenopathy. -------- No additional testing or treatment is needed for patients who meet fewer than three criteria. Patients who meet three or more criteria should have a confirmatory test (either a rapid antigen detection test for GAS or throat culture).
Diagnose serrated polyposis syndrome
(1) five or more serrated polyps proximal to the sigmoid colon, two or more of which are 10 mm in diameter or greater, (2) any number of serrated polyps proximal to the sigmoid colon in an individual with a first-degree relative who has SPS, or (3) more than 20 serrated polyps distributed throughout the colon
For patients with HBV, treatment is recommended for those who
(1) have ALF, (2) have chronic infection with an elevated ALT level and an HBV DNA level greater than 10,000 IU/mL, or (3) either before or while receiving immunosuppressive therapy, including chemotherapy for solid tumors.
role of antibiotics in treating COPD exacerbations
(1) increased dyspnea, sputum volume, and sputum purulence; (2) two of the preceding symptoms if one of the two symptoms is increased purulence; or (3) a requirement for mechanical ventilation (invasive or noninvasive).
The following characteristics are associated with an increased risk for HCC in patients with HBV and are indications for surveillance with ultrasound or other imaging every 6 months:
(1) patients with cirrhosis, (2) Asian men older than 40 years, (3) Asian women older than 50 years, (4) African patients older than 20 years, (5) patients with persistent inflammatory activity (defined as an elevated ALT level and HBV DNA levels greater than 10,000 IU/mL for at least a few years), and (6) patients with a family history of HCC.
indications for HCC surveillance in patients with chronic HBV infection
(1) patients with cirrhosis, (2) Asian men older than 40 years, (3) Asian women older than 50 years, (4) patients with a family history of HCC, and (5) patients with persistent hepatocellular inflammation (defined as elevated alanine aminotransferase [ALT] level and HBV DNA level greater than 10,000 IU/mL) (6) African patients over the age of 20 years
Reflux hypersensitivity is a new diagnosis defined by the presence of four clinical criteria: (
(1) presence of retrosternal symptoms such as heartburn and chest pain; (2) normal endoscopy including esophageal biopsies to exclude eosinophilic esophagitis; (3) absence of any major esophageal motor disorder based on esophageal manometry; (4) association of symptoms with physiologic reflux episodes despite normal acid exposure on a pH monitoring study.
Repeat endoscopy can be considered for gastric ulcers after 8 to 12 weeks of PPI therapy if
(1) symptoms are persistent despite therapy, (2) ulcers have an endoscopic appearance that is concerning for underlying malignancy, (3) visualization of the stomach was incomplete, or (4) biopsies were not taken at the time of the index upper endoscopy.
Hospitalized patients initially treated with parenteral antibiotic therapy can be switched to oral agents when clinical stability has been attained. Clinically stable patients are characterized as having:
(1) temperature of 37.8 °C (100.0 °F) or less, (2) heart rate of 100/min or less, (3) respiration rate of 24/min or less, (4) systolic blood pressure of 90 mm Hg or greater, (5) arterial oxygen saturation of 90% or more or partial pressure of oxygen of 60 mm Hg or greater breathing ambient air, (6) ability to maintain oral intake, and (7) normal mental status.
ACR and EULAR recommend urate-lowering therapy for patients with gout plus any of the following:
(1) ≥stage 2 CKD; (2) ≥2 acute attacks per year; (3) one or more tophi; or (4) uric acid nephrolithiasis.
Indication for urate-lowering therapy for patients with gout plus any of the following:
(1) ≥stage 2 chronic kidney disease; (2) ≥2 acute attacks per year; (3) one or more tophi; or (4) uric acid nephrolithiasis.
standard-dose omeprazole
(20 mg/d)
acceptable timeframe for thrombolysis for ischemic stroke
(3 hours).
Coronary artery calcium scoring is reasonable to further define cardiovascular risk in patients with intermediate risk as determined by the Pooled Cohort Equations
(5% to <7.5%)
A significantly elevated prolactin level usually indicating a prolactinoma is
(>200 ng/mL)
obstructive CAD
(>70% obstruction)
Follicular lymphoma is characterized by the presence of surface B-cell markers
(CD10, 19, 20, and 22) and small cells on morphologic analysis
pneumococcal conjugate vaccine
(PCV-13)
pneumococcal polysaccharide vaccine
(PPSV-23)
combination of parkinsonism and prominent dysautonomia
(Shy-Drager syndrome),
hypoglycemia with subsequent rebound hyperglycemia is known as
(Somogyi effect)
The urine anion gap
(UNa + UK − UCl). The urine anion gap is a surrogate method of estimating the ability of the kidney to excrete an acid load.
FeNa
(USodium × PCr)/(UCr × PSodium) × 100
FEUrea
(UUrea × PCr)/(UCr × PUrea) × 100, with values <35% suggesting a prerenal state.
preferred initial study to evaluate for possible chronic thromboembolic pulmonary hypertension
(V/Q) lung scan
Diagnosis of mild aortic stenosis
(Vmax 2.0-2.9 m/s or mean gradient <20 mm Hg)
According to a 2016 meta-analysis, the D-dimer threshold in patients being evaluated for pulmonary embolism who are older than 50 years should be adjusted based on
(age × 0.01 µg/mL) If D-dimer is lower than that number, no need to get CTA for PE
CREST
(calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia)
hyperglycemia as a result of rising catecholamines is known as
(dawn phenomenon).
GERD alarm features requiring UPPER endoscopy
(dysphagia, unintentional weight loss, hematemesis, or melena) Upper endoscopy should be performed in patients whose symptoms are not responsive to an empiric PPI trial, and it should be the first step in evaluation of patients with alarm symptoms. Most patients with symptoms of heartburn and regurgitation have normal upper endoscopy findings.
when treating patients with bacteremia, an agent with excellent bioavailability should be used such as
(quinolones, trimethoprim-sulfamethoxazole, metronidazole, clindamycin, linezolid)
Milan criteria
(up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm)
Breast conserving therapy means
(wide excision followed by breast radiation)
TIMI score criteria
*Age >=65 *3+ CAD risk Factors (Hypertension, hypercholesterolemia, diabetes, family history of CAD, or current smoker) * Known CAD (>50% stenosis) * 2 episodes of severe angina in 24 hours * Asa use in 7 days * Cadiac enzymes *ST changes >0.5 mm
When to repair AAA
- 5.5 cm in diameter - those that increase in diameter by more than 0.5 cm within a 6-month interval - for those that are symptomatic (tenderness or abdominal or back pain)
Indications for CABG
- Diabetic with disease of left anterior descending AND one of the circumflex arteries - 3 vessel disease - 2-3 vessel disease in whom complete revascularization
Plantar fasciitis tx
- activity modification, application of ice, correcting improper mechanics (for example, using arch supports for pes planus), and heel stretches. - Acetaminophen or NSAIDs can be used to control pain, although neither is thought to alter the underlying pathologic process. - For patients who fail to respond to the aforementioned therapies, ultrasound therapy and glucocorticoid injections may be beneficial, although some experts do not recommend glucocorticoid injections because of the risk of fat atrophy in the heel pad. Plantar fascia release is reserved for patients in whom other therapies are ineffective.
Granulomatosis with polyangiitis (Wegener)
-Upper respiratory tract: perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis. -Lower respiratory tract: hemoptysis, cough, dyspnea. -Renal: hematuria, red cell casts. CXR: large nodular densities PR3-ANCA / c-ANCA ***upper airway, lower airway (lungs), Kidneys)***
Polyarteritis Nodosa (PAN)
-Young adults. -Hepatitis B seropositivity in 30% of patients. -Fever, weight loss, malaise, headache. -GI: abdominal pain, melena. -Hypertension, neurologic dysfunction, cutaneous eruptions, renal damage. -Typically involves renal and visceral (skin, GIT, heart) vessels, not pulmonary arteries-> SPARES THE LUNGS!! (i.e., no pulmonary artery damage) -Immune complex mediated. -Transmural inflammation of the arterial wall with fibrinoid necrosis. -Innumerable renal microaneurysms and spasms on arteriogram. **negative for ANCA
Meralgia Paresthetica
-compression of the *lateral femoral cutaneous nerve * -pain & tingling sensation but *no motor loss* -cause: obesity, postural changes, tight clothing, pregnancy
dipeptidyl peptidase-4 (DPP-4) inhibitors
-gliptin
GLP-1 analogues
-tide GLP-1 analogues are associated with rapid and substantial weight loss, which is likely detrimental to gallbladder function. Rapid weight loss leads to supersaturation of cholesterol in the bile, which substantially increases the risk of gallstones. Subsequently, cholecystitis and cholecystectomy risk also increases. Furthermore, the GLP-1 analogue exenetide may be associated with delayed gallbladder emptying. While DPP-4 inhibitors increase the half-life of endogenous GLP-1, GLP-1 agonists act as direct agonists to the GLP-1 receptor leading to enhanced incretin action, perhaps leading to increase gallbladder and bile duct dysfunction.
indications fo hospitalization after a dog bite
. Patients with sepsis; infected hand bites; nerve, tendon, or crush injuries; severe or deep infections Recommended intravenous antibiotic options include β-lactam/β-lactamase inhibitor combinations, such as ampicillin-sulbactam or piperacillin-tazobactam; carbapenems, such as imipenem, meropenem, or ertapenem; or cefoxitin.
blood smear findings of histo
. Small yeast forms within neutrophils may be seen on peripheral blood smear
How to determine IDA in patients with α-Thalassemia trait (or α-thalassemia minor)
. The red cell distribution width (RDW) is also useful in distinguishing between thalassemia and iron deficiency, because the RDW is often elevated in iron deficiency but normal in thalassemia. No treatment or monitoring is necessary for α-thalassemia trait.
Neuroleptic Malignant Syndrome tx
. Treatment of NMS involves the removal of the causative agent and supportive management; medical options include the muscle relaxant dantrolene (to relieve muscle breakdown) and dopamine agonists, such as bromocriptine
Treatment of painful neuropathies resulting from diabetes
...Only pregabalin, duloxetine, and tapentadol (extended release) have FDA approval for painful diabetic neuropathy, but these agents are all costly, and other less expensive options, such as tricyclic antidepressants, should be tried first.
best stress test for patients with COPD and who cannot exercise
...dobutamine
AHI in OSA
.An AHI of 5 to 15 is indicative of mild OSA AHI of more than 30 reflects severe OSA.
TIMI Risk Score
0-2 Low risk 3-4 Intermediate risk 5-7 High risk
low TIMI risk score
0-2), indicating a low in-hospital risk of death or recurrent ischemia/infarction, predischarge stress testing may be warranted to further define a large ischemic burden and guide revascularization decisions
total calcium declines by _____ for each 1.0 g/dL decrement in serum albumin concentration.
0.8 mg/dL
Sofosbuvir or simeprevir, in combination with pegylated interferon plus ribavirin, is indicated for the treatment of HCV genotype
1 The combination of sofosbuvir and simeprevir, with or without ribavirin, is indicated for interferon-ineligible patients with HCV genotype 1 infection and no underlying kidney disease.
NNT
1 divided by ARR which is the difference in rates of events between the treatment group and control group
NNH
1 divided by the difference in rates of events between the control group and treatment group
Lyme arthritis is excluded if symptoms have been present for longer than ______ and Western blot IgG result is negative
1 month ymptoms present for more than 1 month provide ample time for IgG seroconversion. a positive Western blot IgM result without associated positive IgG result in a patient with more than 30 days of symptoms should be interpreted as a false-positive result.
COPD GOLD B Dx
1 or fewer exacerbations per year, and no hospitalzations Dyspnea while walking on level surface or CAT >=10 (COPD Assessment Test) mMRC (Modified Medical Research Council) Score: >=2
COPD GOLD A Dx
1 or fewer exacerbations per year, and no hospitalzations Dyspnea while walking uphill (but not on level surface) or CAT <10 (COPD Assessment Test) mMRC (Modified Medical Research Council) Score: 0-1
To improve the diagnostic accuracy of the urea breath test and fecal antigen test, H2 blockers should be avoided for_____ prior to testing.
1 to 2 days
Asymptomatic patients with moderate aortic regurgitation should be evaluated on a yearly basis and have echocardiography performed every
1 to 2 years
For patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer), recommended colorectal cancer screening is colonoscopy every _______ beginning at age 20 to 25 years, or 2 to 5 years earlier than the youngest age at diagnosis of colorectal cancer if the affected relative was less than 25 years old.
1 to 2 years
The 2017 American Association of Clinical Endocrinologists and American College of Endocrinology guidelines for management of dyslipidemia and prevention of cardiovascular disease recommend that middle-aged adults (men aged 45-65 years and women aged 55-65 years) without known cardiovascular risk factors undergo cholesterol screening every
1 to 2 years.
A repeat fasting lipid panel should be obtained ________ after initiation of statin therapy to determine medication adherence and effectiveness of treatment.
1 to 3 months
in patients with Familial Adenomatous Polyposis and MYH-Associated Polyposis, Upper endoscopy for surveillance of duodenal cancer is indicated every
1 to 5 years at an interval based on the stage of the duodenal polyposis.
Patients with acute diarrhea without alarm features lasting longer than ____ should have evaluation
1 week
Patients hospitalized for heart failure who are scheduled for a follow-up appointment within
1 week after discharge have a reduced risk of future heart failure hospitalization.
Interval to Next Colonoscopy in patients with sessile serrated polyposis syndrome
1 year
Persistent complex bereavement disorder is when grief lasts for longer than
1 year
Postpolypectomy Surveillance if you have Serrated polyposis syndrome
1 year
Screening recommendations for patients with a history of colorectal cancer consist of follow-up colonoscopy at ____ and at ____ after curative surgical resection; if results of these colonoscopies are normal, the surveillance interval can be extended to ____.
1 year 3 years 5 years according the American Cancer Society's Colorectal Cancer Survivorship Care Guidelines published in 2015, after treatment for stages 1, 2, or 3 colorectal cancer, patients at high risk for recurrence (for example, with poorly differentiated histology, lymphatic or vascular invasions, or positive resection margins) should receive an annual abdominal/pelvic CT scan for 5 years after resection, in addition to surveillance colonoscopy at 1 year. A history and physical examination should also be performed every 3 to 6 months for 5 years. Most experts also recommend serial carcinoembryonic antigen measurements at each visit after resection until 5 years after resection.
Patients with colon cancer should have their first postoperative colonoscopy examination within
1 year of the clearing colonoscopy.
CURB-65
1) Confusion 2) Blood urea nitrogen >20 mg/dL 3) RR≥30 4) BP<90/60 5) 65yo orolder 0-1: home 2: Inpatient wards 3-5: ICU
The diagnosis of Mild Cognitive Impairment is made on the basis of clinical judgment and requires the following four features:
1) subjective reports (from the patient or a reliable informant) of problems with memory, such as forgetfulness, or other cognitive difficulties; (2) objective impairment on cognitive testing in one or more cognitive domains; (3) diminished independence in daily function, with no or minimal problems with complex functional tasks, such as shopping or paying bills; and (4) no significant impairment in occupational or social functioning.
Sentinel lymph node biopsy is recommended for patients with melanomas of
1- to 4-mm thickness to provide accurate staging. It is also recommended for lesions less than 1 mm with certain high-risk features, such as ulceration, more than 1 mitosis/mm2 , or lymphovascular invasion.
3 confirmatory tests for cushing syndrome
1-mg dexamethasone suppression test (given late at night with assessment of cortisol suppression the next morning) 24-hour urine free cortisol testing (to quantify total daily cortisol secretion) measurement of evening salivary cortisol levels (which normally reaches a nadir at that time but remains elevated in patients with Cushing syndrome) ------------------ At least two abnormal first-line screening tests are required for diagnosis. Only after establishing biochemical hypercortisolism should the source of excess cortisol production be sought.
9 Rashes that start on palms and soles
1. Coxsackie (hand Foot & Mouth) 2. Rocky Mountain Spotted Fever (especially of wrist) 3. Syphilis (secondary) 4. Janeway Lesions of bacterial endocarditis 5. Kawasaki Disease 6. Measles 7. Toxic Shock Syndrome 8. Reactive Arthritis 9. Meningococcemia
Indications for antibiotcs in sinusitis
1.) *Any* symptoms\signs persistent and not improving for >=10d 2.) *Severe* symptoms for >= 3d {high fever (39 °C [102.2 °F]) AND purulent nasal discharge OR facial pain} 3.) Worsening or "double sickening" >= 3d "Double sickening" = worsening symptoms following viral illness that were initially improving
Cirrhosis EGD
1.) =< 5mm:
Modalities of screening for colon cancer for patients at average risk
1.) Annual FOBT 2.) Flex sig q 5y with FOB q3y, 3.) Colonoscopy q10y
Indications for adrenal insufficiency testing (i.e., intermediate or unknown risk of HPA suppression)
1.) Daily MORNING dose of prednisone 5-20mg (or its equivalent) for >3wk 2.) Daily EVENING doses of prednisone <5mg 3.) Prior longer duration or higher doses of glucocorticoids in the past year 4.) Inhaled glucocorticoids for 3 weeks 5.) >= 3 intra-aricular or spinal glucocorticoid injections within past 3 months
Indications for stress dose steroids
1.) Daily prednisone >=20mg (or its equivalent) for >3wk 2.) Any patient on any steroids with ANY cushingoid features
What qualifies someone as having above average risk for colon cancer
1.) Family history of an advanced adenoma (defined as ≥1 cm) or with high-grade dysplasia, or villous elements) 2.) Colorectal cancer in a first-degree relative before age 60 years 3.) Colorectal cancer in two or more first-degree relatives at any age
Indications for PPSV23 before the age of 65
1.) Heart disease 2.) Lung disease 3.) DM 4.) Alcoholism 5.) Cigarette smoker 6.) CSF leak 7.) Cochlear implant 8.) Chronic liver disease
Indications for spironolactone
1.) NYHA II-IV AND LVEF =<35% or 2.) Post STEMI with LVEF =< 40% AND symptomatic heart failure OR diabetes mellitus ------ Can only start if: 1.) K+ < 5 AND 2.) GFR > 30
Barretts surveilance
1.) No dysplasia: PPI & EGD in 3-5y 2.) Low grade dysplasia: PPI & EGD q6-12mon, or endoscopic eradication 3.) High grade dysplasia: endoscopic eradication therapy
SBP ppx
1.) Prior episode of SBP 2.) Ascitic fluid protein <1g/dL 3.) Variceal hemorrhage 4.) Cirrhosis + Ascitic fluid protein <1.5g/dL AND any one of the following: Cr >= 1.2, BUN >= 25, Na =< 130, Child-Pugh => 9, Biliubin >= 3
Indications for repeat endoscopy for gastric ulcers
1.) Remains symptomatic after treatment 2.) Cause is uncertain 3) Biopsies were not performed during initial EGD
Asthma step up treatment
1.) SABA PRN 2.) Low dose IG 3.) Low dose IG + LABA 4.) Medium dose IG + LABA 5.) High dose IG + LABA & Omalizumab for patients who have allergies 6.) High dose IG + LABA + oral glucocorticoid AND Omalizumab for patients who have allergies
1st and 2nd line therapy for post herpetic neuralgia
1.) Topical lidocaine 2.) Gabapentin
Individuals require antibiotic prophylaxis from Neisseria meningitidis if they have
1.) close contact (e.g., kissing mouth-to-mouth, endotracheal intubation\management) 2.) prolonged duration (> 8 hours) regardless of vaccination status. Recommended regimens include rifampin, ciprofloxacin, or ceftriaxone Meningococcus usually spreads through droplets of respiratory secretions and can transmit rapidly to contacts within close proximity (3-6 feet)
total calcium declines by 0.8 mg/dL for each ______ decrement in serum albumin concentration.
1.0 g/dL
for every 100 mg/dL increase in the plasma glucose above 100 mg/dL, a decrease in the serum sodium level will occur by approximately ______
1.6 mEq/L
INR cutoff for tPA
1.7
A plasma osmolal gap greater than ____ is abnormal
10
What TSH level do you start treating subcritical hypothyroidism
10
The erythropoiesis-stimulating agents (ESAs) should be considered for patients with chronic kidney disease (CKD) and symptomatic anemia attributable to erythropoietin deficiency when the hemoglobin level is less than
10 g/dL
The expected compensation for chronic respiratory alkalosis is a decrease in the serum bicarbonate of 4 to 5 mEq/L (4-5 mmol/L) for each _______ decrease in the PCO 2
10 mm Hg (1.3 kPa)
Beginning at age ______, APC gene carriers or those with indeterminate status for Familial Adenomatous Polyposis should undergo yearly flexible sigmoidoscopy or colonoscopy.
10 to 15 years
Interval to Next Colonoscopy in patients with <10-mm rectosigmoid hyperplastic polyps
10 years
Postpolypectomy Surveillance if you have serrated polyps which fall under any of the following: <10-mm rectosigmoid hyperplastic polyps
10 years
Clinically stable patients with chemotherapy-induced thrombocytopenia who are not bleeding do not benefit from platelet transfusion when the platelet count is
10,000/µL (10 × 109/L) or greater.
A stool osmotic gap greater than _____ indicates an osmotic diarrhea
100 mOsm/kg (100 mmol/kg)
for every 100 mg/dL increase in the plasma glucose above ______, a decrease in the serum sodium level will occur by approximately 1.6 mEq/L
100 mg/dL
for every ______ increase in the plasma glucose above 100 mg/dL, a decrease in the serum sodium level will occur by approximately 1.6 mEq/L
100 mg/dL
cryoprecipitate is typically reserved for patients with clinically significant bleeding and a fibrinogen level less than
100 mg/dL (1.0 g/L)
concern for toxoplasmosis when CD4 cell count has decreased to less than
100/µL
Urinary calcium (mg/day) for familial hypercalciuric hypocalcemia
100mg
SIBO is therefore typically defined as a bacterial count greater than
105/mL;
Elevated blood pressure:
120-129/<80 mm Hg
An average 24-hour blood pressure measurement by ambulatory blood pressure monitoring (ABPM) of ______ corresponds to a clinic blood pressure measurement of 130/80 mm Hg
125/75 mm Hg
Stage 1 hypertension:
130-139 mm Hg systolic or 80-89 mm Hg diastolic
In patients with a hypertensive intracerebral hemorrhage, recent guidelines support achieving a blood pressure of less than ______mm Hg in the outpatient setting
130/80
An average 24-hour blood pressure measurement by ambulatory blood pressure monitoring (ABPM) of 125/75 mm Hg corresponds to a clinic blood pressure measurement of ______
130/80 mm Hg
an average 24-hour ABPM of ______corresponds to a clinic blood pressure of 140/90 mm Hg.
130/80 mm Hg
Fat excretion above _____ is diagnostic of steatorrhea
14 g/d
In patients with a hypertensive intracerebral hemorrhage characterized by intraventricular extension and cerebral edema, recent guidelines recommend lowering systolic blood pressure to 140 mm Hg with an agent such as nicardipine as the most appropriate initial step to prevent hematoma expansion and neurologic deterioration.
140 mm Hg
In patients with a hypertensive intracerebral hemorrhage characterized by intraventricular extension and cerebral edema, recent guidelines recommend lowering systolic blood pressure to __________ with an agent such as nicardipine as the most appropriate initial step to prevent hematoma expansion and neurologic deterioration.
140 mm Hg
In the acute inpatient setting n a patient with intracranial hemorrhage, systolic blood pressure should be lowered to less than ______ with an intravenous drip if it is greater than 150 mm Hg.
140 mm Hg
an average 24-hour ABPM of 130/80 mm Hg corresponds to a clinic blood pressure of ______
140/90 mm Hg.
histologic analysis must show a minimum of _____ eosinophils/hpf to make the diagnosis of eosinophilic esophagitis
15 eosinophils/hpf
Patients who opt for hemodialysis should be referred for arteriovenous fistula (AVF) placement before their eGFR drops below _______ to allow sufficient time for AVF maturation.
15 mL/min/1.73 m2 (stage G5)
in iron deficiency anemia Transferrin saturation is usually less than
15%
In the acute inpatient setting in a patient with intracranial hemorrhage, systolic blood pressure should be lowered to less than 140 mm Hg with an intravenous drip if it is greater than ______
150 mm Hg.
What platelet level to start warfarin in HITT
150K
In patients with intracranial hemorrhage and a systolic blood pressure greater than 180 mm Hg, blood pressure should be lowered to less than
160/90 mm Hg.
In patients with intracranial hemorrhage and a systolic blood pressure greater than ______ mm Hg, blood pressure should be lowered to less than 160/90 mm Hg.
180 mm Hg
After patients with acute ischemic stroke are treated with intravenous recombinant tissue plasminogen activator, their blood pressure should be maintained at less than _______ mm Hg to avoid intracerebral hemorrhage.
180/105 mm Hg
Blood pressure should be less than ______ mm Hg before thrombolysis
185/110 mm Hg
What LDL do you start high instensity statin regardless
190
If more than 5 L of ascitic fluid is removed during paracentesis, _____ should be given for each liter removed
1g of 25% albumin should be given for each liter removed
4T pretest probability scoring for the possibility of heparin-induced thrombocytopenia
2 Points: Platelet count decrease >50% and platelet nadir ≥20,000/µL (20 × 109/L) Clear onset between days 5-10 or platelet count decrease ≤1 day (with heparin exposure within 30 days) New thrombosis (confirmed); skin necrosis; acute systemic reaction after intravenous unfractionated heparin bolus *********** 1 Point: Platelet count decrease 30%-50% or platelet nadir 10,000-19,000/µL (10-19 × 109/L) Consistent with platelet count decrease between days 5-10, but unclear (e.g., missing platelet counts); onset after day 10; or decrease ≤1 day (heparin exposure 30-100 days ago) Progressive or recurrent clot; nonnecrotizing (e.g., erythematous) skin lesions; suspected thrombosis (not proved) ************* 0 to 3 indicate low probability, 4 or 5 indicate intermediate probability, and 6 to 8 represent high pretest probability
Varicella vaccine
2 doses given at interval of >= 4weeks for all persons lacking immunity
COPD GOLD D Dx
2 or more exacerbations per year OR 1 or more hospitalizations per year Dyspnea while walking on level surface or or CAT >=10 (COPD Assessment Test) mMRC (Modified Medical Research Council) Score: >=2
COPD GOLD C Dx
2 or more exacerbations per year OR 1 or more hospitalizations per year Dyspnea while walking uphill (but not on level surface) or CAT <10 (COPD Assessment Test) mMRC (Modified Medical Research Council) Score: 0-1
Indications for adjusting apixiban dosage
2 out of 3: 1.) 80 years or older 2.) wt < 60kg 3.) Cr 1.5
Delayed Hemolytic Transfusion reactions occur
2 to 10 days after transfusion, are often extravascular, and produce similar clinical signs and symptoms as an extravascular acute hemolytic transfusion reaction. A repeat antibody screen and direct antiglobulin test will be positive. Treatment is supportive. The rate of onset of delayed hemolytic transfusion reactions is slower than that of intravascular acute reaction and signs and symptoms are not as severe. Intravenous fluid hydration and close monitoring are typically sufficient.
Patients with IgG MGUS, an M protein level less than .5 g/dL, and a normal serum FLC ratio may undergo follow-up once every
2 to 3 years. Evaluation should include a CBC, serum calcium and creatinine levels, and repeat M protein testing.
In Staphylococcus aureus Bacteremia, Blood cultures should be repeated every ____ days until they are negative in order to document clearance of bacteremia.
2 to 4 days
esophageal Band ligation requires indefinite endoscopic surveillance, which should be repeated every
2 to 4 weeks until varices are obliterated, then at 3 months, and every 6 to 12 months thereafter to assess for variceal recurrence.
The live-attenuated influenza vaccine given by nasal mist is approved ONLY for persons aged:
2 to 49 years
Polymerase chain reaction should be performed on serum and urine samples for any patient with a clinical presentation typical of symptomatic Zika virus infection who has returned from an endemic area and who has had symptoms within ______ of travel.
2 weeks
Hepatitis A virus vaccine, with a dose of intramuscular immune globulin to provide optimal protection to persons traveling within
2 weeks,
Postmenopausal patients who take aromatase inhibitors are at increased risk for osteoporosis and should receive dual-energy x-ray absorptiometry scans every
2 years. The guidelines also recommend age-appropriate screening for other primary cancers and assessment for alterations in body imaging, lymphedema, and other effects of treatment.
vancomycin is not recommended for MRSA bacteremia if the MIC to vancomycin is greater than
2 µg/mL
Daptomycin is a better therapeutic option than vancomycin for treating methicillin-resistant Staphylococcus aureus with a vancomycin minimum inhibitory concentration greater than
2 µg/mL.
Plasma Osmolality (mOsm/kg H2O)
2 × Serum Sodium (mEq/L) + Plasma Glucose (mg/dL)/18 + BUN (mg/dL)/2.8
Plasma osmolality (mOsm/kg H2O) is calculated as follows
2 × serum sodium (mEq/L) + plasma glucose (mg/dL)/18 + blood urea nitrogen (mg/dL)/2.8
For patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer), recommended colorectal cancer screening is colonoscopy every 1 to 2 years beginning at age 20 to 25 years, or _______ years earlier than the youngest age at diagnosis of colorectal cancer if the affected relative was less than 25 years old.
2-5
even in patients with CKD, you should recheck urate every _____ until allopurinol has the serum urate below 6
2-5 week
For each 10 mm Hg (1.3 kPa) decrease in PCO 2, serum bicarbonate falls acutely by _______ due to intracellular-to-extracellular shift of hydrogen ions as an immediate buffering mechanism.
2.0 mEq/L (2.0 mmol/L)
For each 10 mm Hg (1.3 kPa) decrease in PCO 2, serum bicarbonate falls acutely by ________ due to intracellular-to-extracellular shift of hydrogen ions as an immediate buffering mechanism.
2.0 mEq/L (2.0 mmol/L)
All patients with stage G4 or G5 chronic kidney disease should be referred to a nephrologist for management, and referral for transplant evaluation is indicated once the estimated glomerular filtration rate is below ______
20 mL/min/1.73 m2.
In patients taking amiodarone in combination with simvastatin, the dose of simvastatin should be limited to
20 mg/d to decrease the risk for myopathy.
For patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer), recommended colorectal cancer screening is colonoscopy every 1 to 2 years beginning at age_______, or 2 to 5 years earlier than the youngest age at diagnosis of colorectal cancer if the affected relative was less than 25 years old.
20 to 25 years
week cutoff in pregnancy for HTN Vs. Pre-eclampsia
20 weeks
risk factor for histoplasmosis are a CD4 cell count less than
200/µL
Synovial fluid leukocyte counts less than ______ are considered normal
200/µL (0.2 × 109/L)
Synovial fluid leukocyte counts greater than __________ are associated with inflammatory states
2000/µL (2.0 × 109/L)
the Mini-Mental State Examination, on which a score less than ____ indicates dementia
22
treatment of hypertension in patients with acute ischemic stroke that are out of the tPA window only if blood pressure is greater than ______ mm Hg
220/120 mm Hg
Oral alkali therapy to maintain serum bicarbonate levels between ________ reduces the risk of progression of chronic kidney disease.
23 and 29 mEq/L Treatment with oral sodium bicarbonate, 0.5 mEq/kg/d, is appropriate.
Although aspirin reduces the risk of recurrent stroke if administered within 48 hours of acute ischemic stroke, it should be held in patients given thrombolysis until neuroimaging is performed, typically ______ hours after treatment.
24 hours
All patients with altered mental status after convulsive status epilepticus should have continuous electroencephalographic monitoring for at least
24 hours to detect nonconvulsive seizures.
no further imaging is required for solitary pulmonary nodule if imaging demonstrates stability (and no other new findings) for
24 months
MMR Recommendations for Hematopoietic Stem Cell Transplantationb
24 months after transplantation: 1-2 doses, only if no GVHD or immune suppression
before surgeries with standard risk for bleeding ew oral anticoagulants should be stopped how long prior
24 to 36 hours
Women with BRCA1/2 mutations should undergo breast cancer screening with MRI beginning at age
25
Pulmonary hypertension (PH) is defined by a resting mean pulmonary artery pressure of
25 mm Hg or greate
Diagnosis of Idiopathic Intracranial Hypertension (Pseudotumor Cerebri) is confirmed by a CSF opening pressure greater than
250 mm H2O with normal fluid composition
A score lower than _____ on the Montreal Cognitive Assessment generally suggests cognitive impairment, especially in patients with many years of formal education.
26/30
Pregnant women should receive a single dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine between weeks ________ gestation during each pregnancy, regardless of when they last received either the tetanus and diphtheria (Td) or Tdap vaccine.
27 and 36
To improve the diagnostic accuracy of the urea breath test and fecal antigen test, antimicrobial agents and bismuth should be avoided for _____ before testing
28 days
Measurement of fecal sodium and potassium allows calculation of the osmotic gap, as follows:
290 - (2 × [stool sodium + stool potassium])
Stool osmotic gap calculation
290 - 2*(stool Na + stool K) Normal is <50
serum osmolality equation
2Na + BUN/2.8 + glucose/18
Laparoscopic cholecystectomy can be safely performed during pregnancy, particularly in the _____trimester.
2nd
Mycophenolate mofetil is teratogenic and must be stopped for ____ months prior to becoming pregnant.
3
Serum creatinine cutoff for ACE/ARB initiation
3
Women taking methotrexate must discontinue this medication ______ months prior to attempting to conceive.
3
Surgical evacuation is clinically indicated for hematomas located in the cerebellum, particularly those with a diameter greater than
3 cm
Cannot receive tPA if had significant head trauma or ischemic stroke within
3 mon
Zika virus is often detectable in semen longer than in blood, urine, saliva, or vaginal secretions; virus is typically cleared from semen within _______ months in 95% of male patients.
3 months
In patients with upper gastrointestinal bleeding due to peptic ulcer disease and concomitant cardiovascular disease, aspirin should be resumed within
3 to 5 days; aspirin reduces mortality tenfold over 30 days while increasing rebleeding rates only twofold.
In patients taking an interferon beta as a disease-modifying therapy for multiple sclerosis, serum aminotransferase levels should be measured every _______ months to monitor for autoimmune hepatitis.
3 to 6 months
After completion of treatment, follow-up monitoring in patients with early-stage breast cancer should occur every
3 to 6 months for 3 years, every 6 to 12 months for the next 2 years, and then annually, with annual mammography for all survivors, and MRI of the breast reserved for those at high risk for recurrence.
Patients with polyps larger than 20 mm or polyps removed in pieces should undergo their next colonoscopy in
3 to 6 months to ensure that no residual polyp tissue remains.
Reactive arthritis typically occurs approximately ______ weeks after the infectious trigger,
3 to 6 weeks
Acute ventricular free wall rupture also occurs _____ days after MI
3 to 7
Patients with CIN typically recover kidney function, with the serum creatinine improving within
3 to 7 days
Interval to Next Colonoscopy in patients with 3-10 adenomas, ≥10 mm, villous histology, or high-grade dysplasia
3 years
Interval to Next Colonoscopy in patients with Interval to Next Colonoscopy in patients with sessile serrated polyps ≥10 mm or SSP with dysplasia or traditional serrated adenomas.
3 years
Postpolypectomy Surveillance if you have adenomatous polyps which fall under any of the following 3-10 adenoma ≥10 mm, villous histology high-grade dysplasia
3 years
Postpolypectomy Surveillance if you have serrated polyps which fall under any of the following: SSP ≥10 mm sessile serrated polyps with dysplasia or traditional serrated adenomas
3 years
For patients with large (≥10 mm) or dysplastic sessile serrated polyps or traditional serrated adenomas, the recommended postpolypectomy surveillance colonoscopy interval is
3 years.
Patients with (1) an adenoma 10 mm or larger, (2) three to ten adenomas, (3) an adenoma with a villous component (such as a tubulovillous or villous adenoma), or (4) an adenoma with high-grade dysplasia are considered high risk for colon cancer and should undergo their next colonoscopy in:
3 years.
Adjustment disorder with depressed mood occurs in patients who do not meet the criteria for major depression but have a depressed mood. Symptoms begin within ____ months of a stressful event and do not last longer than ____ months.
3,6
Pneumococcal Immunization Recommendations for Hematopoietic Stem Cell Transplantation
3-6 months after transplantation: 3-4 doses of PCV13 12 months after transplantation: 1 dose of PPSV23
Initial cerebrospinal fluid polymerase chain reaction assay may be falsely negative early in herpes simplex encephalitis and should be repeated ________ days later (in addition to empiric acyclovir) in patients with high clinical suspicion for herpes simplex encephalitis.
3-7 days
An abdominal aortic aneurysm (AAA) is considered to be present when the minimum anteroposterior diameter of the aorta reaches
3.0 cm.
AAA surveillance based on size
3.5 to 4.4 cm, repeat ultrasonography is recommended annually; 4.5 to 5.4 cm, repeat ultrasonography should be performed every 6 to 12 months
Aspirin can be administered safely _____ days after a hypertensive ICH in patients with a strong indication for secondary prevention, such as a concomitant acute coronary syndrome or the presence of arterial stents
30
GFR cutoff for metformin
30
Women with BRCA1/2 mutations should undergo mammography beginning at age
30
The use of gadolinium in MRI studies is relatively contraindicated in patients with an estimated glomerular filtration rate of less than
30 mL/min/1.73 m2 due to the increased risk of NSF
Pharmacologic therapy may be used as an adjunct to diet, physical activity, and behavioral treatments in patients with a BMI of
30 or higher or in patients with a BMI of 27 or higher with overweight- or obesity-associated comorbidities
An increase in the serum creatinine of up to ____% is acceptable with the use of ACE inhibitors or ARBs
30%
COPD GOLD 3 Dx
30% ≤ FEV1 < 50% of predicted
ITP transfusion threshold
30K
Age cutoff for OCP in female smoker
35 and 15 or more cigarettes daily
Size cutoff for nodule vs. mass
3cm
The Schober test measures range of motion of the lumbar spine and is an inexpensive and noninvasive physical examination tool for assessing spine involvement and progression; greater than ______ is normal.
4 cm
The most appropriate fluid-management strategy is to titrate this patient's fluid volume to a central venous pressure (CVP) of
4 mm Hg or less
The expected compensation for chronic respiratory alkalosis is a decrease in the serum bicarbonate of ______ for each 10 mm Hg (1.3 kPa) decrease in the PCO 2
4 to 5 mEq/L (4-5 mmol/L)
Diagnostic studies should not be routinely obtained in patients with nonspecific low back pain; such testing should be reserved for patients with severe or progressive neurologic deficits, patients for whom a serious underlying condition is suspected, or patients who do not have symptom improvement after
4 to 6 weeks of conservative management.
for patients with stage II breast cancer that is hormone receptor positive and HER2 positive, Adjuvant chemotherapy with trastuzumab should be started within
4 to 6 weeks of surgery
Major bleeding associated with vitamin K antagonists should be treated by reversing anticoagulation with
4-factor prothrombin complex concentrate in addition to intravenous vitamin K.
In asymptomatic patients with bicuspid aortic valves, ascending aortic diameter should be reassessed by echocardiography if the aortic root or ascending aorta dimension is greater than or equal to
4.0 cm
Annual evaluation in asymptomatic patients with bicuspid aortic valves should occur if the aortic diameter is greater than
4.5 cm
What age do diabetics start statin therapy regardless
40
screen for DM2 at what age
40
the FDA does not recommend initiation of metformin in patients with estimated GFRs less than
45 mL/min/1.73 m2
a normal QTc is defined as
460 ms or less in women and 440 ms or less in men
Administration of aspirin no later than ________ hours after a stroke is an accepted quality-of-care core metric in primary and comprehensive stroke centers.
48 hours
Aspirin taken within ______ of ischemic stroke onset modestly reduces the risk of recurrent ischemic stroke at 2 weeks without significantly increasing the risk of intracerebral hemorrhage.
48 hours
In patients with acute ischemic stroke who are ineligible for recombinant tissue plasminogen activator therapy, aspirin should be administered within ______ hours of the stroke to reduce the risk of recurrent ischemic stroke.
48 hours
Probiotics reduce the risk of Clostridium difficile infection in hospitalized patients when administered within ________ hours of the first dose of antibiotics.
48 hours
chemoprophylaxis with the neuraminidase inhibitors oseltamivir or zanamivir is recommended for persons who have been exposed to someone known or suspected of having active influenza, but only if the antivirals can be started within ____ hours of the most recent exposure
48 hours
anticoagulant administration must overlap with warfarin for at least
5 days and until the INR is greater than 2 for 24 hours.
Cerebral vasospasm is a potential complication of subarachnoid hemorrhage that most often occurs ______ days after the hemorrhage and is best detected by CT angiography of the brain.
5 to 10 days
In postmenopausal women treated for hormone receptor-positive breast cancer with the aromatase inhibitor anastrozole, recent guidelines recommend that the anastrozole should be continued for
5 to 10 years following primary therapy.
Interval to Next Colonoscopy in patients with sessile serrated polyps <10 mm
5 years
Postpolypectomy Surveillance if you have serrated polyps which fall under any of the following: sessile serrated polyps <10 mm
5 years
Survivors of colorectal cancer should receive an annual abdominal/pelvic CT scan for how long
5 years
after treatment for stages 1, 2, or 3 colorectal cancer, patients at high risk for recurrence (for example, with poorly differentiated histology, lymphatic or vascular invasions, or positive resection margins) should receive an annual abdominal/pelvic CT scan for ______ years after resection
5 years Most experts also recommend serial carcinoembryonic antigen measurements at each visit after resection until 5 years after resection.
When to give revaccination dose of PPSV23
5 years after first dose
Patients with one to two tubular adenomas smaller than 10 mm are considered low risk and should undergo their next colonoscopy in
5 years.
Interval to Next Colonoscopy in patients with 1-2 <10-mm tubular adenomas
5-10 years
Postpolypectomy Surveillance if you have 1-2 adenomatous polyps <10-mm tubular adenomas
5-10 years
Aminoglycosides and anticancer drugs such as cisplatin and carboplatin are directly toxic to the proximal tubular epithelial cells and cause nonoliguric ATN ______days after therapy.
5-10d
in Aminoglycoside-induced acute kidney injury the serum creatinine characteristically rises how long after starting therapy.
5-10d
For mild to moderate UC tx
5-ASA drugs are first-line therapy With these agents, 5-ASA is delivered topically to the bowel lumen, primarily to the colon, with the exception of the time-release formulation of mesalamine, which is able to deliver the drug throughout the small bowel as well as the colon (Table 21). Sulfasalazine may cause folate deficiency, and supplementation is recommended.
stage IV colorectal cancer tx
5-FU, often modified by the reduced folate leucovorin, is the basis of most chemotherapy regimens used in colorectal cancer. Often, the drugs oxaliplatin or irinotecan are added to these agents. The FOLFOX regimen or the 5-FU, leucovorin, and irinotecan (FOLFIRI) regimen are equally acceptable. Bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF), modestly improves outcome when added to chemotherapy regimens. Recent data support the use of either continued bevacizumab or ziv-aflibercept, another anti-VEGF agent, together with second-line chemotherapy.
Patients with mild to moderate ulcerative colitis respond well to
5-aminosalicylate agents. Patients with proctitis or left-sided colitis should receive topical therapy with a 5-aminosalicylate or hydrocortisone suppositories or enemas. If patients require repeated courses of glucocorticoids or become glucocorticoid dependent, thiopurines (6-mercaptopurine or azathioprine) or an anti-TNF agent should be initiated (methotrexate has not been shown to be effective in ulcerative colitis). Anti-TNF agents should be used in patients who do not maintain remission with thiopurines or patients whose disease is refractory to glucocorticoids.
For genetically mediated disorders (such as Marfan syndrome), a lower threshold of valve repair
5.0 cm (4.0-5.0 cm in certain patients) may be used for repair. For patients with a bicuspid aortic valve, repair is indicated if the aortic diameter is greater than 5.5 cm and is reasonable if the diameter is greater than 5.0 cm and the patient has an increased risk of dissection (family history of dissection or rapid growth).
An abdominal aortic aneurysm needs surgical intervention if it is larger than ___ in men, and larger than ___ in women
5.5 cm in men and 5.0 cm in women
Surgery to repair the aortic root or replace the ascending aorta is indicated in patients with a bicuspid aortic valve when the aortic root diameter is greater than
5.5 cm.
EGD in people with dyspepsia when they are above what age
50
A stool osmotic gap between ______ is equivocal.
50 and 100 mOsm/kg (50 and 100 mmol/kg)
If the stool osmotic gap is less than ______, the diarrhea is secretory rather than osmotic.
50 mOsm/kg (50 mmol/kg)
Mammogram begins when
50 to 74 years.
COPD GOLD 2 Dx
50% ≤ FEV1 < 80% of predicted
Most procedures and surgeries can be safely performed with a platelet count of at least
50,000/µL (50 × 109/L), although a platelet count of at least 100,000/µL (100 × 109/L) is recommended for neurosurgical intervention.
age range for colonoscopy screening
50-75 can go up to 85 if have never been screened
worry about Primary CNS lymphoma when CD4 count has dropped to less than
50/µL
Lung cancer screening (annual low dose CT)
55-80 years WITH a 30pack-year smoking history OR former smokers whom have quit in last 15 years
Goal urate for gout
6
Patients with primary and secondary syphilis should have repeat serologic testing at what interval
6 and 12 months with the same testing method used for initial diagnosis; a fourfold decrease in the RPR or VDRL titer is considered significant.
Transfusion-related acute lung injury (TRALI) is characterized by the development of acute lung injury within
6 hours of transfusion of erythrocytes, platelets, or FFP. TRALI is mediated by initial priming of neutrophils in the recipient's lung parenchyma (endothelial damage, for example) followed by their activation by anti-HLA and antineutrophil antibodies present in donor plasma.
Tidal Volume and pleateu pressure for ARDS
6 mL/kg of ideal body weight <30 cm H2O
Social anxiety disorder is characterized by severe, persistent anxiety or fear of social or performance situations (public speaking, meeting unfamiliar people) lasting at least
6 months
any man with potential Zika exposure, regardless of symptom status, abstain from sex or use condoms for______ months months after the last potential Zika exposure or from symptom onset (if symptomatic).
6 months
The goal of HCV treatment is sustained virologic response (SVR), defined as undetectable HCV RNA for _____ months after completion
6 months after completion
In patients with Marfan syndrome and aortic root dilation, surveillance imaging should be performed
6 months after diagnosis and annually thereafter if the aortic size remains stable.
Patients with MGUS are reassessed in what intervals
6 months after initial diagnosis, and, if stable, yearly thereafter.
Tdap Recommendations for Hematopoietic Stem Cell Transplantationb
6 months after transplantation: 3 doses Tdap
In patients with Marfan syndrome, echocardiography should be performed at the time of diagnosis to determine aortic root and ascending aortic diameters and ___ months later to determine their rate of enlargement
6 months later to determine their rate of enlargement. If the maximal aortic diameter is 4.5 cm or greater, more frequent imaging should be considered.
gad
6 months of 3 or more sx: restlessness fatigue concentration difficulties irritability muscle tension sleep disturbance
Generalized anxiety disorder is characterized by excessive anxiety and worry about various events or activities occurring most days for at least
6 months, with difficulty controlling worrying. 1) excessive anxiety or worry about a number of events or activities (for example, school or work) occurring more days than not for at least 6 months; 2) the patient recognizes it is difficult to control the worry; 3) the anxiety or worry is associated with at least three of the following symptoms: restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension, and sleep disturbance; 4) the anxiety, worry, or symptoms cause impairment at school, work, or other settings and cannot be attributable to medical or other psychiatric conditions, medications, or substance use.
in the absence of active goutand once target serum urate is reached, colchicine should be continued for the longer of the following:
6 months; 3 months after reaching target serum urate in a patient without baseline tophi; or 6 months after reaching target serum urate in a patient with baseline tophi that have resolved.
Persons with SCD typically have baseline hemoglobin levels of
6 to 7 g/dL (60-70 g/L)
Persons with sickle cell disease typically have baseline hemoglobin levels of ______in Hb SS and ____ in Hb SC
6 to 7 g/dL (60-70 g/L) in Hb SS and 8 to 10 mg/dL (80-100 g/L) in Hb SC
An adequate antidepressant trial is generally considered to be
6 weeks at a therapeutic dosage
Haemophilus influenzae type B Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
6-12 months after transplantation: 3 doses
Inactivated polio Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
6-12 months after transplantation: 3 doses
Hepatitis B Immunization Recommendations Recommendations for Hematopoietic Stem Cell Transplantationb
6-12 months after transplantation: 3 doses if indications for nontransplant patients are met
Zoster Vaccine age
60
The standard-dose adjuvanted trivalent flu vaccine and the high-dose trivalent flu vaccine are only approved for use in adults aged
65 years and older; the high-dose trivalent vaccine has been shown to be modestly more effective than the standard-dose IIVs in this patient population All types of IIV can be administered to immunocompromised individuals.
A ____-month therapy continuation phase is recommended in patients with active tuberculosis who have certain comorbidities or positive sputum cultures after completing initial therapy.
7
Parasitic infection should be considered as a potential cause of diarrhea lasting for more than
7 days. Giardia lamblia and Cryptosporidium parvum are the most commonly identified parasitic agents definitively known to cause diarrhea in the United States. Amebiasis is relatively uncommon in the United States but can cause hemorrhagic colitis in travelers and may occur several years after return from an endemic area. Because this patient does not have a travel history and her symptoms are of short duration, stool testing for ova and parasites is not necessary at this time.
aneurysms of _____ and greater in the posterior circulation are typically treated with surgery in the absence of contraindications
7 mm
surgery for patients with an asymptomatic intracranial aneurysm in the posterior circulation when the aneurysm shows rapid growth to greater than
7 mm in size and clinical signs consistent with an enlarging aneurysm.
Surgical treatment with clipping or endovascular coiling can be considered in patients with aneurysms of _____ mm or greater in the posterior circulation (posterior communicating and basilar arteries) or _____ mm or greater in the anterior circulation
7 mm or greater in the posterior circulation (posterior communicating and basilar arteries) 12 mm or greater in the anterior circulation
Surgical treatment with clipping or endovascular coiling can be considered in patients with aneurysms of ____ mm or greater in the posterior circulation (posterior communicating and basilar arteries) or ____ mm or greater in the anterior circulation.
7, 12
To improve the diagnostic accuracy of the urea breath test and fecal antigen test, PPIs should be avoided for ______ prior to testing
7-14d
Non-APL AML is treated with
7-day course of cytarabine and a 3-day course of an anthracycline in fit patient
Cutoff between moderate and high intensity statin for diabetics age 40-75
7.5%
In adults 40 to 75 years of age with diabetes mellitus, and an estimated 10-year atherosclerotic cardiovascular disease risk of 7.5% or higher, an LDL cholesterol level of above ___ warrants high intensity statin
70 to 189 mg/dL
Imaging with CT (preferred) or ultrasonography should be performed in patients hospitalized with pyelonephritis if symptoms and fever persist longer than _____ hours to rule out perinephric or intrarenal abscess.
72
In patients with severe acute pancreatitis, enteral feeding should begin approximately ____ hours after presentation.
72 Enteral feeding prevents infections by promoting gut mucosal health and barrier function necessary for preventing leakage or translocation of bacteria that can infect other tissues. Both nasogastric and nasojejunal enteral feeding are safe and have comparable effectiveness. Total parenteral nutrition should be avoided when possible. In mild acute pancreatitis, oral feeding may start when nausea, vomiting, and abdominal pain resolve (or are absent) but should not be withheld on the basis of persistent elevations in pancreatic enzyme levels.
Current guidelines for the treatment of RLS advise supplementation with ferrous sulfate and vitamin C in patients with a serum ferritin below
75 ng/mL (75 µg/L).
Definition of subcentimeter SPN
8 mm or smaller
patients should stop smoking how long before surgery
8 weeks
UOP goal for TLS
80-100cc/hr
Do not give vitamin K to patients taking warfarin unless their INR is above
9.0
Women aged 65 years and older and younger women who have a fracture risk of ______ or higher should be screened for osteoporosis
9.3% or higher
Partners exposed within the preceding _____ days to persons diagnosed with primary, secondary, or early latent syphilis should receive treatment regardless of serologic results.
90
use hypoxia altitude simulation testing to determine the need for oxygen supplementation during air travel In COPD patients with lung disease and sea-level oxygen saturation between
92% and 95%
CrCl cutoff for DOAC
< 30
CrCl cutoff for sprinolactone
< 30
Mycobacterium avium complex infection occurs in HIV-infected patients with CD4 <
< 50 cells/mm3. Disseminated disease presents with fever, night sweats, abdominal pain, diarrhea, and weight loss. Hepatosplenomegaly and abdominal lymphadenopathy are common. Diagnosis is made via blood cultures, and treatment includes clarithromycin and ethambutol.
Normal osmol gap
<10 mOsm/kg (elevated osmol gap is osmolal gap >10 mOsm/kg H2O.)
Platelet cutoff for tPA administration
<100K
Normal blood pressure:
<120/<80 mm Hg
dietary sodium restriction of less than ______ per day is effective in improving blood pressure control in ambulatory patients with advanced kidney disease and other comorbidities.
<2 g/d
Suitable candidates for kidney transplantation should be referred for evaluation once their eGFR is _______
<20 mL/min/1.73 m2.
What glucose level in DKA do you add D5 to IVF
<250
Interval to Next Colonoscopy in patients with ≥10 adenomas on single examination
<3 years; a genetic cause of disease should be investigated
Postpolypectomy Surveillance if you have ≥10 adenomas on single examination
<3 years; a genetic cause of disease should be investigated
Patients with an eGFR of ______ should receive education regarding treatment options, including peritoneal dialysis and hemodialysis, transplantation, and non-dialytic management of ESKD
<30 mL/min/1.73 m2
Goal LDL
=< 70
O2 cutoff for need for in flight O2 in COPD patients
=<92% or less at sea level
ASCVD risk to initiate pharmacological mgmt in stage one HTN
=>10%
Hypodensity greater than ______ on head CT is an absolute contraindication for tPA
> 1/3 MCA territory
Urine osmolality to determine if concentrated or dilute
> 100mOsm/kg H2O <
Cutoffs for mild, moderate, severe hypothermia
> 35-32, 32-28, 28 <
Solitary Pulmonary Nodule immediate biopsy size
>0.8cm
AVOID dosing erythropoietin to achieve a hemoglobin level greater than ______
>11.5 g/dL
Combination antihypertensive therapy is appropriate for patients who are ______ mm Hg above their target blood pressure goal.
>20/10 mm
Urine sodium cutoff to determine if elevated\decreased
>20<
Percutaneous drainage is typically indicated in patients with diverticulitis with larger abscesses greater than
>3 cm
Hematuria is defined as
>3 erythrocytes/hpf and may be either macroscopic (grossly visible) or microscopic (detectable only on urine testing)
Fasciotomy is indicated when intracompartment pressure increases such that perfusion to muscle tissue is
>30 mm Hg Fasciotomy may be considered for patients with immediately threatened limbs when time to revascularization is more prolonged (>4 hours)
An increase in serum creatinine of greater than ______ from baseline after beginning therapy with an ACE inhibitor or angiotensin receptor blocker may be associated with an increased incidence of end-stage kidney disease, myocardial infarction, heart failure, and death.
>30%
Varicella-zoster Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
>4 weeks before transplantation: varicella if not immune 24 months after transplantation: 2 doses varicella if seronegative and only if no GVHD or immunosuppression
Varicella-zoster Immunization Recommendations for Solid Organ Transplantation
>4 weeks before transplantation: varicella if not immune >4 weeks before transplantation: zoster if same indications as nontransplant patients are met Both contraindicated after transplantation
Size cutoff for immediate adrenalectomy
>4cm
Potassium cutoff in DKA to withhold K+
>5.2
In bacterial infection, the synovial fluid leukocyte count is usually greater than
>50,000/µL [50 × 109/L] with neutrophil predominance
PCWP (pulmonary capillary wedge pressure) suggestive of LHF
>= 15mmHg
Thyroid nodule size for biopsy
>= 1cm
What A1c do you start insulin for Dm2
>=10
Coronary Artery Calcium score for statin initiation
>=100
What A1c do you immediately start 2 agents
>=9
Treat a patient with a dog bite.
A 3- to 5-day course of prophylaxis with amoxicillin-clavulanate Alternatively, doxycycline alone or a combination of a fluoroquinolone (ciprofloxacin or levofloxacin) or trimethoprim-sulfamethoxazole plus an anaerobic antibiotic (such as clindamycin or metronidazole) can be used in patients allergic to β-lactam antibiotics.
MELD score and Billirubin level cutoffs for TIPS contraindications
A TIPS can be an attractive option for patients whose ascites does not improve with medical management with a low-sodium diet (<2 g/d) and the usual diuretics (spironolactone and furosemide). However, a TIPS is contraindicated in patients with MELD scores greater than 15 to 18 or serum bilirubin levels greater than 4 mg/dL (68.4 µmol/L), owing to high risk of mortality.
uality improvement tool that is used to organize root causes of a problem
A cause-and-effect diagram
popping sound is reported and there is evidence of knee instability
A complete anterior cruciate ligament tear
when a popping sound is reported and there is evidence of knee instability
A complete anterior cruciate ligament tear
knee joint instability accompanied by joint line tenderness and swelling
A complete medial or lateral collateral ligament tear
knee joint instability accompanied by joint line tenderness and swelling.
A complete medial or lateral collateral ligament tear
On examination, there is lateral joint line tenderness and increased laxity and pain with varus stress
A lateral collateral ligament tear
tear results from a direct varus (laterally directed) force and is associated with lateral knee pain and swelling
A lateral collateral ligament tear
Treat functional dyspepsia
A low-dose tricyclic antidepressant may be effective in the treatment of functional dyspepsia when symptoms do not respond to proton pump inhibitor or H2-blocker therapy.
criteria for establishing that a patient with tuberculosis is noncontagious
A patient with active tuberculosis must undergo adequate tuberculosis treatment for at least 2 weeks, demonstrate improvement of symptoms, and have three consecutive negative sputum smears to be considered noncontagious.
time cutoff to give tPA for ischemic stroke
A recently completed meta-analysis showed that the net outcome of alteplase administration within 4.5 h of stroke was positive in that the probability of achieving an excellent outcome exceeded the risk of death from intracerebral hemorrhage, especially for patients with severe stroke.
Diagnose temporal lobe epilepsy
A rising epigastric sensation is the most common epileptic aura that originates in the temporal lobe; electroencephalographic and MRI findings are often normal. The aura is a simple partial seizure, which can become a complex partial seizure and lead to altered sensorium and automatisms (such as "fidgety" behavior). The absence of focal findings on MRI and electroencephalography (EEG) does not rule-out a diagnosis of epilepsy and is in fact a common finding in temporal lobe epilepsy.
ABI for PAD
ABI values between 0.91 and 0.99 are considered borderline, and while equivocal for PAD, these patients are at increased risk for adverse cardiovascular events. An ABI greater than 1.40 is associated with calcification of the arterial wall and may occur in patients with medial calcinosis, diabetes mellitus, or end-stage kidney disease. This finding is uninterpretable, and therefore a toe-brachial index is recommended for diagnosing PAD in patients who are at risk for PAD and have an ABI above 1.40. A toe-brachial index below 0.70 is considered diagnostic of PAD.
In patients with ascites associated with cirrhosis, All patients should discontinue ______
ACE inhibitors, angiotensin receptor blockers, and NSAID
Therapies that decrease mortality in HFrEF
ACE inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitor β-Blockers Aldosterone antagonists (if NYHA class II to IV) Hydralazine/isosorbide dinitrate (black patients with NYHA class III/IV symptoms) Ivabradine
Patients with glucocorticoid-responsive UC disease are often treated with _____ for maintenance
AZA or 6-MP for maintenance.
Treat a patient who has myasthenia gravis but no thymoma
According to a recently completed randomized clinical trial comparing the effectiveness of early thymectomy versus best medical therapy in the treatment of myasthenia gravis, early thymectomy has significant clinical benefit in patients without thymoma.
in a patient with neurologic symptoms and a single ring-enhancing lesion on brain MRI suggesting acute demyelination and dissemination in time, the next best step to confirm the diagnosis of multiple sclerosis is
According to newly revised diagnostic criteria for MS, in a patient with neurologic symptoms and a single ring-enhancing lesion on brain MRI suggesting acute demyelination and dissemination in time, spinal cord imaging of the cervical and thoracic spines is recommended to establish dissemination in space and thus confirm the diagnosis of multiple sclerosis.
posterior heel pain, stiffness, and tenderness approximately 2 to 6 cm proximal to the Achilles tendon insertion. Pain is generally burning, worsens with activity, and improves with rest.
Achilles tendinopathy
Diagnose Achilles tendinopathy
Achilles tendinopathy classically presents with burning heel pain and stiffness that worsen with activity and improve with rest
when a person participating in a strenuous activity such as basketball hears a popping sound in the heel
Achilles tendon rupture
Platelet transfusion threshold
Active bleeding: 50K DIC: 100K Normal: 10K Fever\Sepsis: 20K ●Neurosurgery or ocular surgery - 100,000/microL ●Most other major surgery - 50,000/microL ●Endoscopic procedures - 50,000/microL for therapeutic procedures; 20,000/microL for low risk diagnostic procedures ●Bronchoscopy with bronchoalveolar lavage (BAL) - 20,000 to 30,000/microL [12] ●Central line placement - 20,000/microL [13] ●Lumbar puncture - 10,000 to 20,000/microL in patients with hematologic malignancies ●Lumbar puncture - greater than 40,000 to 50,000 in patients without hematologic malignancies, ●Epidural anesthesia - 80,000/microL [16] ●Bone marrow aspiration/biopsy - 20,000/microL
condition with peripheral eosinophilia and hypocomplementemia and shows evidence of inflammation on urinalysis, frequently with eosinophiluria present
Acute kidney injury is a common result of cholesterol embolization, which causes peripheral eosinophilia and hypocomplementemia and shows evidence of inflammation on urinalysis, frequently with eosinophiluria present.
Respiratory acidosis
Acute: 1.0 mEq/L (1.0 mmol/L) ↑ [HCO 3] for each 10 mm Hg (1.3 kPa) ↑ in PCO 2 Chronic: 3.5 mEq/L (3.5 mmol/L) ↑ [HCO 3] for each 10 mm Hg (1.3 kPa) ↑ in PCO 2 Failure of the [HCO 3] to increase to the expected value = complicating metabolic acidosis; excessive increase in [HCO 3] = complicating metabolic alkalosis
Respiratory alkalosis
Acute: 2.0 mEq/L (2.0 mmol/L) ↓ [HCO 3] for each 10 mm Hg (1.3 kPa) ↓ in PCO 2 Chronic: 4.0-5.0 mEq/L (4.0-5.0 mmol/L) ↓ [HCO 3] for each 10 mm Hg (1.3 kPa) ↓ in PCO 2 Failure of the [HCO 3] to decrease to the expected value = complicating metabolic alkalosis; excessive decrease in [HCO 3] = complicating metabolic acidosis
Winter's Formula
Acute: PCO 2 = (1.5) [HCO 3] + 8
CAP tx inpatient if factor(s) for CA-MRSA, cavitary infiltrates, or compatible sputum Gram stain
Add vancomycin or linezolid to β-lactamb plus either azithromycin or a fluoroquinolonec
Treat squamous cell carcinoma of the neck with
Adjuvant combined-modality chemoradiation therapy following surgical resection if either positive resection margins or those with metastatic lymph nodes associated with extracapsular extension otherwise, just do surgery
Contact with or participation in recreational sports in fresh water lakes, streams, or rivers (including brackish water) Contact with medicinal leeches
Aeromonas hydrophila Cellulitis is nonspecific in clinical appearance; minor trauma to skin usually leads to inoculation of organism
workup order of any thunderclap headache
Affected patients require emergent evaluation with head CT, and if CT scans are normal, lumbar puncture is mandatory. Neurovascular imaging with catheter magnetic resonance or CT angiography may be necessary to diagnose cerebral aneurysm, vascular malformation, arterial dissection, venous thrombosis, or reversible cerebral vasoconstriction syndrome (RCVS; also known as Call-Fleming syndrome).
follow-up care of patients who achieve SVR after treatment of chronic HCV infection
After SVR, patients with cirrhosis or with stage 3 fibrosis should undergo surveillance for hepatocellular carcinoma twice annually for an indefinite duration. Patients with cirrhosis should also undergo endoscopic screening for esophagogastric varices. Patients with HCV who have decompensated disease or localized hepatocellular carcinoma are candidates for liver transplantation. Posttransplant hepatitis C viremia occurs in nearly all patients and has a variable natural history. Treatment with antiviral agents can be effective for patients with recurrent HCV after liver transplantation. All patients in remission should undergo evaluation for modifiable risk factors for liver injury, such as alcohol, drug use, fatty liver, and diabetes mellitus, with counseling about the importance of avoiding alcohol and drugs which cause liver injury and adherence to disease management strategies for diabetes mellitus if present.
Testicular cancer workup and treatment
After a palpable mass is identified, testicular ultrasonography is performed to confirm the presence of a solid mass, following which radical inguinal orchiectomy is usually performed In conjunction with histologic sampling, it is important to measure serum tumor marker levels, which include β-human chorionic gonadotropin, lactate dehydrogenase, and α-fetoprotein. The serum α-fetoprotein level is never elevated in patients with pure seminomas, and β-human chorionic gonadotropin is only elevated in approximately 20% of patients with pure seminomas. Nonseminomatous germ cell tumors can contain elements of seminoma, but those elements are mixed with tumors with nonseminomatous histologies, which include yolk sac tumor, choriocarcinoma, and embryonal carcinoma. This distinction is important for determining the correct treatment. Once a diagnosis is made, a clinical stage is determined by tumor marker assessment and CT to identify metastatic disease and assess retroperitoneal lymph nodes. Because many testicular cancer treatments can affect future fertility, obtaining a sperm count and discussing sperm banking should occur before treatment is initiated unless treatment needs to start emergently.
Meningicoccal vaccine
Age 16 x1
When to start screening for colon cancer if above average risk
Age 40 or at an age 10 years younger than the earliest age of the case in the immediate family
Mammogram screening
Age 50-74, q2y
Colonoscopy screening with no risk factors
Age 50-75
What 4 criteria excludes you from receiving tPA if you are in the 3-4.5hour window
Age > 80 NIHSS > 25 Diabetic with a previosu stroke ANY anticoagulant use (regardless of INR)
leading cause of blindness in older patients
Age-related macular degeneration (AMD)
Treatment of pressure ulcers
Air-fluidized beds have been shown to enhance healing of pressure ulcers compared with standard hospital mattresses. Dressings, such as hydrocolloid dressings, are used to maintain a moist wound environment while also controlling exudate. Debridement of nonviable tissue via surgical or nonsurgical techniques (for example, wet-to-dry dressings) is also indicated
Biventricular Pacemaker (cardiac resynchronization therapy) indications
All of the following: NYHA class II to IV Ejection fraction ≤35% On guideline-directed medical therapy Ventricular dyssynchrony (LBBB with a QRS duration ≥150 msec)
All patients with HIV infection should be evaluated for what other infections
All patients with HIV infection should be evaluated for active hepatitis B and C because coinfection is associated with increased risk for progression and worse prognosis. Hepatitis C should be tested for annually.
the only curative therapy for follicular lymphoma is
Allogeneic hematopoietic stem cell transplantation
Treat advanced chronic lymphocytic leukemia that is resistant to standard therapy with
Allogeneic hematopoietic stem cell transplantation, a potentially curative therapy option, should be considered for a young patient with advanced chronic lymphocytic leukemia associated with a high risk of disease progression.
The timing of LP in patients with suspected meningitis with any of the following require a preceding noncontrast head CT scan:
Altered mental status Immunocompromised state History of central nervous system disease New-onset seizure Papilledema Focal neurologic deficit ***Patients who do not require a head CT scan prior to LP should undergo LP before the administration of antimicrobials.*** Antimicrobial treatment prior to LP can reduce the yield of cerebrospinal fluid gram stain and culture, but most pathogens can still be successfully cultivated for 4-10 hours after antibiotic initiation.
Nephrolothiasis with stones that have coffin shape
Ammonium magnesium phosphate (struvite)
________ refers to dermatomyositis with cutaneous involvement in the absence of clinical, laboratory, electromyogram, or biopsy evidence of myositis
Amyopathic dermatomyositis
________ should be initiated in patients with osteoarthritis if first-line therapy with acetaminophen does not provide adequate relief.
An NSAID
Treat a patient who has Löfgren syndrome.
An NSAID such as naproxen
characterized by pain and knee instability that occur after a person rapidly decelerates and pivots;
An anterior cruciate ligament tear
examination findings include a large effusion with increased laxity seen with both the anterior drawer and Lachman tests
An anterior cruciate ligament tear
Diagnose hypereosinophilic syndrome
An elevated eosinophil count (>1500/µL [1.5 × 109/L]) without a secondary cause and evidence of organ involvement
Diagnose irritable bowel syndrome
An essential initial step in management of IBS is the clear establishment of the diagnosis with explanation of and reassurance regarding the patient's symptoms. In addition to reassurance, over-the-counter remedies addressing constipation or diarrheal symptoms can be recommended, as these agents are safe and potentially effective. osmotic laxative polyethylene glycol is likely to be well tolerated and to improve this patient's constipation symptoms. The passage of mucus is commonly reported in IBS, so this symptom alone does not warrant colonoscopy.
Order of neuroimaging for first unprovoked seizure
An urgent noncontrast head CT is recommended to exclude hemorrhage in patients with focal neurologic deficits, impaired mental status, or head trauma. An MRI is preferred in otherwise clinically stable patients and should be performed at, or very soon after, presentation. EEG also is recommended for all patients with an unprovoked seizure
Piriformis syndrome tx
Analgesic agents and physical therapy focusing on stretching exercises are the mainstays of therapy.
Fever, leukopenia, and thrombocytopenia in a patient undergoing treatment for Lyme disease suggest coinfection with
Anaplasma phagocytophilum. Although amoxicillin is active against Lyme disease, it is not effective therapy for A. phagocytophila. Doxycycline would have offered the advantage of treating the Lyme disease and an incubating asymptomatic infection with Anaplasma.
treat oral factor Xa inhibitors ( rivaroxaban, apixaban, and edoxaban) overdose with
Andexanet alfa
Albumin-Corrected Anion Gap
Anion Gap + 2.5 × [Normal Albumin - Measured Albumin (g/dL)]
Influenza (inactivated only) Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
Annually
Influenza (inactivated only) Immunization Recommendations for Solid Organ Transplantation
Annually
3 Autoantibodies associated with Poly\Dermato Myositis
Anti-Jo-1, anti-SRP, anti-Mi-2
Autoantibodies associated with diffuse scleroderma
Anti-Scl-70 (anti-DNA Topoisomerase I)
Autoantibodies associated with mixed connective tissue disease
Anti-U1 RNP (ribonucleoprotein)
VTE tx in pregnancy
Anticoagulants should be continued for at least 6 weeks postpartum, for a minimum therapy duration of 3 months. In the final month of pregnancy, a switch from LMWH to UFH can be considered because of UFH's shorter half-life.This allows an epidural catheter for anesthesia to be placed when the activated partial thromboplastin time for UFH is normal, whereas a 24-hour period is necessary after the last LMWH dose before placing a catheter. In addition, UFH can be completely reversed with protamine if major bleeding occurs, whereas LMWH is only partially reversible.
In MS, use this for the pharmacologic treatment of Depression
Antidepressants (such as SSRIs, SNRIs, tricyclic antidepressants, antipsychotic agents)
treatment for hormone receptor positive breast cancer
Antiestrogen treatments for metastatic breast cancer include aromatase inhibitors, tamoxifen, ovarian suppression in premenopausal women, fulvestrant (an estrogen receptor down-regulator), megestrol acetate, and estradiol.
treatment duration for vertebral OM
Antimicrobial therapy is given for 6 to 8 weeks
CAP tx inpatient if risk factor(s) for Pseudomonas aeruginosa or gram-negative rods on sputum Gram stain
Antipseudomonal β-lactam with pneumococcal coverage (cefepime, imipenem, meropenem, or piperacillin-tazobactam) plus ciprofloxacin or levofloxacin (750 mg); or antipseudomonal β-lactam with pneumococcal coverage plus an aminoglycoside plus azithromycin; or antipseudomonale β-lactam with pneumococcal coverage plus an aminoglycoside plus a respiratory fluoroquinolone
tPA absolute contraindications
Any previous intracerebral hemorrhage Known cerebrovascular lesion (e.g., arteriovenous malformation) Ischemic stroke within 3 months Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Significant closed head or facial trauma within 3 months
Diagnose Takayasu arteritis
Arteriography of the aorta and its branches can be used to confirm the diagnosis of Takayasu arteritis.
5 A's for smoking cessation
Ask Advise Assess Assist Arrage followup
diagnose cushing syndrome
At least two abnormal first-line screening tests are required for diagnosis. After documentation of excess cortisol production, ACTH levels may be useful in determining if hypercortisolism is ACTH-dependent or -independent; An 8-mg dexamethasone suppression test is helpful in differentiating between Cushing disease (pituitary tumor-secreting ACTH) and ectopic ACTH production A pituitary MRI should be ordered only after hypercortisolism and Cushing syndrome are diagnosed and a pituitary adenoma is suspected as a cause.
Tx of Babesiosis with sx
Atovaquone plus azithromycin is the treatment of choice for mild-to-moderate disease. In severe disease, clindamycin plus quinine is preferable.
ASD complications
Atrial arrhythmias (atrial fibrillation & flutter) Stroke due to paradoxical embolization Migraine headache Pulmonary hypertension and Eisenmenger syndrome
Manage therapy for ulcerative colitis during pregnancy
Azathioprine maintenance therapy for inflammatory bowel disease should be continued throughout pregnancy
how to treat diarrhea caused by Campylobacter
Azithromycin or erythromycin × 3-5 days
tx for Chlamydia cervicitis, urethritis, or proctitis
Azithromycin, 1 g PO single dose, or doxycycline, 100 mg PO twice daily for 7 days
Patients with suspected chronic myeloid leukemia should be tested for
BCR-ABL
Indications for bariatric surgery
BMI of 40 or higher BMI of 35 or higher with obesity-related comorbid conditions (e.g., type 2 diabetes mellitus, coronary heart disease, obstructive sleep apnea, osteoarthritis)
clue cells
BV
______ is a protozoal infection that is primarily spread through Ixodes ticks and is most commonly found among residents or travelers to the coastal northeastern United States.
Babesiosis
Edematous pruritic lesion with central eschar; spore-forming organism
Bacillus anthracis Contact with infected animals or animal products
treatment of muscle spasms and cramps due to corticospinal tract injury from multiple sclerosis
Baclofen
In MS, use this for the pharmacologic treatment of Spasticity
Baclofen (oral or intrathecal pump), tizanidine, cyclobenzaprine, gabapentin, benzodiazepines, carisoprodol, botulinum toxin
Unilateral then bilateral purulent eye discharge without pain or visual disturbance
Bacterial conjunctivitis
Empyema
Bacterial organisms seen on Gram stain or aspiration of pus on thoracentesis pH <7.0 Antibiotics, thoracostomy tube drainage, early consultation with a thoracic surgeon for possible thoracoscopic debridement
Gitelman syndrome mimics what diuretic use
Bartter and Gitelman syndromes. These rare autosomal recessive genetic disorders of renal sodium and chloride transporters clinically mimic loop diuretic and thiazide diuretic use, respectively
How often to get CBC & CMP for AEDs
Because many AEDs are associated with liver abnormalities and/or blood dyscrasias, obtaining a complete blood count and comprehensive metabolic profile at 6 and 12 months in the first year of therapy is advisable; if no abnormalities are detected, yearly monitoring is reasonable.
first-line treatment for Graves disease
Because thionamide drugs also have an immunomodulatory effect that reduces autoantibody titers, antithyroid drugs are often first-line treatment for Graves disease If the patient does not go into remission or if disease recurs, definitive therapy with radioactive iodine ablation or surgery is recommended. However, in patients with Graves ophthalmopathy, there is an acute escalation of thyroid autoantibody titers following radioiodine therapy that may exacerbate ocular symptoms. Such patients may be better treated with thionamides and/or surgery.
do not combine triptans with
Because women with migraine with aura have an increased risk of stroke, estrogen-containing oral contraceptives, which further increase stroke risk, should be avoided.
Pneumococcal Immunization Recommendations for Solid Organ Transplantation
Before transplantation: PCV13 followed 8 weeks later by PPSV23 5 years after transplantation: 1 dose PPSV23
Inactivated polio Immunization Recommendations for Solid Organ Transplantation
Before transplantation: complete series
Hepatitis A Immunization Recommendations for Solid Organ Transplantation
Before transplantation: complete series if not already immune
Hepatitis B Immunization Recommendations for Solid Organ Transplantation
Before transplantation: complete series if not already immune
Tdap Recommendations for Solid Organ Transplantation
Before transplantation: complete series, including Tdap booster
Human papillomavirus Immunization Recommendations for Solid Organ Transplantation
Before transplantation: per recommendations for nontransplant patients
reduce urinary incontinence in older patients with dementia
Behavioral therapy utilizing prompted voiding
characterized by recurrent painful oral ulcers plus at least two of the following: recurrent painful genital ulcers, eye involvement, skin involvement, and pathergy
Behçet syndrome
Treat a patient with benign paroxysmal positional vertigo.
Benign paroxysmal positional vertigo can be effectively treated with the Epley maneuver, which is performed to reposition otoliths from the semicircular canal into the vestibule of the ear.
only High risk (of thrombosis) conditions
Bileaflet mechanical aortic valve AND 1 other risk factor for stroke (e.g., HTN, DM) VTE within 1 year BUT > 3 months Active malignancy WITHIN 6 months AF with CHA2DS2-VASc 4-5
the most common clinical presentation in patients with symptomatic gallstones
Biliary colic e usual presentation of biliary colic is episodic, severe abdominal pain typically in the epigastrium and/or right upper quadrant but occasionally in the right lower or mid-abdomen. The pain rapidly intensifies over a 15-minute interval to a steady plateau that lasts as long as 3 hours and resolves slowly. The pain is often associated with nausea or vomiting, and there is no jaundice. Pain may radiate to the interscapular region or right shoulder
Diagnose abdominal compartment syndrome
Bladder pressure measurement
Dx of AML
Blast forms must account for at least 20 percent of the total cells of the bone marrow aspirate the presence of 20 percent or more blasts in the peripheral blood is also diagnostic of AML
the most appropriate diagnostic test to perform in patient who most likely has disseminated gonococcal infection (DGI)
Blood cultures or cultures of the genitourinary tract or pharynx are useful diagnostic tests in the setting of bacteremia from disseminated gonococcal infection.
In MS, use this for the pharmacologic treatment of Limb tremor
Botulinum toxin
the most effective treatment of focal forms of dystonia, including blepharospasm
Botulinum toxin injection is the most effective treatment of focal forms of dystonia, including blepharospasm.
Asthma diagnosis on spirometry
Bronchodilator administration showing: Increase in (FEV1) of 12% or more from baseline AND An absolute increase of 200 mL or more. It can also be an increase of more than 200 mL in the forced vital capacity (FVC)
Diagnose diffuse alveolar hemorrhage in a patient with systemic lupus erythematosus
Bronchoscopy with bronchoalveolar lavage (BAL) and biopsy is the most appropriate diagnostic test to perform next
antidepressant for sexual side effects
Bupropion
all patients who present with prepatellar bursitis should have performed
Bursal fluid aspiration
is approved for the treatment of anxiety disorders, but not depression
Buspirone
medically unexplained symptoms (MUS)
CBT
Causes of glomerulonephritis with low compl
CLAMP
preferred catheter for CRRT
CRRT is performed continuously (24 hours/day) through a venovenous access. Venous access is obtained by placing a large double-lumen catheter into either the internal jugular, femoral, or subclavian vein, as would be done for hemodialysis. There are several variations of CRRT that may involve diffusion-based solute removal (dialysis) or convection-based solute and water removal (filtration).
Because of the high risk for metastases in patients with inflammatory breast cancer, staging with ________ is recommended.
CT and bone scanning
Diagnose chronic mesenteric ischemia
CT angiography CT scan may show evidence of diffuse small-bowel dilation, which is suggestive of abnormal small-bowel motility. If progressive and left untreated, chronic mesenteric ischemia can rarely lead to intestinal infarction. Vascular surgical intervention is the treatment of choice.
Cerebral vasospasm is a potential complication of subarachnoid hemorrhage that most often occurs 5 to 10 days after the hemorrhage and is best detected by
CT angiography of the brain
first-line imaging approach in patients with suspected acute aortic dissection
CT aortography
For patients who decline colon cancer screening with colonoscopy, the 3 second tier Multi-Society Task Force recommendations are
CT colonography every 5 years, a combination FIT-fecal DNA test every 3 years, or flexible sigmoidoscopy every 5 to 10 years
When blood cultures are negative, the microbiologic cause of vertebral osteomyelitis should be determined by
CT-guided needle aspiration biopsy to determine the most appropriate antimicrobial therapy.
Electrolyte measurements in TLS
Calcium decreased, everything else increased
Nephrolothiasis with stones that have Envelope\Dumbell shape
Calcium oxalate
Nephrolothiasis with stones that have wedge\prism shape
Calcium phosphate
"Δ-Δ ratio"
Calculating the ratio of the change in the anion gap (Δ anion gap) to the change in bicarbonate level (Δ bicarbonate), or the "Δ-Δ ratio," can help confirm if there is a coexisting acid-base disturbance. A ratio of <1 may reflect the presence of concurrent normal anion gap metabolic acidosis, whereas a ratio of >2 may indicate the presence of metabolic alkalosis.
Well's score for DVT
Calf swelling ≥3cm = +1 Swollen unilateral superficial veins (nonvaricose) = +1 Unilateral pitting edema = +1 Swelling of the entire leg = +1 Localized tenderness along the deep venous system = +1 Previously documented DVT = +1 Active cancer or treatment in previous 6 months = +1 Paralysis, paresis, recent cast immobilization of legs = +1 Recently bedridden for ≥3 days; major surgery = +1 Alternative explanation for leg symptoms at least as likely = +1 0-1 points = DVT unlikely; obtain D-dimer assay. If negative, no further evaluation; if positive, obtain Doppler ultrasonography. >1 point = DVT likely; obtain Doppler ultrasonography.
infection associated with Contact primarily with dogs
Capnocytophaga canimorsus Cellulitis and sepsis particularly in patients with functional or anatomic asplenia
first-line test in evaluating the small bowel in patients with obscure gastrointestinal bleeding after a negative upper endoscopy and colonoscopy
Capsule endoscopy
drug of choice for treating trigeminal neuralgia
Carbamazepine Dizziness and drowsiness are common adverse effects. Serum carbamazepine drug levels, complete blood counts (to check for potential agranulocytosis), and serum electrolyte levels (to check for potential hyponatremia) should be intermittently monitored. Oxcarbazepine, a structural derivative of carbamazepine, is a more expensive choice that has fewer adverse effects and drug interactions. Second-line agents, such as gabapentin, baclofen, clonazepam, lamotrigine and other antiepileptic drugs, may be considered as adjunctive therapies. Approximately 30% of patients do not respond to drug treatment, even after two or three trials of single or multiple agents, at which point surgical procedures should be considered. Noninvasive options include percutaneous radiofrequency coagulation, glycerol injection, or focused stereotactic (gamma knife) radiation. These techniques are generally effective in greater than 50% of patients. Posterior fossa microvascular decompression of a vessel adjacent to the trigeminal nerve root is more invasive but typically more than 90% effective and is recommended in settings of low surgical risk.
choice for empiric therapy in patients with ventilator-associated pneumonia likely caused by extended-spectrum β-lactamase-producing Enterobacteriaceae species.
Carbapenems, such as meropenem
the only reliably effective medications for idiopathic intracranial hypertension
Carbonic anhydrase inhibitors
High-Risk Procedures for bleeding
Cardiac Vascular Neurosurgical Intraabdominal Urologic (e.g., TURP) Joint replacement Laminectomy Renal biopsy Endoscopy with FNA
SAAG ≥1.1 g/dL (11 g/L) Total Protein ≥2.5 g/dL (25 g/L)
Cardiac ascites, Budd-Chiari syndrome
a patient with acute headache and neck pain associated with Horner syndrome should be suspected of having
Carotid artery dissection should be suspected in a patient with acute headache and neck pain associated with Horner syndrome.
________ studies compare the outcomes of patients with a disease to those without a disease
Case-control studies compare the outcomes of patients with a disease (cases) to those without a disease (controls).
Low-Risk Procedures for bleeding
Cataract surgery tooth extraction CVC removal pacemaker\ICD placement LN biopsy endoscopy withOUT needly biopsy Carpal tunnel repair
preferred for the treatment of patients with pelvic inflammatory disease who require hospitalization
Cefotetan plus doxycycline The absence of cervical motion, uterine, or adnexal tenderness makes PID unlikely
Parenteral therapy for Pelvic inflammatory disease
Cefotetan, 2 g every 12 h or cefoxitin, 2 g every 6 h, plus doxycycline, 100 mg PO or IV every 12 h, ____________________ or clindamycin, 900 mg every 8 h, plus gentamicin, 2 mg/kg loading dose followed by 1.5 mg/kg every 8 hours or a single daily dose of 3-5 mg/kg/d
Treatment lyme disease with Encephalopathy or encephalomyelitis
Ceftriaxone or intravenous penicillin G
tx for Disseminated gonococcal infectionc
Ceftriaxone, 1 g IM or IV every 24 h
Treatment of epididymitis
Ceftriaxone, 250 mg IM single dose, plus doxycycline, 100 mg PO twice daily for 10 days
tx for Cervicitis and urethritis (empiric therapy)
Ceftriaxone, 250 mg IM single dose, plus azithromycin, 1 g PO single dose (preferred), or doxycycline 100 mg PO twice daily for 7 days
tx for Gonococcal cervicitis, urethritis, or proctitis and pharyngeal infection
Ceftriaxone, 250 mg IM single dose, plus azithromycin, 1 g PO single dose (preferred), or doxycycline, 100 mg PO twice daily for 7 days
tx for Epididymitis
Ceftriaxone, 250 mg IM single dose, plus doxycycline, 100 mg PO twice daily for 10 days
Oral/IM therapy for Pelvic inflammatory disease
Ceftriaxone, 250 mg IM single dose, plus doxycycline, 100 mg PO twice daily for 14 days with or without metronidazole, 500 mg PO twice daily for 14 days, or cefoxitin, 2 g IM single dose, with probenecid, 1 g PO, plus doxycycline, 100 mg PO every 12 h for 14 days, with or without metronidazole, 500 mg PO twice daily for 14 days
Reynolds pentad
Charcot triad (fever, right upper quadrant pain, and jaundice) or Reynolds pentad (Charcot triad plus hypotension and mental status change).
appropriate adjuvant therapy for patients with stage III colon cancer
Chemotherapy with capecitabine and oxaliplatin (CAPOX) or leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX)
the usual initial radiographic study used to evaluate patients with nonresponsive pneumonia
Chest CT, which provides improved detection of parenchymal abnormalities nonresponsive pneumonia is defined as a lack of significant clinical response within 72 hours of initiating therapy
Giant papillary conjunctivitis with itching and watery discharge, preauricular lymphadenopathy
Chlamydial conjunctivitis
Diseases associated with p-ANCA
Churgg Strauss (eosinophilic granulomatosis with polyangiitis) Microscopic polyangiitis Ulcerative Colitis Primary Sclerosis Cholangitis
SAAG ≥1.1 g/dL (11 g/L) Total Protein <2.5 g/dL (25 g/L)
Cirrhosis
patients who have undergone successful resection of stage II or stage III non-small cell lung cancer, regardless of histologic type, require
Cisplatin-based adjuvant chemotherapy
H. Pylori treatment regimen for patients with penicillin allergy
Clarithromycin, metronidazole, and omeprazole
Löfgren syndrome
Clinical Presentation of Sarcoidosis that Does Not Warrant a Biopsy Bilateral hilar lymphadenopathy, migratory polyarthralgia, erythema nodosum, and fevers
How often for echo surveillance for aortic regurgitation [EF <50%; LVESD >50 mm]
Clinical eval every 6-12 mo; echo every 6-12 mo, more frequently for dilating LV
How often for echo surveillance for aortic regurgitation [EF ≥50%; LVESD ≤50 mm]
Clinical eval every 6-12 mo; echo every 6-12 mo, more frequently for dilating LV
How often for echo surveillance for aortic regurgitation [Severe (VC >0.6 cm, ERO >0.3 cm2, RV ≥60 mL/beat, RF ≥50%)]
Clinical eval every 6-12 mo; echo every 6-12 mo, more frequently for dilating LV
How often for echo surveillance for mitral regurgitation [Severe (VC ≥0.7 cm, ERO ≥0.4 cm2, RV ≥60 mL/beat, RF ≥50%)]
Clinical eval every 6-12 mo; echo every 6-12 mo, more frequently for dilating LV
How often for echo surveillance for aortic regurgitation [Mild (VC <0.3 cm, ERO <0.10 cm2, RV <30 mL/beat, RF <30%); normal EF]
Clinical eval yearly; echo every 3-5 y
How often for echo surveillance for Moderate (Vmax 3.0-3.9 m/s or mean gradient 20-39 mm Hg) aortic stenosis
Clinical eval yearly; echo every 1-2 y
How often for echo surveillance for aortic regurgitation [Moderate (VC 0.3-0.6 cm, ERO 0.10-0.29 cm2, RV 30-59 mL/beat, RF 30%-49%)]
Clinical eval yearly; echo every 1-2 y
Surveillance for Moderate (Vmax 3.0-3.9 m/s or mean gradient 20-39 mm Hg) aortic stenosis
Clinical eval yearly; echo every 1-2 y
How often for echo surveillance for mitral stenosis [Severe (MVA ≤1.5 cm2, diastolic pressure half-time ≥150 msec or ≥220 msec with very severe stenosis, PASP >30 mm Hg)]
Clinical eval yearly; echo every 1-2 y for MVA 1.0-1.5 cm2, every year for MVA <1.0 cm2
How often for echo surveillance for Mild (Vmax 2.0-2.9 m/s or mean gradient <20 mm Hg) aortic stenosis
Clinical eval yearly; echo every 3-5 y
How often for echo surveillance for mitral stenosis [Mild and moderate (MVA >1.5 cm2, diastolic pressure half-time <150 msec)]
Clinical eval yearly; echo every 3-5 y
Surveillance for Mild (Vmax 2.0-2.9 m/s or mean gradient <20 mm Hg) aortic stenosis
Clinical eval yearly; echo every 3-5 y
How often for echo surveillance for mitral regurgitation [Mild and moderate (VC <0.7 cm, ERO <0.40 cm2, RV <60 mL/beat, RF <50%)]
Clinical eval yearly; echo every 3-5 y for mild severity, every 1-2 y for moderate severity
How often for echo surveillance for Severe (Vmax ≥4 m/s or mean gradient ≥40 mm Hg, AVA ≤1.0 cm2) aortic stenosis
Clinical eval yearly; echo every 6-12 mo
How often for echo surveillance for Very severe (Vmax ≥5 m/s or mean gradient ≥60 mm Hg) aortic stenosis
Clinical eval yearly; echo every 6-12 mo
Surveillance for Severe (Vmax ≥4 m/s or mean gradient ≥40 mm Hg, AVA ≤1.0 cm2) aortic stenosis
Clinical eval yearly; echo every 6-12 mo
Surveillance for Very severe (Vmax ≥5 m/s or mean gradient ≥60 mm Hg) aortic stenosis
Clinical eval yearly; echo every 6-12 mo
How often for echo surveillance for [at risk (VC <0.3 cm)] mitral regurgitation
Clinical eval yearly; echo only if symptomatic
Well's score for PE
Clinical signs and symptoms of DVT = 3 Heart rate >100/min = 1.5 Previously documented DVT or PE = 1.5 Bedridden ≥3 days or major surgery in previous 4 weeks = 1.5 Hemoptysis = 1 Active cancer = 1 (3 - 1.5, 1.5, 1.5 - 1, 1) ----- ≤4 points = PE unlikely. 4-6 points = moderate possibility of PE. >6 points = high probability of PE.
standard of care for patients following surgical resection for nonmetastatic renal cell carcinoma
Close observation
Difference between DIC and Liver Failure
Coagulopathy of liver disease is characterized by prolonged prothrombin and activated partial thromboplastin times and increased factor VIII level. In liver failure, all clotting factor activity levels are low except for factor VIII, which is synthesized in all endothelial cells rather than only hepatic endothelial cells. Additionally, good hepatic function is required for factor VIII clearance, thus factor VIII levels increase in liver disease.
________ should be considered in any patient with a respiratory illness who lives or has spent time in southwestern United States, Mexico, and South and Central America.
Coccidioidomycosis
first-line therapy for chronic insomnia disorder
Cognitive behavioral therapy for insomnia
In MS, use this for the non-pharmacologic treatment of Cognitive dysfunction
Cognitive rehabilitation and accommodation strategies
_______ studies investigate the outcomes of similar patients with different exposures
Cohort studies
______ is recommended after recovery because diverticulitis may be precipitated by a sigmoid cancer
Colonoscopy
Common variable immunodeficiency (CVID
Common variable immunodeficiency (CVID) involves B- and T-cell abnormalities, and the usual manifestation is hypogammaglobulinemia. Bacterial infections, often of the sinus tract and lungs, are common, and the immune dysregulation seen in CVID is associated with autoimmunity and malignant disease. However, CVID is not associated with recurrent meningococcal infection.
During these seizures, patients may exhibit semipurposeful behaviors known as automatisms, such as lip smacking or fumbling of the fingers.
Complex partial seizures are associated with a disturbance of awareness.
Treatment for urolithiasis
Consult urology if any of the following 4: 1.) Stone 10mm or more 2.) Urosepsis 3.) Renal Failure (acute) 4.) Complete obstruction --------------------------- If none of the above, then: Hydration, Pain control, Alpha blockers, Strain Urine. Consult urology if pain uncontrolled or no passage of stone within 4-6 weeks ------- Stone 10-15mm: shockwave lithotripsy or ureteroscopy Stone > 15mm: endoscopic stone fragmentation
Manage diabetes mellitus medications in the preoperative setting.
Continuation of long-acting insulin while withholding scheduled short-acting insulin during fasting affords the best approach to glycemic control in the immediate perioperative period. In most cases, long-acting insulins (glargine and detemir) should be continued uninterrupted at the same dose unless a patient has risk factors for hypoglycemia or is undergoing a procedure requiring a prolonged period without enteral nutrition
MMR Recommendations for Solid Organ Transplantation
Contraindicated after transplantation
the next best choice of study in evaluating for acute or chronic osteomyelitis when MRI with contrast, is contraindicated
Contrast-enhanced CT
preferred study for preoperative staging of patients with newly diagnosed colorectal cancer
Contrast-enhanced CT scanning of the chest, abdomen, and pelvis Preoperative measurement of serum carcinoembryonic antigen (CEA) levels is also routinely done.
Treatment of Severe coccidioidal pneumonia or disseminated Coccidioidomycosis
Conventional or lipid formulation of amphotericin B until improved, then itraconazole or fluconazole
diagnostic test of choice for most solid breast lesions lesions
Core needle biopsy
Acute Bronchitis
Cough > 5d to 3w
presence of hyperintensities in the cerebral cortex (cortical ribboning), basal ganglia, or thalamus on diffusion-weighted imaging
Creutzfeldt-Jakob disease can be diagnosed by the presence of hyperintensities in the cerebral cortex (cortical ribboning), basal ganglia, or thalamus on diffusion-weighted imaging, which is highly sensitive and specific for the diagnosis.
the cerebrospinal fluid (CSF) demonstrates elevated 14-3-3 protein in
Creutzfeldt-Jakob disease.
Patient abducts arm to 90 degrees and then actively adducts arm across body. Positive test: Pain in the acromioclavicular joint region
Cross-arm (suggests acromioclavicular joint disorder)
Manage cyclic mastalgia
Cyclic mastalgia is initially treated conservatively; measures include education, reassurance, and use of a well-fitting support bra.
Treat a patient who has interstitial lung disease associated with diffuse cutaneous systemic sclerosis
Cyclophosphamide has been shown to have some benefit in patients who have interstitial lung disease associated with diffuse cutaneous systemic sclerosis.
Tx of MCTD with interstitial lung disease
Cyclophosphamide may be tried for interstitial lung disease and phosphodiesterase inhibitors and/or anti-endothelin therapies for pulmonary arterial hypertension.
GERD red flags
DRAWB Dysphagia Recurrent vomiting Anemia Weight loss Bleeding
Daily ______ is recommended for patients with giant cell arteritis
Daily low-dose aspirin is recommended for patients with giant cell arteritis because of their increased risk for cardiovascular events.
moderate persistent asthma
Daily symptoms, more than once a week nighttime awakenings... tx: low dose
In MS, use this for the pharmacologic treatment of Impaired mobility
Dalfampridine
______ is a better therapeutic option than vancomycin for treating methicillin-resistant Staphylococcus aureus with a vancomycin minimum inhibitory concentration greater than 2 µg/mL.
Daptomycin
Treat suspected methicillin-resistant Staphylococcus aureus cellulitis and bacteremia in a patient who is intolerant of vancomycin.
Daptomycin is an effective alternative to vancomycin for the treatment of methicillin-resistant Staphylococcus aureus cellulitis and bacteremia in patients unable to take vancomycin.
anti-Scl-70 antibodies are associated with
DcSSc (15%-40% prevalence). Patients who have DcSSc without anti-Scl-70 antibodies may instead have antibodies to an alternative antigen, RNA polymerase III. Still other autoantibodies have been identified whose sensitivity for SSc is low (20%) but whose specificity is high (>95%)
Treat an unstageable pressure ulcer
Debridement of eschar is necessary in patients with unstageable pressure ulcers to assess the depth of the wound and promote wound healing.
Treatment of patients with Parkinson disease who have sustained motor benefit from levodopa but are limited by disabling medication-related adverse effects that are refractory to medical management
Deep brain stimulation (DBS) surgery
cryoglobulinemia
Definitive cryoglobulinemia treatment requires clearance of the driving antigen. For patients with hepatitis C-related type II cryoglobulinemia, this means resolving the hepatitis C infection with antiviral therapy. However, if the vasculitic organ involvement is severe, reduction of cryoglobulins themselves is imperative. Classic treatment involves glucocorticoids, cyclophosphamide, and plasmapheresis. More recently, anti-B-cell therapy with rituximab has demonstrated efficacy at reducing cryoglobulinemia and may provide a less toxic alternativ
characterized by sudden high fever, frontal headache and retro-orbital pain, myalgias and arthralgias, severe lower back pain, and rash that appears as the fever abates.
Dengue fever
Infective endocarditis prophylaxis is currently recommended for patients undergoing the following procedures:
Dental procedures Respiratory tract incision GI\GU procedure in the setting of active infection Surgery on infected skin or muscle Surgical placement of prosthetic cardiac material
Polycythemia Vera dx
Determination of serum erythropoietin level and JAK2
3 screening tests for Cushing's
Dexamethasone suppression 24 hour urine free-cortisol late-night salivary cortisol assay
In MS, use this for the pharmacologic treatment of Pseudobulbar affect
Dextromethorphan-quinidine
Examples of Impaired motility diarrhea
Diabetes mellitus Postsurgery Hyperthyroidism Scleroderma
patient comes to office with white coat hypertension, what is next best step
Diagnose white coat hypertension using ambulatory blood pressure monitoring.
Lambert-Eaton Myasthenic Syndrome Diagnosis
Diagnosis is confirmed by detection of serum anti-voltage-gated calcium channel antibodies and the EMG finding of facilitation of motor response to rapid repetitive stimulation.
Diagnose IgG4-related disease.
Diagnosis is made by tissue biopsy and the demonstration of a characteristic histology, which includes the following: - Dense lymphoplasmacytic infiltrate - CD4-positive T cells and plasma cells in germinal centers - IgG4-staining plasma cells constituting more than 50% of the total plasma cells - Storiform (spokes on a wheel-appearing) fibrosis - Obliterative phlebitis - Rare neutrophils and no granulomas
Diagnose PSC
Diagnosis is usually established with a characteristic cholangiogram on MRCP (Figure 27). Patients without large-duct disease require liver biopsy for diagnosis.
diagnosis of paroxysmal nocturnal hemoglobinuria
Diagnosis of PNH is based on flow cytometry results, which can detect CD55 and CD59 deficiency on the surface of peripheral erythrocytes or leukocytes. presents with hemolytic anemia, hypocellular bone marrow, and lack of CD55 and CD59.
Diagnosis of Sjögren syndrome
Diagnosis of Sjögren syndrome is based primarily on typical sicca symptoms as well as glandular (enlarged lacrimal and/or parotid glands) and extraglandular manifestations. It is helpful to confirm eye and mouth dryness in an objective manner, for example, by documenting reduced tear production utilizing the Schirmer test (decreased wetting of tear test strips) or with special stains and slit-lamp examination. Rarely, gallium scanning or sialography may be warranted to characterize the exocrine gland involvement.
Diagnosis of acute HIV infection
Diagnosis of acute HIV infection relies on detecting the virus by RNA polymerase chain reaction or p24 antigen testing. HIV infection has changed significantly with the recent implementation of the fourth-generation HIV test. This test combines an immunoassay for HIV antibody with a test for HIV p24 antigen ( Figure 22 ). This improves the ability of the test to detect early HIV infection because p24 antigen becomes detectable a week before antibody in acute infection. Detection of antigen may help diagnose patients as early as 2 weeks after infection. Western blot testing is no longer recommended. Combined antibody/antigen testing with the approved assay has a specificity of 99.6% but must be confirmed with additional testing.
first-line treatment for restless legs syndrome
Dopamine agonists, such as ropinirole, pramipexole, or rotigotine
Treatment lyme disease with Oligoarticular arthritis
Doxycyclinea or amoxicillin; intravenous ceftriaxone for recurrent symptoms
Patient's arm is passively abducted to 90 degrees; patient is then asked to slowly lower arm to waist. Positive test: Patient's arm will drop down
Drop-arm Patient's arm will drop down (indicates supraspinatus tear)
what kind of precaution on the door does a patient with Neisseria meningitidis need
Droplet isolation is instituted for patients who have a suspected or known illness transmitted by large-particle droplets (>5 µm in size)
Asthma exacerbation
Duonebs, Steroids, O2 Reassess in 4 hours PEFR > 70%: Home with PO steroids PEFR 40-70%: Wards PEFR < 40%: ICU
in patients with isolated superficial venous thrombophlebitis, ____ is indicated to assess for the possibility of an associated deep venous thrombosis (DVT)
Duplex ultrasonography
The National Stroke Association recommends hospitalization for all patients with a first TIA within the last 24-48 hours and the following conditions:
Duration of symptoms > 1 hour Symptomatic internal carotid artery stenosis > 50% Multiple recurrent TIAs Atrial fibrillation or other known cardiac source of embolus Hypercoagulable state High risk of stroke after TIA as determined by the ABCD2 score (6 or higher)
Barrett's diagnosis
EGD shows columnar lined esophagus AND esophageal biopsy shows intestinal metaplasia
treatment of epidermal growth factor receptor (EGFR) mutation positive adenocarcinoma of the lung
EGFR tyrosine kinase inhibitor (such as erlotinib, gefitinib, or afatinib)
In the evaluation of metastatic adenocarcinoma of the lung, routine testing now includes evaluating for the activating mutations
EGFR, EML4/ALK and ROS1. These three driver mutations are targeted by oral tyrosine kinase inhibitors that may be used as treatment before chemotherapy For patients with an EGFR mutation, erlotinib is a commonly used agent; crizotinib and ceritinib target both the ROS1 and EML4/ALK mutations
Describe the rash in RMSF
Early on, the rash is often macular and localized to the wrists and ankles. Over time, this evolves to a diffuse petechial eruption, usually sparing the face. Involvement of palms and soles is characteristic of RMSF, although it is not universal. The hallmark of RMSF is a petechial rash, seen in more than 85% of patients by the end of the first week of illness ( Figure 9 ). Skin lesions may lag behind other symptoms; only 50% of patients have visible rash by the third day of illness. Therefore, the diagnosis should be considered in any patient presenting with a fever and possible tick exposure regardless of the presence of a rash. Skin lesions typically start at the distal extremities and progress centrally. The rash involves the palms and soles in more than 30% of patients but usually spares the face.
therapy of choice for candidemia and most other forms of invasive candidiasis
Echinocandins (caspofungin, anidulafungin, and micafungin)
Omalizumab has been shown to be effective in moderate to severe persistent asthma with the following 3 criteria:
Effective in moderate to severe persistent asthma with the following 3: (1) symptoms inadequately controlled with inhaled glucocorticoids (2) allergies to perennial aeroallergens and (3) serum IgE levels between 30 and 700 U/mL (30-700 kU/L).
CML tx
Either imatinib or second-generation TKIs such as nilotinib or dasatinib
Management of clinically unstable Primary Spontaneous Pneumothorax regardless of size
Emergent needle decompression followed by thoracostomy tube insertion A large, hemodynamically significant pneumothorax (tension pneumothorax) should be managed by high-flow supplemental oxygen and emergent needle thoracostomy followed by thoracostomy tube placement and hospitalization.
Treatment of PTX with Clinical instability regardless of size
Emergent needle decompression followed by thoracostomy tube insertiona
tx of ethylene glycol overdose
Empiric therapy with sodium bicarbonate, fomepizole, and hemodialysis is indicated for patients with suspected ethylene glycol intoxication. Intravenous sodium bicarbonate therapy is also recommended in suspected ethylene glycol or methanol ingestion when the blood pH is below 7.30
When transvaginal ultrasonography is performed as an initial study and an endometrial thickness of less than or equal to ____ mm is found, endometrial sampling is not required.
Endometrial thickness of greater than 4mm should be further evaluated by endometrial sampling.
inflammation of the aqueous and vitreous humors. It is usually caused by bacterial or fungal infection following surgery
Endophthalmitis
achalasia tx
Endoscopic pneumatic dilation is an effective nonsurgical treatment for achalasia; the main complication is perforation, which occurs in 1.9% of patients. Laparoscopic surgical myotomy leading to disruption of circular muscle fibers is the surgical treatment of choice. Fundoplication is recommended after myotomy to prevent reflux, but PPI therapy may still be needed if heartburn symptoms are present.
Fulminant C Diff tx
Enteric vancomycin plus parenteral metronidazole: Vancomycin 500 mg orally or via nasogastric tube four times daily, AND Metronidazole 500 mg intravenously every 8 hours If ileus is present, rectal vancomycin may be administered as a retention enema (500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours)§
__________ should be performed after a negative upper endoscopy and colonoscopy or after a positive capsule endoscopy
Enteroscopy should be performed after a negative upper endoscopy and colonoscopy or after a positive capsule endoscopy.
characterized by eosinophilia, migratory pulmonary infiltrates, purpuric skin rash, and mononeuritis multiplex in the setting of antecedent atopy
Eosinophilic granulomatosis with polyangiitis
Churgg-Strauss Syndrome
Eosinophilic granulomatosis with polyangiitis term-0 P-ANCA / Myeloperoxidase(MPO)-ANCA Elevated IgE Asthma Wrist/foot drop Skin nodules or purpura
ABPA
Eosinophilla > 500 uL IgE > 417 IU/mL
subacute pain in the superolateral testis, is often associated with lower urinary tract symptoms, and is relieved by testicular elevation.
Epididymitis
Nonpainful red, flat, superficial eye lesion that allows visualization of the underlying vasculature
Episcleritis
Primary CNS lymphoma is strongly associated with
Epstein-Barr virus infection, and polymerase chain reaction of cerebrospinal fluid to detect Epstein-Barr virus can facilitate the diagnosis.
treatment of EGFR mutation-positive patients with metastatic NSCLC
Erlotinib
tender, subcutaneous nodules presenting as barely appreciable convexities on the skin surface, with a reddish hue in the acute phase, frequently bilateral and symmetrical, and it usually occurs on the distal lower extremities, but it may also appear on the trunk, thighs, or upper extremities
Erythema nodosum
uncomplicated acute bacterial prostatitis is most commonly caused by
Escherichia coli, Serratia species, and Klebsiella species
How frequently should those at greater than average risk for colon cancer
Every 5 years beginning at age 40 years (or at an age 10 years younger than the earliest age of the case in the immediate family)
Treat migraine without aura with
Evidence-based guidelines suggest that NSAIDs, triptans, and dihydroergotamine are effective treatments for acute migraine without aura and that NSAIDs are preferred as initial treatment because of their greater cost-effectiveness.
GOLD Model for Classifying Exacerbation Risk and Symptom Burden in COPD Category A
Exacerbations Per Year ≤1, CAT Score <10, mMRC Score 0-1
GOLD Model for Classifying Exacerbation Risk and Symptom Burden in COPD Category B
Exacerbations Per Year ≤1, CAT Score ≥10, mMRC Score ≥2
GOLD Model for Classifying Exacerbation Risk and Symptom Burden in COPD Category C
Exacerbations Per Year ≥2, CAT Score <10, mMRC Score 0-1
GOLD Model for Classifying Exacerbation Risk and Symptom Burden in COPD Category D
Exacerbations Per Year ≥2/≥1 with hospital admission, CAT Score ≥10, mMRC Score ≥2
Prevent recurrent vulvovaginal candidiasis (defined as four or more episodes in 1 year)
Extended-course antifungal agent
Patient's arm is abducted to 20 degrees. Examiner passively externally rotates arm. Positive test: Patient is unable to maintain a position of full external rotation
External rotation lag Patient is unable to maintain a position of full external rotation (suggests possible tear of supraspinatus and infraspinatus muscles)
Patient's arm is placed at side with elbow flexed 90 degrees. Examiner stabilizes elbow and applies force proximal to wrist while patient attempts external rotation. Positive test: Pain or weakness
External rotation resistance Pain or weakness (suggests infraspinatus tear or tendinopathy)
COPD GOLD 4 Dx
FEV1 <30% of predicted
PFTs in Severe Persistent Asthma
FEV1 <60% of predicted FEV1/FVC reduced >5%
Asthma exacerbation tx
FEV1 or PEF >= 70% = Home FEV1 or PEF 40% - 69% = Wards FEV1 or PEF <40% = ICU
PFTs in Moderate Persistent Asthma
FEV1 ≥60% but <80% of predicted FEV1/FVC reduced ≤5%
COPD GOLD 1 Dx
FEV1 ≥80%
PFTs in Mild Persistent Asthma
FEV1 ≥80% of predicted FEV1/FVC normal
Treatment lyme disease with Cranial nerve palsies, meningitis
Facial nerve palsy: doxycyclinea Other neurologic manifestations: ceftriaxone or intravenous penicillin G
episodes of fever, polyserositis, arthritis, erysipeloid rash around the ankles, and elevated acute phase reactants
Familial Mediterranean fever
alternative first-line urate-lowering agent in patients who cannot tolerate or have a contraindication to xanthine oxidase inhibitor therapy
Febuxostat is an alternative first-line therapy for urate lowering. In contrast to the purine analogue allopurinol, febuxostat is a non-purine, non-competitive xanthine oxidase inhibitor that is more specific than allopurinol. Febuxostat is newer and more expensive than allopurinol. It is less likely to cause hypersensitivity reactions and may be used in patients who have had adverse reactions to allopurinol. Febuxostat is excreted via the gastrointestinal tract and kidneys and needs no dose adjustment for patients with mild to moderate chronic kidney disease. Febuxostat should be avoided in patients taking other purine analogues such as azathioprine or 6-mercaptopurine because toxic levels of either or both drug may ensue.
Neuroimaging is indicated for suspected secondary headaches that exhibit one of the clinical red flags. Secondary headache disorders are defined by identifiable organic causation and typically display one of the following clinical "red flags."
First or worst headache Abrupt-onset or thunderclap attack Progression or fundamental change in headache pattern Abnormal physical examination findings Neurologic symptoms lasting greater than 1 hour New headache in persons younger than 5 years or older than 50 years New headache in patients with cancer or immunosuppression or in pregnant women Association with alteration in or loss of consciousness Headache triggered by exertion, sexual activity, or Valsalva maneuver
Treat viral upper respiratory tract infection
First-generation antihistamine and decongestant preparations (such as chlorpheniramine-pseudoephedrine), inhaled ipratropium, and cromolyn sodium may be used to decrease sneezing and rhinorrhea.
Treatment of Coccidioidal meningitis
Fluconazole
Treatment of Nonmeningeal cryptococcosis
Fluconazole
Treat a patient with Coccidioides immitis meningitis
Fluconazole is the treatment of choice for coccidioidal meningitis, because it offers a good response rate and a favorable safety profile.
the most appropriate treatment recommendation for otherwise healthy persons with mild travelers' diarrhea.
Fluid replacement with aggressive oral hydration
how to treat diarrhea caused by ETEC (travelers' diarrhea)
Fluoroquinolone × 3 days, azithromycin × 1 dose, or rifaximin × 3 days
how to treat diarrhea caused by Yersinia
Fluoroquinolone × 3 days; trimethoprim-sulfamethoxazole × 3 days
how to treat diarrhea caused by Shigella
Fluoroquinolone × 3 days; azithromycin × 3 days
how to treat diarrhea caused by Vibrio
Fluoroquinolone × 3 days; azithromycin × 3 days
Causes of nephrotic syndromes
Focal Segmental Minimal change Membranous Amyloidosis Diabetic glomerulonephropathy Membranoproliferative (both)
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >4 to 6mm with low pretest probability
Follow-up CT at 12 months if unchanged, no further follow-upe
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is ≤4mm with high pretest probability
Follow-up CT at 12 months if unchanged, no further follow-upe
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >8mm with low pretest probability
Follow-up CT at around 3, 9, and 24 months; dynamic contrast-enhanced CT, PET, and/or biopsy
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >8mm with high pretest probability
Follow-up CT at around 3, 9, and 24 months; dynamic contrast-enhanced CT, PET, and/or biopsy (same as for low pretest prob)
When to get Coronary artery calcium score
For patients with intermediate risk a 10-year risk of ASCVD of below 5% is considered low risk 5% to below 7.5% is classified as intermediate risk 7.5% or above is designated as high risk.
Carpal Tunnel Syndrome tx
For patients with mild to moderate symptoms, initial therapy consists of avoiding repetitive hand and wrist motions. Neutral-position wrist splinting appears to be more effective when used full time rather than only at night. Local glucocorticoid injection can provide short-term symptomatic improvement (up to 10 weeks), and a 2-week course of an oral glucocorticoid can result in short-term symptom improvement lasting for up to 1 month. Surgery is considered first-line therapy for those who have severe disease on nerve conduction testing and in those who have muscle wasting on examination. Additional indications for surgery include failure to respond to conservative therapy, intolerable pain, and progressive numbness or weakness.
Stage I seminoma treatment
For patients with seminoma confined to the testis (stage I), orchiectomy is usually curative. Active surveillance consists of regular tumor marker and imaging assessments with the purpose of evaluating for evidence of recurrence.
Treatment for patients with latent TB that is suspected to be resistant to isoniazid or who cannot take isoniazid
Four months of daily rifampin
Ulceroglandular syndrome characterized by ulcerative lesion with central eschar and localized tender lymphadenopathy; constitutional symptoms are often present
Francisella tularensis
Contact with or bite from infected animal (particularly cats) or arthropod bites (particularly ticks)
Francisella tularensis Ulceroglandular syndrome characterized by ulcerative lesion with central eschar and localized tender lymphadenopathy; constitutional symptoms are often present
All patients with stage ______ chronic kidney disease should be referred to a nephrologist for management, and referral for transplant evaluation is indicated once the estimated glomerular filtration rate is below 20 mL/min/1.73 m2.
G4 or G5
In MS, use this for the pharmacologic treatment of Neuropathic pain
Gabapentin, pregabalin, duloxetine, tricyclic antidepressants, tramadol, carbamazepine, topiramate, capsaicin patch
Surveillance if you have HNPCC
Genetic counseling colonoscopy every 1 to 2 years beginning at age 20 to 25 years, or 2 to 5 years earlier than the youngest age at diagnosis of colorectal cancer if the affected relative was less than 25 years old.
Surveillance if you have Familial Adenomatous Polyposis and MYH-Associated Polyposis
Genetic counseling and should be offered genetic testing. Because MAP is autosomal recessive, both parents must be carriers of an MYH mutation in order for a child to inherit the syndrome. Beginning at age 10 to 15 years, APC gene carriers or those with indeterminate status for FAP should undergo yearly flexible sigmoidoscopy or colonoscopy. Individuals who have or who are at risk for MAP should undergo colonoscopy every 2 to 3 years beginning at age 25 to 30 years. After colectomy is performed, lifelong yearly surveillance of the rectum or ileal pouch is required to manage recurrent polyposis and decrease the risk of rectal or pouch adenocarcinoma. Upper endoscopy for surveillance of duodenal cancer is indicated every 1 to 5 years at an interval based on the stage of the duodenal polyposis.
patients with chronic diarrhea and exposure to young children or potentially contaminated water such as lakes and streams
Giardiasis
Indications for albumin in SBP
Give 1.5g/kg on day 1 and 1g/kg on day 3 if they have any of the following: 1.) Cr > 1 2.) Bili > 4 3.) BUN > 30
Differentiate between glomerular and nonglomerular hematuria.
Glomerular hematuria typically features brown- or tea-colored urine with dysmorphic erythrocytes (or acanthocytes) and/or erythrocyte casts on urine sediment examination. Glomerular hematuria is typically characterized by brown- or tea-colored urine with dysmorphic erythrocytes (or acanthocytes) and/or erythrocyte casts on urine sediment examination, although some glomerular disorders may cause gross hematuria. Other findings suggestive of a glomerular source include proteinuria. Nonglomerular bleeding typically presents with isomorphic erythrocytes in the urine without evidence of glomerular dysfunction.
the most appropriate method to distinguish between a flare of inflammatory myopathy and glucocorticoid-induced toxic myopathy in a patient with persistent myopathy
Glucocorticoid tapering is the most appropriate method to distinguish between a flare of inflammatory myopathy and glucocorticoid-induced toxic myopathy in a patient with persistent myopathy.
IgG4-associated cholangitis TX
Glucocorticoids
the cornerstone of treatment for autoimmune pancreatitis
Glucocorticoids
Tx of MCTD with arthritis and myositis
Glucocorticoids, azathioprine, and methotrexate
Diagnose a superficial incisional surgical site infection
Gram stain and culture of the fluid drainage from the incision site Patients with superficial incisional surgical site infection typically have inflammatory changes at the incision site, with or without purulent drainage, and generally without systemic signs of infection such as fever.
with this disease, RAIU and scan will show markedly increased uptake with diffuse activity on the scan
Graves disease
tx of systemic sclerosis-associated esophagitis and gastritis
H2 blockers and proton pump inhibitors
Determination of _____ is indicated for patients with newly diagnosed metastatic gastric cancer
HER2 tumor status as the anti-HER2 monoclonal antibody trastuzumab, when added to a systemic chemotherapy regimen, is beneficial in treating patients whose tumors overexpress HER2.
In patients with focal segmental glomerulosclerosis (FSGS), check for what disease
HIV
Test used to rule out the antibody-negative "window period" of acute HIV infection
HIV NAAT to detect viral RNA Western blot testing for HIV antibody is no longer recommended for confirmatory testing of immunoassay results because of a higher risk for false-negative or indeterminate results early in the course of HIV infection.
5-mm or larger induration is considered positive in patients with
HIV infection, organ transplants, and fibrotic changes on chest radiograph consistent with old tuberculosis, and recent contacts of a person with active tuberculosis
The development of explosive onset or severe flare of psoriatic arthritis should raise suspicion for concomitant
HIV infection.
Contraindications to Live Vaccines
HIV or AIDS with a CD4 cell count ≤200/µL or ≤15% of total lymphocytes Immunosuppressant therapy, ≥20 mg/d of prednisone or equivalent Leukemia, lymphoma, bone marrow malignancies lymphatic system malignancies Cellular immunodeficiency Solid-organ transplant recipient Current hematopoietic stem cell transplantation
Patients experiencing platelet transfusion refractoriness because of alloimmunization should receive
HLA-matched platelets.
lateral great toe deviation with bony deformity on the medial aspect of the first metatarsal phalangeal joint
Hallux valgus deformity (bunion)
Patient's shoulder is flexed to 90 degrees, elbow is flexed to 90 degrees, and forearm is placed in neutral rotation. Then, while supporting the arm, the humerus is rotated internally. Positive test: Pain
Hawkins Positive test: Pain (suggests subacromial impingement)
Difference bettwen vestibular neuronitis and labrynthitis
Hearing Loss is only with labyrinthitis
Indications for vancomycin in neutropenic fever include:
Hemodynamic instability Severe sepsis Pneumonia Positive blood cultures for a gram-positive organism (prior to speciation results) Suspected catheter-related infection (eg, chills during infusion, cellulitis around entry site) Skin or soft-tissue infection
Indications for Diagnostic Bronchoscopy
Hemoptysis Stridor or localized wheeze Pulmonary infections Diagnosis and/or staging of bronchogenic carcinoma Diagnosis of pulmonary metastases Evaluation of a pulmonary nodule Persistent pulmonary infiltrate Mucus plugging Foreign-body aspiration Diffuse parenchymal lung disease
Any change in the neurologic examination in patients diagnosed with a stroke, particularly in patients treated with thrombolysis, should prompt consideration of
Hemorrhage after thrombolysis for ischemic stroke can be detected on a noncontrast CT scan of the head.
Skin biopsy will show leukocytoclastic vasculitis and, on immunofluorescence, IgA and C3 complement deposition. Kidney biopsy will show IgA nephropathy. Serum IgA levels may be elevated
Henoch-Schönlein Purpura
_______ is typically associated with membranous glomerulopathy
Hepatitis B
Dead space physiology
High V/Q or (V/Q = infinity)
initial treatment if patient has suspected ischemic stroke that meets any of the exclusion criteria for thrombolysis
High-dose (325-mg) aspirin
gold standard diagnostic test for bronchiectasis
High-resolution CT
High-risk gastric ulcers
High-risk ulcers have active arterial spurting or a nonbleeding visible vessel
Treatment of high risk ulcers seeon on upper endoscopy
High-risk ulcers have active arterial spurting or a nonbleeding visible vessel (Figure 32). They should be treated endoscopically with hemoclips, thermal therapy, or injection of sclerosants, which are all equally effective at achieving hemostasis. Local injection of the vasoconstrictor epinephrine may be used adjunctively to aid immediate hemostasis for optimizing visibility for subsequent and more durable endoscopic therapy; however, epinephrine injection alone is inadequate for durable hemostasis.
Diagnose chronic osteomyelitis
Histopathology and full microbiologic studies are important for diagnosing chronic osteomyelitis and isolating the causative pathogen in order to direct appropriate treatment.
endemic mycosis in the United States (primarily in the Ohio and Mississippi river valleys) and is also prevalent in Central America.
Histoplasma
tPA relative contraindications
History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)a History of ischemic stroke (>3 months), dementia, or known intracranial pathology Traumatic or prolonged (>10 minutes) CPR or major surgery (<3 weeks) Recent (within 2-4 weeks) internal bleeding Noncompressible vascular puncture site For streptokinase/anistreplase: previous exposure (>5 days) or previous allergic reaction to these agents Pregnancy Active peptic ulcer disease Current use of anticoagulants: the higher the INR, the higher the bleeding risk
Criteria for Lung Transplantation in Patients with COPD
History of exacerbation associated with acute hypercapnia (arterial PCO 2 >50 mm Hg [6.7 kPa]) Pulmonary hypertension Cor pulmonale Pulmonary hypertension and cor pulmonale FEV1 <20% of predicted with DLCO <20% of predicted or homogeneous distribution of emphysema
Lung transplant criteria
History of exacerbation associated with acute hypercapnia (arterial PCO 2 >50 mm Hg [6.7 kPa]) Pulmonary hypertension Cor pulmonale Pulmonary hypertension and cor pulmonale FEV1 <20% of predicted with DLCO <20% of predicted or homogeneous distribution of emphysema
prepatellar bursitis
Housemaids knee can be cause by repeated trauma or pressure from extensive kneeling. Propensity to secondary infection with Staph A Bogginess and tenderness at inferioanterior aspect of knee
Tx of SLE with skin involvement
Hydroxychloroquine
best treatment option for essential thrombocythemia when treatment is required in patients older than 60 years, those with a platelet count greater than 1 million/µL (1000 × 109/L), or those with a history of thrombosis
Hydroxyurea plus low-dose aspirin
Roux-en-Y gastric bypass kidney stones
Hyperoxaluria Hypocitraturia
Treatment for non-small cell lung cancer based on stage
I & II: Surgery III: Chemoradiation IV: systemic chemotherapy in those with adequate performance status based on the pattern of metastatic spread and the results of histologic and molecular assessment
Stages of breast CA
I) ≤2 cm negative lymph nodes ---------- IIA) ≤2 cm if 1 to 3 positive lymph nodes 2.1-5 cm if negative lymph nodes ---------- IIB) 2.1-5 cm with 1 to 3 positive lymph nodes or >5 cm tumor with negative lymph nodes ---------- III) Any tumor size with ≥4 positive axillary lymph nodes positive infraclavicular or supraclavicular nodes, and/or positive ipsilateral internal mammary nodes (clinically detected, or on sentinel node biopsy if ≥4 positive axillary nodes); tumors >5 cm with ≥1 positive nodes; tumor extension to chest wall or skin ---------- IV) Distant mets
Stages of colon CA
I) Patients with ulcerative colitis or Crohn colitis should receive surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years of disease. II) Tumor invades full thickness of the bowel and may invade into pericolonic or perirectal fat (T3, T4); lymph nodes not involved (N0) III)One or more lymph nodes involved with cancer (N1, N2); any T stage IV)Metastatic tumor spread to distant site (M1); any T stage; any N stage
Stages of non-small cell lung CA
I) Solitary tumor without regional (peribronchial or hilar) or mediastinal lymph node involvement. IA) less than 3 cm IB) greater than 3 cm but less than 5 cm II) greater than 5 cm; regional lymph node involvement; tumor invasion into local structures, such as the pleura or chest wall; or tumors that are located near the carina III) mediastinal lymph node involvement IV) metastatic disease or an ipsilateral malignant pleural effusion.
Tx for Patient with HIV with TST >5 mm or positive IGRA results
INH, 300 mg/d for 9 months
contraception in women with a history of migraines preceded by visual aura
IUD
Meningitis treatment for Patient age >50 y or those with altered cell-mediated immunity
IV ampicillin (Listeria coverage) plus IV ceftriaxone or cefotaxime plus IV vancomycin
Meningitis treatment for Immunocompetent host age <50 y with community-acquired bacterial meningitis
IV ceftriaxone or cefotaxime plus IV vancomycin
Meningitis treatment for Allergies to β-lactams
IV moxifloxacin instead of cephalosporin IV trimethoprim-sulfamethoxazole instead of ampicillin
Meningitis treatment for Hospital-acquired bacterial meningitis
IV vancomycin plus either IV ceftazidime, cefepime, or meropenem
Meningitis treatment for Neurosurgical procedures
IV vancomycin plus either IV ceftazidime, cefepime, or meropenem
Treat Helicobacter pylori infection after initial treatment failure.
If Helicobacter pylori infection is not eradicated with primary therapy, a second-line salvage therapy should contain an alternative antibiotic to clarithromycin, and the treatment should be at least 10 days in duration to maximize the likelihood of treatment success.
postoperative chemoradiation and chemotherapy are indicated in rectal cancer if
If pathology findings indicate that the tumor is a higher T stage than expected (T3 or T4) or if any of the locoregional lymph nodes in the mesorectum are found to contain cancer (N1 or N2) However, if the final pathology report confirms stage I rectal cancer, the probability of cure with surgery alone is high, and no additional treatment is indicated. Neither chemotherapy, radiation therapy, nor combined chemotherapy plus radiation has been demonstrated to improve outcomes in patients with stage I rectal cancer, and all of them would expose these patients to unnecessary risk and toxicity.
Indications for parathyroidectomy
If symptomatic. If asymptomatic, then GATC: GFR < 60 Age < 50 T-score < -2.5 Calcium > 1mg above ULN
Non-fulminant C Diff 1st reoccurrence tx
If vancomycin was used for the initial episode: Vancomycin pulsed-tapered regimen: 125 mg orally four times daily for 10 to 14 days, then 125 mg orally twice daily for 7 days, then 125 mg orally once daily for 7 days, then 125 mg orally every 2 or 3 days for 2 to 8 weeks, OR Fidaxomicin 200 mg orally twice daily for 10 days If fidaxomicin or metronidazole was used for the initial episode: Vancomycin 125 mg orally four times daily for 10 days
_______ is associated with abdominal pain, palpable purpura, arthralgia, and glomerulonephritis, with normal complement levels.
IgA vasculitis (Henoch-Schönlein Purpura)
characterized by the lymphoplasmacytic infiltration and enlargement of various structures, including the pancreas, lymph nodes, salivary glands, periaortic region leading to retroperitoneal fibrosis, kidneys, and skin.
IgG4-related disease
characterized by infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4 levels.
IgG4-related interstitial nephritis here is often other organ involvement and occasionally associated glomerular lesions, including membranous and membranoproliferative glomerulonephritis.
diagnosis of Waldenström macroglobulinemia
IgM monoclonal gammopathy of any size in the serum >=10% of the bone marroq bx must demonstrate infiltration by small lymphocytes that exhibit plasmacytoid or plasma cell differentiation (the >=10% difference is to differentiate from MGUS)
Noble maneuver
Iliotibial band integrity With patient supine, examiner repeatedly flexes and extends knee with examiner's thumb placed on lateral femoral epicondyle. Positive test: Reproduces patient's pain (suggests iliotibial band syndrome)
lateral knee pain that is worsened by walking down an incline
Iliotibial band syndrome
Osteonecrosis (avascular necrosis) of the femoral head dx
Imaging with MRI (early-stage disease) or plain radiographs (later-stage disease) is necessary to establish the diagnosis.
Best way to dx RMSF
Immunohistochemistry or PCR of a skin biopsy specimen allows diagnosis at the time of acute infection.
Diarrea with Bloating, nausea, Features of underlying disorder
Impaired motility!!!! Diabetes mellitus Postsurgery Hyperthyroidism Scleroderma
Treat candidemia in a postsurgical patient.
In a patient with candidemia, echinocandins such as caspofungin, anidulafungin, and micafungin are the empiric therapy of choice.
Treat agitation in a patient with dementia.
In a patient with dementia accompanied by severe agitation that poses a risk to self or others, antipsychotic treatment is appropriate (e.g., quetiapine); haloperidol is not recommended as first-line therapy in nonemergency situations because of its higher adverse event profile.
Epididymitis tx
In older men and persons who practice anal intercourse, infectious epididymitis should be treated with ceftriaxone and a fluoroquinolone [Escherichia coli, Enterobacteriaceae, and Pseudomonas] All other men are treated with ceftriaxone (250-mg intramuscular injection in one dose) plus doxycycline (100 mg by mouth twice daily for 10 days) Epididymitis can also be due to noninfectious causes (for example, trauma, autoimmune disease, or vasculitis). Treatment includes scrotal support, ice, and NSAIDs.
Monitor a patient with chronic noncancer pain on opioid therapy.
In patients on long-term opioid therapy for chronic noncancer pain, adherence monitoring in the form of regular surveillance of prescription monitoring programs should be performed to reduce prescription drug abuse.
Manage a central line-associated fungal bloodstream infection.
In patients with candidemia associated with an intravenous catheter, the catheter should be removed and empiric antifungal therapy initiated. Empiric antifungal therapy should be based on the most likely organism (such as Candida albicans) because candidemia can be prolonged and may lead to metastatic complications (endophthalmitis, endocarditis, osteomyelitis) if not already present at the time of diagnosis.
Manage degenerative cervical spondylotic myelopathy
In patients with compressive cervical spondylotic myelopathy and no contraindications, surgical decompression is the most appropriate treatment, even in those older than 65 years.
Parkinson's dyskinesia tx
In patients with dyskinesia, adding amantadine may help a subset of patients Although amantadine can be effective against dyskinesia, increasing the dosage further may worsen the hallucinations.
Treat essential tremor
In patients with essential tremor, propranolol and primidone are FDA approved first-line therapies.
Treat insomnia in a patient in whom sleep hygiene techniques are ineffective
In patients with insomnia in whom sleep hygiene techniques are ineffective, sleep restriction may be beneficial; sleep restriction limits and then gradually increases the time in bed for sleep.
treat bladder spasticity due to myelopathy from multiple sclerosis (MS)
In patients with multiple sclerosis, anticholinergic agents (oxybutynin) reduce the intensity and frequency of bladder spasms and thus may reduce symptoms of urgency, frequency, and incontinence.
imaging study to get in a patient with optic neuritis
In patients with optic neuritis, an MRI of the brain should be obtained to evaluate for brain lesions consistent with multiple sclerosis, which is the most common cause.
In patients with organ-threatening or life-threatening ANCA-associated vasculitis, initial treatment
In patients with organ-threatening or life-threatening ANCA-associated vasculitis, initial treatment with glucocorticoids and either rituximab or cyclophosphamide is recommended for remission induction.
Treat refractory temporal lobe epilepsy
In patients with refractory temporal lobe epilepsy, surgery is the most likely intervention to stop seizures and thus improve quality of life
Treat a patient who has scleroderma renal crisis
In patients with scleroderma renal crisis, treatment with an ACE inhibitor is essential to restore kidney function and manage hypertension.
Diagnose exercise-induced bronchospasm and possible asthma with
In patients with symptoms of exercise-induced bronchospasm and/or asthma but normal spirometry findings, bronchial challenge testing is warranted for further evaluation. (such as with methacholine)
Diagnose bacterial overgrowth syndrome due to systemic sclerosis-associated intestinal disease
In patients with systemic sclerosis, malabsorption due to bacterial overgrowth is evaluated by obtaining a glucose hydrogen breath test.
Treat primary progressive aphasia
In primary progressive aphasia, occupational therapy for speech and language can teach the patient and family compensatory strategies to improve communication.
urine chloride cutoff for high\low
In such patients, a low (<15 mEq/L [15 mmol/L]) urine chloride suggests reduction in extracellular volume and the presence of saline-responsive metabolic alkalosis. If the urine chloride is high (>15 mEq/L [15 mmol/L]), the metabolic alkalosis is saline resistant and can be caused by active diuretic use, stimulant laxative abuse, and rare renal tubular disorders such as Gitelman and Bartter syndromes.
What GFR to switch thiazides to loop diuretics to treat HTN
In the setting of chronic kidney disease stage 4 and greater (glomerular filtration rate <30 mL/min/1.73 m2), thiazide diuretics lose potency, and loop diuretics may often be required.
thiazide diuretics lose potency at what CKD stage
In the setting of chronic kidney disease stage 4 and greater (glomerular filtration rate <30 mL/min/1.73 m2), thiazide diuretics lose potency, and loop diuretics may often be required.
GCA tx
In virtually all instances, patients with GCA should receive oral prednisone (60 mg/d [or 1 mg/kg/d]). In patients with visual loss, intravenous (IV) pulse glucocorticoids (typically methylprednisolone, 1000 mg/d for 3 days) may be tried, although restoration of vision should not be anticipated. Prednisone should generally be administered for approximately 1 month (or until resolution of signs and symptoms), with subsequent dose reduction at a rate of about 10% every few weeks. The ESR usually responds rapidly and can then serve as a marker of disease activity. Patients should be monitored for relapse, in which case prednisone should be transiently increased; treatment duration may range from 6 to 18 months.
Manage heavy menstrual bleeding caused by polycystic ovary syndrome.
In women with polycystic ovary syndrome, heavy menstrual bleeding, and hirsutism who do not desire fertility, estrogen-progestin oral contraceptive pills are first-line therapy to provide endometrial protection and suppress androgen production.
Treat severe menopausal vasomotor symptoms in a woman whose uterus has been removed
In women without a uterus taking systemic estrogen therapy for management of menopausal symptoms, concurrent progestin is not indicated. There is some evidence that transdermal estrogen may be associated with less thromboembolic risk than oral estrogen by avoiding the hepatic first-pass effect.
In MS, use this for the non-pharmacologic treatment of Depression
Individual or group counseling
Indications for genetic test with Breast and/or Ovarian Cancer
Individual with a family history of a known deleterious BRCA1/2 mutation Individual with breast cancer diagnosed before age 45 years Individual with breast cancer diagnosed before age 50 years if family history includes very few female first- or second-degree relatives or if one relative is diagnosed with breast cancer at any age Individual with breast cancer diagnosed at any age if one or more relatives is diagnosed with epithelial ovarian cancer Breast cancer in women of Ashkenazi (Eastern European) Jewish ancestry Men with breast cancer diagnosed at any age Individual with more than three family membersb with breast cancer, ovarian cancer, pancreatic cancer, and/or aggressive prostate cancer Individual with triple-negative breast cancerc diagnosed before age 60 years Individual with epithelial ovarian cancer diagnosed at any age
Who to screen for BRCA
Individual with a family history of a known deleterious BRCA1/2 mutation Individual with breast cancer diagnosed before age 45 years Individual with breast cancer diagnosed before age 50 years if family history includes very few female first- or second-degree relatives or if one relative is diagnosed with breast cancer at any age Individual with breast cancer diagnosed at any age if one or more relatives is diagnosed with epithelial ovarian cancer Breast cancer in women of Ashkenazi (Eastern European) Jewish ancestry Men with breast cancer diagnosed at any age Individual with more than three family membersb with breast cancer, ovarian cancer, pancreatic cancer, and/or aggressive prostate cancer Individual with triple-negative breast cancerc diagnosed before age 60 years Individual with epithelial ovarian cancer diagnosed at any age
Treatment of Cryptococcal meningitis in Patients without HIV/AIDS or transplantation
Induction period: amphotericin B and flucytosine for ≥4 weeks Consolidation period: oral fluconazole for 8 weeks Maintenance period: oral fluconazole for 6-12 months
Treatment of Cryptococcal meningitis in Transplant recipients
Induction period: lipid formulation of amphotericin B and flucytosine for 2 weeks Consolidation period: oral fluconazole for 8 weeks Maintenance period: oral fluconazole for 6 months to 1 year
SAAG <1.1 g/dL (11 g/L) Total Protein ≥2.5 g/dL (25 g/L)
Infections, malignancy, pancreatic ascites
Diarrea with Abdominal pain ± fever, bleeding, weight loss
Inflammatory Inflammatory bowel disease Invasive/inflammatory infections (e.g., Clostridium difficile) Ischemia
Examples of Inflammatory diarrhea
Inflammatory bowel disease Invasive/inflammatory infections (e.g., Clostridium difficile) Ischemia
Treatment for COPD GOLD Stage D
Inhaled glucocorticoid + Long-acting β2-agonist and/or Long-acting anticholinergic
Treatment for COPD GOLD Stage C
Inhaled glucocorticoid + Long-acting β2-agonist or Long-acting anticholinergic
Treat asthma during pregnancy
Inhaled glucocorticoids, most β2-agonists, and the leukotriene antagonist montelukast are considered safe in pregnancy. Asthma management during pregnancy should consist of optimization of anti-inflammatory therapy, management of gastroesophageal reflux, and smoking cessation
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >6 to 8mm with high pretest probability
Initial follow-up CT at 3 to 6 months then at 9 to 12 months and 24 months if no change
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >4 to 6mm with high pretest probability
Initial follow-up CT at 6 to 12 months then at 18 to 24 months if no change
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is >6 to 8mm with low pretest probability
Initial follow-up CT at 6 to 12 months then at 18 to 24 months if no change
gastroparesis tx
Initial management consists of the prompt identification and treatment of dehydration, electrolyte disturbances, and micronutrient deficiencies, as these can worsen symptoms associated with gastroparesis. Dietary modification and optimization of glycemic control in patients with diabetes should be the first treatment intervention. Specific diet recommendations include small, low-fat meals consumed four to five times per day. Insoluble fiber (found in fresh fruits, fresh vegetables, and bran) should be avoided. High-calorie liquids can be used to increase the liquid nutrient component of meals. Carbonated beverages, alcohol, and tobacco smoking should be minimized or ideally avoided. On-demand use of antiemetic agents is effective in addressing nausea and vomiting associated with gastroparesis; however, these agents have no effect on gastric emptying. Prokinetic agents can be used in conjunction with dietary management and aggressive glycemic control to improve gastric emptying. Metoclopramide is the only prokinetic agent approved by the FDA for the treatment of gastroparesis. Given the risk of side effects, including dystonia, parkinsonism-type movements, and tardive dyskinesia, the lowest dose should be used (starting at 5 mg three times daily), should be taken with meals, and should be advanced slowly to a maximum total dose of 40 mg a day (10 mg four times daily).
Ankle Sprains tx
Initial therapy includes Rest, Ice, Compression, and Elevation (RICE). NSAIDs are useful for pain control. Early mobilization appears to be superior to prolonged rest. Once pain and swelling subside, proprioception training along with range-of-motion and strengthening exercises should be initiated to prevent chronic instability and predisposition to reinjury. Surgery is indicated only for patients with complete tears and those with chronic instability in whom conservative interventions are ineffective.
Type 4 (Hyperkalemic Distal) Renal Tubular Acidosis tx
Initial treatment includes correction of the underlying cause if possible, with discontinuation of offending medications. In most cases, treatment of hyperkalemia with sodium bicarbonate or sodium polystyrene sulfonate results in improvement of the acidosis. Replacement of mineralocorticoids with fludrocortisone is indicated for patients with Addison disease and should be considered for those with hyporeninemic hypoaldosteronism unless hypertension or heart failure is present. Management should also include dietary potassium restriction to approximately 2000 mg/d.
Osteonecrosis (avascular necrosis) of the femoral head tx
Initial treatment includes therapies to control pain (such as NSAIDs), reduced weight bearing, and range of motion exercises. Most patients with osteonecrosis will eventually need surgical intervention with hip replacement.
Tx IgG4-related disease.
Initial treatment is prednisone, 0.5-0.6 mg/kg/d for 2 to 4 weeks, followed by a slow taper over months. Azathioprine, mycophenolate mofetil, and methotrexate have been used as glucocorticoid-sparing agents. Recently, rituximab has shown significant benefit in patients with IgG4-related disease and appears to selectively affect IgG4 production; it may replace prednisone as the treatment of choice in severe or refractory disease. Treatment response may be limited by the amount of fibrosis present prior to therapy initiation.
Adhesive capsulitis tx
Injection of glucocorticoids into the glenohumeral joint Surgery is generally reserved for patients who do not improve with 6 to 12 weeks of conservative measures.
preferred screening for Mycobacterium tuberculosis infection in a patient who is unlikely to return for follow-up
Interferon-γ release assay is preferred for tuberculosis screening in groups at high risk for not returning for interpretation of skin test results and those who have received bacillus Calmette-Guérin as a vaccine or for cancer treatment.
Intermediate-risk gastric ulcers
Intermediate-risk ulcers have adherent clots
Treatment of intermediate risk ulcers seeon on upper endoscopy
Intermediate-risk ulcers have adherent clots (Figure 31). They should be vigorously irrigated to dislodge the clot and guide treatment. With successful dislodgment, ulcers should be treated according to recommendations for low-risk ulcers (see previous paragraph) or high-risk ulcers (see next paragraph). For persistent clots, however, the benefit of mechanically removing the clot is unclear but is possibly greater when patients have risk factors for rebleeding, as defined later. After endoscopy, patients with persistent clots should remain hospitalized and should receive continuous intravenous PPI therapy for 72 hours, as for high-risk ulcers.
Patient internally rotates arm behind back. Examiner lifts hand off patient's back and patient is asked to maintain position while examiner applies a counteracting force. Positive test: Patient is unable to maintain position
Internal rotation lag Positive test: Patient is unable to maintain position (suggests subscapularis tear)
the management of HOA involving the first carpometacarpal joint when nonpharmacologic methods of management have failed to provide improvement in pain and function
Intra-articular glucocorticoids
Evaluate a patient for primary angiitis of the central nervous system.
Intracerebral angiography with brain biopsy can provide a definitive diagnosis in patients with suspected primary angiitis of the central nervous system.
Treat upper airway cough syndrome due to allergic rhinitis
Intranasal glucocorticoids are first-line therapy for patients with upper airway cough syndrome due to allergic rhinitis; antibiotics should not be used without clear evidence of bacterial infection.
treatment of viral sinusitis
Intranasal glucocorticoids, antihistamines, and topical decongestants
anticoagulant treatment of choice around the time of delivery
Intravenous UFH
initial treatments for myasthenic crisis
Intravenous immune globulin and plasmapheresis
econd-line therapy for severe inflammatory myopathies that are refractory to treatment with a glucocorticoid and at least one other immunosuppressive agent.
Intravenous immunoglobulin (IVIG)
the most common cause of hyporesponsiveness to erythropoietin
Iron deficiency
caused by prolonged sitting, especially on hard surfaces. The pain is aggravated with sitting or lying down, and the pain usually radiates to the back of the thigh.
Ischial bursitis
Causes of RTA 2
Isolated Type 2 (Proximal) Renal Tubular Acidosis: 1.) Primary: hereditary (Na-HCO 3 cotransporter); sporadic (often transient) 2.) Hereditary carbonic anhydrase deficiency 3.) carbonic anhydrase inhibitors ------------------ Fanconi Syndrome (associated glycosuria, phosphaturia, aminoaciduria, hypouricemia): 1.) Primary: hereditary Fanconi syndrome 2.) Genetic: cystinosis; Wilson disease 3.) Acquired: Sjögren syndrome; paraproteinemias; vitamin D deficiency 4.) Drugs/toxins: ifosfamide; tacrolimus; cyclosporine; toluene; outdated tetracycline; lead; mercury; cidofovir; tenofovir
3 regimens for treating latent TB
Isoniazid Daily for 9 months Isoniazid and rifapentine Once weeklyb for 3 months (12 weeks), so long as it is administered as directly observed therapy (that is, a health care worker directly observes the ingestion of a medication) Rifampin Daily for 4 months
Only alcohol that causes elevated anion gap but normal osmol gap
Isopropyl alcohol
Treatment of Cutaneous sporotrichosis
Itraconazole
Treatment of Mild to moderate acute pulmonaryb Histoplasmosis
Itraconazole
Treatment of Allergic bronchopulmonary aspergillosis
Itraconazole or voriconazole
Treatment of Primary pulmonary (patient at high risk)c Coccidioidomycosis
Itraconazole, fluconazole
Treatment of Aspergilloma (fungus ball)
Itraconazole, voriconazole, posaconazole
tick that transmits Lyme disease
Ixodes scapularis ticks
Babesiosis is a protozoal infection that is primarily spread through ______ and is most commonly found among residents or travelers to the coastal northeastern United States.
Ixodes ticks
Babesiosis is a protozoal infection that is primarily spread through
Ixodes ticks and is most commonly found among residents or travelers to the coastal northeastern United States.
Screening for ________ is currently recommended as a risk mitigation strategy for patients with MS treated with natalizumab
JC virus antibody screening
Epilepsy can go into remission, and many childhood epilepsy syndromes often resolve in adulthood. A major exception is
JME, which typically is regarded as a life-long condition requiring continuous treatment
nonerosive arthritis most commonly caused by systemic lupus erythematosus and is characterized by reducible subluxation of the digits, swan neck deformities, and ulnar deviation of the fingers due to attenuation of the joint-supporting structures
Jaccoud arthropathy
Pott disease
Joint infections with M. tuberculosis present as an indolent process, often in the hip, knee, or spine
radiographic hallmarks of OA
Joint-space narrowing (articular cartilage loss), subchondral sclerosis, and marginal osteophyte formation
Urine studies in RTA 1
K+: Decreased Urine AG: Positive Urine pH: >5.5
Urine studies in RTA 2
K+: Decreased Urine AG:Negative Urine pH: Variable
Urine studies in RTA 4
K+: Increased Urine AG: Positive Urine pH: <5.5
All patients with metastatic colorectal cancer should undergo tumor genotyping to identify mutations in the
K-ras and N-ras genes
Kidney transplant patients are at particularly high risk for what cancer
Kidney transplant patients are at particularly high risk for squamous cell carcinomas of the skin and posttransplant lymphoproliferative disease and should be evaluated for these diseases, in addition to age- and sex-appropriate screening.
Diagnosis of HOCM
LV wall thickness >= 15mm
Iliotibial band syndrome
Lateral pain with tenderness at lateral femoral condyle with flexion and extension
Anticentromere antibodies are associated with
LcSSc (15%-40% prevalence) and the CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome,
Manage liver toxicity in a patient taking leflunomide.
Leflunomide can induce elevation of liver chemistries, which is usually reversible with dose reduction or drug discontinuation. Leflunomide inhibits lymphocyte activation by blocking the pyrimidine synthesis pathway. It is approved to treat rheumatoid arthritis, in which its efficacy is comparable to methotrexate. Toxicities include gastrointestinal upset, diarrhea, aminotransaminase elevations, cytopenias, infection, and teratogenesis.
Prevent Febrile Nonhemolytic Transfusion Reaction
Leukoreduction of packed red blood cells and platelets before storage
AED for women with epilepsy who take oral contraceptives
Levetiracetam has no major drug-to-drug interactions with hormonal contraceptives and thus is appropriate to use in women with epilepsy who take oral contraceptives.
Initial therapy for parkinson's in older patients
Levodopa should be started as initial therapy in older patients and as replacement or additional therapy in younger patients who did not benefit or had adverse effects from dopamine agonists. Also, gait impairment and freezing that can increase the risk of falls mandate initiation of levodopa therapy. The immediate-release formulations of levodopa provide a higher peak dose effect than similar doses of sustained-release formulations. Therefore, immediate-release formulations commonly are used during the wake cycle and sustained-release formulations, if needed, at nighttime. However, sustained-release levodopa or dopamine agonists can be added to immediate-release levodopa to provide more sustained levels of dopamine receptor activation, thereby delaying the development of levodopa-related motor complications. A typical initial dose of levodopa is 300 mg/d divided into three doses, with most patients benefitting from a slow titration to minimize adverse effects; further dose adjustment should be made on an individual basis.
Treat irritable bowel syndrome with constipation that is refractory to standard laxative therapy
Linaclotide is FDA approved for the treatment of irritable bowel syndrome with constipation in adults; like lubiprostone, it is second-line therapy for patients whose symptoms have not responded to standard laxative therapy.
Treatment of Blastomycosis with CNS involvement
Lipid formulation of amphotericin B followed by fluconazole
Treatment of Acute progressive disseminated Histoplasmosis
Lipid formulation of amphotericin B followed by itraconazole
Treatment of Blastomycosis with Cutaneous/pulmonary/extrapulmonary manifestations
Lipid formulation of amphotericin B followed by itraconazole
Treatment of Moderately severe to severe pulmonary Histoplasmosis
Lipid formulation of amphotericin B followed by itraconazole
Treatment of Mucormycosis
Liposomal amphotericin B, high-dose amphotericin B deoxycholate
Complicated Pleural Effusion
Loculated or thickened pleura pH <7.2 OR glucose <60 mg/dL (3.3 mmol/L) Antibiotics, thoracostomy tube drainage, early consultation with a thoracic surgeon for possible thoracoscopic debridement
Treatment for COPD GOLD Stage B
Long-acting anticholinergic or Long-acting β2-agonist
Polycythemia Vera tx
Low-dose aspirin*** (<100 mg/d) decreases arterial and venous clot risk in PV and should be initiated unless strong contraindications exist. Phlebotomy*** is the mainstay of therapy and may be safely applied in addition to aspirin in patients younger than 60 years without a previous thromboembolic event. The goal of phlebotomy is to attain a hematocrit level of less than 45%. This may be achieved by weekly phlebotomy and may be maintained with intermittent treatments. Hydroxyurea***, an antimetabolite chemotherapeutic agent, can be used in conjunction with phlebotomy in patients older than 60 years or those with previous thromboembolic events.
tx of Behçet syndrome
Low-dose prednisone or colchicine is used for oral/genital ulcers, high-dose prednisone and immunomodulating agents such as azathioprine are used for more severe disease. Tumor necrosis factor (TNF)-α inhibitors, interferon alfa, and anti-interleukin (IL)-1β therapy have been used in recalcitrant or severe cases.
Treatment of low risk ulcers seeon on upper endoscopy
Low-risk ulcers are clean-based or have a nonprotuberant pigmented spot (Figure 30). Oral PPI therapy should be initiated, and patients should be allowed to eat. Early hospital discharge should be arranged
Microscopic polyangiitis
Lung, Kidneys, Skin (palpable purpura) Glomerulonephritis No Granulomas MPO-ANCA / p_ANCA Similar to Wegeners but without nasopharyngeal involvement Treat with cyclophosphamide, steroids
Ddx of middle mediastinal mass
Lymphadenopathy is the most common cause of a middle mediastinal mass.
right-sided cancer and early age of colon cancer, think:
Lynch syndrome
a self-limiting form of sarcoidosis characterized by acute arthritis, bilateral hilar lymphadenopathy, and erythema nodosum
Löfgren syndrome
The U.S. Multi-Society Task Force guidelines on colorectal cancer recommended that all newly diagnosed patients with colorectal cancers be tested for
MMR deficiency to rule out Lynch syndrome. Lynch syndrome, also called hereditary nonpolyposis colorectal cancer . This condition is caused by a germline mutation in one of several mismatch repair genes and is transmitted in autosomal dominant fashion.
Imaging of choice in secondary headache
MRI
Patients with systemic lupus erythematosus who have pain or limitation of motion of the large joints, especially the hips, should be evaluated for osteonecrosis with what imaging modality when plain radiographs are normal
MRI
best imaging technique for diagnosing osteomyelitis
MRI
the most sensitive imaging technique for detecting early inflammation in the spine and sacroiliac joints in patients with suspected spondyloarthritis
MRI
Diagnose a suspected full-thickness rotator cuff tear
MRI is the preferred imaging modality for diagnosing full-thickness rotator cuff tears.
for patients with incomplete recovery 3 months after onset of facial nerve palsy despite appropriate initial treatment, the next best step is
MRI of the brain is an appropriate next step in management for patients with incomplete recovery 3 months after onset of facial nerve palsy despite appropriate initial treatment to rule out an underlying structural abnormality.
guidelines for management of adults with HAP and VAP recommend empiric coverage for
MRSA and Pseudomonas
Diagnosis of mild\moderate mitral stenosis
MVA >1.5 cm2, diastolic pressure half-time <150 msec
Diagnosis of severe mitral stenosis
MVA ≤1.5 cm2, diastolic pressure half-time ≥150 msec or ≥220 msec with very severe stenosis, PASP >30 mm Hg
Family history of premature CAD
Male first-degree relative or father younger than 55 Female first-degree relative or mother younger than 65
Prolonged Qtc
Males = >450 Females = >470
Febrile Nonhemolytic Transfusion Reaction treatment
Management consists of transfusion discontinuation to exclude a more serious transfusion reaction, acetaminophen for fever, and meperidine for rigors.
Tx sjogren syndrome
Management of Sjögren syndrome consists of symptomatic, local, and systemic approaches ( Table 24 ). Sicca symptoms are treated with hydration and lubrication, although other local measures and medications may be helpful. Avoidance of medications that worsen sicca (for example, anticholinergic agents) is recommended. Immunosuppressive therapy does not alleviate sicca symptoms but may suppress extraglandular manifestations.
Common appropriate indications for placement of catheters include:
Management of acute urinary retention Measurement of urine output in critically ill patients Management of neurogenic bladder Management of hematuria with clots During surgery to assess volume status End-of-life care
tx of older patient is experiencing disequilibrium, or unsteadiness with walking or standing
Management of disequilibrium involves physical therapy, visual and auditory screening followed by correction of impairment, and mobility aids that stabilize ambulation; extensive imaging and testing is unnecessary.
increased anion gap metabolic acidosis with normal plasma lactate levels
Manifestations of D-lactic acidosis include intermittent confusion, slurred speech, ataxia, and an increased anion gap metabolic acidosis with a normal plasma lactate level.
In MS, use this for the non-pharmacologic treatment of Urinary retention
Manual pelvic pressure, intermittent catheterization
How long does a patient have to be seizure-free in order to be weaned from treatment
Many patients who have been seizure free for 2 to 4 years can choose to be weaned from AEDs; seizure recurrence after AED withdrawal in these patients is 30% to 40% over 5 years. Those with normal EEG and MRI results who have no other risks factors for epilepsy are more likely to remain seizure free after stopping their medications.
Treat subacute, nonspecific low back pain
Massage therapy for low back pain is likely to be helpful in patients with subacute symptoms and no abnormal neurologic findings. Back pain is classified as acute (lasting <4 weeks), subacute (lasting 4-12 weeks), or chronic (lasting >12 weeks); therefore, this patient's clinical findings are consistent with a subacute process.
Indications for valve replacement with aortic stenosis
Mean gradient > 40mmHg or valve area < 1cm^2
Diagnosis of PAH
Mean pulmonary artery pressure >= 25mmHg at rest
Rubeola
Measles is characterized by fever, malaise, and prominent upper respiratory infection manifestations consisting of the classic triad of conjunctivitis, cough, and coryza. Generally, the exanthem begins 2 to 4 days later, often with small, whitish spots on the buccal mucosa (Koplik spots), followed by a morbilliform rash on the face and neck, which eventually spreads to the extremities. Unlike the rash of smallpox, these lesions typically blanch and do not become vesicular.
determine the cause of metabolic alkalosis.
Measurement of urine chloride levels can be useful to determine volume status and saline responsiveness in patients with metabolic alkalosis.
VERY-high risk (of thrombosis) conditions which require AC bridging for surgery
Mechanical mitral valve Cage-ball or tilting disk mechanical aortic valve VTE within 3 months Severe thrombophilia (e.g., protein C deficiency) AF with CHA2DS/-VASc >= 6 AF with TIA/stroke within 3 months AF with rheumatic valve disease
Mechanical stone removal is appropriate for patients with kidney stones over what size
Mechanical stone removal is appropriate for patients with large (>10 mm) kidney stones or those with smaller stones who have failed medical management or have complicated nephrolithiasis (urosepsis, acute kidney injury, anuria, refractory pain).
occurs as a result of a contact injury from a medially directed (valgus) force
Medial collateral ligament tears
Pes Anserine Bursitis
Medial pain Point tenderness at pes anserine bursa
Examples of Secretory diarrhea
Medications (e.g., colchicine, NSAIDs) SIBO Hormone-producing tumors (e.g., gastrinoma, VIPoma, carcinoid, somatostatinoma) Bile acid malabsorption Noninvasive infections (e.g., cholera)
Examples of Osmotic diarrhea
Medications (e.g., magnesium sulfate laxative) Carbohydrate malabsorption
Who to screen for Barrett's
Men with chronic GERD and 2 or more of the following: 1.) Age >=50 2.) White 3.) Hiatal hernia 4.) Obesity or increased waist circumference 5.) Current or former tobacco use 6.) First degree relative with BE/EAC
Medial-lateral grind maneuver
Meniscal integrity With patient supine, examiner places calf in one hand and thumb and index finger of opposite hand over joint line and applies varus and valgus stress to tibia during extension and flexion. Positive test: Grinding sensation palpable over joint line (suggests meniscal injury)
Thessaly maneuver
Meniscal integrity Examiner holds patient's outstretched hands while patient stands on one leg with knee flexed to 5 degrees and with other knee flexed to 90 degrees with foot off of floor. Patient rotates body internally and externally three times. Repeat with knee flexed 20 degrees. Always perform on uninvolved knee first. Positive test: Medial or lateral joint line pain (suggests meniscal tear)
second-line therapy for patients with PCOS with significant menstrual irregularities and hirsutism who are unable to tolerate oral contraceptive pills.
Metformin
initial treatment of choice for patients with new-onset, rapidly progressive, or erosive rheumatoid arthritis
Methotrexate
Diagnose lymphocytic colitis.
Microscopic colitis is characterized by histologic inflammation in endoscopically normal-appearing colonic mucosa; patients lack signs of systemic inflammation and present with painless watery diarrhea without bleeding. The diagnosis of MC is made by histologic evaluation of colonic biopsies; the classic finding is intraepithelial lymphocytosis (>20 intraepithelial lymphocytes per 100 epithelial cells). In collagenous colitis, the increase in intraepithelial lymphocytes may be less pronounced than in lymphocytic colitis, and the main histologic feature is thickening of the subepithelial collagen band (usually >10 µm).
the most common symptomatic manifestation of heart involvement in systemic sclerosis
Microvascular cardiomyopathy is the most common symptomatic manifestation of heart involvement in systemic sclerosis and presents with heart failure.
can be used as adjunctive therapy for refractory ascites, especially in patients with hypotension
Midodrine
diagnose vWD
Mild vWD may not be detected by the Platelet Function Analyzer-100 (PFA-100®) assay, necessitating measurement of vWF antigen and activity levels for diagnosis. Additionally, levels of vWF fluctuate in response to estrogens, stress, exercise, inflammation, and bleeding, and repeated assays may be required to make the diagnosis.
Classification of COPD Severity by Spirometry (In Patients with FEV1/FVC <70%), GOLD Stage 1
Mild. FEV1 ≥80% of predicted
ARDS dx
Mild: PaO2/FIO2 ≤300 mm Hg (40.0 kPa) but >200 mm Hg (26.6 kPa) Moderate: PaO2/FIO2 ≤200 mm Hg (26.6 kPa) but >100 mm Hg (13.3 kPa) Severe: PaO2/FIO2 ≤100 mm Hg (13.3 kPa)
how to treat diarrhea caused by Salmonella
Mild: none Underlying disease or severe illness: fluoroquinolone plus parenteral third-generation cephalosporin
basic calcium phosphate deposition, is characterized by pain, stiffness, and swelling that tend to occur gradually over time, often with a preceding trauma or history of overuse on the affected side, with a predilection for women older than the age of 70 years
Milwaukee shoulder syndrome
an overlap syndrome that includes features of systemic lupus erythematosus, systemic sclerosis, and/or polymyositis in the setting of positive anti-U1-ribonucleoprotein antibodies.
Mixed connective tissue disease
Characterized by features of systemic sclerosis, polymyositis, and SLE
Mixed connective tissue disease (MCTD)
anti-U1-ribonucleoprotein antibodies
Mixed connective tissue disease (MCTD)
Treat fatigue in multiple sclerosis.
Modafinil is often a successful treatment of fatigue in multiple sclerosis.
In MS, use this for the pharmacologic treatment of Fatigue
Modafinil, armodafinil, amantadine, amphetamine stimulants
ASCVD score for statin initiation
Moderate intensity = >= 7.5% to <20% High intensity = >=20%
Classification of COPD Severity by Spirometry (In Patients with FEV1/FVC <70%), GOLD Stage 2
Moderate. 50% ≤ FEV1 < 80% of predicted
how to diagnose diarrhea caused by Cyclospora
Modified acid-fast stain
how to diagnose diarrhea caused by Cryptosporidium
Modified acid-fast stain, stool antigen
how to assess prandial insulin coverage in patients who have type 2 diabetes mellitus with at-goal preprandial readings but with hemoglobin A1c values not at goal
Monitoring postprandial blood glucose levels to Identify postprandial hyperglycemia as a cause of elevated hemoglobin A1c levels. Adequate meal-time coverage with insulin can be determined by measuring postprandial blood glucose levels. If her 1- to 2-hour postprandial blood glucose values are elevated above 180 mg/dL (10.0 mmol/L), her meal-time insulin should be increased or the composition of her meals should be altered to decrease her blood glucose
β-thalassemia tx
Monthly erythrocyte transfusion should be initiated for hemoglobin levels less than 7 g/dL (70 g/L) Subcutaneous desferrioxamine or an oral iron chelation agent (deferasirox, deferiprone), as monotherapy or combined, have shown good efficacy in reducing liver and myocardial iron load. Allogeneic hematopoietic stem cell transplantation (HSCT) can be curative and should be considered with severe forms, preferably before the onset of end-organ damage.
UC tx
More severe UC is often treated with oral glucocorticoids such as prednisone, 40 to 60 mg/d.
Manage otitis media with effusion.
Most cases of otitis media with effusion resolve spontaneously; observation and symptomatic treatment of conditions contributing to eustachian tube dysfunction are appropriate. Most cases of OME will resolve without treatment over the course of 12 weeks. Although many patients with OME are treated with decongestants, antihistamines, or nasal glucocorticoids
Treat metastatic pancreatic cancer with
Multiagent systemic chemotherapy with 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) however, this regimen has substantial toxicity and is only a reasonable option in patients who are both medically well (have an excellent performance status) and who are highly motivated. A more recent trial has shown that the addition of liposomally encapsulated paclitaxel (nab-paclitaxel) to gemcitabine also improves outcome modestly, albeit with some increased toxicity.
Patients with HIV/AIDS with CD4 cell counts less than 50/µL hould undergo prophylaxis against
Mycobacterium avium complex
Prophylaxis when CD4 <50
Mycobacterium avium complex Azithromycin, 1200 mg/week
skin infection in patients who obtain pedicures at nail salons that use contaminated whirlpool footbaths
Mycobacterium fortuitum
Exposure to freshwater footbaths/pedicures at nail salons; infection following augmentation mammoplasty and open heart surgery
Mycobacterium fortuitum Multiple boils; razor shaving strongly associated
bug associated with skin infections typically develop at sites of skin injury that have been exposed to salt or fresh water, such as in fish tanks (fish tank granuloma)
Mycobacterium marinum
Contact with fresh water or salt water, including fish tanks and swimming pools
Mycobacterium marinum Lesion often trauma-associated and often involving upper extremity; papular lesions become ulcerative at site of inoculation; ascending lymphatic spread can be seen ("sporotrichoid" appearance); systemic toxicity usually absent
Tx of SLE with kidney involement
Mycophenolate mofetil or Cyclophosphamide
the diagnosis of _______ should be considered in all patients with weakness, fatigue, and a myopathic waddling gait who also have muscle stiffness and delayed grip relaxation
Myotonic dystrophy
Treat non-acetaminophen-related acute liver failure with
N-acetylcysteine has been shown in a randomized controlled trial to improve transplant-free survival in non-acetaminophen-related acute liver failure in patients with grade I or II hepatic encephalopathy.
guideline for the noninvasive management of low back pain for patients with chronic low back pain that does not improve with nonpharmacologic interventions
NSAID Duloxetine is recommended by the ACP guideline as a second-line therapy for chronic low back pain. Duloxetine does have a small effect on pain and function and should be considered if patients cannot take NSAIDs or as an adjunctive therapy to an NSAID.
Because methotrexate and other DMARDs do not achieve immediate results when beginning treatment for RA, either _____ or _____ may be needed as a short-term "bridge" while the DMARD begins to take effect.
NSAID or glucocorticoid therapy
first-line therapy for ankylosing spondylitis
NSAIDs
mild to moderate migraine tx
NSAIDs
Treat primary dysmenorrhea
NSAIDs and cyclooxygenase-2 inhibitors are an effective treatment for primary dysmenorrhea; however, in patients who cannot tolerate NSAIDs or have incomplete relief of symptoms, use of combined estrogen-progestin hormonal contraceptive therapy is effective.
Acute gout is usually treated with
NSAIDs as first-line therapy and colchicine as second-line therapy. Allopurinol is usually given for prophylaxis along with colchicine to patients with recurrent gout, tophaceous gout, nephrolithiasis, radiographic evidence of gouty arthritis, or urinary uric acid excretion > 1100 mg/day. Patients who develop a gouty attack while taking allopurinol should not undergo dose adjustments or drug discontinuation until 3-4 weeks after the acute inflammation subsides
ICD indications
NYHA class II or III while taking guideline-directed medical therapy AND Expectation of survival >1 year AND Either of the following: 1.) Ischemic cardiomyopathy ≥40 days post MI or nonischemic cardiomyopathy with ejection fraction ≤35% (primary prevention) 2.) History of hemodynamically significant ventricular arrhythmia or cardiac arrest (secondary prevention)
TTP pentad
Nasty Fever Torched His Kidneys Neurologic sx Fever Thrombocytopenia Hemolysis Kidney failure-- uremia
in patients with large (>2 cm) colon adenomas or adenomas with invasive cancer and favorable prognostic features, National recommendations for postpolypectomy surveillance intervals are
National recommendations for postpolypectomy surveillance intervals are as short as 3 to 6 months in patients with large (>2 cm) adenomas or adenomas with invasive cancer and favorable prognostic features.
Treatment of PTX with >2 cm on chest radiograph, breathlessness, and chest pain
Needle aspiration; if reaccumulation then insertion of a small-bore (<14 Fr [4.7 mm]) thoracostomy tube
Management of Primary Spontaneous Pneumothorax >2 cm on chest radiograph
Needle aspiration; if reaccumulation then insertion of a small-bore (<14 Fr [4.7 mm]) thoracostomy tube
Patient's scapula is stabilized and shoulder is flexed with arm fully pronated. Positive test: Pain
Neer Pain (suggests subacromial impingement or rotator cuff tendinitis)
in a patient who desires breast-conserving surgery with HER2-amplified or triple-negative breast cancers and for patients with larger cancers who desire breast-conserving surgery, indicated is:
Neoadjuvant chemotherapy trastuzumab-based
SAAG <1.1 g/dL (11 g/L) Total Protein <2.5 g/dL (25 g/L)
Nephrotic syndrome, myxedema
Hydralazine and isosorbide dinitrate improve symptoms and reduce mortality in patients with
New York Heart Association class III or IV heart failure symptoms who are black and are already on maximal therapy.
Treat a patient with a furuncle
No antibiotic treatment is needed after incision and drainage of a simple furuncle, except in patients who are immunosuppressed, who do not respond adequately to incision and drainage or antibiotics without MRSA activity, or who have systemic signs of infection.
Fleischner Criteria for Surveillance Imaging of Subcentimeter Solitary Solid Pulmonary Nodules if nodule is ≤4mm with low pretest probability
No follow-up needed
In MS, use this for the pharmacologic treatment of Cognitive dysfunction
No proven therapy
Treatment of Pulmonary (patient at low risk) Coccidioidomycosis
No treatment indicated
gait abnormalities, urinary symptoms, and cognitive decline
Normal Pressure Hydrocephalus Abnormal gait is usually the first and principal symptom of NPH. This gait is characterized by a wide base, with slow, small steps and reduced foot-to-floor clearance, and can be accompanied by freezing of gait and postural instability. Urinary frequency and urgency typically precede incontinence and cognitive dysfunction. The cognitive dysfunction follows a pattern of impaired attention, psychomotor slowing, executive dysfunction, and impaired recall.
Treat reversible cerebral vasoconstriction syndrome
Normalization of blood pressure is recommended in patients with reversible cerebral vasoconstriction syndrome
tx for adult patients with asymptomatic gallstones
Observation
Management of Primary Spontaneous Pneumothorax <2 cm on chest radiograph
Observation alone; may be managed as an outpatient if easy access to medical care is available if clinical symptoms change
Treatment of PTX with <2 cm on chest radiograph, minimal symptoms
Observation alone; may be managed as an outpatient if easy access to medical care is available if clinical symptoms change
Manage IgA nephropathy
Observation with serial blood pressure measurements, urine studies, and serum creatinine levels is appropriate for patients with IgA nephropathy with low-risk features for progression. Patients with proteinuria and risk factors for progression may benefit from ACE inhibitors or ARBs. A 6-month course of glucocorticoids has also shown benefit in such patients.
In MS, use this for the non-pharmacologic treatment of Limb tremor
Occupational therapy
anti-GBM antibody disease microscopy findings
On kidney biopsy, there is a proliferative GN, often with many crescents. There is linear deposition of immunoglobulin (usually IgG) along the GBM by immunofluorescence, but electron microscopy does not show electron-dense deposits.
bone pain and hypophosphatemia with kidney phosphate wasting in the setting of low 1,25-dihydroxy vitamin D and normal 25-hydroxy vitamin D concentrations
Oncogenic osteomalacia
Bacterial meningitis spinal fluid analysis
Opening pressure: 200-500 mm H2O Leukocyte count: 1000-5000/µL (1000-5000 × 106/L) Leukocyte predominance: Neutrophils Glucose: <40 mg/dL (2.2 mmol/L) Protein: 100-500 mg/dL (1000-5000 mg/L) Gram stain: Positive in 60%-90% Culture: Positive in 70%-85%
Viral meningitis spinal fluid analysis
Opening pressure: ≤250 mm H2O Leukocyte count: 50-1000/µL (50-1000 × 106/L) Leukocyte predominance: Lymphocytes Glucose: >45 mg/dL (2.5 mmol/L) Protein: <200 mg/dL (2000 mg/L) Gram stain: Negative Culture: Negative
the drug class of choice for treatment of non-neuropathic pain in critically ill patients, including mechanically ventilated adult patients in the ICU
Opioids, and should be given in an interrupted fashion when needed.
Treatment lyme disease with First-degree heart block:
Oral doxycyclinea, amoxicillin, or cefuroxime axetil
Treatment lyme disease with Multiple erythema migrans, often with fever, headache, myalgias
Oral doxycyclinea, amoxicillin, or cefuroxime axetil
Treatment lyme disease with Single erythema migrans at site of inoculation
Oral doxycyclinea, amoxicillin, or cefuroxime axetil
Prevent vasospasm after AH
Oral nimodipine is indicated in all patients with aneurysmal subarachnoid hemorrhage. Administration of oral nimodipine for 21 days after the hemorrhage is indicated in all patients with aneurysmal subarachnoid hemorrhage.
Patients with SSc who have evidence of alveolitis and/or rapidly progressive lung disease may be treated with
Oral or intravenous cyclophosphamide provides modest benefit in the first year, but these benefits are lost by 24 months of follow-up. Azathioprine may have a role as maintenance therapy following a 6-month course of cyclophosphamide. High-dose glucocorticoids are frequently used in SSc patients with ILD, but there is no clear evidence of their benefit, and their use may convey an increased risk of SRC.
1st line tx for knee and hip OA
Oral preparations are usually first-line NSAID therapy in patients without a contraindication to treatment due to efficacy and cost-effectiveness. Topical NSAIDs are considered to provide similar pain relief OA as oral medications with fewer gastrointestinal effects. Furthermore, the American College of Rheumatology currently recommends topical NSAIDs rather than oral NSAIDs for patients aged 75 years or older.
Diarrea that stops with fasting associated with Bloating, gas
Osmotic!!! Medications (e.g., magnesium sulfate laxative) Carbohydrate malabsorption
form of conductive hearing loss characterized by gradual onset, difficulty hearing low-pitched sounds, and no history of exposure to loud noises.
Otosclerosis
In MS, use this for the pharmacologic treatment of Urinary urgency/frequency
Oxybutynin, tolterodine
most effective acute cluster headache treatments
Oxygen therapy and subcutaneous sumatriptan
Winter's Formula
PCO 2 = (1.5) [HCO 3] + 8
most sensitive method for diagnosing babesiosis
PCR
in patients with Hodgkin lymphoma, but not in those with NHL Early repeat scanning with ____ provides important prognostic information
PET scan
The staging evaluation of Hodgkin lymphoma consists of
PET scanning and a bone marrow biopsy after lymph node biopsy results confirm a diagnosis.
Solid Solitary Pulmonary Nodules Ranging from Greater than 8 mm to Less than 30 mm with intermediate (5%-65%) pretest probability of malignancy
PET/CT imaging: Tissue diagnosis or excision if the nodule demonstrates high metabolic activity, as defined by the concentration of uptake of the tracer (fluorodeoxyglucose) At least short-term surveillance if negative, but consider more aggressive evaluation depending on individual patient factors
Manage gastroesophageal reflux disease In a patient without alarm feature
PPI
Tx of MCTD with esophageal dysmotility
PPI
when a patient is taking an NSAID, always make sure they are also taking a
PPI
COPD GOLD A Tx
PRN SABA
Thyroid storm tx
PTU and propranolol are the preferred agents because they have the added benefit of blocking peripheral conversion of T4 to T3. Additionally, high-dose glucocorticoids reduce T4 conversion to bioactive T3. At least 1 hour after the first dose of a thionamide, iodine drops should be administered to inhibit further release of thyroid hormone from the gland. Acetaminophen and cooling blankets may be used to control the hyperthermia.
Patient actively abducts arm. Positive test: Pain between 60 and 120 degrees of abduction
Painful arc (suggests subacromial impingement)
Examples of Steatorrhea diarrhea
Pancreatic insufficiency Small-bowel mucosal disease (e.g., celiac disease) SIBO Bile acid deficiency Lymphatic obstruction
Treat a patient who has parvovirus B19 infection
Parvovirus B19 infection and its associated arthritis are generally self-limited; therefore, management is symptomatic, and an NSAID such as ibuprofen should alleviate symptoms until the episode resolves.
infection associated with Contact primarily with cats
Pasteurella multocida
Diagnose a primary central nervous system lymphoma.
Pathologic analysis, usually of a brain biopsy specimen, to confirm primary central nervous system lymphoma is required before beginning treatment with methotrexate-based chemotherapy and possible whole-brain radiation.
Manage an asymptomatic patient who has babesiosis
Patients diagnosed with babesiosis who are asymptomatic should undergo a repeat polymerase chain reaction assay in 3 months to detect parasite clearance but do not need treatment.
Treat a patient with a brain abscess resulting from dental sepsis with
Patients suspected of having brain abscess from a likely odontogenic source should begin empiric antibiotic therapy with intravenous penicillin and metronidazole.
refractory epilepsy dx
Patients who do not respond to either their first or their second AED (in sequence or combination)
Treat a patient with a second recurrence of Clostridium difficile infection.
Patients who have more than one recurrence of Clostridium difficile infection should be treated with oral vancomycin given at tapered doses over 6 to 8 weeks.
Patients with a family history suggestive of an inherited disorder should receive ________ before undergoing genetic testing.
Patients with a family history suggestive of an inherited disorder should receive genetic counseling before undergoing genetic testing.
Indication for albumin in cirrhotic patient with SBP
Patients with a serum creatinine level greater than 1 mg/dL (88.4 µmol/L), a serum bilirubin level greater than 4 mg/dL (68.4 µmol/L), or a blood urea nitrogen level greater than 30 mg/dL (10.7 mmol/L) should receive 1.5 g/kg of albumin on the day of the diagnosis of SBP and 1 g/kg of albumin on day 3
Treatment of gallbladder disease is with
Patients with acute cholecystitis should be given an intravenous antibiotic such as a β-lactam/β-lactamase inhibitor or a third-generation cephalosporin plus metronidazole. Patients who improve should undergo cholecystectomy during the same hospitalization; urgent cholecystectomy can be considered for patients who do not improve with antibiotics. Percutaneous or endoscopically placed cholecystostomy tubes can be used in patients with acute cholecystitis who are not improving or who are at unacceptably high risk for cholecystectomy. Open cholecystectomy may be necessary for patients with unfavorable anatomy, extensive upper abdominal adhesions, or severe acute inflammation of the gallbladder and surrounding tissues.
positive Thessaly and medial-lateral grind tests on examination
Patients with acute meniscal injuries
Patients with ankylosing spondylitis who are responding well to treatment should be monitored clinically and do not require periodic imaging studies less than
Patients with ankylosing spondylitis who are responding well to treatment should be monitored clinically and do not require periodic imaging studies less than every 2 years unless absolutely necessary.
Manage acute cholangitis.
Patients with cholangitis should receive immediate broad-spectrum antimicrobial therapy; if rapid improvement is not seen, urgent endoscopic stone removal should be performed.
Treat chronic neurogenic neck pain.
Patients with chronic neurogenic neck pain may respond to agents such as gabapentin and tricyclic antidepressants.
MELD score for liver transplant
Patients with cirrhotic-stage liver disease and a Model for End-Stage Liver Disease (MELD) score of 15 or greater have better survival with liver transplantation than without.
in cryptogenic ischemic stroke, Monitor for
Patients with cryptogenic ischemic stroke require prolonged cardiac monitoring to detect atrial fibrillation, which is found in as many as 25% of these patients. as many as 25% of patients with cryptogenic ischemic stroke have paroxysmal atrial fibrillation on prolonged cardiac monitoring of up to 30 days; patients who have premature atrial contractions and other findings of ectopy on short-term telemetry may be more likely to have this finding. Continued cardiac rhythm monitoring to detect atrial fibrillation is thus advisable
Treat calcium oxalate nephrolithiasis in a patient with enteric hyperoxaluria
Patients with enteric hyperoxaluria and calcium oxalate nephrolithiasis may benefit from treatment with bile salt binders to decrease intestinal oxalate absorption. Urine citrate inhibits stone formation by binding calcium in the tubular lumen, preventing it from precipitating with oxalate. Citrate excretion can be enhanced in patients with low urine citrate levels by alkalinizing the serum with potassium citrate, which decreases uptake of filtered citrate from the tubular lumen.
Vaccinate a patient with anatomic asplenia against pneumococcal disease by giving the pneumococcal vaccinations in what order
Patients with functional or anatomic asplenia should receive a dose of pneumococcal conjugate vaccine (PCV13), followed by a dose of pneumococcal polysaccharide vaccine (PPSV23) 8 weeks later. Both pneumococcal vaccines are recommended in these patients; however, when PCV13 is indicated, it should be given before PPSV23. Therefore, administration of PCV13 would be appropriate now, followed by a single dose of PPSV23 8 weeks later. Administration of a second dose of PPSV23 is recommended 5 years after administration of the first PPSV23 dose for patients aged 19 to 64 years who have functional or anatomic asplenia. Furthermore, individuals who receive PPSV23 before age 65 years should receive an additional dose of PPSV23 at age 65 years provided that at least 5 years have passed since the most recent PPSV23 administration.
Screen for ______ in a patient with symptoms of irritable bowel syndrome with diarrhea
Patients with irritable bowel syndrome with diarrhea (IBS-D) should undergo screening for celiac disease with serum tissue transglutaminase testing, as celiac disease has greater prevalence in patients with IBS-D than in the general population.
At what intervals do patients with UC need colonoscopies
Patients with long-standing colitis associated with inflammatory bowel disease are at increased risk for colon cancer and should undergo surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years of disease.
When to start screening patients with UC for colon cancer
Patients with long-standing colitis associated with inflammatory bowel disease are at increased risk for colon cancer and should undergo surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years of disease.
Treat a patient with catheter-associated urinary tract infection.
Patients with probable catheter-associated urinary tract infection should have the catheter removed and appropriate antimicrobial treatment provided for the infection, based on results of a urine culture.
Management of Meningiomas
Patients with small, asymptomatic meningiomas without evidence of invasion of other intracranial structures and without surrounding edema are usually followed clinically and radiographically, with a first follow-up MRI performed 3 to 6 months after the tumor is identified to ensure that it is not an atypical meningioma exhibiting rapid growth. Patients with large or symptomatic tumors, tumors that invade surrounding parenchyma, or tumors that grow over time may be considered for surgery and/or radiation therapy. If intervention is indicated, surgical resection is usually the first-line therapy, followed by radiation for higher-grade tumors or tumors that could not be resected completely. Rarely, arterial embolization is used to shrink large tumors before resection.
Diagnose sporadic Creutzfeldt-Jakob disease
Patients with sporadic Creutzfeldt-Jakob disease usually present in the seventh decade of life and have disordered cognition, ataxia or spasticity, myoclonus, and elevated 14-3-3 protein in the cerebrospinal fluid.
Stage II seminoma treatment
Patients with stage II seminomas receive adjuvant radiotherapy or cisplatin-based chemotherapy depending on the extent of lymphadenopathy.
Colonoscopy surveillence if you have IBD
Patients with ulcerative colitis or Crohn colitis should receive surveillance colonoscopy every 1 to 2 years beginning after 8 to 10 years of disease.
Patients with uncomplicated gallstone-induced acute pancreatitis should undergo
Patients with uncomplicated gallstone-induced acute pancreatitis should undergo cholecystectomy prior to hospital discharge to prevent recurrent attacks.
Treat tophaceous gout with _________ in a patient who has not responded to oral urate-lowering therapy
Pegloticase may be considered for patients with resistant gout who have not responded to oral urate-lowering therapy
first-line therapy for women with stress urinary incontinence
Pelvic floor muscle training, along with other conservative measures such as weight loss
the most common cause of upper gastrointestinal bleeding
Peptic ulcer disease
Hepatitis A Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
Per recommendations for nontransplant patients
Human papillomavirus Immunization Recommendations for Hematopoietic Stem Cell Transplantationb
Per recommendations for nontransplant patients
Meningococcal Immunization Recommendations for Solid Organ Transplantation or Hematopoietic Stem Cell Transplantationb
Per recommendations for nontransplant patients
preferred treatment for severe symptomatic mitral stenosis
Percutaneous balloon mitral valvuloplasty
Mitral valve replacement is indicated in patients with symptomatic (NYHA functional class III-IV) severe mitral stenosis when
Percutaneous balloon mitral valvuloplasty is unavailable or contraindicated or valve morphology is unfavorable.
next step for gastroesophageal reflux disease in a patient whose symptoms did not respond to proton pump inhibitor therapy
Perform ambulatory pH impedance monitoring Ambulatory pH impedance testing while not taking a proton pump inhibitor is useful in patients who have atypical symptoms of gastroesophageal reflux to determine if reflux is the cause of the symptoms; it is also useful in patients who are symptomatic while on a proton pump inhibitor to determine if there is continued acid exposure.
the most common cardiac manifestation of rheumatoid arthritis
Pericarditis Pericarditis is the most common cardiac manifestation of rheumatoid arthritis and is often asymptomatic.
Indications for followup documentation of H. Pylori eradication (fecal antigen test or urea breath test)
Persistent symptoms s/p tx and H-Pylori associated ulcer
Tenderness on the anteromedial aspect of the knee 5 to 8 cm below the joint line is reproduced by palpation or by having the patient take a step up
Pes anserine bursitis
usually develops as the result of overuse or constant friction and stress on proximal anteromedial tibia. Tenderness on the anteromedial aspect of the knee about 4 to 5 cm below the joint line is reproduced by palpation
Pes anserine bursitis
autosomal dominant condition with hamartomatous polyps
Peutz-Jeghers syndrome (PJS)
In MS, use this for the non-pharmacologic treatment of Impaired mobility
Physical and occupational therapy; use of braces, canes, rolling walkers, or electrostimulatory walk-assist devices
Treat a patient with olecranon bursitis
Physical protection of the bursa and NSAID therapy are effective treatments for noninfectious olecranon bursitis
In MS, use this for the non-pharmacologic treatment of Spasticity
Physical therapy, stretching, massage therapy
pain and tenderness near the medial plantar heel surface that usually occurs with the first few steps taken after prolonged inactivity
Plantar fasciitis
pain and tenderness near the medial plantar heel surface. Pain typically occurs upon awakening and after prolonged rest
Plantar fasciitis
Light's Criteria
Pleural fluid total protein/serum total protein >0.5 Pleural fluid LDH/serum LDH >0.6 Pleural fluid LDH >2/3 the upper limit of normal for serum LDH
Patients who have undergone transplantation are at high risk for __________ infection, especially during the first 6 to 12 months and after episodes of rejection requiring increased immunosuppression.
Pneumocystis jirovecii
Prophylaxis when CD4 <200/µL
Pneumocystis jirovecii TMP-SMX double-strength tablet once daily or three times weekly
Patients with HIV/AIDS with CD4 cell counts less than 200/µL should undergo prophylaxis against
Pneumocystis jirovecii,
A systemic vasculitis primarily affecting medium-sized arteries at points of bifurcation. Microaneurysm formation with rupture can result in hemorrhage, thrombosis, and organ ischemia or infarction. The kidneys, skin, peripheral nerves, joints, muscles, and gastrointestinal tract are commonly affected. AKI is caused by ischemic changes in the glomeruli and renal artery vasculitis.
Polyarteritis nodosa (PAN)
Diagnosis of hepatic vein thrombosis (the Budd-Chiari syndrome) or portal vein thrombosis should prompt consideration of
Polycythemia Vera
dx of viral meningitis
Polymerase chain reaction (PCR) and other molecular tests are available for diagnosis of numerous viral causes. CSF PCR studies may be used for diagnosing HSV and enterovirus meningitis;
any patient with a clinical presentation typical of symptomatic Zika virus infection who has returned from an endemic area and who has had symptoms within 2 weeks of travel should have what test ordered
Polymerase chain reaction should be performed on serum and urine samples
most sensitive diagnostic modality available for herpes simplex virus infection
Polymerase chain reaction testing of genital lesions
Causes of nephritic syndromes
Post strep IgA Nephropathy Alport Goodpasture (RPGN) Granulomatosis with Polyangiitis (Wegener) (RPGN) Microscopic polyangiitis (RPGN) Membranoproliferative (both)
a disorder of cerebrovascular regulation frequently showing clinical and neuroimaging overlap with RCVS. Headaches are common but not necessarily thunderclap in type. Nausea, vomiting alterations in mental status, seizures, and visual compromise are all frequently noted. Brain MRI reveals areas of white matter edema in posterior brain regions (occipital and parietal cortex), and vasoconstriction may not be present.
Posterior reversible encephalopathy syndrome (PRES)
characterized by preceding symptoms of an upper respiratory tract infection suggestive of streptococci, followed by the nephritic syndrome and low C3 levels with normal C4 levels.
Poststreptococcal glomerulonephritis
Definition of orthostatic hypotension
Postural (orthostatic) hypotension is diagnosed when, within two to five minutes of quiet standing (after a five-minute period of supine rest), one or both of the following is present At least a 20 mmHg fall in systolic pressure At least a 10 mmHg fall in diastolic pressure
the strongest nonmodifiable predictor of the development of acute kidney injury after cardiac surgery.
Preexisting chronic kidney disease
anterior knee pain and swelling. Possible causes include direct trauma, gout, and infection. On examination, a palpable fluid collection is often present
Prepatellar bursitis
CAP outpatient tx if previously healthy and no risk factor(s) for drug-resistant Streptococcus pneumoniae:
Previously healthy and no risk factor(s) for drug-resistant Streptococcus pneumoniae: Macrolide (azithromycin, clarithromycin, or erythromycin) or doxycycline
need for pre op stress dose steroids
Primary adrenal insufficiency; ≥10 mg of daily prednisonea for ≥3 weeks in past year In those circumstances, intravenous hydrocortisone, 50 to 100 mg, is administered shortly before anesthesia induction and then continued every 8 hours for up to 48 hours after surgery.
Causes of RTA 4
Primary aldosterone deficiency is seen in primary adrenal deficiency (Addison disease). Hyporeninemic hypoaldosteronism occurs in patients with various kidney diseases (including acute glomerulonephritis) and chronic nephropathies (such as diabetes mellitus, systemic lupus erythematosus, or AIDS). Patients with conditions that cause tubulointerstitial disease, including urinary obstruction, sickle cell disease, medullary cystic kidney disease, and kidney transplant rejection, may demonstrate resistance to aldosterone. Drug-induced type 4 (hyperkalemic distal) RTA can be caused by numerous drugs that reduce aldosterone production, including ACE inhibitors, cyclooxygenase inhibitors, trimethoprim, and heparin.
Causes of RTA 1
Primary: hereditary Genetic: sickle cell disease; Fabry disease; Wilson disease; elliptocytosis Medullary cystic kidney disease Autoimmune disorders: Sjögren syndrome; systemic lupus erythematosus Nephrocalcinosis/hypercalciuria Dysproteinemias: amyloidosis; cryoglobulinemia; hypergammaglobulinemia Drugs/toxins: amphotericin B; lithium; analgesic abuse Tubulointerstitial disease: reflux nephropathy; obstructive uropathy; kidney transplant rejection
alternative first-line urate-lowering agent in patients who cannot tolerate or have a contraindication to xanthine oxidase inhibitor therapy
Probenecid
most appropriate contraceptive option for women at increased risk for venous thromboembolism (VTE)
Progestin-releasing intrauterine devices they are not associated with increasing the VTE risk further, whereas progestin-only pills, implants, and injections may slightly increase the risk for thrombosis.
treatment of differentiation syndrome
Prompt initiation of glucocorticoids and brief interruption of the medications are effective in treatment.
In MS, use this for the non-pharmacologic treatment of Fatigue
Proper sleep hygiene, regular exercise
primary prevention of variceal hemorrhage in patients with cirrhosis and endoscopy-documented esophageal varices
Propranolol
most common structural disorder that occurs following tetralogy of Fallot repair
Pulmonary regurgitation
a known complication of catheter ablation of atrial fibrillation and may present with unexplained dyspnea is
Pulmonary vein stenosis
characterized by painful pustules that rapidly ulcerate and expand, with edematous, rolled, or undermined borders that may have a violaceous hue
Pyoderma gangrenosum (PG)
How often to check TSH when starting to treat for hypothyroidism
Q6wk til at goal, then q6-12mon
periarticular osteopenia and marginal erosions on xray
RA
Rapid Shallow Breathing Index (RSBI)
RR / Vt (L)
stage IB through stage IV cervical cancer tx
Radiation therapy and concurrent chemotherapy
Treat a patient with a rising prostate-specific antigen after prostatectomy with
Radiation therapy to the pelvis with concurrent androgen deprivation therapy with leuprolide
Skin induration plus one or more of the following extracutaneous features strongly suggests the diagnosis of SSc:
Raynaud phenomenon, digital infarction, and/or pitting; heartburn, dysphagia, or diarrhea; hypertension and/or kidney disease; dyspnea on exertion, interstitial lung disease, or pulmonary arterial hypertension; or mucocutaneous telangiectasias.
Patients with MCTD must have positive anti-U1-RNP antibodies and at least three of the following five features
Raynaud phenomenon, edema of the hands, sclerodactyly, synovitis, myositis.
characterized by an asymmetric monoarthritis or oligoarthritis in the lower extremities as well as enthesopathy, dactylitis, and sacroiliitis
Reactive arthritis
Treat panic disorder
Recommended treatment of panic disorder is a combination of cognitive-behavioral therapy and medication
IBS (irritable bowel syndrome)
Recurrent abd discomfort for >=3d/month for the last 3 months & >=2 more of the the following: • Sx improve with BM • change in frequency • change in form
Leukoreduction
Reduces class I HLA alloantibody production and subsequent : - platelet transfusion refractoriness, - febrile nonhemolytic transfusion reactions, - transmission of CMV.
LVRS criteria
Remain symptomatic despite maximal pharmacologic therapy Completed pulmonary rehabilitation Evidence of bilateral predominant upper-lobe emphysema on CT scan Postbronchodilator total lung capacity of >100% and residual lung volume >150% of predicted Maximum FEV1 >20% and ≤45% of predicted and DLCO ≥20% of predicted Ambient air arterial Pco 2 ≤60 mm Hg (8.0 kPa) and arterial PO 2 ≥45 mm Hg (6.0 kPa)
Lung volume reduction surgery (LVRS) for COPD
Remain symptomatic despite maximal pharmacologic therapy Completed pulmonary rehabilitation Evidence of bilateral predominant upper-lobe emphysema on CT scan Postbronchodilator total lung capacity of >100% and residual lung volume >150% of predicted Maximum FEV1 >20% and ≤45% of predicted and DLCO ≥20% of predicted Ambient air arterial Pco 2 ≤60 mm Hg (8.0 kPa) and arterial PO 2 ≥45 mm Hg (6.0 kPa)
Treat Crohn disease unresponsive to tumor necrosis factor therapy.
Replacing adalimumab with ustekinumab is the best treatment for this patient. Ustekinumab is a monoclonal antibody to the p40 subunit of interleukin-12 and interleukin-23 initially indicated for the treatment of psoriasis and psoriatic arthritis.
CAP outpatient tx if Risk factor(s) for drug-resistant S. pneumoniae or underlying comorbidities
Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin) or β-lactam plus a macrolide or doxycycline
Bug that causes RMSF
Rickettsia rickettsii
initial therapy for a patient with active tuberculosis
Rifampin, isoniazid, pyrazinamide, and ethambutol These agents are administered for 8 weeks as part of the initiation phase, and then isoniazid and rifampin are continued for 4 or 7 months as part of the continuation phase. The longer course is recommended in patients who: - have cavitary pulmonary disease at diagnosis and positive sputum cultures after completing initial therapy, - patients who did not receive pyrazinamide as part of the initial therapy, - patients who are receiving once-weekly rifapentine and isoniazid whose sputum cultures remain positive after the initial 2-month phase.
reatment for irritable bowel syndrome with diarrhea
Rifaximin In case of recurrent symptoms, rifaximin can be prescribed for up to two additional course
Axis Deviation, leads I and II
Right together Left away
Clinical clues for ASD
Right ventricular heave Wide, fixed splitting of the second sound Midsystolic pulmonary flow or ejection murmur (The murmur associated with an atrial septal defect is a midsystolic flow murmur caused by the ejection of increased right-sided volume, owing to the left-to-right shunt that occurs initially with this defect. This murmur is best heard over the pulmonic area of the chest and may radiate toward the back, as with the murmur of pulmonary stenosis.) Right axis deviation & incomplete right bundle branch block
symptoms of fever, petechial rash, and lymphocytic meningitis suggest
Rocky Mountain spotted fever
COPD GOLD C Tx
SABA PRN & LAMA & (For frequent exacerbations: LABA + ICS)
COPD GOLD D Tx
SABA PRN & LAMA + LABA & (For frequent exacerbations: ICS)
COPD GOLD B Tx
SABA PRN & LABA or LAMA
Mononeuritis multiplex is highly specific for vasculitic disorders that affect the vasa vasorum or nerve vascular supply but can also occur in systemic inflammatory disorders such as
SLE
SSc pruritus is managed with
SSc pruritus is managed symptomatically with antihistamines and skin emollients.
Baseline and annual monitoring of PAH is recommended in all patients with
SSc without advanced ILD
All surgical patients should be screened for OSA with a validated tool such
STOP-BANG
duplex ultrasonography is indicated in superficial venous thrombophlebitis when
SVT of the great or small saphenous vein is present, if extremity swelling is more pronounced than would be expected from the SVT alone, a nd if symptoms progress
characterized by tenderness to palpation of the sacroiliac joint, pain that is reproduced with the FABER (Flexion, ABduction, External Rotation) test, and no pain with passive range of motion of the hip
Sacroiliitis
Treatment for lyme disease with Multiple erythema migrans, often with fever, headache, myalgias
Same as for localized Oral doxycyclinea, amoxicillin, or cefuroxime axetil
Severe ocular pain that worsens with eye movement and light exposure; a raise hyperemic lesion that may be localized or diffuse and obscures the underlying vasculature
Scleritis
painful inflammation of the fibrous layers of the eye underlying the episclera and conjunctiva, is often associated with systemic diseases including inflammatory connective tissue disorders and infections
Scleritis
surveillance for hepatocellular carcinoma in a patient with chronic hepatitis B infection
Screening and surveillance for hepatocellular carcinoma consist of cross-sectional imaging with ultrasound, CT, or MRI. The most appropriate management is ultrasound imaging of the liver every 6 months
Diarrea with Large-volume, watery stools Does not stop with fasting
Secretory!!! Medications (e.g., colchicine, NSAIDs) SIBO Hormone-producing tumors (e.g., gastrinoma, VIPoma, carcinoid, somatostatinoma) Bile acid malabsorption Noninvasive infections (e.g., cholera)
how to treat patients with peripheral psoriatic arthritis refractory to prior trials of tumor necrosis factor α inhibitors
Secukinumab is a human anti-interleukin-17A monoclonal antibody that can be used in patients with peripheral psoriatic arthritis refractory to prior trials of tumor necrosis factor α inhibitors; it can be given with or without methotrexate.
first-line therapy for patients with social anxiety disorder
Selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitor venlafaxine
therapy for migraine without aura in patients not responding to NSAIDs or oral triptans, especially those with vomiting
Self-administered subcutaneous sumatriptan
When tuning fork is placed against the mastoid process until it can no longer be heard and then moved to directly outside the ear (Rinne test), the tuning fork is best heard after removal from the mastoid.
Sensorineural hearing loss
for patients with melanomas of 1- to 4-mm thickness, next best step is
Sentinel lymph node biopsy. to provide accurate staging, as metastasis to regional lymph nodes is the most important prognostic factor in patients with early-stage melanoma.
most appropriate management strategy of Acute HBV
Serial monitoring of liver enzymes and markers of liver synthetic function
Management of supratherapeutic INR
Serious of life threatening bleed at ANY INR: - IV VitK 10mg - FFP - Recombinant factor VIIa - Prothromin Complex Concentrate INR >9: - Hold warfarin - Vit K PO high dose (2.5-5mg) INR 5-9: - Hold warfarin and resume when INR therapeutic - Administer Vit K PO low dose (1-2.5mg) if at increased risk for bleeding INR <5: - Hold warfarin for 1-2 days or decrease dose
Lyme Arthritis dx
Serologic testing for Borrelia burgdorferi is the diagnostic test of choice for this disease and is typically done with an enzyme-linked immunosorbent assay (ELISA) screening test, followed by confirmation by Western blot.
mainstay of syphilis diagnosis
Serologic testing is the mainstay of syphilis diagnosis. Results of nonspecific tests (rapid plasma reagin [RPR] test, VDRL test) may be negative in primary infection but will be positive, generally at high titers, in secondary syphilis. Titers are lower in latent and tertiary infection. Positive findings on nonspecific tests should always be confirmed with a specific treponemal test (T. pallidum particle agglutination assay or fluorescent treponemal antibody absorption test) because biologic false-positive results can occur.
How to diagnose late disseminated lyme disease with Oligoarticular arthritis
Serologic testing, PCR of synovium or synovial fluid
How to diagnose late disseminated lyme disease with Encephalopathy or encephalomyelitis
Serologic testing, intrathecal antibody, CSF PCR
Anion Gap
Serum Sodium (mEq/L) − [Serum Chloride (mEq/L) + Serum Bicarbonate (mEq/L)]
Patients undergoing outpatient parenteral antimicrobial therapy with nafcillin must undergo weekly monitoring for adverse drug effects by monitoring their
Serum creatinine level, complete blood count, and liver enzyme tests should be monitored weekly Monitoring of oxacillin and carbapenems is similar to that of nafcillin, monitoring of other β-lactam antibiotics is similar to that of nafcillin except that liver enzyme testing is not necessary; antipseudomonal penicillins necessitate checking the serum potassium level weekly.
Serum-effusion for transudates (the difference between the serum and pleural values) for patients being diuresed
Serum effusion protein gradient: >3.1 Serum effusion albumin gradient: >1.2
Diagnose monoclonal gammopathy of undetermined significance.
Serum free light chain (FLC) testing should be performed.
Multiple myeloma dx
Serum protein electrophoresis and serum free light chain
Classification of COPD Severity by Spirometry (In Patients with FEV1/FVC <70%), GOLD Stage 3
Severe 30% ≤ FEV1 < 50% of predicted
Alarm Features Requiring Evaluation in Patients with Acute Diarrhea
Severe abdominal pain Bloody stools Fever Recent hospitalization or antimicrobial use Elderly patients Immunocompromised patients Patients with inflammatory bowel disease Pregnant patients
Indications for Immediate Removal of Cuffed Tunnel Hemodialysis Catheters in Patients With Known or Suspected Catheter-Related Bacteremia
Severe sepsis Hemodynamic instability Evidence of metastatic infection Infection of catheter exit site or tunnel Persistent fever and/or bacteremia >48-72 h despite adequate antibiotic coverage and no other suspected source Infection due to high risk and difficult-to-cure organisms, including Staphylococcus aureus, Pseudomonas, or fungi
Diagnose thrombotic microangiopathy.
Shiga toxin-associated hemolytic uremic syndrome is a diarrhea-associated syndrome of microangiopathic hemolytic anemia, thrombocytopenia, and kidney failure caused by Shiga toxin-producing Escherichia coli.
Treat quinolone-resistant Shigella species
Shigella isolates with a ciprofloxacin minimum inhibitory concentration of 0.12 μg/mL or greater should be considered resistant to this agent, and alternative therapies should be used.
Treatment for COPD GOLD Stage A
Short-acting anticholinergic PRN or Short-acting β2-agonist PRN
Serologic testing for Lyme disease is required unless they have the following associated conditions
Single erythema migrans at site of inoculation Multiple erythema migrans, often with fever, headache, myalgias
Characteristics of intermediate risk SPN
Size (cm): 0.8-2.0 Age: 40-60 Smoker: Current Smoking cessation: 5-15 Margin characteristics: Scalloped
Characteristics of low risk SPN
Size (cm): <0.8 Age: <40 Smoker: Never Smoking cessation: >15y Margin characteristics: Smooth
Characteristics of high risk SPN
Size (cm): >= 2.0 Age: >60 Smoker: Current Smoking cessation: <5 Margin characteristics: Corona radiata or spiculated
Uncomplicated Pleural Effusion
Small (<10 mm on lateral decubitus radiographic view), free flowing pH: unknown Glucose: unknown Antibiotics and serial follow-up to ensure resolution; if no resolution or ongoing sepsis, consider thoracentesis
lung cancer which typically presents on imaging as a large hilar mass with bulky mediastinal lymphadenopathy
Small cell lung cancer
diagnostic imaging workup of renal cell carcinome
Small lesions should be biopsied if possible. Larger lesions can be removed without biopsy if imaging findings are consistent with malignancy. Additionally, CT to evaluate the local disease extent and assess for metastatic disease is also recommended.
Small-Moderate Uncomplicated Pleural Effusion
Small to moderate effusion (>10 mm to <1/2 hemithorax), free flowing pH >7.2 Glucose >60 mg/dL (3.3 mmol/L) Antibiotics, thoracentesis, and serial follow-up to ensure resolution; if no resolution or ongoing sepsis, consider repeat thoracentesis and need for drainage
Manage a sporadic juvenile polyp.
Solitary juvenile polyps are one of the most commonly found polyps; they confer no future health risk once the polyp is removed and do not require surveillance endoscopy.
Hepatitis A virus vaccine, with a dose of intramuscular immune globulin to provide optimal protection to persons traveling within 2 weeks, should be given to any person planning travel to
South Asia, Africa, and South and Central America.
Treat compressive spinal cord lesions due to plasmacytoma
Spinal cord compression by skeletal lesions resulting from plasmacytoma should be treated initially with radiation therapy in patients with no spinal instability and only minor neurologic deficits.
severe leg pain that is absent when seated and may be relieved when leaning forward
Spinal stenosis
when patients with COPD experience a change in symptoms, obtain in clinic a:
Spirometry
Diagnose suspected occupational asthma
Spirometry before and after rechallenge with workplace exposures is helpful to confirm the diagnosis of occupational asthma Treatment of occupational asthma should follow guidelines for typical asthma, and allergen exposure should be controlled or eliminated if possible.
Manage sporadic gastric fundic gland polyps
Sporadic fundic gland polyps have been associated with proton pump inhibitor use and do not require excision or surveillance Adenomatous and hyperplastic polyps are associated with atrophic gastritis, intestinal metaplasia, and H. pylori infection. Adenomas are dysplastic and warrant excision, whereas only 20% of hyperplastic polyps harbor dysplasia. Polypectomy of lesions larger than 5 mm is recommended. Less common gastric polyps include inflammatory fibroid polyps, hamartomas, pancreatic rests, and carcinoids.
Provide the appropriate prevention strategy for NSAID-induced injury.
Standard-dose daily proton pump inhibitor therapy significantly reduces the risk of NSAID-induced gastric injury. misoprostol, 200 µg four times daily, is an alternative; however, side effects such as abdominal cramps and diarrhea may be limiting.
A patient with recently diagnosed influenza pneumonia and cavitary lesions on chest radiograph most likely has
Staphylococcus aureus postinfluenza community-acquired pneumonia.
Diarrea with Bulky, greasy, oily, malodorous stools, Weight loss
Steatorrhea!!!! Pancreatic insufficiency Small-bowel mucosal disease (e.g., celiac disease) SIBO Bile acid deficiency Lymphatic obstruction
how to diagnose giardia
Stool O & P microscopy or stool antigen
how to diagnose Amebiasis
Stool O & P microscopy, stool antigen
Definition of MILD Ulcerative Colitis
Stools (number per day): <4 Blood in stool: Intermittent Temperature: Normal Pulse (beats per minute): Normal Hemoglobin: Normal Erythrocyte sedimentation rate (mm/h): <30
Definition of SEVERE Ulcerative Colitis
Stools (number per day): >6 Blood in stool: Frequent Temperature: >37.5 °C (99.5 °F) Pulse (beats per minute): >90 Hemoglobin: <75% of normal Erythrocyte sedimentation rate (mm/h): >30
Manage acalculous cholecystitis
Supportive treatment with intravenous antibiotic coverage of anaerobic and gram-negative bacteria is required. Definitive therapy with cholecystectomy is preferred but may be contraindicated in severely ill patients. Therapeutic decompression can be achieved with image-guided percutaneous cholecystostomy tube placement. The mortality rate for acute acalculous cholecystitis is between 10% and 50%.
characterized by pain with active shoulder abduction and a positive painful arc. Internal and external rotation may also elicit pain with involvement of other rotator cuff tendons. Pain is typically elicited with active but not passive range of motion.
Supraspinatus tendinitis
Treatment of Stage I and II Colon Cancer
Surgery An exception is patients with stage II colon cancer with characteristics associated with a high risk for recurrence (T4 disease and inadequate lymph node sampling [<12 lymph nodes examined], lymphovascular invasion, poorly differentiated histology, or clinical perforation or obstruction). In these patients, the prognosis is similar to that of patients with stage III disease, and adjuvant chemotherapy may be appropriate.
Treat early-stage triple-negative breast cancer with
Surgery followed by Adjuvant chemotherapy, typically anthracycline-based chemotherapy, is recommended for patients with triple-negative breast cancers who have no medical contraindications to this regimen.
Treatment for stage I or II NSCLC
Surgery with curative intent Adjuvant chemotherapy has a proven role in patients with resected stage II and resected stage III disease. Cisplatin-based combination therapy has demonstrated a clear survival advantage in these settings.
treatment of choice for patients with symptomatic severe aortic stenosis who are at low surgical risk.
Surgical aortic valve replacement Transcatheter aortic valve replacement (TAVR) is an option for patients with an indication for aortic valve replacement but who are not operative candidates or are at high risk for death or major morbidity with open aortic valve replacement.
Solid Solitary Pulmonary Nodules Ranging from Greater than 8 mm to Less than 30 mm with high (>65%) pretest probability of malignancy
Surgical excision (consider PET/CT imaging for staging first)
major initial management option for patients with a solitary, accessible brain metastasis and controlled extracranial disease
Surgical resection
Solid Solitary Pulmonary Nodules Ranging from Greater than 8 mm to Less than 30 mm with low (<5%) pretest probability of malignancy
Surveillance CT at 3 to 6 months 9 to 12 months and 18 to 24 months (re-evaluate for PET imaging, tissue diagnosis, or excision if evidence of growth)
Indications for pacemaker placement
Symptomatic bradycardia without reversible cause Asymptomatic bradycardia with significant pauses (>3 seconds in sinus rhythm) Asymptomatic bradycardia with persistent heart rate <40/min Atrial fibrillation with 5-second pauses Asymptomatic complete heart block or Mobitz type 2 second-degree atrioventricular block Alternating bundle branch block
Indications for treatment of subclinical hypothyroidism if TSH < 10 but > UNL, AND NOT positive for anti-thyroid peroxidase antibody
Symptoms Goiter Pregnant Hypercholesterolemia Ovulatory dysfunction with infertility
Indications for mitral valve replacement in mitral regurgitation
Symptoms (class I) LVEF 30%-60% (class I) LV end-systolic diameter ≥40 mm (class I) Moderate (class IIa) or severe (class I) mitral regurgitation at time of other cardiac surgery LVEF >60% and LV end-diastolic diameter <40 mm with high likelihood of surgical success (>95%) and low expected mortality (<1%) (class IIa) LVEF >60% and LV end-diastolic diameter <40 mm with progressive increase in LV size or decrease in LVEF on serial imaging studies (class IIa) Pulmonary hypertension (PA systolic pressure ≥50 mm Hg) (class IIa) New-onset atrial fibrillation (class IIa)
7 Mitral regurgitation Indications for Interventions
Symptoms (class I) LVEF 30%-60% (class I) LV end-systolic diameter ≥40 mm (class I) Moderate (class IIa) or severe (class I) mitral regurgitation at time of other cardiac surgery LVEF >60% and LV end-diastolic diameter <40 mm with high likelihood of surgical success (>95%) and low expected mortality (<1%) (class IIa) LVEF >60% and LV end-diastolic diameter <40 mm with progressive increase in LV size or decrease in LVEF on serial imaging studies (class IIa) Pulmonary hypertension (PA systolic pressure ≥50 mm Hg) (class IIa) New-onset atrial fibrillation (class IIa)
Indications for aortic valve replacement in aortic regurgitation
Symptoms (class I) LVEF <50% (class I) Moderate (class IIa) or severe (class I) aortic regurgitation at time of other cardiac surgery LV dilatation (end-systolic dimension >50 mm) (class IIa)
Indications for aortic valve replacement in aortic stenosis
Symptoms (class I) LVEF <50% (class I) Moderate (class IIa) or severe (class I) aortic stenosis at time of other cardiac surgery Abnormal blood pressure response (decrease in systolic blood pressure) during exercise (class IIa) Asymptomatic patients with very severe aortic stenosis (class IIa)
Indications for mitral valve replacement in mitral stenosis
Symptoms (class I) Very severe mitral stenosis (MVA <1.0 cm2) and no symptoms if valve morphology favorable for balloon valvotomy (class IIa) Severe mitral stenosis at time of other cardiac surgery (class I)
Mild Persistent Asthma Dx
Symptoms: >2 days/week but not daily Nighttime awakenings: 3-4 ×/month SABA use for symptom control (not prevention of EIB): >2 days/week but not more than 1 ×/d Interference with normal activity: Minor limitation Lung function: FEV1 ≥80% of predicted FEV1/FVC normal
Moderate Persistent Asthma Dx
Symptoms: Daily Nighttime awakenings: >1 ×/week but not nightly SABA use for symptom control (not prevention of EIB): Daily Interference with normal activity: Some limitation Lung function: FEV1 ≥60% but <80% of predicted FEV1/FVC reduced ≤5%
Severe Persistent Asthma Dx
Symptoms: Throughout the day Nighttime awakenings: Often 7 ×/week SABA use for symptom control (not prevention of EIB): Several times a day Interference with normal activity: Extremely limited Lung function: FEV1 <60% of predicted FEV1/FVC reduced >5%
Intermittent Asthma Dx
Symptoms: ≤2 days/week Nighttime awakenings: ≤2 ×/month SABA use for symptom control (not prevention of EIB): ≤2 days/week Interference with normal activity: None Lung function: Normal FEV1 between exacerbations FEV1 ≥80% of predicted FEV1/FVC normal
Brugada syndrome.
Syncope, VF, coved ST-segment elevation in early precordial leads (V1-V3)
Joint fluid analysis
Synovial fluid leukocyte counts less than 200/µL (0.2 × 109/L) are considered normal 200/µL and 2000/µL (0.2 × 109/L and 2.0 × 109/L) are associated with noninflammatory conditions greater than 2000/µL (2.0 × 109/L) are associated with inflammatory states. In bacterial infection, the synovial fluid leukocyte count is usually >50,000/µL [50 × 109/L] with neutrophil predominance
the standard of care for refractory dyspnea in advanced disease at the end of life
Systemic opioids
Metastatic breast cancer treatment
Systemic treatment is the mainstay Radiation is used to treat painful bone metastases. Surgery can stabilize impending pathologic fractures. Either may be used to treat oncologic emergencies, such as spinal cord compression and brain metastases
Pre-eclampsia with severe features dx
Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg on two occasions at least four hours apart while the patient is on bedrest New-onset cerebral or visual disturbance Severe headache ( headache that persists and progresses despite analgesic therapy and not accounted for by alternative diagnoses) Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis or serum transaminase concentration ≥2 times the upper limit of the normal range, or both <100,000 platelets/microL (serum creatinine >1.1 mg/dL [97.2 micromol/L] or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema
TTE is indicated for patients with the following kinds of murmurs
Systolic murmurs ≥grade 3/6 late systolic murmurs holosystolic murmurs Diastolic or continuous murmurs Murmurs with accompanying symptoms
intermediate or high risk TIMI
TIMI score ≥3
rasburicase
TLS + AKI
bladder cancer tx
TURBT + Calmette-Guerin\chemo Cystectomy is recommended only for patients with frequent, high-grade recurrences occurring within a short period. Conversely, patients with muscle-invasive disease often are treated with radical cystectomy, although bladder-sparing approaches can be considered in some patients. Neoadjuvant cisplatin-based chemotherapy is also recommended, as it can improve survival in patients with muscle-invasive disease; however, the role of adjuvant chemotherapy is much less clear.
Mild intermittent asthma
TX: PRN Albuterol inhaler
mild persistent asthma
TX: PRN Albuterol inhaler + daily Fluticasone low dose (inhaled steroid)
characterized by pain and paresthesias in the medial ankle that extend into the midfoot
Tarsal tunnel syndrome
pain and paresthesias in the medial ankle extending into the foot that worsen with standing, walking, and running. Pain can be reproduced by tapping on the posterior tibial nerve along its course
Tarsal tunnel syndrome
Tdap
Td q 10y, with once being Tdap Every single pregnancy women get it 27-36 weeks
serum CK levels and EMG findings in Glucocorticoid-Induced Myopathy
Testing reveals normal serum CK levels and normal EMG findings.
initial evaluation of metastatic nonsquamous non-small cell lung cancer
Testing to identify an epidermal growth factor receptor (EGFR) mutation as patients with EGFR mutations who are treated with EGFR tyrosine kinase inhibitors.(such as erlotinib, gefitinib, or afatinib)
a type 2 (proximal) renal tubular acidosis with urine loss of bicarbonate as well as phosphaturia, glucosuria, and aminoaciduria is called
The Fanconi syndrome
March Hemoglobinuria
The Prussian blue stain for urine hemosiderin will be positive Urinalysis findings show evidence of blood in the urine by dipstick but no erythrocytes.
useful to treat patients in whom hypertension and gout are both clinical concerns
The angiotensin receptor blocker losartan and calcium channel blockers
the 2 autoantibodies with the greatest specificity for the diagnosis of rheumatoid arthritis
The combination of anti-cyclic citrullinated peptide antibodies and rheumatoid factor
If a patient has an ischemic stroke while on aspirin, for secondary prevention you should add this medication to aspirin
The combination of aspirin and dipyridamole has been shown to be superior to aspirin alone in reducing the risk of recurrent stroke.
Diagnosis of dengue
The diagnosis is based on clinical suspicion in a patient who traveled to an endemic area and presents with fever and other typical signs, symptoms, and laboratory abnormalities. Diagnosis is confirmed by serologic testing (IgM and IgG) or reverse transcriptase PCR. Therapy is supportive.
The distinction between dementia with Lewy bodies and Parkinson disease dementia
The distinction between dementia with Lewy bodies and Parkinson disease dementia depends on the onset of cognitive impairment relative to motor impairment. If dementia precedes, occurs concurrently with, or develops within 1 year of onset of parkinsonian motor symptoms, the diagnosis is dementia with Lewy bodies. In contrast, Parkinson disease dementia describes dementia occurring at least 1 year after a diagnosis of Parkinson disease has been well established. The parkinsonism of dementia with Lewy bodies is less responsive to levodopa than is Parkinson disease.
Manage hand-based osteoarthritis
The most appropriate management is a home-based hand exercise program for this patient with hand osteoarthritis (HOA). In addition to symptomatic treatment with acetaminophen, a home-based hand exercise program has been shown to be well tolerated and to significantly improve activity performance, grip strength, and pain in women with HOA.
Ddx of posterior mediastinal mass
The most common cause of a posterior mediastinal mass is a neurogenic tumor.
Ddx of anterior mediastinal mass
The most common cause of an anterior mediastinal mass is thymoma; other causes include lymphoma and teratoma.
Diagnose posttransplantation diabetes mellitus.
The oral glucose tolerance test is the preferred test to make a diagnosis of posttransplantation diabetes mellitus.
ALL Diagnosis
The presence of 25% lymphoblasts in the blood or bone marrow
Diagnose granulomatosis with polyangiitis
The presence of antiproteinase 3 antibodies (c-ANCA/anti-PR3) is sufficient to establish a diagnosis of granulomatosis with polyangiitis in patients with classic upper airway manifestations, pulmonary infiltrates/nodules, and urinary abnormalities consistent with glomerulonephritis.
Indications for chest tube with pleural effusion
The presence of pus, positive Gram stain, or culture in the pleural fluid, any of which are diagnostic of empyema A pleural pH less than 7.2 in a patient with suspected pleural space infection
in ADPKD patients with a family history of hemorrhagic stroke or ICA, these patients should undergo what screening
The prevalence is higher in ADPKD patients with a family history of hemorrhagic stroke or ICA; these patients should undergo screening MR angiography of the cerebral arteries if kidney function is normal, with follow-up scans at regular intervals.
Treat lateral epicondylosis (lateral epicondylitis)
The primary treatment of lateral epicondylosis is avoidance of activities that cause pain Surgical treatment is indicated only for refractory cases of epicondylosis. Patients should first be treated with appropriate conservative measures, including rest and NSAIDs. The risks of surgical intervention would be warranted in this patient only if she had not responded to all nonsurgical therapy.
the greatest influence on the prognosis in patients with diffuse large B-cell lymphoma is
The revised International Prognostic Index (r-IPI) score
distinguish critical illness myopathy from its less common counterpart critical illness neuropathy
The serum CK level is elevated, which helps to distinguish critical illness myopathy from its less common counterpart critical illness neuropathy.
Diagnose microscopic colitis
The symptoms of MC are similar to other chronic causes of nonbloody diarrhea, such as celiac disease and IBS; therefore, colonic mucosal biopsies are required for diagnosis. Lymphocytic and collagenous colitis are the two subtypes of MC, and they are distinguishable only by histology. The diagnosis of MC is made by histologic evaluation of colonic biopsies; the classic finding is intraepithelial lymphocytosis (>20 intraepithelial lymphocytes per 100 epithelial cells). In collagenous colitis, the increase in intraepithelial lymphocytes may be less pronounced than in lymphocytic colitis, and the main histologic feature is thickening of the subepithelial collagen band (usually >10 µm).
Jugular Venous Waves
The upward deflections are: the "a" (atrial contraction), "c" (ventricular contraction and resulting bulging of tricuspid into the right atrium during isovolumetric systole) and "v" = venous filling
Lambert-Eaton Myasthenic Syndrome tx
Therapy consists of treating any underlying malignancy or, in nonparaneoplastic disease, immunosuppression.
Microscopic colitis tx
Therapy for MC is based on symptom severity. Any potentially causative medication should be stopped if possible. In mild disease, antidiarrheal therapy such as loperamide or diphenoxylate can be used. In moderate disease, bismuth subsalicylate may be beneficial. In severe cases or those that do not respond to antidiarrheal agents or bismuth, budesonide is the treatment of choice. It is highly effective (response rates of ≥80%), but the risk of relapse is high once budesonide is stopped (70%-80%); many patients require long-term maintenance therapy with low-dose budesonide or an immunomodulator such as AZA. . For patients who do not respond to or do not tolerate budesonide, treatment with a bile salt binder such as cholestyramine may be effective. In severe cases, treatment with an anti-TNF agent may be needed.
Treat microscopic colitis
Therapy for microscopic colitis is based on symptom severity and may consist of withdrawal of an offending drug or administration of loperamide or diphenoxylate for mild persistent disease, bismuth subsalicylate for moderate disease, or budesonide for severe disease. Drugs that have been highly associated with microscopic colitis include aspirin, acarbose, lansoprazole, NSAIDs, ranitidine, sertraline, and ticlopidine. Celiac disease is also associated with microscopic colitis. Treatment may be as simple as drug withdrawal or treatment of celiac disease. In mild persistent disease, antidiarrheal therapy such as loperamide or diphenoxylate can be used.
Therapy for nontyphoidal Salmonella
Therapy for mild nontyphoidal Salmonella gastroenteritis should be withheld in otherwise healthy patients because treatment may increase duration of bacterial shedding.
Focal segmental glomerulosclerosis tx
Therapy is usually with glucocorticoids or calcineurin inhibitors, both at the time of initial presentation and for relapsing disease. In secondary FSGS caused by infection or drugs, treatment of the infection or removal of the offending agent may halt progression of the disease and improve symptoms. In obese patients with likely secondary FSGS, weight loss is sometimes associated with a drop in proteinuria, as is the use of ACE inhibitors or angiotensin receptor blockers (ARBs), and is the preferred initial therapy.
metastatic renal cell carcinoma treatment
These agents are categorized as vascular endothelial growth factor (VEGF) inhibitors and mammalian target of rapamycin (mTOR) inhibitors. VEGF inhibitors include bevacizumab and various VEGF tyrosine kinase inhibitors, such as sunitinib, sorafenib, pazopanib, and axitinib. The mTOR inhibitors include temsirolimus and everolimus. Most patients receive a VEGF tyrosine kinase inhibitor in the first-line setting. Those with high-risk disease, which is determined by performance status, elevated serum lactate dehydrogenase level, elevated serum calcium level, and anemia, are often treated with an mTOR inhibitor, although sunitinib is also active against high-risk disease. Agents with demonstrated activity in second-line treatment include axitinib, sorafenib, and everolimus. Bevacizumab, a monoclonal antibody directed against VEGF, can also be used with interferon alfa in first-line treatment or as a single agent in second-line or later treatment.
lab values in RMSF
Thrombocytopenia and elevated aminotransferase levels are common. The leukocyte count in RMSF may be elevated, normal, or low. When lumbar puncture is performed, CSF demonstrates a lymphocyte-predominant pleocytosis.
Diagnose thrombotic thrombocytopenic purpura
Thrombotic thrombocytopenic purpura is a clinical diagnosis that requires the presence of thrombocytopenia and microangiopathic hemolytic anemia, which is confirmed by schistocytes on the peripheral blood smear Assays for ADAMTS-13 activity and inhibitor titer are available but are best used for prognosis rather than to guide therapy, because TTP requires immediate treatment that cannot be delayed until laboratory test results are available.
1st and 2nd MCC anterior mediastinal mass
Thymoma , lymphoma, teratoma
Order what test when evaluating suspected reflex syncope triggered by : - standing, - unexplained episodes of syncope in a high-risk setting, - recurrent episodes of syncope in the absence of organic heart disease, or - recurrent episodes of syncope in the presence of heart disease when cardiac causes are excluded
Tilt-table testing it may be helpful in differentiating orthostatic hypotension from neurocardiogenic syncope
In MS, use this for the non-pharmacologic treatment of Urinary urgency/frequency
Timed voids, avoidance of caffeine
how to treat diarrhea caused by Amebiasis
Tinidazole or metronidazole
an oral agent that is FDA approved to treat moderate to severe rheumatoid arthritis in patients who have experienced an inadequate response to methotrexate
Tofacitinib
how to treat the symptoms of dry eyes which has not responded to topical lubrication or punctal plugs in patients with primary Sjögren syndrome
Topical cyclosporine
Best 3 medications for chronic migraine prevention
Topiramate Beta Blocker Valpro
Topiramate can cause a mild, usually subclinical
Topiramate can cause a mild, usually subclinical acidosis and a low serum bicarbonate level but does not affect the serum sodium level. It is also associated with kidney stones, weight loss, and acute angle-closure glaucoma.
the most efficacious in the management of severe osteoarthritis of the knee that has not responded to local and systemic treatment
Total knee replacement (TKR)
Prophylaxis when CD4 <100
Toxoplasmosis positive serologic results TMP-SMX double-strength tablet once daily
patient with CKD who is allergic to allopurinol needs to be started on
Treat hyperuricemia with febuxostat in a patient with an adverse reaction to allopurinol.
Type 1 (Hypokalemic Distal) Renal Tubular Acidosis tx
Treatment consists of potassium citrate at a dose of 1 mEq/kg/d.
ABPA tx
Treatment consists of standard asthma therapies and the lowest dose of systemic glucocorticoids that effectively controls symptoms. Antifungal agents may be warranted to reduce fungal colonization, and omalizumab may also have a role in therapy.
Morton neuroma tx
Treatment consists of using metatarsal padding, wearing broad-toed footwear, and avoiding high-heeled shoes. For patients who fail to respond to these conservative measures, a single combination lidocaine and glucocorticoid injection often provides significant pain relief. Surgical intervention is reserved for patients who fail to respond to at least 12 months of conservative therapy.
Acromioclavicular Joint Degeneration tx
Treatment includes NSAIDs and activity modification. Glucocorticoid injection may also provide short-term pain relief. Surgery is rarely indicated.
Hallux valgus deformity (bunion)
Treatment includes NSAIDs, orthotic devices, and possibly surgery.
Tarsal tunnel syndrome tx
Treatment includes activity modification, orthotics, anti-inflammatory agents, and occasionally glucocorticoid injections. Surgical decompression is reserved for patients who do not benefit from conservative measures.
anti-N-methyl-D-aspartate receptor (anti-NMDAR) antibody encephalitis tx
Treatment includes removal of the teratoma to eradicate the immune stimulus and immunosuppression with glucocorticoids or intravenous immune globulin.
PBC tx
Treatment of pruritus associated with PBC and other liver diseases is challenging. Antihistamines such as hydroxyzine can be helpful for sedation in patients who have itching that is most troublesome at night. Cholestyramine, rifampin, naltrexone, and sertraline may also be beneficial, but responses are widely variable. Patients with PBC should be assessed for consequences of long-term decreased bile acid secretion, including fat-soluble vitamin deficiencies and metabolic bone disease, with appropriate treatment as indicated. Ursodiol slows disease progression and may prevent or delay advanced disease and the need for liver transplantation. Forty percent to 50% of patients with PBC treated with ursodiol continue to have a serum ALP level greater than 1.5 times the upper limit of normal and have a worse outcome than those with treatment response. Nonresponse is more common in younger patients with PBC. Outcomes with liver transplantation for PBC are excellent. Disease recurrence after transplantation occurs in 20% of patients but only rarely causes graft failure.
chronic inflammatory demyelinating polyradiculoneuropathy tx
Treatment options include prednisone, immunosuppressive therapies, and periodic IVIG or plasmapheresis.
HBV tx
Treatment usually consists of entecavir or tenofovir. For most patients, chronic treatment is necessary unless seroconversion of HBeAg or hepatitis B surface antigen (HBsAg) is observed. Lamivudine, adefovir, and telbivudine are used less often because of development of resistance with chronic use. Pegylated interferon may be used for patients without cirrhosis who have high ALT levels, relatively low HBV DNA levels, and ability to tolerate the side effects of pegylated interferon.
Treat a patient with HIV/AIDS and disseminated Mycobacterium avium complex infection.
Treatment with clarithromycin, ethambutol, and rifabutin is recommended for disseminated Mycobacterium avium complex infection in patients with HIV/AIDS whose CD4 cell counts are less than 50/µL.
Treat an adult with severe Henoch-Schönlein purpura
Treatment with prednisone should be considered for patients who have severe Henoch-Schönlein purpura with involvement of multiple organ systems.
numerous leukocytes on the wet mount with motile organisms
Trichomonas
copious, malodorous, pale yellow or gray frothy discharge with vulvar itching, burning, and postcoital bleeding
Trichomoniasis The most appropriate additional intervention in this patient is to treat her partner
Indications for tricuspid valve replacement in tricuspid regurgitation
Tricuspid valve repair if anatomy favorable Tricuspid valve replacement (bioprosthetic)
treatment of cyclic vomiting syndrome
Tricyclic antidepressants
Diagnose trigeminal neuralgia.
Trigeminal neuralgia typically results in brief episodes of lancinating pain affecting either the second or third distribution of the trigeminal nerve (cranial nerve V2 or V3); the pain can occur spontaneously or be triggered by sensory stimulation of the face or mouth.
how to treat diarrhea caused by Cyclospora
Trimethoprim-sulfamethoxazole
______ are used in migraine patients not responding to one or more NSAID
Triptans
which 2 antipsychotics are the least likely to cause tardive dyskinesia
Typical and most atypical antipsychotic agents can cause tardive dyskinesia. The main exceptions are quetiapine and clozapine.
Eighty percent of patients with primary sclerosing cholangitis have
UC, and need a colonoscopy
choice of breast imaging for pregnant patients in order to avoid radiation exposure
Ultrasonography
Imaging order for nephrolithiasis workup
Ultrasonography and noncontrast helical CT of the abdomen are testing options for evaluation of suspected nephrolithiasis; CT is indicated if initial ultrasound testing is negative in a patient with a high clinical suspicion for kidney stones. However, ultrasonography is less sensitive than CT for detecting kidney stones in the distal ureter or for evaluating other potential nonurologic conditions that may be responsible for the pain. Given this patient's clinical picture that is consistent with nephrolithiasis but with a negative ultrasound for kidney stones, further imaging with noncontrast helical abdominal CT is indicated. Additionally, the absence of hydronephrosis on ultrasound does not rule out nephrolithiasis.
the preferred diagnostic imaging modality for pregnant patients with suspected nephrolithiasis
Ultrasonography is the preferred diagnostic imaging modality for pregnant patients with suspected nephrolithiasis because it does not expose patients to radiation.
most cost-effective study to detect the presence of ascites
Ultrasound should be followed by diagnostic paracentesis when ascites is present. Ascitic fluid analysis should include measurement of albumin and total protein; cell count and bacterial cultures should be checked when infection is suspected.
surveillance upper endoscopy in a patient with familial adenomatous polyposis
Upper endoscopy is recommended for surveillance of duodenal cancer every 1 to 5 years in all patients with familial adenomatous polyposis.
preferred initial diagnostic test for suspected esophageal cancer
Upper endoscopy with biopsy
which kidney stones are radiolucent on plain radiograph but are visualized on CT scan or ultrasound.
Uric acid stones
Urine Anion Gap
Urine Sodium + Urine Potassium - Urine Chloride
Screen all patients for CKD with
Urine albumin excretion measurement is appropriate for this patient with risk factors for chronic kidney disease (CKD).
Urine phosphate excretion is greater than _____ or an FEPO4 greater than ____ indicates renal phosphate wasting
Urine phosphate excretion >100 mg/d or an FEPO4 >5% indicates renal phosphate wasting.
unilateral eye pain, photophobia, and ciliary flush; it is commonly associated with autoimmune disorders, arthritides associated with HLA-B27 antigen, infection, malignancy, and sarcoidosis
Uveitis
Diagnosis of moderate aortic regurgitation
VC 0.3-0.6 cm, ERO 0.10-0.29 cm2, RV 30-59 mL/beat, RF 30%-49%
Diagnosis of mild aortic regurgitation
VC <0.3 cm, ERO <0.10 cm2, RV <30 mL/beat, RF <30%); normal EF
Diagnosis of mild\moderate mitral regurgitation
VC <0.7 cm, ERO <0.40 cm2, RV <60 mL/beat, RF <50%
Diagnosis of severe aortic regurgitation
VC >0.6 cm, ERO >0.3 cm2, RV ≥60 mL/beat, RF ≥50%
Diagnosis of severe mitral regurgitation
VC ≥0.7 cm, ERO ≥0.4 cm2, RV ≥60 mL/beat, RF ≥50%
________ therapy is effective in treating women who have moderate to severe symptoms of genitourinary syndrome of menopause that have not responded to lubricants
Vaginal estrogen
Non-fulminant C Diff 1st occurrence tx
Vancomycin 125 mg orally four times daily for 10 days, OR Fidaxomicin 200 mg orally twice daily for 10 days If above agents are unavailable: Metronidazole 500 mg orally three times daily for 10 days¶
Non-fulminant C Diff 2nd reoccurrence tx
Vancomycin pulsed-tapered regimen (outlined above), OR Fidaxomicin 200 mg orally twice daily for 10 days, OR Vancomycin followed by rifaximin: Vancomycin 125 mg orally four times per day for 10 days, then Rifaximin 400 mg three times daily for 20 days, OR Fecal microbiota transplantationΔ
__________ is more effective in achieving smoking cessation than bupropion or single-agent nicotine replacement therapy but not more effective than combination nicotine replacement therapy
Varenicline
Live vaccines
Varicella, Influenza, Herpes Zoster, MMR
Diagnose ventilator-induced lung injury
Ventilator-induced lung injury is most likely to occur when the tidal volume and/or plateau pressure are too high; tidal volume should be limited to 6 mL/kg of ideal body weight and plateau pressure less than 30 cm H2O.
Normal Pressure Hydrocephalus tx
Ventriculoperitoneal shunt placement is the standard of care for NPH. Large-volume lumbar puncture or a lumbar drainage trial with cognitive and motor testing and symptom assessment before and after testing can be used to evaluate potential response to shunting.
Classification of COPD Severity by Spirometry (In Patients with FEV1/FVC <70%), GOLD Stage 4
Very severe FEV1 <30% of predicted
characterized by acute, severe, and persistent nonpositional peripheral vertigo, usually following a viral upper respiratory tract infection
Vestibular neuronitis
Gastrointestinal infections caused by ________are associated with ingestion of contaminated seafood, particularly shellfish, and can be severe in patients with liver dysfunction.
Vibrio species
Patients with iron overload syndromes, including those with hereditary hemochromatosis, are at risk for
Vibrio vulnificus infection is associated with ingestion of raw seafood, especially oysters, and the risk of sepsis and death is increased in persons with hereditary hemochromatosis
Patients who are immunocompromised, particularly those with liver disease, are at increased risk for infection with
Vibrio vulnificus, a curved gram-negative bacilli Guideline recommendations for the management of these infections include antibiotic therapy with doxycycline plus ceftazidime in addition to surgery.
Contact with salt water or brackish water or contact with drippings from raw seafood
Vibrio vulnificus, other Vibrio species May cause cellulitis through direct inoculation into skin or may be ingested, leading to bacteremia with secondary skin infection Hallmark is hemorrhagic bullae in area of cellulitis
________ is now suggested for all patients with MS to reduce the accumulation of new lesions on MRI
Vitamin D supplementation
Diagnosis of moderate aortic stenosis
Vmax 3.0-3.9 m/s or mean gradient 20-39 mm Hg
Diagnosis of severe aortic stenosis
Vmax ≥4 m/s or mean gradient ≥40 mm Hg, AVA ≤1.0 cm2
Diagnosis of very severe aortic stenosis
Vmax ≥5 m/s or mean gradient ≥60 mm Hg
Treatment of Invasive aspergillosis
Voriconazole
ARDS vent settings
Vt= 6mL/kg of IBW Plateau =< 30 cm H2O PaO2 55-80
Anticoagulation in pregnancy for mechanical valve prosthesis
Weeks 6-12 -Warfarin dose ≤5 mg for therapeutic INR -Continue warfarin (class IIa) -UFH: IV; aPTT 2 × control (class IIb) -Anti-factor Xa adjusted LMWH (class IIb) -Warfarin dose >5 mg for therapeutic INR -UFH: IV; aPTT 2 × control (class IIa) -Anti-factor Xa adjusted LMWH (class IIa) Weeks 13-37 -Warfarin (therapeutic INR) Weeks 37 to term -UFH (IV; aPTT 2 × control)
Anticoagulation in pregnancy for VTE
Weeks 6-12: -Warfarin (if dose to attain INR 2-3 is ≤5 mg) -UFH (IV or SQ; aPTT 2 × control) -Weight-based LMWH Weeks 13-37: -UFH (SQ; aPTT 2 × control) -Weight-based LMWH -Warfarin (INR 2-3) Weeks 37 to term: -UFH (IV; aPTT 2 × control)
Anticoagulation in pregnancy for Atrial Fibrillation
Weeks 6-12: -Warfarin (if dose to attain INR 2-3 is ≤5 mg) -UFH (IV or SQ; aPTT 2 × control) -Weight-based LMWH Weeks 13-37: -UFH (SQ; aPTT 2 × control) -Weight-based LMWH -Warfarin (INR 2-3) Weeks 37 to term: -UFH (IV; aPTT 2 × control)
Diseases associated with c-ANCA
Wegeners (granulomatosis with polyangiitis)
Fever, headache, and focal limb weakness following outdoor activities suggest
West Nile neuroinvasive disease, and the most appropriate diagnostic test is for West Nile virus antibodies within cerebrospinal fluid.
the postexposure prevention of choice for varicella infection in patients with contraindication to varicella vaccination
When administered within 3 to 5 days of exposure, the varicella vaccine has proved beneficial in preventing infection and diminishing disease severity in susceptible persons when infection occurs. However, this is a live-attenuated vaccine and is contraindicated in patients who are immunocompromised or taking immunosuppressive therapies, as well as in pregnant women.
Fulminant C Diff criteria
White blood cell count >15,000 and serum creatinine ≥1.5 mg/dL and one of the following shock ileus megacolon
______ should be considered in all patients younger than 40 years of age who have unexplained liver disease
Wilson disease Diagnose Wilson disease presenting as acute liver failure.
Osteoporosis screening
Women 65 and older or younger women with 10 year fracture risk is >= 9.3%
Patellofemoral Syndrome
Women > Men Poorly localized anterior pain Pain reproduced with patellar compression during extension
HPV screening
Women age 21-65. Every 3 years. Once they turn 30 they can go every 5 years if pap + HPV testing.
candidates for breast cancer prophylaxis
Women older than 35 years with a 5-year breast cancer risk of 1.7% or higher or with lobular carcinoma in situ or atypical ductal hyperplasia
American Cancer Society Recommendations for MRI Breast Cancer Screening
Women with BRCA1/2 mutations Women who are a first-degree relative of a BRCA1/2 carrier, but are untesteda Women with a strong family history of breast cancer with a lifetime breast cancer risk of ≥20% to 25% as calculated by modelsb largely dependent on family history Women who had radiation to the chest wall between ages 10 and 30 years (e.g., mantle radiation therapy for Hodgkin lymphoma) Women with a history of other rare familial breast cancer syndromes
Patient's elbow is flexed to 90 degrees with thumb pointing up. Examiner grasps wrist and attempts to resist active supination and elbow flexion by patient. Positive test: Pain
Yergason Positive test: Pain (suggests bicipital tendinitis)
gastroenteritis associated with consumption of chitterlings (pork intestines)
Yersinia enterocolitica
The patient has bone metastases from breast cancer and should be started on
Zoledronic acid infused every three months
reducing skeletal-related events in patients with bone metastases from breast cancer, prostate cancer, or multiple myeloma is done by
Zoledronic acid infused every three months
The main factors that distinguish a cardiac source for ascites from other sources are
a SAAG of 1.1 g/dL (11 g/L) or greater and an ascitic fluid total protein level of 2.5 g/dL (25 g/L) or greater.
Patients who take bisphosphonates or denosumab should receive
a baseline dental evaluation, schedule regular dental appointments during treatment, maintain good oral hygiene, and report any jaw pain or areas of poor gingival healing.
Treat prostate cancer metastatic to bone with
a bisphosphonate and radiopharmaceutical agent radium-223 External-beam radiation to metastatic sites can be considered for treatment of patients with spinal cord compression or for those with focal symptomatic bone metastases,
should be performed in all patients with syncope.
a careful history and physical examination including measurement of orthostatic vital signs, electrocardiography
Platelet clumping signifies pseudothrombocytopenia, which will resolve if blood is redrawn using
a citrated or heparinized tube.
Treat acute kidney injury in the context of cirrhosis with
a colloid fluid challenge Acute kidney injury occurs in approximately 20% of hospitalized patients with cirrhosis; such patients should receive a fluid challenge (usually with 25% albumin) to evaluate fluid responsiveness before hepatorenal syndrome can be diagnosed. After stopping diuretics and lactulose, the best initial treatment is intravenous colloid administration, usually in the form of 25% albumin, administered at 1 g/kg body weight per day in divided doses.
Patients with HER2-positive breast tumors measuring 0.5 cm, or larger and/or positive lymph nodes, should receive
a combination of adjuvant chemotherapy and trastuzumab
The preoperative staging workup for colon cancer should include
a complete colonoscopy (if technically feasible) and contrast-enhanced CT scans of the chest, abdomen, and pelvis. Preoperative measurement of serum carcinoembryonic antigen (CEA) levels is also routinely done. Patients with local or locoregional rectal cancer require further preoperative staging with endorectal ultrasonography or a pelvic MRI to assess the depth of tumor penetration (T stage), degree of lymph node involvement (N stage), and any metastasis (M stage).
A hallmark feature of upper extremity peripheral arterial disease on physical examination is
a difference in systolic blood pressures between the arms (typically >15 mm Hg).
gliptin
a dipeptidyl peptidase-4 inhibitor, reduces the removal of incretin, thereby inhibiting glucagon release and increasing insulin secretion. Sitagliptin may be used as a second-line agent in patients with diabetes when glycemic goals are not met with lifestyle modifications and metformin; however, its use is contraindicated in the setting of severe kidney dysfunction (creatinine clearance <50 mL/min/1.73 m2)
All patients with metastatic melanoma should have their tumor tested for the presence of
a driver V600 BRAF mutation. If this mutation is present in patients with poor prognostic features, treatment with a BRAF inhibitor is recommended as initial therapy. Chemotherapy with dacarbazine, the only chemotherapeutic agent approved for treatment of metastatic melanoma, has a response rate of only 7% to 12% and has not been shown to improve overall survival. It is usually reserved for patients who are not candidates for high-dose interleukin-2 (IL-2), ipilimumab, or BRAF inhibitor therapy. High-dose interferon alfa is used as adjuvant therapy for patients with nonmetastatic melanoma who are at high risk for recurrence but is inferior to other immunotherapy options, including ipilimumab and high-dose IL-2, for patients with metastatic melanoma. In patients with metastatic melanoma, treatment with ipilimumab improves overall survival. However, the response to ipilimumab can be delayed and there can be transient worsening of disease initially. In patients with poor prognostic features and a BRAF V600 mutation, the more rapid response of a BRAF inhibitor is preferred. If this patient's melanoma does not have a driver BRAF mutation, then treatment with ipilimumab would be offered.
Most patients with ischemic stroke will arrive beyond the stated windows for intravenous thrombolysis. For most of these patients, aspirin is appropriate, but only after
a dysphagia evaluation documenting the ability to safely swallow. In those unable to swallow, a rectal formulation of aspirin is available.
For patients with autosomal dominant polycystic kidney disease, screening for intracranial cerebral aneurysms using MR angiography is only recommended for those with
a family history of aneurysm or subarachnoid hemorrhage, those with a previous rupture, or those with high-risk occupations in which a rupture would affect the lives of others.
Women being treated for breast cancer who wish to preserve fertility should be referred to
a fertility specialist to discuss embryo cryopreservation or other fertility preservation methods before adjuvant chemotherapy is initiated.
consider a noncontrast head CT in patients with TBI who have had no loss of consciousness or posttraumatic amnesia but have one of the following
a focal neurologic deficit, vomiting, severe headache, physical signs of a basilar skull fracture, Glasgow Coma Scale score less than 15, coagulopathy, dangerous mechanism of injury, such as ejection from a motor vehicle or a falling from a height of more than 3 feet.
Treat adenocarcinoma of unknown primary site predominantly below the diaphragm in the same manner as
a gastrointestinal malignancy. Platinum-based chemotherapy regimens such as carboplatin plus paclitaxel or cisplatin plus etoposide would be reasonable for treating patients with a poorly differentiated cancer of unknown primary site (CUP), such as a germ cell (testicular) tumor.
The most common clinical manifestation of secondary syphilis is
a generalized rash that is typically nonpruritic and often involves the palms and soles Lesions can coalesce in intertriginous areas to form plaques (condyloma lata), and superficial erosions may occur on mucosal surfaces (mucous patches). Fever, malaise, and generalized lymphadenopathy are common.
Patients with tuberculous meningitis should receive
a glucocorticoid in addition to antituberculous therapy. The recommended dose of dexamethasone is 12 mg/d for 3 weeks, with gradual tapering during the following 3 weeks. Some experts use prednisone instead of dexamethasone, and others recommend a slightly longer duration of glucocorticoid therapy (approximately 8 weeks). The recommendations for duration of treatment of extrapulmonary tuberculosis are generally the same as for pulmonary tuberculosis (6-9 months). However, the recommended treatment duration for tuberculous meningitis is longer (9-12 months), with the exact duration determined by response to therapy and antibiotic sensitivities of the isolate.
Cardiac catheterization should be reserved for patients with high-risk features on exercise stress testing, such as
a high-risk Duke treadmill score (below −11), hypotension severe ST-segment depression, early-onset angina.
First step in patients with apparent malignant superior vena cava syndrome
a histologic diagnosis should be established, whenever possible, before treatment is begun. Mediastinoscopy is routinely used to obtain tissue biopsy samples for histologic diagnosis. Percutaneous transthoracic CT-guided needle biopsy appears to be a safe alternative to mediastinoscopy and has a sensitivity of 75%.
Use caution in nuc (vasodilators) stress test in patients with
a history of COPD but are contraindicated in a patient who is actively wheezing.
The diagnosis of lupus nephritis, suggested by proteinuria (>500 mg/24 h) or cellular casts (erythrocytes or leukocytes) in the urine sediment, must be confirmed and classified with
a kidney biopsy
SPN definition
a lesion less than 3 cm in size surrounded by normal lung parenchyma
Bartter syndrome mimics the effect of
a loop diuretic and is accompanied by increased urine sodium (>40 mEq/L [40 mmol/L]), urine potassium (>40 mEq/L [40 mmol/L]), and chloride excretion (>40 mEq/L [40 mmol/L]).
Patients with CKD and hyperphosphatemia should be counseled regarding
a low phosphate diet, and most patients require phosphate binders.
When the suspicion of a subarachnoid hemorrhage is high and the noncontrast CT scan of the head is normal, ______ is required
a lumbar puncture is required to evaluate the cerebrospinal fluid for erythrocytes or xanthochromia. Once SAH has been ruled out, MRA may be needed to exclude other arterial causes, such as cervicocephalic arterial dissection.
Glucocorticoids are not effective for maintaining remission in UC. Therefore, in patients whose disease responds to glucocorticoids, the dose should be tapered over 2 to 4 months while transitioning to
a maintenance medication (AZA, 6-MP, or a biologic agent).
. Status migrainosus is defined as
a migraine attack extending beyond 72 hours and is the most common complication of acute migraine. The condition is characterized by persistent severe pain that often is accompanied by protracted nausea with vomiting and profound sensory sensitivities
Risk factors for progression of monoclonal gammopathy of undetermined significance to multiple myeloma include
a non-IgG M protein, an M protein level of at least 1.5 g/dL, and an abnormal serum free light chain ratio.
Exercise electrocardiographic testing is recommended as the initial test of choice in patients with
a normal baseline electrocardiogram and an intermediate pretest probability of coronary artery disease based on age, sex, and symptoms.
clinical criteria for diagnosing vascular neurocognitive disorder require evidence of a cognitive disorder plus
a previous clinical stroke or neuroimaging evidence that confirms the existence of cerebrovascular disease.
The typical clinical presentation of typhoid fever is
a progressively rising fever accompanied by abdominal pain, initial constipation followed by diarrhea, relative bradycardia; tender hepatosplenomegaly is common.
Use of pirfenidone in the treatment of idiopathic pulmonary fibrosis is associated with
a reduction in the rate of decline in forced vital capacity in patients with mild and severe disease.
All patients on scheduled opioid therapy should be prescribed
a scheduled stimulant laxative. such as senna
In patients with aggressive breast cancer who develop severe arthralgia while on antiestrogen therapy due to an aromatase inhibitor, you should initiate a
a second aromatase inhibitor should be tried; if the arthralgia fails to resolve, tamoxifen should be started.
Patients with an elevated alkaline phosphatase level in the absence of other abnormal liver chemistry test results should undergo measurement of
a serum γ-glutamyl transferase level or fractionation of alkaline phosphatase isoenzymes to confirm a hepatic cause.
out-patient treatment of status migrainosus
a several-day course of oral glucocorticoids
Delayed hyperhemolytic transfusion reaction can occur several days after transfusion and is diagnosed by
a significant decrease in the hemoglobin level with reticulocytosis and concomitant increases in the bilirubin and lactate dehydrogenase levels.
Closure of a VSD is generally indicated when there is
a significant shunt (Qp:Qs ratio is 2.0 or greater), and there is evidence of left ventricular volume overload; an additional indication for closure is a history of endocarditis.
Once the presence of dementia has been confirmed, a what imaging do you order
a structural neuroimaging study (MRI or CT scan) should be obtained to evaluate for nondegenerative causes that would alter management, such as cerebrovascular disease, neoplasm, subdural hematoma, or hydrocephalus.
A dissection involving the ascending aorta (Stanford type A) is
a surgical emergency
fever of unknown origin (FUO), defined as
a temperature greater than 38.3 °C (100.9 °F) for at least 3 weeks that remains undiagnosed after two visits in the ambulatory setting or 3 days of in-hospital assessment When a patient has been reasonably evaluated (laboratory studies, repeat blood cultures, imaging studies) for ongoing fever, a diagnosis of fever of unknown origin should be reached and the patient should be observed in case further interventions would be appropriate later.
Definitive diagnosis of Aspergillus sinusitis requires
a tissue biopsy demonstrating hyphae and a positive culture for Aspergillus, and use of the galactomannan antigen immunoassay to detect galactomannan in serum has a high sensitivity and specificity in patients at high risk. The appearance of septate hyphae with acute angle branching on histopathologic testing can be diagnostic. The galactomannan assay is an important non-culture-based tool for the diagnosis of invasive aspergillosis. Detection of galactomannan in serum has a high sensitivity and specificity in patients at high risk; galactomannan can also be detected in cerebrospinal fluid specimens from patients with CNS aspergillosis and in bronchoalveolar lavage fluid from those with invasive pulmonary aspergillosis. It is useful in early detection and in therapeutic monitoring. Voriconazole is the therapy of choice for most patients with invasive aspergillosis because of its potent fungicidal activity against Aspergillus species. Culture confirmation is important to distinguish Aspergillus from other filamentous fungal infections.
In patients with acute knee pain, plain radiographs are generally needed only if
a traumatic fracture is suspected.
In patients with inadequately controlled rheumatoid arthritis who are taking methotrexate, the addition of __________ is appropriate to improve signs and symptoms of disease.
a tumor necrosis factor α inhibitor (etanercept)
Acute meniscal tears occur from
a twisting of the knee when the foot is planted and the knee is flexed.
The Fanconi syndrome is characterized by
a type 2 (proximal) renal tubular acidosis with urine loss of bicarbonate as well as phosphaturia, glucosuria, and aminoaciduria.
Aortic valve replacement is recommended in asymptomatic patients with severe aortic valve stenosis, generally defined as
a valve area below 1 cm2
Patients with type 1 hepatorenal syndrome should be treated with
a vasoconstrictor and albumin recommendations state that patients in the ICU with type I hepatorenal syndrome should be treated with norepinephrine and albumin, whereas patients on the general ward should be treated with midodrine, octreotide, and albumin. Patients with type I hepatorenal syndrome who do not respond to medical therapy and are suitable candidates should undergo liver transplantation with or without simultaneous kidney transplantation, depending on the duration of kidney dysfunction. Patients with type 1 hepatorenal syndrome who do not receive therapy usually die within weeks.
The classic presentation of eosinophilic esophagitis is
a young man with solid-food dysphagia that requires endoscopy for removal.
Treatment of Candidemia
aAnidulafungin, caspofungin, or micafungin; alternatives: Fluconazole, voriconazole, lipid formulation of amphotericin B
Mononeuritis multiplex is characterized by
abnormal findings in the territory of two or more nerves in separate parts of the body and is highly specific for vasculitis but can occur in systemic inflammatory disorders such as systemic lupus erythematosus.
Fever accompanying abdominal pain in a critically ill patient should prompt an assessment for
acalculous cholecystitis (acute cholecystitis without gallstones).
An NSAID should be initiated in patients with osteoarthritis if first-line therapy with ________ does not provide adequate relief.
acetaminophen
In patients with osteoarthritis, initial treatment with ________ for pain control is generally recommended.
acetaminophen
Hemophila A&B produce a prolonged
activated partial thromboplastin time that fully corrects in a mixing study.
High-risk gastric ulcers are characterized by
active arterial spurting or a nonbleeding visible vessel;
In patients with gout, continuation of flare prophylaxis and urate-lowering therapy is currently indicated if there is any evidence of
active disease, including flares or tophi.
Bupropion is contraindicated in patients with
active eating disorders or a history of seizures, and it may destabilize mood in patients with bipolar disorder
synovial fluid analysis with crystals within neutrophils
active gout
Patients with chronic kidney disease and normal calcium and phosphorus levels should be treated with
active vitamin D analogues to reduce elevated parathyroid hormone levels and prevent renal osteodystrophy.
cauda equina syndrome, characterized by
acute low back pain, radicular features, saddle anesthesia, urinary retention, absence of reflexes, and decreased anal tone. However, all of these features are uncommonly present early in the syndrome. For example, pain is the most common early symptom and may precede other neurologic findings; bowel and bladder dysfunction are usually late manifestations and do not occur in all patients
positive Thessaly and medial-lateral grind tests on examination
acute meniscal injuries
Orlistat may be a cause of acute kidney injury by triggering
acute oxalate nephropathy, particularly in patients with volume depletion or chronic kidney disease.
The only clear indication for an IVC filter is
acute pelvic or proximal leg DVT who cannot undergo anticoagulation because of active bleeding or a very high bleeding risk.
Patellofemoral Pain Syndrome Treatment is
addressing the underlying disorder, activity modification, and physical therapy NSAIDs, acetaminophen, bracing, and patellar taping all have limited efficacy.
The CDC has established three criteria that must be met to establish a patient as no longer infectious with TB:
adequate treatment for tuberculosis for greater than 2 weeks; improvement of symptoms; and three consecutive negative sputum smears (collected at 8- to 24-hour intervals, including one early-morning collection).
how can you tell when active TB is no longer contagious
adequate tuberculosis treatment for at least 2 weeks demonstrate improvement of symptoms have three consecutive negative sputum smears
Management of uric acid nephrolithiasis
adequate urine output, urine alkalinization, and xanthine oxidase inhibitors if needed to decrease uric acid production. Preventive measures include maintaining urine output >2 L/24 h and urine alkalinization to a pH of 6.1 to 7.0. Xanthine oxidase inhibitors (such as allopurinol) may be used in patients with hyperuricosuria (>1000 mg/24 h [59 mmol/d]) and patients without hyperuricosuria who have recurrent uric acid stones despite other treatments.
The response to obstructive sleep apnea treatment is dependent on
adherence to continuous positive airway pressure (CPAP) therapy; the level of adherence to therapy can be established by downloading and reviewing data from the CPAP device.
decreased range of motion and pain with shoulder movement in all directions. On examination, there is loss of both active and passive range of motion with all cardinal shoulder movements and tenderness at the insertion of the deltoid tendon
adhesive capsulitis
In patients with estrogen receptor-positive DCIS,________ decreases the risk of local recurrence of both DCIS and invasive cancer by 20% to 25% and of contralateral breast cancer by 50%, but it does not confer a survival advantage.
adjuvant tamoxifen
characterized by high spiking fevers, arthritis, rash, high neutrophil counts, and markedly elevated serum ferritin
adult-onset Still disease iagnosis is clinical, based on exclusion of infection, malignancy, or other rheumatologic diseases.
When to screen for lipid disorders
ag 35 in men, age 45 in women. Start in age 20 for anyone at increase risk for cardiovascular event
Criteria effective for distinguishing giant cell arteritis from other vasculitides include
age >50, localized new-onset headache, erythrocyte sedimentation rate >50 mm/h, and temporal artery tenderness.
Patients with lower gastrointestinal bleeding do not require hospitalization when they meet four criteria
age less than 60 years, no hemodynamic instability, no evidence of gross rectal bleeding, and identification of an obvious anorectal source of bleeding on rectal examination or sigmoidoscopy.
risk factors for statin-associated adverse effects
age older than 75 years, chronic kidney disease, and use of a medication known to interact with statins (diltiazem
Most patients with class III lupus nephritis and all patients with class IV lupus nephritis benefit from
aggressive combination immunosuppressive therapy. Glucocorticoids plus either cyclophosphamide or mycophenolate mofetil
UOP rate for tx of rhabdo
aggressive intravenous isotonic fluid resuscitation, correction of the underlying cause, and maintenance of urine output >300 mL/h
Pill-induced esophagitis is characterized by chest pain, dysphagia, and odynophagia and has been associated with what pills
alendronate, quinidine, tetracycline, doxycycline, potassium chloride, ferrous sulfate, and mexiletine.
Type 2 (Proximal) Renal Tubular Acidosis tx
alkali replacement with the addition of a thiazide diuretic, which causes mild volume depletion that enhances the proximal reabsorption of sodium and bicarbonate.
Treatment of RTA 2
alkali replacement with the addition of a thiazide diuretic.
When to screen for HCV
all adults 1945-1965
Herpes zoster
all nonimmunocompromised persons >=60y
all patients with stages 1 through 5 chronic kidney disease not on dialysis be treated with _______ therapy independent of their cholesterol levels.
all patients with stages 1 through 5 chronic kidney disease not on dialysis be treated with statin therapy independent of their cholesterol levels.
When to screen for chlamydia
all sexually active women =<24y
When to screen for gonorrhea
all sexually active women at increased risk
Pulmonary Rehab indications in COPD
all symptomatic patients with an FEV1 less than 50% of predicted and specifically for those hospitalized with an acute exacerbation of COPD
how to work up white coat hypertension
ambulatory blood pressure monitor
Struvite stones are composed of magnesium ammonium phosphate and occur only when
ammonium production is increased, which elevates the urine pH and decreases the solubility of phosphate.
Treat Helicobacter pylori infection In patients with prior exposure to macrolide antibiotics or those in areas with clarithromycin resistance rates of 15% to 20% or higher
amoxicillin, levofloxacin, and omeprazole clarithromycin should be avoided in treatment regimens to eradicate Helicobacter pylori. The American College of Gastroenterology guidelines recommend asking patients with H. pylori infection about prior macrolide antibiotic use for any reason.
Patients with amyloidosis should undergo
amyloid typing of amyloid deposits to further classify the type of amyloidosis present.
In patients in whom testing for FVL is indicated, the presence of FVL can be detected by
an APC resistance assay that assesses the ability of protein C to inactivate factor Va.
Pulmonary rehabilitation is recommended for all symptomatic patients with COPD who have
an FEV1 less than 50% of predicted and specifically for those hospitalized with an acute COPD exacerbation; it may also be considered for symptomatic or exercise-limited patients with an FEV1 greater than or equal to 50% of predicted. According to the 2017 GOLD guidelines, all patients with group B, C, or D stage COPD should enroll in a pulmonary rehabilitation program.
In patients with severe acute respiratory distress syndrome, use a positive end-expiratory pressure level that achieves adequate oxygenation with an FIO2 of less than
an FIO2 of less than 0.6 and does not cause hypotension.
AL amyloidosis is diagnosed by
an abdominal fat pad aspirate and bone marrow biopsy in most cases
Decision-making capacity exists when a patient demonstrates
an ability to understand relevant information, appreciate the situation and its possible consequences, manipulate information rationally, and make a reasoned choice.
parkinsonian-hyperpyrexia syndrome
an acute syndrome resembling neuroleptic malignant syndrome caused by sudden withdrawal of dopaminergic medications
Following response to acute treatment, patients with a single episode of unipolar major depression should continue antidepressants for
an additional 6 months Patients with an increased risk of recurrence should be maintained on antidepressants for at least an additional 1-3 years to reduce risk of relapse and can also consider continuing treatment indefinitely. Those with a history of highly recurrent illness (eg, ≥3 lifetime depressive episodes), chronic episodes (≥2 years), or severe episodes (eg, suicide attempts) are particularly good candidates for maintaining antidepressant treatment indefinitely.
If Helicobacter pylori infection is not eradicated with primary therapy, a second-line salvage therapy should contain
an alternative antibiotic to clarithromycin, and the treatment should be at least 10 days in duration to maximize the likelihood of treatment success Two universally recommended second-line therapies are (1) a 10- to 14-day course of bismuth subsalicylate, metronidazole, tetracycline, and a proton pump inhibitor (PPI), or (2) a 10-day course of levofloxacin, amoxicillin, and a PPI.
glutide
an analog of human glucagon-like peptide 1, patients with suboptimally controlled type 2 diabetes mellitus (hemoglobin A1c ≥7%) and high cardiovascular risk, patients randomized to receive liraglutide had a significantly lower risk for the primary outcome of first occurrence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke
Confirm a flare of systemic lupus erythematosus with
an anti-double-stranded DNA antibody measurement. Anti-double-stranded DNA antibodies correlate with systemic lupus erythematosus disease activity, particularly active kidney disease or glomerulonephritis.
Treat Crohn disease in a pregnant patient
an anti-tumor necrosis factor
Patients with estrogen receptor-positive breast cancer who develop metastases limited to bone after a long disease-free interval should be treated initially with
an aromatase inhibitor (anastrozole)
For women who are postmenopausal at breast cancer diagnosis or who become postmenopausal after the first 2 to 3 years of tamoxifen therapy, treatment should include
an aromatase inhibitor.
in a patient with suspected gastroesophageal reflux disease Evaluate chest pain with
an exercise stress test Although gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain, a cardiac evaluation should be considered to rule out cardiac causes before initiating treatment for GERD.
Cervicitis is characterized by
an inflamed, friable cervix and should be treated with ceftriaxone and azithromycin.
In patients taking In patients taking _____ as a disease-modifying therapy for multiple sclerosis, serum aminotransferase levels should be measured every 3 to 6 months to monitor for autoimmune hepatitis.
an interferon beta
asthma dx on spirometry
an obstructive pattern and a significant bronchodilator response (200 mL and 12% increase in FEV1)
Patients with acute pyelonephritis who do not require hospitalization should begin empiric treatment with
an oral fluoroquinolone, such as ciprofloxacin.
Treat a postmenopausal patient with estrogen receptor-positive and progesterone receptor-positive ductal carcinoma in situ following lumpectomy and radiotherapy with
anastrozole
Men who have a persistently elevated serum prostate-specific antigen level immediately following surgery for prostate cancer have a high likelihood of harboring distant metastatic disease and should be started on
androgen deprivation therapy.
According to recent new guidelines, magnetic resonance angiography of the brain is recommended for patients with a family history of
aneurysm
In patients with active overt gastrointestinal bleeding, the treatment is
angiography because it can identify bleeding and allows for therapeutic intervention with embolization.
Women who received chest wall radiation (such as mantle radiation therapy for Hodgkin lymphoma) between the ages of 10 and 30 years are at high risk for developing breast cancer and should be screened with
annual mammograms and breast MRIs.
If the aortic root or ascending aortic diameter is greater than 4.5 cm, reimaging should be performed
annually
Diagnose patellofemoral pain syndrome.
anterior knee pain that is slow in onset and typically made worse with running, climbing stairs, and prolonged sitting. On examination, there is frequently increased patellar laxity with medial and lateral displacement. Additionally, pain may be reproduced when posteriorly directed pressure is applied to the patella. Treatment is often challenging but generally consists of addressing any identified underlying causes (such as deconditioning), activity modification, and physical therapy.
Autoantibodies associated with CREST
anti centromere
Autoantibodies associated with pemphigus vulgaris
anti desmoglein
Autoantibodies associated with celiac disease
anti endomysial, anti tissue transglutaminase
Autoantibodies associated with DM1
anti glutamic acid decarboxylase (GAD-65)
Autoantibodies associated with drug induced lupus
anti histone
Autoantibodies associated with pernicious anemia
anti parietal cell
Autoantibodies associated with membranous nephropathy
anti phospholipase A2 receptor
On kidney biopsy, there is a proliferative GN, often with many crescents. There is linear deposition of immunoglobulin (usually IgG) along the GBM by immunofluorescence, but electron microscopy does not show electron-dense deposits.
anti-GBM antibody
Neonatal congenital heart block affects approximately 2% of pregnancies in which the mother is positive for anti-
anti-Ro/SSA or anti-La/SSB antibodies.
Prevent chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation with
anti-T-lymphocyte immune globulin
Autoantibodies associated with goodpasture syndrome
anti-basement
Pes anserine bursitis tx
anti-inflammatory medications and application of ice as well as avoidance of direct pressure, squatting, and overuse. If conservative measures are ineffective, glucocorticoid injection may be considered.
Autoantibodies associated with autoimmune hepatitis
anti-smooth muscle
test preferred for West Nile virus meningitis
antibody detection in CSF
CREST syndrome
anticentromere antibody
tx for Parkinson's patients with prominent tremor
anticholinergic medications may provide some additional benefit, but their high adverse effect profiles limit their use, especially in patients with cognitive impairment and in older patients.
In a terminally ill patient, feelings of guilt, hopelessness, helplessness, and worthlessness may distinguish depression from
anticipatory grief
When valve replacement is indicated, a bioprosthesis is preferred in patients of any age for whom
anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired.
pregnant Patients with antithrombin deficiency should receive
anticoagulant therapy throughout her pregnancy and for 6 weeks postpartum
In patients with metastatic brain tumors and one or more seizures, which are the best AEDs
antiepileptic drug regimens that do not induce hepatic enzymes and thus have limited interaction with commonly used chemotherapy regimens are favored. Valproic acid is a non-enzyme-inducing AED that is appropriate to treat this patient. Other AEDs that would be reasonable to use include lacosamide, lamotrigine, and levetiracetam.
Autoantibodies associated with bullous pemphigoid
antihemidesmosome
Autoantibodies associated with hashimoto's thyroiditis
antimicrosomal, antithyroglobulin
The diagnosis of primary biliary cirrhosis, now termed "primary biliary cholangitis," is generally made on the basis of a cholestatic liver enzyme profile in the setting of a positive
antimitochondrial antibody test.
Patients with hospital-acquired diarrhea who test negative for Clostridium difficile infection should be treated with
antimotility agents to suppress symptoms and not undergo additional testing or treatment for C. difficile.
Screening for tuberculosis is indicated before initiation of
any biologic agent
after initiation of treatment and with dose increases of spironolactone with furosemide In patients with ascites associated with cirrhosis Serum creatinine and electrolyte levels should be checked at
approximately 1 week after initiation of treatment and with dose increases.
Hepatocellular adenomas that should be treated with surgical resection are the ones that
are larger than 5 cm or that exhibit β-catenin nuclear reactivity
Palpable lump or mass and age <30y found on ultrasound to be simple cyst
aspirate and repeat breast exam in 4-6 weeks
In patients with acute ischemic stroke who are ineligible for recombinant tissue plasminogen activator therapy, ______ should be administered within 48 hours of the stroke
aspirin should be administered within 48 hours of the stroke to reduce the risk of recurrent ischemic stroke.
In patients with clinical symptoms suggestive of bronchospastic disease (such as cough or unexplained dyspnea) but with normal spirometry, bronchial challenge testing such as methacholine may be helpful to evaluate for
asthma
TTE for which murmur when
asymptomatic patients with a systolic murmur that is grade 3/6 or higher, a late or holosystolic murmur, or a diastolic or continuous murmur and for patients with a murmur and accompanying symptoms.
Diagnostic criteria for somatic symptom disorder
at least one somatic symptom causing distress or interference with daily life; excessive thoughts, feelings, and behaviors related to the somatic symptoms; and persistence of somatic symptoms for at least 6 months.
treatment for metastatic non-small cell lung cancer after progression on a platinum-based chemotherapy regimen
atezolizumab
Uveitis is commonly associated with
autoimmune disorders, arthritides associated with HLA-B27 antigen, infection, malignancy, and sarcoidosis
In patients taking an interferon beta as a disease-modifying therapy for multiple sclerosis, serum aminotransferase levels should be measured every 3 to 6 months to monitor for
autoimmune hepatitis.
Patients with recurrent chemotherapy-sensitive Hodgkin lymphoma are usually candidates for
autologous HSCT
The xanthine oxidase inhibitor febuxostat is contraindicated in patients taking
azathioprine, which undergoes metabolism via xanthine oxidase; concomitant use of these agents can lead to dangerously high levels of azathioprine.
positive whiff test
bacterial vaginosis
The primary screening test for achalasia is
barium esophagogram, which demonstrates dilation of the esophagus and narrowing at the gastroesophageal junction, described as a "bird's beak." Manometry should be performed to confirm the diagnosis; it is the most sensitive test to demonstrate incomplete LES relaxation and aperistalsis
preop workup for NSCLC
baseline pulmonary function with measurement of DLCO and spirometry in all potential surgical candidates is necessary. Depending on results of baseline pulmonary function testing, further evaluation to assess predicted postoperative pulmonary function and exercise capacity may be indicated. Some patients are considered to have unresectable disease based on poor pulmonary function or the presence of extensive medical comorbidities rather than disease stage. In these patients or those of advanced age, stereotactic ablative radiation therapy may be an alternative treatment option, as phase II trials have found it can result in tumor control rates similar to surgery.
Milwaukee shoulder syndrome
basic calcium phosphate deposition, is characterized by pain, stiffness, and swelling that tend to occur gradually over time, often with a preceding trauma or history of overuse on the affected side, with a predilection for women older than the age of 70 years
Nitrofurantoin is is not adequate treatment for pyelonephritis because
because active levels are achieved only in the urine and not in the kidney parenchyma.
general treatment approach for Crohn disease
begin thiopurine therapy with azathioprine or 6-mercaptopurine if a patient requires repeated courses of glucocorticoids begin therapy with anti-tumor necrosis factor (anti-TNF) agents if these other therapies are unsuccessful.
The rash of smallpox
begins as small red dots on the pharyngeal and buccal mucosa with centripetal spreading to the hands and face, followed by the arms, legs, and feet; the rash progresses in synchronous fashion, from macules to papules to vesicles and pustules before crusting over An incubation period of 10 to 14 days precedes clinical infection; patients are not contagious during that time. Treatment of smallpox is supportive. The nucleotide analogue cidofovir possesses good in vitro activity and may offer some therapeutic benefit. Postexposure vaccination with vaccinia, targeting close contacts of patients with smallpox who will be at greatest risk for contracting the disease ("ring vaccination"), offers some protection from the infection and is best if provided within 3 days after exposure. Patients remain contagious until all scabs and crusts are shed.
A solid breast lesion with uniform borders and uniformly sized internal echoes
benign fibroadenoma
reduce asthma exacerbations in patients with eosinophil counts greater than 300 cells/uL and severe persistent asthma uncontrolled by medium to high-dosage inhaled glucocorticoids plus long-acting β2-agonists with:
benralizumab
Treat secondary syphilis with
benzathine penicillin, A single dose of 2.4 million units given intramuscularly is the treatment of choice
Synovial fluid leukocyte counts between __________ are associated with noninflammatory conditions,
between 200/µL and 2000/µL (0.2 × 109/L and 2.0 × 109/L)
In women who carry deleterious BRCA1/2 mutations, prophylactic bilateral salpingo-oophorectomy (BSO) is recommended
between ages 35 and 40 years, once childbearing is complete
Two anti-vascular endothelial growth factor inhibitors have been linked to thrombotic microangiopathy
bevacizumab and sunitinib thrombotic microangiopathy, which typically subsides after stopping the drug.
most common defect associated with Coarctation of the aorta
bicuspid aortic valve
Treat constipation due to dyssynergic defecation with
biofeedback therapy
Workup for NSCLC
biopsy diagnose CT chest\abd + bone scan + brain MRI
Histoplasma capsulatum, is typically found in soil contaminated with
bird or bat droppings, which encourage spore formation
Patients with breast cancer with lytic bone metastases are treated with
bisphosphonates to decrease bone pain and skeletal-related events such as bone fractures and reduce the need for palliative radiation therapy.
Indications for treatment with isosorbide dinitrate + hydralazine
black patients with heart failure and reduced ejection fraction and NYHA class III and IV symptoms
The use of the nonbiologic disease-modifying antirheumatic alkylating agent cyclophosphamide is associated with increased risk of
bladder cancer
red eye with scales and crusts around the eyelashes or dandruff like skin change and greasy scales around the eyelashes
blepharitis
Oncogenic osteomalacia is characterized by
bone pain and hypophosphatemia with kidney phosphate wasting in the setting of low 1,25-dihydroxy vitamin D and normal 25-hydroxy vitamin D concentrations
coarctation of rhe aorta features
brachial-femoral pulse delay . continuous murmur, due to blood flow through collateral vessels (eg, intercostal arteries), that is best heard at the posterior interscapular area.
Patients with newly diagnosed atypical ductal hyperplasia should be offered
breast cancer chemoprophylaxis; exemestane is associated with the greatest reduction in breast cancer risk.
Ductal carcinoma in situ (DCIS) can be treated with
breast-conserving therapy or mastectomy if the disease is more extensive or if clear margins cannot be obtained by a wide excision.
Diagnose pulmonary sarcoidosis with
bronchoscopic biopsy.
Treat microscopic colitis in patients with severe disease or in those that do not respond to antidiarrheal agents or bismuth
budesonide
Metastatic NSCLC (stage IV) is not curable, and treatment in these patients is
by definition, palliative.
Tx of MCTD with Raynaud phenomenon
calcium channel blockers
Evaluation of the serum sodium level after initiating the drug and at 3 months is recommended for what 2 AEDs
carbamazepine and oxcarbazepine
Diagnose carbon monoxide poisoning with
carboxyhemoglobin measurement
The most common cause of reduced left ventricular function in heart transplant patients after the first year is
cardiac allograft vasculopathy.
A serum-ascites albumin gradient (SAAG) of 1.1 g/dL (11 g/L) or greater with an ascitic fluid total protein level of 2.5 g/dL (25 g/L) or greater indicates a
cardiac cause of ascites. The main factors that distinguish a cardiac source for ascites from other sources are a SAAG of 1.1 g/dL (11 g/L) or greater and an ascitic fluid total protein level of 2.5 g/dL (25 g/L) or greater.
Cholinesterase inhibitors should be used with caution in patients with
cardiac conduction abnormalities, active peptic ulcer disease (because of the risk of bleeding), and seizures.
Treatment-related complications in men who had therapy for testicular cancer include
cardiovascular disease (specifically metabolic syndrome), kidney disease, peripheral neuropathy, chronic pulmonary toxicity, secondary malignancy, and sexual dysfunction.
Complications of tertiary syphilis
cardiovascular disease, gumma
Treat cervicitis with
ceftriaxone and azithromycin.
Treatment lyme disease with heart block higher than first degree heart block
ceftriaxone or intravenous penicillin G
Typhoid Fever
ceftriaxone, fluoroquinolones, and azithromycin
commonly presents with thunderclap headaches that recur over several days or weeks
cerebral vasoconstriction syndrome
Patients who have syphilis of unknown duration and an abnormal neurologic examination should undergo
cerebrospinal fluid analysis to confirm or exclude the diagnosis of neurosyphilis before treatment is started.
Once the presence of dementia has been confirmed, a structural neuroimaging study (MRI or CT scan) should be obtained to evaluate for nondegenerative causes that would alter management, such as
cerebrovascular disease, neoplasm, subdural hematoma, or hydrocephalus
tx of metastatic NSCLC
chemo
Treatment of extensive stage lung cancer
chemotherapy usually consisting of a platinum-containing doublet
Patients who have a positive reaction to tuberculin skin testing should be further evaluated by
chest radiography to rule out active tuberculosis infection.
Patients with reactive arthritis, even if asymptomatic, should be tested for
chlamydia infection using a DNA amplification urine test.
antihypertensive with a beneficial effect with respect to reducing hip and pelvic fracture risk compared with other antihypertensives
chlorthalidone
Excessive oxalate in the urine may result from excessive intake (from foods such as
chocolate, spinach, rhubarb, or green and black tea)
Biliary pain associated with dilated bile ducts on ultrasound
choledocholithiasis
The use of glucagon-like peptide (GLP-1) analogues (exenetide and liraglutide) in the treatment of diabetes mellitus is associated with an increased risk of
cholestasis, cholelithiasis, and cholecystectomy. GLP-1 also enhances the proliferation and activity of cholangiocytes, thereby raising concerns of increased gallbladder and bile duct diseases with prolonged use of these drugs.
synovial fluid analysis with extracellular crystals
chronic gout diagnosis
American College of Cardiology/American Heart Association/Heart Failure Society of America recommend replacing an ACE inhibitor or angiotensin receptor blocker with the angiotensin receptor-neprilysin inhibitor valsartan-sacubitril in patients with
chronic heart failure with reduced ejection fraction who are mildly to moderately symptomatic and tolerate ACE inhibitor or angiotensin receptor blocker therapy. In patients with HFrEF (ejection fraction ≤35%) and NYHA functional class II to IV symptoms who are taking guideline-directed medical therapy and in sinus rhythm with heart rate of 70/min or higher, treatment with ivabradine has been associated with a reduction in the composite endpoint of cardiovascular death and heart failure hospitalization. Before the resting heart rate is assessed for potential initiation of ivabradine, β-blockers should be titrated to target doses. Because this patient is already taking the target dose of carvedilol with a resting heart rate of 60/min, there is no indication for ivabradine.
Risk factors for drug-resistant S. Pneumoniae pneumonia:
chronic heart, lung, liver, or kidney disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressive conditions use of immunosuppressive drugs), recent (within 3 months) antimicrobial use, residence in regions with a high rate (>25%) of infection with high-level (minimum inhibitory concentration ≥16 µg/mL) macrolide-resistant S. pneumoniae.]:
Progressive weakness, areflexia, and sensorimotor neuropathy with a progression extending beyond 8 weeks since onset of symptoms are characteristic of
chronic inflammatory demyelinating polyradiculoneuropathy.
Aortic valve replacement is indicated for asymptomatic patients with aortic regurgitation with
chronic severe aortic regurgitation and LV systolic dysfunction (LV ejection fraction ≤50%), patients with chronic severe aortic regurgitation undergoing coronary artery bypass graft (CABG) or surgery on the aorta or other heart valves.
Patients with uncomplicated acute bacterial prostatitis should be treated empirically with
ciprofloxacin for 4 to 6 weeks; trimethoprim-sulfamethoxazole is an alternative. Follow-up evaluation with repeat culture is necessary to ensure response to treatment.
Uncomplicated cutaneous anthrax should be treated with
ciprofloxacin, levofloxacin, moxifloxacin, or doxycycline and should be reported to local health authorities. Uncomplicated cutaneous anthrax is defined as the absence of systemic symptoms and involvement of the head or neck in the absence of extensive swelling.
Low-risk gastric ulcers
clean-based or have a nonprotuberant pigmented spot
Low-risk gastric ulcers are
clean-based or have a nonprotuberant pigmented spot
Acute HBV infection will resolve (defined as
clearance of hepatitis B surface antigen within 6 months)
Common criteria for diagnosis of chronic pancreatitis consist of
clinical features (pain, recurrent attacks of pancreatitis, weight loss) with objective findings of steatorrhea and pancreatic calcifications.
Diagnosis of Myasthenia Gravis is based on
clinical findings, detection of disease-specific antibodies (acetylcholine receptor antibodies in 90% of patients with MG and anti-muscle-specific kinase [MuSK] antibodies in another 5% [with 5% of patients remaining antibody negative]), and EMG findings (such as a characteristic decremental response to repetitive stimulation). CT of the chest should be obtained in patients with MG to screen for thymoma, a tumor associated with the disease.
surgery for patients with an asymptomatic intracranial aneurysm in the posterior circulation when the aneurysm shows rapid growth to greater than 7 mm in size and
clinical signs consistent with an enlarging aneurysm.
Transition to fluconazole can occur in a patient with candidiasis after 5 to 7 days of therapy with an echinocandin if the patient is
clinically stable, the isolate is susceptible to fluconazole, and repeat blood cultures are negative.
Treat systemic exertion intolerance disease (formerly known as chronic fatigue syndrome) with
cognitive-behavioral therapy
Treat a patient who has familial Mediterranean fever with
colchicine
Use of diltiazem is a relative contraindication to what gout med
colchicine
Before starting ethambutol, patients should be evaluated for
color discrimination and visual acuity because an adverse effect of the drug is a retrobulbar neuritis manifesting as decreased green-red color discrimination or decreased visual acuity.
Patients with Burkitt lymphoma always warrant aggressive and immediate therapy with
combination chemotherapy [Combination chemotherapy consisting of rituximab plus hyperfractionated (rapidly cycled) cyclophosphamide, vincristine, doxorubicin, and dexamethasone (R-hyper-CVAD)] aggressive intravenous hydration urine alkalinization administration of allopurinol or rasburicase.
Treat moderate persistent asthma with
combination inhaled glucocorticoid and long-acting β2-agonist therapy.
Stage III and IV Hodgkin lymphoma (or those with B symptoms, regardless of stage) in patients without B symptoms can be treated effectively with
combination of doxorubicin, bleomycin, vinblastine, and dacarbazine remains the standard of care for all stages of classic Hodgkin lymphoma when chemotherapy is indicated. Rituximab is added to this combination in patients with CD20-positive disease (nodular lymphocyte-predominant subtype).
Lab workup for diarrhea if history and initial labwork unrevealing
combination of stool tests should be performed to subclassify the type of diarrhea. A 48- to 72-hour stool collection with analysis of fat content measures the amount of diarrhea and steatorrhea. Patients with steatorrhea should undergo evaluation for small-bowel mucosal disorders (celiac disease, Whipple disease), small intestinal bacterial overgrowth (SIBO), and pancreatic insufficiency
Treat a patient with metastatic BRAF-mutated melanoma with
combination therapy with vemurafenib and the MEK inhibitor cobimetinib,
increased laxity and pain with valgus stress
complete medial collateral ligament tear
tear results from a direct valgus (medially directed) force and typically presents as joint instability accompanied by medial knee pain and swelling
complete medial collateral ligament tear
Piriformis syndrome is caused by
compression of the sciatic nerve by the piriformis muscle. Patients describe chronic posterior pain in the buttock. Risk factors include prolonged sitting, such as in truck drivers.
patients with chronic venous insufficiency, first-line therapy
compression, leg elevation, and exercise. Addressing reversible risk factors, such as weight loss in obese patients, is also advisable. Diuretics should generally be avoided in these patients. Ablation therapy (chemical, surgical, and thermal) should be reserved for patients who have failed to respond to conservative therapy for at least 6 months and who have documented retrograde valvular flow on duplex ultrasonography (>0.5 seconds in duration). Compression stockings are frequently used to prevent postthrombotic syndrome following venous thromboembolism, although a recent randomized controlled trial did not find any benefit. Dry skin, itching, and eczematous changes are treated with moisturizers.
Definition of limited stage small cell lung cancer
confined to a single hemithorax, which could include ipsilateral supraclavicular lymph node disease, and requires that all disease be encompassed by a single radiation portal.
Resectable pancreatic tumors are
confined to the pancreas or just beyond it that correspond to stage IA (tumor limited to the pancreas and ≤2 cm in diameter), IB (tumor limited to the pancreas but >2 cm in diameter), and IIA (tumor extension beyond the pancreas but without involvement of the celiac axis) without involved lymph nodes or evidence of metastatic disease.
Hepatobiliary scintigraphy is indicated to
confirm or exclude the diagnosis of acute cholecystitis when the initial ultrasound is indeterminate.
CURB-65
confusion, BUN >20 mg/dL respiration rate ≥30/min], blood pressure [systolic <90 mm Hg, diastolic <60 mm Hg], age ≥65 years)
For failed endoscopic hemostasis or recurrent lower GI bleeding, the next therapeutic step is
consultation with interventional radiology for arterial embolization of the bleeding source
Deep brain stimulation is the appropriate treatment of patients with advanced Parkinson disease who
continue to benefit from dopaminergic medications but experience medication-related complications.
Diagnose nonconvulsive status epilepticus with
continuous electroencephalographic monitoring
All patients with altered mental status after convulsive status epilepticus should have
continuous electroencephalographic monitoring for at least 24 hours to detect nonconvulsive seizures
Excisional biopsy of breast mass is used when
core needle biopsy findings are nondiagnostic or when biopsy and imaging studies do not concur
Treatment of RTA 4
correction of the underlying cause, treatment of hyperkalemia, discontinuation of offending medications, dietary potassium restriction.
Patients presenting with a multisystem vasculitic disease, particularly if the C4 is low, the C3 is relatively preserved, and rheumatoid factor is present, should be considered for what diagnosis
cryoglobulinemia
Mantle cell lymphoma is a rare form of non-Hodgkin lymphoma characterized by extranodal involvement and overexpression of
cyclin D1, and it is associated with a poor prognosis.
primary angiitis of the central nervous system tx
cyclophosphamide and high-dose glucocorticoids
Patients with UC whose symptoms do not respond to glucocorticoids are treated with
cyclosporine, a biologic agent, or colectomy.
Nephrolothiasis with stones that have hexagonal shape
cysteine
Diagnosis bladder cancer with initial test of
cystoscopy with biopsy
In patients with advanced ovarian cancer, diagnosis may be made by
cytologic evaluation of ascites or pleural fluid, or by image-guided biopsy of peritoneal masses.
Any bloody fluid obtained from breast cyst aspiration requires
cytologic examination
treatment for latent tuberculosis infection
daily isoniazid with pyridoxine (vitamin B6) for 9 months
______ is a voltage-gated potassium channel antagonist that can potentiate action potentials along demyelinated axons and is used in patients with multiple sclerosis (MS) for potassium channel blockade. This medication can improve lower extremity function and walking speed and endurance.
dalfampridine (4-aminopyridine) is renally excreted, must be renally dosed in AKI
Subcutaneous unfractionated or low-molecular-weight heparin for DVT ppx should be started in all patients with impaired mobility by hospital day ____ for ischemic stroke and by hospital day ____ (if no active bleeding is documented) in hemorrhagic stroke.
day 1 = ischemic stroke day 4 = hemorrhagic stroke
Patients with carpal tunnel syndrome who have active denervation on nerve conduction studies and have muscle weakness and atrophy on clinical examination should undergo
decompression surgery to prevent irreversible motor weakness.
Diagnose cannabinoid hyperemesis syndrome.
defined by the presence of three clinical criteria: (1) episodic vomiting resembling cyclic vomiting syndrome in terms of onset, duration, and frequency; (2) presentation after prolonged, excessive cannabis use; (3) relief of vomiting episodes with sustained cessation of cannabis use.
Pre-eclampsia with severe features tx
deliver at 34 weeks
Definitive therapy for preeclampsia is
delivery of the baby.
Overcorrection of chronic asymptomatic hyponatremia should be reversed using
desmopressin with 5% dextrose
Histoplasmosis dx
detection of histoplasma antigen in body fluids, which is present in up to 90% of patients with acute progressive disseminated histoplasmosis, or by isolation of H. capsulatum from bodily fluids or tissues
This medication will improve outcomes in patients with a presumptive diagnosis of bacterial meningitis due to Streptococcus pneumoniae
dexamethasone
Treat newly diagnosed immune thrombocytopenic purpura with
dexamethasone
Kidney transplant recipients require lifelong immunosuppression and must be monitored for metabolic complications such as
diabetes mellitus and dyslipidemia.
Patients with Sjögren syndrome have up to a 44-fold higher risk of developing lymphoma, the most common being
diffuse B-cell and mucosa-associated lymphoid tissue (MALT) lymphomas.
Lymphangioleiomyomatosis findings on CT
diffuse, thin-walled, small cysts on CT Diagnosis is based on imaging studies with diffuse thin-walled cysts (Figure 11) as well as spontaneous pneumothorax, angiomyolipomas, and elevated vascular endothelial growth factor-D (VEGF-D)
tPA is contraindicated if you have any abnormal clotting test slash CBC if you are taking what medications
direct factor Xa inhibitors or direct thrombin inhibitors
Pulmonary hypertension related to left-sided heart disease is classified as group 2; treatment is
directed at the underlying cardiac disease.
The most appropriate treatment of medication-related tardive dyskinesia is
discontinuation of the causative dopamine blocker agent.
Metoclopramide is the only drug approved by the FDA for the treatment of gastroparesis; however, metoclopramide is associated with side effects such as hyperprolactinemia, galactorrhea, and tardive dyskinesia that require
discontinuation of the drug
Airborne and contact precautions are indicated to prevent spread of infection in patients with which circumstances of zoster infections
disseminated zoster infection or those who are immunocompromised with localized zoster infection
Type A dissections or intramural hematomas involve the ascending aorta or aortic arch, whereas type B syndromes begin
distal to the left subclavian artery
All of the available cholinesterase inhibitors are approved for mild to moderate Alzheimer disease, except _______, which is also approved for the severe stage.
donepezil
The ankle-brachial index (ABI) is obtained by measuring the systolic pressures in the
dorsalis pedis and posterior tibialis arteries on both sides. The ABI for each leg is the highest ankle pressure for that side divided by the highest brachial pressure (regardless of side). An ABI of 0.90 or lower establishes a diagnosis of peripheral arterial disease (PAD). In this patient, the right ABI is greater than 1.40. An ABI above 1.40 suggests noncompressible vessels, which may reflect medial calcification but is not diagnostic of flow-limiting atherosclerotic disease.
Rocky Mountain spotted fever tx
doxycycline Doxycycline is contraindicated in pregnancy; chloramphenicol is an alternative option.
Tx of OA in patients that have already tried an NSAID as well as glucocorticoid and hyaluronic injections without symptomatic relief
duloxetine
Nine modifiable risk factors account for more than 90% of the risk for acute myocardial infarction; in descending order, these are:
dyslipidemia, smoking, psychosocial stressors, diabetes mellitus, hypertension, obesity, alcohol consumption, physical inactivity, and diet low in fruits and vegetables.
PAH workup
echo then right heart cath
Treat a patient with venous thromboembolism who wishes to breastfeed with
either Warfarin orlow-molecular-weight heparin
any episode of gross hematuria requires a urologic evaluation consisting of imaging of the urinary system with what imaging modality
either a CT with contrast or an MRI and cystoscopy.
Patients with new-onset heart failure with multiple risk factors or symptoms of coronary artery disease should be evaluated by
either a stress test or cardiac catheterization.
The usual therapeutic agents for proliferative forms of lupus nephritis are
either cyclophosphamide or mycophenolate mofetil
Patients in myasthenic crisis should be treated emergently with
either plasmapheresis or intravenous immunoglobulin. High-dose glucocorticoids can initially aggravate symptoms of myasthenia gravis. These agents can be started after therapy with plasmapheresis or IVIG has been initiated.
Achilles tendon rupture tx
either surgery or immobilization of the ankle in plantar flexion accompanied by an early range-of-motion protocol appear to have a similar risk of rerupture, although surgery is associated with a high risk of complications, including infection.
For patients with known coronary artery disease (CAD) but normal cardiac function scheduled for intermediate-risk surgery (defined as a risk of cardiac death or nonfatal myocardial infarction of 1%-5%), __________ is indicated according to the current American College of Cardiology/American Heart Association (ACC/AHA) guideline
electrocardiography
Spinal cord compression from metastatic disease requires
emergent use of high-dose glucocorticoids and subsequent treatment with surgical decompression followed by radiation for most tumor types
diarrhea, bloating, flatulence, and weight loss in patients with Roux-en-Y gastric bypass ould receive
empiric antibiotic treatment for small intestinal bacterial overgrowth (SIBO) Ciprofloxacin and metronidazole are used to treat patients with documented small intestinal bacterial overgrowth. a lactose-free diet should be considered if the response to antimicrobial agents is incomplete.
in patients with end-stage kidney disease who are on dialysis and have suspected catheter-related infection, immediately you should give
empiric broad-spectrum antibiotics
Tamoxifen increases the risk of
endometrial cancer and venous thromboembolic events in women over age 55 years. Other toxicities include hot flushes, vaginal discharge, and sexual dysfunction. Yearly pelvic examinations are recommended, and abnormal vaginal bleeding should be reported to their physicians.
Patients with Barrett esophagus with high-grade dysplasia are often treated with
endoscopic ablation
For patients with confirmed Barrett esophagus with low-grade dysplasia and without life-limiting comorbidity, the preferred treatment modality is
endoscopic ablative therapy
Diagnose an insulinoma with
endoscopic ultrasound
the most appropriate initial test for suspected Clostridium difficile infection.
enzyme-linked immunosorbent assay (ELISA) for Clostridium difficile toxins A and B
Swallowed aerosolized glucocorticoids such as fluticasone are often used as a treatment fo
eosinophilic esophagitis
a young man with solid-food dysphagia that requires endoscopy for removal
eosinophilic esophagitis
present with redness, irritation, and tearing but not significant ocular pain
episcleritis
Familial Mediterranean fever is characterized by
episodes of fever, polyserositis, arthritis, erysipeloid rash around the ankles, and elevated acute phase reactants; a response to colchicine is useful in the clinical diagnosis.
diagnose CML
etection of the (9;22) translocation by routine cytogenetics or fluorescence in situ hybridization or of the BCR-ABL fusion transcript by reverse transcriptase-polymerase chain reaction
Management of most patients with smoldering myeloma consists of
evaluation every 3 to 6 months. Testing includes a CBC, serum calcium and creatinine levels, and repeat M protein assessment; other testing should be guided by history and physical examination.
The recommended surveillance interval for colonoscopy screening in patients who have or are at risk for Lynch syndrome is
every 1 to 2 years beginning at age 25 years, or 2 to 5 years earlier than the youngest age at diagnosis of colorectal cancer if the affected relative was younger than 25 years old.
Individuals who have or who are at risk for MYH-Associated Polyposis should undergo colonoscopy every _______ beginning at age 25 to 30 years
every 2 to 3 years beginning at age 25 to 30 years
Owing to the heightened risk of early local recurrence after rectal cancer therapy, patients with rectal cancer should undergo a flexible sigmoidoscopy evaluation of the anastomosis every ____ months for the first ___ years.
every 3 to 6 months for the first 3 years.
patients receiving tenofovir require urinalysis every _____ months because proteinuria is usually the first manifestation of tenofovir nephrotoxicity
every 6 to 12 months
According to a guideline from the American College of Cardiology/American Heart Association, patients with claudication and a borderline resting ankle-brachial index value should undergo
exercise ankle-brachial index testing to evaluate for peripheral artery disease.
test to do before initiating treatment for PAH
exercise testing such as the 6-minute walk test should be performed to determine functional impairment and to serve as a baseline with which to compare therapeutic response.
Definition of extensive-stage small cell lung cancer
extends beyond a single hemithorax
patients with severe hypothermia and hemodynamic instability
extracorporeal support, including cardiopulmonary bypass, is recommended because it maximizes the rewarming rate and can provide hemodynamic support.
Initial therapy for parkinson's in younger patients (age <65-70 years)
f dopamine agonists
mononucleosis usually presents as
fatigue, sore throat with tonsillar exudates, splenomegaly, and posterior cervical lymphadenopathy.
HPV vaccine
females aged 11 to 26 years males aged 11 to 21 years. offered through age 26 years to men who are immunocompromised (including those infected with HIV) and men who have sex with other men.
Treat a patient with iron deficiency with
ferrous sulfate supplementation, 325 mg every day
high-risk features of acute pericarditis may be present and warrant hospitalization for treatment and monitoring for possible complications; these include
fever, leukocytosis, acute trauma, abnormal cardiac biomarkers, an immunocompromised host, oral anticoagulant use, large pericardial effusions, evidence of cardiac tamponade.
bisphosphonates can cause
fever, kidney injury, hypocalcemia, and osteonecrosis of the jaw
Frequent ophthalmologic examinations are recommended for patients taking ______ for MS because of the risk of macular edema.
fingolimod
The ECG in ostium primum atrial septal defect characteristically demonstrates
first-degree atrioventricular block, left axis deviation, and right bundle branch block.
Diffuse idiopathic skeletal hyperostosis is a noninflammatory condition defined by the presence of
flowing osteophytes involving the anterolateral aspect of the thoracic spine at four or more contiguous vertebrae with preservation of the intervertebral disk space and the absence of apophyseal joint or sacroiliac inflammatory changes such as erosions.
In HIV patients with dysphagia or other swallowing symptoms indicate esophageal involvement, and treatment of esophageal candidiasis requires a systemic agent such as
fluconazole
Candida esophagitis should be treated with
fluconazole Fluconazole is the first-line therapy for Candida esophagitis and is a more effective therapy than swallowed nystatin.
Patients with acute ipilimumab toxicity should receive
fluid replacement and immediate glucocorticoid therapy to reverse the damage this agent can cause; delay in treatment can be fatal.
Inpatient antimicrobial regimens for Acute Pyelonephritis
fluoroquinolones, aminoglycosides with or without ampicillin, extended-spectrum cephalosporins or extended-spectrum penicillins with or without an aminoglycoside, and carbapenems
Sulfasalazine may cause _____ deficiency, and supplementation is recommended.
folate
An elevated homocysteine level is 90% sensitive for
folate deficiency (so long as methylmalonic acid is normal)
Treatment for patients with stage III NSCLC with mediastinal lymph node involvement
for most patients with stage III NSCLC, combined chemoradiation therapy given with curative intent is the preferred treatment approach. There is no single standard chemotherapy regimen used, but treatment with cisplatin- or carboplatin-based chemotherapy can be given. For patients with T3N1 disease, surgery can be done as initial therapy, although the procedure should include mediastinal lymph node dissection. If mediastinal lymph nodes are negative, adjuvant chemotherapy should be given. In patients with positive mediastinal lymph nodes, sequential chemotherapy and radiation is recommended. For patients with limited mediastinal lymph node involvement, chemotherapy or chemoradiation can be given initially, followed by surgery in patients without disease progression. Following surgery, patients with positive margins or multistage mediastinal lymph node involvement who were treated with chemotherapy only before surgery should be offered adjuvant radiotherapy. Adjuvant chemotherapy has a proven role in patients with resected stage II and resected stage III disease. Cisplatin-based combination therapy has demonstrated a clear survival advantage in these settings.
In patients with acute coronary syndrome in whom the culprit artery has been successfully treated with primary percutaneous coronary intervention (PCI) or thrombolysis, __________ may be appropriate to assess whether one or more non-culprit artery lesions should be treated with PCI or coronary artery bypass graft surgery.
fractional flow reserve
determining whether revascularization of non-culprit artery stenosis is appropriate in a patient with acute coronary syndrome is done by
fractional flow reserve (FFR)
The American College of Chest Physicians recommends initiating a trial of __________ in patients with unexplained chronic cough.
gabapentin
prophylactic cholecystectomy should be performed in asymptomatic patients with gallbladder polyps larger than
gallbladder polyps larger than 1 cm or those with polyps of any size with gallbladder stones or primary sclerosing cholangitis
Treatment of CMV esophagitis
ganciclovir and valganciclovir
Quadruple therapy with a proton pump inhibitor, amoxicillin, bismuth, and metronidazole is an appropriate treatment for H. pylori infection in
geographic areas with high degrees of drug resistance to clarithromycin.
adjuvant chemotherapy
given after definitive surgery with curative intent .The purpose of adjuvant chemotherapy is to eradicate any residual microscopic metastatic disease that might still be present outside of the surgical field.
neoadjuvant chemotherapy
given before planned definitive surgery with curative intent given before surgery in an attempt to eradicate any unseen micrometastases that might be present outside of the surgical field.
phentermine-topiramate is contraindicated in
glaucoma
In patients treated with glucocorticoids for inflammatory myopathies, persistence of weakness after normalization of the serum CK level may indicate
glucocorticoid-induced myopathy.
Treat minimal change glomerulopathy with
glucocorticoids
Treatment of warm autoimmune hemolytic anemia is
glucocorticoids to halt immune-mediated erythrocyte destruction and allow bone marrow to regenerate the erythrocytes Rituximab and splenectomy are typically reserved to treat patients in whom first-line therapy for WAIHA has failed; they are not used in the acute setting. An inadequate response to glucocorticoids may indicate the need for splenectomy or alternative immunosuppression.
The initial treatment of polymyositis or dermatomyositis with muscle involvement is
glucocorticoids, most commonly prednisone IIM management requires a comprehensive approach combining aggressive pharmacotherapy, physical therapy to maintain muscle strength, and supportive interventions. Glucocorticoids, initiated at high doses and tapered once serum muscle enzymes normalize, are the mainstay treatment for PM and DM.
The initial treatment of insomnia focuses on implementing
good sleep hygiene, which refers to the optimization of the environmental and behavioral factors associated with sleep.
Treat hepatitis C virus infection in a patient with stage 5 chronic kidney disease using
grazoprevir and elbasvir
Iron deficiency is the most common cause of hyporesponsiveness to erythropoietin, and guidelines recommend ______ hemodialysis patients who require iron
guidelines recommend intravenous rather than oral iron replacement among hemodialysis patients who require iron.
Washed platelets are typically reserved for patients who
have had severe allergic reactions to platelet transfusion (such as patients who are IgA deficient).
Treatment of limited stage small cell lung cancer:
have single, small primary tumors without associated lymph node involvement (T1-2 and N0) and require invasive staging of the mediastinum with endobronchial ultrasonography or mediastinoscopy to exclude occult disease. patients with limited-stage small cell lung cancer that is too advanced for surgical resection is combined chemotherapy and radiation therapy
Erlotinib is a tyrosine kinase inhibitor with activity against tumors expressing mutations in
he epidermal growth factor receptor (EGFR)
Acute liver failure (ALF) is defined by
he onset of HE, jaundice, and coagulopathy (INR ≥1.5) in patients without a history of chronic liver disease
cilostazol is contraindicated in patients with
heart failure or a left ventricular ejection fraction below 40%. This contraindication exists because cilostazol has a similar pharmacologic action to the inotropic drugs milrinone and amrinone, which demonstrated increased mortality rates with long-term use in patients with heart failure.
In adults undergoing doxorubicin therapy, the drug should be discontinued if there is evidence of
heart failure, a 10% or greater decline in left ventricular ejection fraction to below the lower limit of normal, an absolute left ventricular ejection fraction of less than 45%, a 20% decline in left ventricular ejection fraction to any level
The American College of Physicians guideline for the noninvasive management of low back pain recommends nonpharmacologic treatment with
heat for the initial management of acute and subacute low back pain.
Most women with vWD experience
heavy menstrual bleeding
Treat high-risk myelodysplastic syndrome with
hematopoietic stem cell transplantation.
Following endoscopic therapy, the strongest predictors of recurrent bleeding are
hemodynamic instability, active bleeding at endoscopy, ulcer size greater than 2 cm, and ulcer location (posterior duodenal or high lesser gastric curvature). Additional predictors may also include age 60 years or older, comorbid illness, and postendoscopy hemoglobin level less than 10 g/dL (100 g/L).
Indications for hospitalization of Acute Pyelonephritis
hemodynamic instability, inability to tolerate oral medications, host factors such as pregnancy or presence of kidney stones or other obstructions, presence of comorbidities, an unstable social situation that may compromise adherence or follow-up
Prescribers of direct-acting antiviral agents for the treatment of hepatitis C virus infection should test all patients for evidence of
hepatitis B virus infection before initiation of hepatitis C virus treatment, and patients in whom current or prior infection is identified should be monitored for hepatitis B virus reactivation and hepatitis flares during treatment and follow-up.
________ is typically associated with cryoglobulinemic glomerulonephritis
hepatitis C
Conjunctivitis associated with herpes zoster rash involving opthalmic division of 5th cranial nerve
herpes zoster conjunctivitis
Adult-onset Still disease is characterized by
high spiking fevers, arthritis, rash, high neutrophil counts, and markedly elevated serum ferritin.
Adult-onset Still disease tx
high-dose NSAIDs and/or prednisone, with methotrexate as a standard second-line agent.
Treat moderate dry age-related macular degeneration with __________ to prevent progression to advanced disease
high-dose antioxidants
After extubation in nonsurgical patients at low risk for reintubation, immediate use of supplemental oxygen for 24 hours should be via
high-flow nasal cannula for 24 hours followed by conventional oxygen by nasal cannula
imaging on IPF
high-resolution CT findings of peripheral- and basal-predominant septal line thickening and honeycomb change;
if the FABER (Flex, ABduct, and Externally Rotate) test demonstrates limited range of motion or hip pain
hip pathology is likely.
Inactivated influenza vaccine can be safely administered to patients with an egg allergy who have only experienced ________ upon exposure to eggs.
hives
Patients with a history of early breast cancer who develop findings suspicious for metastatic breast cancer should undergo biopsy of one of the suspected metastatic sites to confirm the diagnosis and to assess
hormone receptor and HER2 status, as these may differ from the original cancer.
Febrile nonhemolytic transfusion reactions are common and occur within several
hours of an erythrocyte or platelet transfusion. Febrile nonhemolytic transfusion reactions are mediated by the generation of leukocyte-derived cytokines during erythrocyte and platelet storage. Symptoms include fever, chills, rigors, or dyspnea. Management consists of transfusion discontinuation to exclude a more serious transfusion reaction, acetaminophen for fever, and meperidine for rigors.
Uncomplicated kidney stones <10 mm in size may usually be treated with
hydration, analgesia, observation, and periodic re-evaluation) and medical expulsive therapy, which usually consists of either an α-blocker (such as tamsulosin) or calcium channel blocker (such as nifedipine)
he simplest and most widely available diagnostic modality for suspected SIBO
hydrogen breath testing
In the event that monotherapy is insufficient to induce remission in RA or maintain a low disease activity state, then you should initiate a second disease-modifying drug such as
hydroxychloroquine or sulfasalazin
Medications that are safe for use during SLE pregnancies include
hydroxychloroquine, prednisone, and azathioprine (if an immunosuppressive agent is absolutely needed).
Behavioral variant frontotemporal dementia is characterized by
hyperorality, loss of insight, loss of empathy, compulsive behaviors, impaired social conduct, and an early age of onset.
Denosumab can cause
hypocalcemia and osteonecrosis of the jaw
carbamazepine and oxcarbazepine is associated with
hyponatremia
Intravenous dextrose-containing fluids can exacerbate ______ by stimulating insulin release
hypophosphatemia
ATRA and ATO can cause a differentiation syndrome characterized by
hypoxemia, pulmonary infiltrates, and fever.
Treat chronic lymphocytic leukemia
ibrutinib, a Bruton tyrosine kinase inhibitor
Treat dabigatran overdose with the newly approved reversal agent
idarucizumab.
preferred test to confirm west nile
identification of the IgM antibody in the cerebrospinal fluid (CSF)
Diagnose radiation pneumonitis
imaging finding of a nonanatomic straight line demarcating involved versus uninvolved lung parenchyma is pathognomonic of radiation pneumonitis Patients with radiation pneumonitis present with cough and/or dyspnea approximately 6 to 12 weeks after the exposure Gemcitabine is associated with radiation pneumonitis and drug-induced pneumonitis
A diagnosis of ALF necessitates
immediate contact with a liver transplant center, regardless of the cause.
criterion to indicate successful reperfusion after the administration of thrombolytic therapy
improvement in ST-segment elevation greater than 50% on an electrocardiogram (ECG) obtained 60 minutes after the administration of thrombolytic therapy
what patients need ampicillin for meningitis tx
in patients older than 50 years, or persons with impaired cell-mediated immunity
Treat established, progressive rheumatoid arthritis that has been unresponsive to a disease-modifying antirheumatic drug and etanercept
in patients with established rheumatoid arthritis with moderate to high disease activity who have not responded to monotherapy with methotrexate or combination therapy with methotrexate and a tumor necrosis factor (TNF)-α inhibitor, a non-TNF biologic such as rituximab should be substituted for the TNF-α inhibitor while continuing the methotrexate
Treat a patient with severe alcoholic hepatitis.
in patients with severe alcoholic hepatitis, prednisolone can reduce 28-day mortality rates.
Although out-of-center sleep testing is appropriate for patients with a high pretest probability of uncomplicated moderate to severe obstructive sleep apnea, those with heart failure or advanced pulmonary disease or those at risk for central sleep apnea should undergo
in-laboratory polysomnographic diagnostic testing. for everyone else, do Out-of-center sleep testing
Contraindications to kidney biopsy
include bleeding diatheses, severe anemia (especially with patient refusal of blood transfusions), UTI, hydronephrosis, uncontrolled hypertension, anatomic abnormalities, renal tumor, atrophic kidneys, and an uncooperative patient.
Findings of primary open angle glaucoma include
increased cup:disc ratio, (>0.5) vertical extension of the central cup, disc hemorrhages, and increased intraocular pressure.
Treat a patient with frequent acute exacerbations of COPD with the combination of inhaled
indacaterol and glycopyrrolate According to the FLAME trial, combination inhaled indacaterol/glycopyrrolate (LABA/LAMA) is superior to combination inhaled salmeterol/fluticasone (LABA/IG) in reducing the rate of acute COPD exacerbations in patients who experience frequent exacerbations.
Treatment of Cryptococcal meningitis in Patients with AIDS
induction period: amphotericin B and flucytosine for 2 weeks Consolidation period: oral fluconazole for 8 weeks Maintenance period: oral fluconazole for ≥1 year
Even after eradication of the giardia, diarrhea may persist because of
infection-induced lactose intolerance, and diet modification in the months after treatment will minimize postinfective symptoms.
IgG4-related disease is characterized by
infiltration of different organs by lymphoplasmacytic infiltrates of IgG4-positive plasma cells with resultant fibrosis associated with elevated serum IgG4 levels.
The three anti-TNF antibodies approved for inducing and maintaining remission in UC are
infliximab, adalimumab, golimumab. The integrin-blocking antibody vedolizumab blocks leukocyte trafficking and is also approved for the treatment of UC.
Brain tumor associated with the following features on MRI:
intense homogeneous contrast enhancement ("lightbulb sign") and a dural tail.
In order to meet criteria for dementia, a patient's cognitive deficits must
interfere with daily functioning and result in some loss of independence. A detailed history of the patient's abilities to perform activities of daily living, such as paying bills, managing financial records, assembling tax records, shopping alone, working on hobbies, taking medications, driving, and remembering recent holidays or family events, should be obtained to elicit any change in function
best way to test for latent TB in the setting of previous bacillus Calmette-Guérin vaccination
interferon-γ release assay
First-line therapy for convulsive status epilepticus is
intravenous (IV) lorazepam followed by IV phenytoin or fosphenytoin
in-patient treatment of status migrainosus
intravenous dihydroergotamine This drug is administered in conjunction with either prochlorperazine or metoclopramide over the course of 1 to 3 days.
Treat a multiple sclerosis relapse
intravenous methylprednisolone, 1 g/d for 3 to 5 days Relapses that are refractory to glucocorticoid treatment may respond to rescue therapy with plasmapheresis.
In a patient with typical migraine not relieved by oral medications, treat/prevent emesis with
intravenous metoclopramide
Endophthalmitis Treatment
intravitreal antibiotics. Prognosis is dependent on how quickly treatment is started and the virulence of the pathogen.
stage I rectal cancer is defined as a tumor that
invades into, but not fully through, the rectal wall, with no evidence of lymph node metastases Surgical resection is the initial treatment
Treat a patient with stage III resected melanoma
ipilimumab improves both disease-free and overall survival
unless proven otherwise gastrointestinal blood loss is the presumed cause of
iron deficiency In men and nonmenstruating women
The most common adverse effect of levetiracetam is
irritability and other adverse effects on mood
Gilbert syndrome
is a benign condition characterized by mild unconjugated hyperbilirubinemia, which is caused by a congenital decrease in hepatic uridine diphosphate glucuronyl transferase. Patients with Gilbert syndrome have a defect in the ability to conjugate bilirubin, resulting in unconjugated hyperbilirubinemia. The bilirubin level tends to be highest when the patient is fasting or ill but is usually less than 3 mg/dL (51.3 µmol/L).
A pseudorelapse of multiple sclerosis
is a worsening of baseline neurologic symptoms or recurrence of previous symptoms that occurs in the setting of physiologic stressors, such as a superimposed infection. Treat a pseudorelapse of multiple sclerosis, differentiating it from an actual relapse.
Diagnosis of Typhoid Fever
isolating the organism from blood, stool, urine, or bone marrow. Serologic assays that detect specific S. enterica serotype Typhi antibodies have good sensitivity and specificity.
Treatment of latent TB in who are pregnant or plan to become pregnant
isoniazid is recommended for treatment of LTBI if the patient has been recently exposed to a person with known tuberculosis or if she has HIV. If not, many experts would recommend that treatment of LTBI be deferred until after delivery. Isoniazid treatment is not a contraindication for breastfeeding.
Treatment of high-altitude pulmonary edema is
ith supplemental oxygen, rest, and consideration of descent from altitude; vasodilators such as nifedipine can be used as adjunctive treatment.
low urine chloride is less than
ith volume depletion, the urine sodium concentration is generally low (<20 mEq/L [20 mmol/L]) due to the kidney's conservation of sodium.
ongoing symptomatic inappropriate sinus tachycardia
ivabradine can effectively reduce the heart rate
The gold standard for diagnosing gout is
joint aspiration and synovial fluid analysis
Patellar Tendonitis
jumper's knee; kicker's knee (basketball, volleyball) Pain localized at and below patella tenderness at inferior margin of patella
a hyperkeratotic rash found on the soles and palms that may be indistinguishable from pustular psoriasis
keratoderma blenorrhagicum
Patients starting topiramate should be counseled about the risk of developing
kidney stones and the need to stay hydrated
Patients with pyelonephritis who remain febrile after 72 hours of appropriate antibiotic therapy should undergo
kidney ultrasonography, CT, or MRI to investigate for complications, such as perinephric or intrarenal abscess. Abscess drainage is usually required except for very small collections or those for which the causative factor (such as a kidney stone) may be removed to allow drainage.
In older patients with seizures who are treated with an antiepileptic drug, the best 3 choices for AEDs are
lamotrigine, levetiracetam, and gabapentin Because these medications have fewer adverse effects, older patients are more likely to continue taking them, which increases the likelihood of seizure freedom.
In patients with ascites associated with cirrhosis who cannot tolerate diuretics (such as those with kidney dysfunction or hyponatremia) or in whom diuretics are ineffective can be treated with
large-volume paracentesis
prior to start of tumor necrosis factor α inhibitor therapy Patients should be screened for
latent tuberculosis
Coronary artery bypass grafting is recommended for patients who remain symptomatic with optimal medical therapy and have specific angiographic findings:
left main disease or multivessel disease with involvement of the proximal left anterior descending artery AND concomitant reduced systolic function or diabetes mellitus.
Peripartum cardiomyopathy is
left ventricular systolic dysfunction identified toward the end of pregnancy or in the months following delivery in the absence of another identifiable cause. Prompt initiation of medical therapy is recommended for women with peripartum cardiomyopathy and includes an ACE inhibitor or an angiotensin receptor blocker (after delivery), β-blockers, digoxin, hydralazine, nitrates, and diuretics.
Nonextensive superficial venous thrombophlebitis, defined as
less than 5 cm in length and not near the deep venous system, treated with only symptomatic therapy consisting of analgesics, anti-inflammatory medications, and warm or cold compresses for symptom relief, because the risk of progression into the deep venous system and of PE is low.
Spinal cord compression from metastatic disease does not require initial surgical decompression and may be treated urgently with radiation therapy if they are one of the certain readiosensitive tumor types:
leukemia, lymphoma, myeloma, germ cell tumors
Treat generalized epilepsy in a woman of childbearing age.
levetiracetam
The biologic agent tofacitinib is associated with a risk of causing an abnormal
lipid profile.
tx of disseminated histoplasmosis
liposomal amphotericin B with long-term suppressive therapy following short-term treatment.
overwhelmingly the most common site of metastasis of neuroendocrine tumors
liver Because well-differentiated NETs are so indolent, patients often can be effectively managed with expectant observation and serial imaging. Triple-phase contrast-enhanced CT scanning or MRI with gadolinium are the preferred imaging modalities. Indium 111 pentetreotide scanning can be used to establish the presence of somatostatin receptors, which are commonly expressed on these tumors.
Gastrointestinal infections caused by Vibrio species are associated with ingestion of contaminated seafood, particularly shellfish, and can be severe in patients with ________
liver dysfunction.
Patients with cirrhosis who meet the Milan criteria (up to three hepatocellular carcinoma tumors ≤3 cm or one tumor ≤5 cm) are best treated with
liver transplantation and have excellent 5-year survival rates.
Treat sympathomimetic overdose with
lorazepam
shunt physiology
low V/Q or shunt (V/Q=0)
Patients with metabolic syndrome who have a 10-year cardiovascular risk of 10% or higher should be treated with
low-dose aspirin for primary prevention of cardiovascular disease.
Treat polymyalgia rheumatica with
low-dose prednisone, initially at 10 to 20 mg/d, which should result in rapid resolution of symptoms.
For postmenopausal women with noninfectious genitourinary symptoms that are not relieved with over-the-counter therapies, Treat genitourinary syndrome of menopause with
low-dose vaginal estrogen
The preferred initial diagnostic test to perform in a pregnant patient with possible pulmonary embolism is
lower extremity venous duplex ultrasonography to assess for the presence of deep venous thrombosis, which, if present, would obviate the need for radiation and contrast exposure associated with other diagnostic studies. If her ultrasound is normal, a ventilation-perfusion (V/Q) lung scan is the next preferred modality. If a V/Q scan is unavailable, CT pulmonary angiography is the next diagnostic choice. Unfortunately, no validated clinical prediction rules exist for assessing pretest probability of PE in pregnant women. Additionally, D-dimer levels are normally elevated during pregnancy. Therefore, D-dimer testing has minimal clinical utility in evaluating for the presence of PE or DVT.
Patients suspected of having VAP should undergo
lower respiratory tract sampling, followed by microscopic analysis and culture of the specimen
In patients with pulmonary cryptococcosis, , even in the absence of CNS symptoms, you should still perform a
lumbar puncture should be performed to determine if central nervous system (CNS) infection is also present
Standardized evaluation for encephalitis includes
lumbar puncture, brain MRI, and electroencephalography. EEG is indicated to confirm the diagnosis of encephalitis, provide information that may help identify a causative organism, and assess the need for antiepileptic therapy. Nonconvulsive seizures, defined as the presence of seizure activity on EEG in the absence of myoclonic movements or other clinical evidence of seizures, could contribute to alterations in consciousness. Nonconvulsive status epilepticus may be focal or generalized and has been reported with viral and autoimmune encephalitides. Nonconvulsive status epilepticus in patients with encephalitis is associated with a delay in initiating antiepileptic therapy and an increased risk for death.
The only intervention shown to improve survival in selected patients with IPF is
lung transplantation.
Paraneoplastic limbic encephalitis is most commonly associated with
lung tumors (usually small cell lung cancer), breast cancer, thymoma, germ cell tumors, and Hodgkin lymphoma.
Patients with Sjögren syndrome have up to a 44-fold higher risk of developing
lymphoma, the most common being diffuse B-cell and mucosa-associated lymphoid tissue (MALT) lymphomas.
Common bile duct stones are most reliably diagnosed with
magnetic retrograde cholangiopancreatography (MRCP) or endoscopic ultrasound, but they can occasionally be seen on abdominal CT or ultrasound. Management of known common bile duct stones consists of removal, usually with endoscopic retrograde cholangiopancreatography; however, experienced surgeons may be able to remove common bile duct stones at the time of laparoscopic cholecystectomy.
acute pancreatitis is more likely to progress to chronic pancreatitis in patients with three risk factors:
male sex, alcohol use, and tobacco use.
Absolute contraindications to lung transplantation
malignancy within the last 2 years, infection with hepatitis B or C virus with histologic evidence of significant liver damage, active or recent cigarette smoking, drug or alcohol abuse, severe psychiatric illness, documented nonadherence with medical care, and absence of social support
Palpable lump or mass and age <30y if found on ultrasound to have bloody fluid (or if mass persists)
mammography and Bx
Palpable lump or mass and age <30y if found on ultrasound to have complex cyst
mammography and FNA or CNBx
Palpable lump or mass and age <30y if found on ultrasound to have solid mass
mammography and core biopsy or surgical excision
Transfusion-associated Circulatory Overload treatment
management consists of transfusion discontinuation, diuretic therapy, and supportive care. Prevention includes a slower infusion rate (1 mL/kg/hour) and diuretic therapy between transfusions to maintain euvolemia for those at risk.
Transfusion-associated Circulatory Overload tx
management consists of transfusion discontinuation, diuretic therapy, and supportive care. Prevention includes a slower infusion rate (1 mL/kg/hour) and diuretic therapy between transfusions to maintain euvolemia for those at risk.
Splenectomy has been shown to be beneficial in patients with CLL who have
marked splenomegaly or profound cytopenias in which splenomegaly may be a contributing factor. However, it is usually reserved for patients whose disease does not respond to chemotherapy or other treatments.
AAA screening
maximum diameter is 3.5 to 4.4 cm, repeat ultrasonography is recommended annually 4.5 to 5.4 cm, repeat ultrasonography should be performed every 6 to 12 months
Diagnose a central pain syndrome
may affect a specific area of the body or occur more diffusely; pain is usually constant, with bursts of more severe pain, often exacerbated by cough, temperature changes, movement, or emotions
use of glucocorticoids as adjunctive therapy in community-acquired pneumonia (CAP) demonstrated that glucocorticoid use decreases the need for ______ in hospiatlized patients with CAP
mechanical ventilation
typically present with medial knee pain and joint instability. On examination, there is medial joint line tenderness and increased laxity with valgus stress testing
medial collateral ligament tears
Alarm symptoms of dyspepsia
melena, rectal bleeding, unintentional weight loss, anorexia, early satiety, persistent or recurrent vomiting, dysphagia, odynophagia, family history of upper gastrointestinal malignancy, personal history of PUD or malignancy, prior gastric surgery, abdominal mass, or anemia
glomerulopathy associated with renal vein thrombosis
membranous glomerulopathy
nephrotic syndrome with the highest propensity for thromboembolic events
membranous glomerulopathy
Patients with late complement component deficiencies are suceptible to what types of infections
meningococcal or gonococcal infections.
Neurosyphilis can present as
meningovascular, parenchymatous, or ocular disease
Locking and catching are common symptoms of what knee injuries
meniscal injuries
Secondary osteoarthritis may occur in the setting of hemochromatosis, which is associated with an arthropathy that is osteoarthritis-like, but characteristically involves the
metacarpophalangeal and wrist joints.
for early rheumatoid arthritis of less than 6 months' duration regardless of disease activity, Current guidelines continue to recommend monotherapy, preferably with
methotrexate
in addition to prednisone, high-risk patients with polymyalgia rheumatica should be treated with
methotrexate to minimize relapse and adverse effects from chronic glucocorticoid therapy.
β-blockers that have been shown to provide benefit in patients with HFrEF are
metoprolol succinate, carvedilol, and bisoprolol.
mammography findings requiring biopsy
microcalcifications or spiculations
diagnostic criteria for migraine
migraine attacks should last between 4 and 72 hours if untreated, and the pain must possess two of the following four features: 1.) unilateral location, 2.) throbbing nature, 3.) moderate or severe intensity, 4.) aggravation with physical activity.
A presumptive diagnosis of nonalcoholic steatohepatitis can be made in a patient with
mild abnormalities of aminotransferase levels, risk factors for nonalcoholic fatty liver disease (such as diabetes mellitus, obesity, and hyperlipidemia), and imaging features consistent with hepatic steatosis.
Surgery is indicated for patients with asymptomatic chronic severe mitral regurgitation with
mild to moderate LV dysfunction (ejection fraction of 30%-60% and\or LV end-systolic dimension ≥40 mm Mitral valve repair is the operation of choice
First-line therapy for erectile dysfunction includes lifestyle
modification (weight loss, exercise, smoking cessation), psychotherapy as needed, and phosphodiesterase type 5 inhibitors.
tx of medication-induced psychosis in parkinson's
monitoring for infection and metabolic derangement and discontinuing anticholinergic drugs, amantadine, or dopamine agonists. Discontinuing catechol-O-methyltransferase and monoamine oxidase type B inhibitors also can be considered but may worsen the wearing-off phenomenon. A reduction in levodopa dosing may be required. When necessary, the preferred antipsychotic agents are clozapine and quetiapine.
Patients with HER2-amplified metastatic breast cancer are treated with
monoclonal antibodies against the HER2 receptor. Trastuzumab
Patients with Barrett esophagus with with low-grade dysplasia, surveillance is
more frequent, usually 6 to 12 months following confirmation by an expert pathologist
When to give abx with Travelers' diarrhea
more than four unformed stools per day with fever and blood, pus, or mucus in the stool. Antibiotic treatment may also be a reasonable option in patients with milder illness if it is markedly disruptive to travel plans
Avoid what opioid in kidney failure
morphine estimated glomerular filtration rate <30 mL/min/1.73 m2
follicular lymphoma causing Symptomatic systemic disease requires
multiagent therapy that traditionally includes rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP); rituximab plus cyclophosphamide, vincristine, and prednisone (R-CVP); or rituximab and bendamustine.
Genetic testing for BRCA gene mutations should only be performed in patients with a family history that is
multiple family members with breast cancer, the presence of both breast and ovarian cancer, breast cancer diagnosis before the age of 50 years, breast cancer in one or more male family members, bilateral breast cancer, and Ashkenazi Jewish heritage.
The combination of parkinsonism, cerebellar ataxia, and early postural instability and falls is most consistent with a diagnosis of
multiple system atrophy.
JC virus antibody screening is currently recommended as a risk mitigation strategy for patients with MS treated with
natalizumab because elevated levels of JC virus antibody have been correlated with an increased risk of progressive multifocal leukoencephalopathy (PML) in patients taking this drug
Acute hyperpurulent ocular discharge in a sexually active adult
neisseria gonorrhoea conjunctivitis
Inflammatory breast cancer is treated with
neoadjuvant chemotherapy, followed by surgery, and then radiation.
Fetuses of mothers who are positive for anti-Ro/SSA or anti-La/SSB antibodies are at risk for developing
neonatal lupus erythematosus
A mass in the posterior mediastinum is usually a
neurogenic tumor in adults neurogenic tumors tend to arise from the nerve sheaths (for example, schwannomas)
indications for early surgery in native valve infective endocarditis include
new heart block valve stenosis or regurgitation resulting in heart failure; left-sided endocarditis caused by Staphylococcus aureus, fungal, or other highly resistant organisms; endocarditis complicated by annular or aortic abscess; a endocarditis with persistent bacteremia fever lasting longer than 5 to 7 days after starting antibiotic therapy.
regimen of choice in all patients with symptomatic cystitis iwhom are allergic to sulfa drugs
nitrofurantoin for 5 days
Symptomatic treatment, such as NSAIDs, gabapentin, and glucocorticoid injections, and conservative treatment, such as nocturnal neutral position wrist splinting and occupational therapy, may be appropriate therapy for patients with mild to moderate carpal tunnel syndrome, but only if they have
no evidence of weakness, atrophy, or active motor denervation on nerve conduction studies. Weight reduction also can be helpful in patients with obesity.
Myelodysplastic syndrome should be managed based on risk stratification, with patients with low-risk disease requiring
no treatment.
α-Thalassemia trait (or α-thalassemia minor), which is associated with mild anemia, microcytosis, hypochromia, target cells on the peripheral blood smear, and, in adults, normal hemoglobin electrophoresis results, requires
no treatment.
gram-positive, rod-shaped bacteria that forms partially acid-fast beaded branching filaments.
nocardia
Treat chronic respiratory failure due to muscular weakness with
nocturnal noninvasive positive pressure ventilation (NPPV). No clear guidelines exist for when to start mechanical ventilation in patients with chronic respiratory failure due to progressive muscular weakness; however, signs that ventilatory support is required include the inability to breathe while lying flat, low FVC, low vital capacity, and decreased negative inspiratory pressure. Frequently used clinical indicators for the need of ventilatory assistance include an FVC less than 50% of predicted, a vital capacity below 60% of predicted (or 1 L), or a maximal inspiratory pressure of less than −30 cm H2O. I
Patients receiving long-term immunosuppressive therapy are at greater risk for developing
non-Hodgkin lymphoma.
In a patient with a suspected transient ischemic attack, the most appropriate test to exclude significant atherosclerotic disease is
noninvasive carotid ultrasonography
First-line therapy for the management of fibromyalgia is
nonpharmacologic therapy, particularly an individualized low-impact aerobic exercise program. First-line therapy in the management of fibromyalgia is nonpharmacologic therapy, particularly aerobic exercise, as well as education and psychosocial support. . Tricyclic antidepressants such as amitriptyline and desipramine are often used as initial pharmacologic treatment. Cyclobenzaprine can also be used as an alternative to tricyclic antidepressants. For patients who cannot tolerate or do not respond to tricyclic antidepressants, pregabalin, duloxetine, or milnacipran can be used. In some cases, these drugs can also be used as initial therapy. Gabapentin is a reasonable option instead of pregabalin for some patients. Combination therapy can be used for patients unresponsive to monotherapy. In these circumstances, different classes of drugs are used to take advantage of multiple mechanisms of action for reducing pain and to target different symptoms. Some combinations that have been used in clinical practice include amitriptyline with fluoxetine, and pregabalin with duloxetine.
HBV tx goal
normalization of the ALT level and a decline in HBV DNA level to <50 IU/mL. Only a few patients will become HBsAg negative with treatment; therefore, cure of HBV is an unrealistic goal for most chronically infected patients.
The most appropriate diagnostic test for lung cancer is the one that
not only confirms the diagnosis in the least invasive fashion but also provides adequate staging to help plan treatment options. Needle aspiration of the left supraclavicular lymph nodes is the least invasive procedure
follicular lymphoma causing localized symptoms can be treated effectively with
nvolved-field radiation therapy combined with rituximab.
In patients with mild lower urinary tract symptoms caused by benign prostatic hyperplasia, the treatment is
observation with conservative therapy measures is appropriate
Acute Stress Disorder (ASD)
occurs within a month after exposure to traumatic stress lasting 3 or more days AND 1 month or LESS Tx: CBT
Sx treatment for carcinoid tumor
octreotide
Who to treat for essential thrombocythemia
older than 60 years, those with a platelet count greater than 1 million/µL (1000 × 109/L), those with a history of thrombosis
Localized GISTs are managed with
one location: surgical resection Location outside the stomach, larger size, and higher mitotic index: surgical resection and imatinib
Criteria for Lynch syndrome are fulfilled when a patient has
one or more first degree relatives, or two or more second degree relatives, diagnosed with colorectal cancer before age 50 years, and by the presence of metachronous or synchronous cancers of colon, endometrium, ovarian, ureter, stomach, pancreas, sebaceous, or small intestine
Indications for ICD in HCM
one or more major risk factors for sudden cardiac death: - prior cardiac arrest - massive myocardial hypertrophy - family history of sudden cardiac death - ventricular tachycardia - blunted blood pressure response to exercise - unexplained syncope
Targeted therapy with an intra-articular glucocorticoid injection is appropriate in patients with osteoarthritis who have
one symptomatic joint.
AAA screening
one-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men ages 65 to 75 years who have ever smoked.
Metabolic alkalosis
or each ↑ 1.0 mEq/L (1.0 mmol/L) in [HCO 3], PCO 2 ↑ 0.7 mm Hg (0.09 kPa)
Low-risk gastric ulcers are clean-based or have a nonprotuberant pigmented spot and should be treated with
oral PPI therapy, initiation of refeeding within 24 hours, and early hospital discharge.
treatment of allergic conjunctivitis
oral antihistamines, topical antihistamines (olopatadine ophthalmic 0.1%, ketotifen ophthalmic), and artificial tears.
UTIs caused by most Candida species should be treated with
oral fluconazole for 14 days; for fluconazole-resistant strains, amphotericin B deoxycholate for 1 to 7 days is recommended. However, patients with asymptomatic candiduria alone do not require treatment.
severe UC is often treated with
oral glucocorticoids such as prednisone, 40 to 60 mg/d. Doses above 60 mg provide little if any additional efficacy with more side effects. Budesonide is a glucocorticoid with high first-pass metabolism available in a controlled ileal-release formulation frequently used in CD.
Moderate to severe ulcerative colitis is often treated with
oral glucocorticoids such as prednisone, 40 to 60 mg/d. Patients whose disease does not respond to oral glucocorticoids should be hospitalized and given intravenous glucocorticoids or should be treated with an anti-TNF agent. The three anti-TNF antibodies approved for inducing and maintaining remission in UC are infliximab, adalimumab, and golimumab
Although continuous positive airway pressure (CPAP) is the preferred treatment for obstructive sleep apnea, patient preference or intolerance of CPAP should prompt consideration of other treatments such as
oral mandibular advancement appliances.
first like Pharmacologic therapy for weight loss
orlistat
Syncope workup
orthostatic blood pressure cardiovascular examination, including auscultation for valvular heart disease (aortic stenosis) and the murmur of hypertrophic cardiomyopathy,
Diagnose hereditary spherocytosis
osmotic fragility test with 24-hour incubation Folic acid supplementation is recommended in moderate and severe forms of HS. Splenectomy is effective in reducing hemolysis and should be considered in severe conditions. Partial splenectomy can be effective, especially in children in whom preserved splenic immune function is desired. It is important to appropriately vaccinate patients against encapsulated organisms such as Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis before splenectomy.
Patients with systemic lupus erythematosus who have pain or limitation of motion of the large joints, especially the hips, should be evaluated for
osteonecrosis using MRI when plain radiographs are normal.
Patients with giant cell arteritis should undergo
osteoporosis screening when starting steroids and yearly chest x-rays (up to ten years) to identify patients with thoracic aortic aneurysms.
The risk of ______ cancer may be especially increased in women with dermatomyositis.
ovarian
Women with cancer of unknown primary site presenting as abdominal carcinomatosis and ascites are classified as a favorable prognostic subgroup and should be treated as if they have
ovarian cancer Cytoreductive surgery followed by systemic chemotherapy (tumor debulking along with total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, selective lymphadenectomy, and appendectomy, as well as administration of a platinum/taxane-containing chemotherapy regimen).
Diagnose human papillomavirus infection in a patient with head and neck cancer
p16 immunohistochemistry testing to detect human papillomavirus
Permissive Hypercapnia in ARDS
pH >= 7.2
for patients with respiratory failure due to progressive idiopathic pulmonary fibrosis The American Thoracic Society recommends _____ rather than intubation and mechanical ventilation
palliation of symptoms
Treat chronic pancreatitis with
pancreatic enzymes.
In hospitalized patients with Parkinson disease, sudden withdrawal of dopaminergic medications can lead to
parkinsonian-hyperpyrexia syndrome
the postexposure prevention of choice for varicella infection in patients without contraindication to varicella vaccination
passive immunoprophylaxis with varicella-zoster immune globulin
Prasugrel Contraindicated in
patients >75 years of age, low body weight (<60 kg [132 lb]), or history of stroke/TIA
A 3- to 5-day course of prophylaxis with amoxicillin-clavulanate is recommended for patients who are bitten by a dog and have one of the following conditions:
patients who are immunosuppressed (including those with asplenia or who have significant liver disease); have moderate-to-severe wounds, particularly on the face or hand; have wounds near a joint or bone; have wounds associated with significant crush injury or edema.
When do furuncles need antibiotic treatment
patients who are immunosuppressed, who do not respond adequately to incision and drainage or antibiotics without MRSA activity, or who have systemic signs of infection
Patients with asymptomatic candiduria require no antifungal therapy, except in
patients who are neutropenic or who are undergoing urinary tract procedures If treatment becomes necessary, oral fluconazole is the drug of choice.
Inpatient epilepsy monitoring is recommended for
patients who have not responded to two or more AEDs to determine their candidacy for epilepsy surgery and to exclude PNES
Washing of blood products is for
patients with a history of severe/recurrent allergic reactions, IgA deficiency (when IgA-deficient donors are unavailable), complement-dependent autoimmune hemolytic anemia. Also reduces the amount of potassium transfused for use in patients who are at risk for hyperkalemia.
radiographic hallmarks of rheumatoid arthritis
periarticular osteopenia and marginal erosions
Imaging with CT (preferred) or ultrasonography should be performed in patients hospitalized with pyelonephritis if symptoms and fever persist longer than 72 hours to rule out
perinephric or intrarenal abscess.
indications for a urinary catheter include
perioperative use for selected surgeries (should be removed before the end of the second postoperative day), need for accurate measurement of urine output in critically ill patients in the ICU, management of acute urinary retention or bladder outlet obstruction, assistance in open sacral or perineal wound healing for patients who are incontinent, and, as an exception, end-of-life patient comfort if needed
Patients with an eGFR <30 mL/min/1.73 m2 should receive education regarding treatment options, including
peritoneal dialysis and hemodialysis, transplantation, and non-dialytic management of ESKD
indications for giving both hepatitis A vaccination and intramuscular immune globulin
persons older than 40 years, those with chronic medical conditions, immunocompromised persons, or those with chronic liver disease who plan to depart within 2 weeks to an endemic area
patients with left bundle branch block undergoing nuclear stress testing should be administered a
pharmacologic stressor even if they are able to exercise because of the potential for a false-positive test owing to a septal perfusion abnormality that may occur with exercise
First-line treatment of major depression in patients with cognitive impairment is
pharmacotherapy, with or without psychotherapy.
Treat patients with pulmonary arterial hypertension and a negative vasoreactivity test
phosphodiesterase-5 inhibitors (sildenafil, tadalafil) or endothelin receptor antagonists (bosentan, ambrisentan) in patients who have a positive response to vasoreactivity testing (a decrease in mean pulmonary artery pressure of at least 10 mm Hg without significant reductions in cardiac output or systemic blood pressure), oral calcium channel blockers such as nifedipine are a reasonable initial therapy. In those with a negative vasoreactivity test, calcium channel blockers are not beneficial.
Primary membranous glomerulopathy is associated with the antibody to
phospholipase A2 receptor (PLA2R) on the podocyte surface
Postoperative surveillance for patients with colorectal cancer includes
physical examination and serum carcinoembryonic antigen measurement every 3 to 6 months, and CT scans of the chest and abdomen (and pelvis for patients with rectal cancer) annually for 3 to 5 years; colonoscopy, if done preoperatively, should be performed 1 year after resection and then repeated at 3- to 5-year intervals.
treatment of chronic cervical or lumbar stenosis or acute disk herniations
physical therapy and symptomatic management of spasticity and pain (with oral or injected medications) can control symptoms in most patients. However, surgical decompression may also be required for those refractory to medical management.
rest, ice, and physical therapy to strengthen the quadriceps and hamstring muscles. Consideration for surgical intervention for acute meniscal tears is typically limited to patients who have significant mechanical symptoms that persist beyond 4 weeks. MRI is reserved for patients in whom surgery is being considered and in patients with persistent locking and catching despite appropriate initial management.
physical therapy. Surgery for chronic degenerative meniscal tears is usually limited to patients with persistent mechanical symptoms or effusions.
Multiple myeloma requires therapy when
plasma cells represent more than 10% of the total marrow cellularity, and she does not meet CRAB (hyperCalcemia, Renal failure, Anemia, Bone disease)
DAPT of choice in STEMI getting thrombolysis is aspirin and
plavix
the most appropriate test to diagnose a possible tuberculous effusion is
pleural fluid adenosine deaminase measurement.
Abestosis on chest imaging
pleural plaques
HAP/VAP diagnosis
pneumonia occurring more than 48 hours after admission that was not incubating at admission. Ventilator-associated pneumonia (VAP) is defined as pneumonia developing 48 hours after endotracheal intubation.
Patients with ________ typically present with fever, arthralgia, myalgia, skin findings, abdominal pain, weight loss, and peripheral nerve manifestations, most commonly mononeuropathy or mononeuritis multiplex.
polyarteritis nodosa
ESR elevations are used to identify and monitor disease activity in rheumatologic diseases, especially in
polymyalgia rheumatica and giant cell arteritis
Patients with chronic liver disease and portosystemic shunting can develop a form of PAH referred to as
portopulmonary hypertension The diagnosis of portopulmonary hypertension is suggested by evidence of pulmonary hypertension in the setting of portal hypertension.
The diagnosis of celiac disease requires
positive serologic markers and a compatible small-bowel biopsy. IgA tissue transglutaminase (tTG) antibodies and endomysial antibodies (EMA) are sensitive and specific serologic markers; testing for these should be done while the patient is consuming gluten. The classic findings on small-bowel histology are intraepithelial lymphocytosis, crypt elongation, and villous blunting (Figure 22). Mild cases may show only lymphocytosis (stage 1) or hyperplasia (stage 2). Villous blunting can be partial (stage 3) or complete (stage 4). However, these changes are not specific for celiac disease (Table 17); therefore, the diagnosis also relies on positive serologic tests. If the diagnosis is unclear (such as in patients with equivocal or conflicting biopsies or serologies) or if a patient is following a gluten-free diet when serologic studies are performed, HLA haplotyping may be helpful.
Tarsal tunnel syndrome
posterior tibial nerve compression within the tarsal tunnel below the medial malleolus. It most commonly arises in the setting of a calcaneous, medial malleolus, or talus fracture, but it can also be associated with rheumatoid arthritis, diabetes mellitus, thyroid disorders, pregnancy, and wearing tight-fitting shoes.
Treatment of RTA 1
potassium citrate at a dose of 1 mEq/kg/d.
Poststreptococcal glomerulonephritis is characterized by
preceding symptoms of an upper respiratory tract infection suggestive of streptococci, followed by the nephritic syndrome and low C3 levels with normal C4 levels.
Treatment of Bell's palsy with oral ______ within the first 72 hours expedites both the speed and the rate of full recovery.
prednisone
lung volume reduction surgery results in improved survival compared with medical treatment In patients with severe COPD and
predominantly upper-lobe emphysema and low post-rehabilitation exercise capacity
Contraindications to ECG stress test
preexcitation, LBBB, a paced rhythm, or baseline ST-segment depression greater than 1 mm
For patients with persistent pain due to chronic pancreatitis, __________ may be offered adjunctively, as part of a step-up approach to pain management, after an initial trial of acetaminophen, ibuprofen, and/or tramadol.
pregabalin (or a low-dose tricyclic antidepressant)
treating asymptomatic bacteriuria are supported by only two indications:
pregnancy and medical clearance before an invasive urologic procedure
EKG baseline abnormalities which preclude an ekg stress test
presence of left ventricular hypertrophy with repolarization abnormalities (ST-segment depressions) greater than 0.5 mm, preexcitation, left bundle branch block, a paced rhythm
Acromioclavicular Joint Degeneration dx
presents as pain located on the superior aspect of the shoulder, although pain may be poorly localized. The acromioclavicular joint is often tender to palpation. Pain is frequently elicited on physical examination with the arm on the affected side adducted across the body (see cross-arm test in Table 45) and with abduction beyond 120 degrees. Plain radiographs reveal degenerative changes.
Diagnose acromioclavicular joint degeneration
presents with pain located on the superior aspect of the shoulder, tenderness to palpation of the acromioclavicular joint, and pain with shoulder adduction and abduction beyond 120 degrees.
Irradiation Is Used to
prevent transfusion-associated GVHD Indicated in patients with: - severe, inherited T-cell immunodeficiency syndromes - Hodgkin lymphoma - recipients of allogeneic or autologous hematopoietic stem cell transplantation; - purine analog-based chemotherapy (fludarabine, cladribine, deoxycoformycin), - alemtuzumab, - rabbit antithymocyte globulin therapy; - immunocompetent patients receiving HLA-matched platelets or transfusions from relatives
Do not start an AED for a first seizure unless the patient has risk factors that increase the likelihood for future events, such as:
previous head trauma with loss of consciousness, a focal brain lesion on MRI, postictal Todd paralysis (focal weakness after a seizure)
tx of systemic sclerosis-associated Dysmotility
promotility agents such as metoclopramide; in refractory cases, octreotide can be tried
Patients with small cell lung cancer who experience a complete or near-complete response following treatment with chemotherapy or combined chemotherapy and radiation therapy should be offered
prophylactic cranial irradiation to reduce the incidence of brain metastases and improve overall survival.
venous thromboembolism prophylaxis in patients who have undergone cancer surgery is
prophylactic-dose low-molecular-weight heparin for up to 28 days after surgery
Echo frequency for Asymptomatic aortic stenosis if the mean gradient is 40 or above
q0.5-1y
Echo frequency for Asymptomatic aortic stenosis if the transvalvular velocity is 4 or higher
q0.5-1y
If AAA maximum diameter is 4.5 to 5.4 cm, repeat ultrasonography is recommended
q0.5y-1y
Echo frequency for Asymptomatic aortic stenosis if the mean gradient is 20-39
q1-2y
Echo frequency for Asymptomatic aortic stenosis if the transvalvular velocity is 3-3.9
q1-2y
After colectomy is performed in patients with Familial Adenomatous Polyposis and MYH-Associated Polyposis, , lifelong surveillance of the rectum or ileal pouch is required to manage recurrent polyposis and decrease the risk of rectal or pouch adenocarcinoma should be obtained how often
q1y
If AAA maximum diameter is 3.5 to 4.4 cm, repeat ultrasonography is recommended
q1y
Echo frequency for Asymptomatic aortic stenosis if the mean gradient is <20
q3-5y
Echo frequency for Asymptomatic aortic stenosis if the transvalvular velocity is 2-2.9
q3-5y
In patients with Barrett esophagus and no dysplasia, surveillance with upper endoscopy is recommended every
q3-5y
All first-degree relatives of patients with hypertrophic cardiomyopathy should undergo screening how often
q5y
FDA-approved pharmacologic treatments for bipolar depression are
quetiapine monotherapy and combination olanzapine-fluoxetine.
Stage I and II Hodgkin lymphoma in patients without B symptoms (limited to lymph nodes and the same side of the diaphragm) can be treated effectively with
radiation alone or radiation combined with a short course of chemotherapy.
If surgery is not possible In patients with localized non-small cell lung cancer
radiation therapy is recommended as an alternative.
The standard treatment regimen for patients with stage I, II, or III anal squamous cell carcinoma is
radiation therapy with concurrent chemotherapy consisting of mitomycin plus 5-fluorouracil.
treatment of non-metastatic renal cell carcinoma
radical or partial nephrectomy. For patients who are not surgical candidates, active surveillance or ablative treatment can be considered for those with small tumors
Erosive OA is a subset of primary OA, diagnosis is
radiographic, based on the presence of central erosions (contrasting with the marginal erosions of rheumatoid and psoriatic arthritis) and collapse of the subchondral bone in the affected joints.
The Ottawa ankle and foot rules
radiographs should be obtained when a patient is: - unable to walk four steps both immediately after the injury - during evaluation and when focal tenderness is present at the posterior aspect of either malleolus, the navicular bone, or the fifth metatarsal base. - If these criteria are not met, obtaining radiographs is not necessary, as the probability of an ankle fracture is exceedingly low.
metastatic prostate cancer tx
radiotherapy, concurrent with androgen deprivation therapy,
Patients with tumor lysis syndrome and evidence of uric acid nephropathy require treatment with
rasburicase to reduce serum urate levels. Rasburicase rapidly converts uric acid to allantoin, which is 5 to 10 times more soluble than uric acid and readily excreted through the kidney. Rasburicase has a much faster action than allopurinol and can decrease serum urate levels within 4 hours of administration. Urine alkalinization increases the excretion of uric acid by increasing its solubility. However, in the setting of hyperphosphatemia, it can cause precipitation of calcium phosphate crystals in the kidney. Urine alkalinization is not necessary when rasburicase is used, and it role in TLS is controversial.
Routine second-look endoscopy in all upper GI bleed patients is not recommended, but a second attempt at endoscopic therapy is recommended for
rebleeding and when the initial examination was incomplete. Repeat endoscopy can be considered for gastric ulcers after 8 to 12 weeks of PPI therapy if (1) symptoms are persistent despite therapy, (2) ulcers have an endoscopic appearance that is concerning for underlying malignancy, (3) visualization of the stomach was incomplete, or (4) biopsies were not taken at the time of the index upper endoscopy.
MYH-associated polyposis is an autosomal ______ disorder
recessive
After colectomy is performed in patients with Familial Adenomatous Polyposis and MYH-Associated Polyposis, , lifelong yearly surveillance of the rectum or ileal pouch is required to manage recurrent polyposis and decrease the risk of
rectal or pouch adenocarcinoma
Behçet syndrome is characterized by
recurrent painful oral ulcers plus at least two of the following: recurrent painful genital ulcers, eye involvement, skin involvement, and pathergy.
. Patients with selective IgA deficiency may be asymptomatic or present with
recurrent sinopulmonary infections (otitis media, sinusitis, pneumonia) or gastrointestinal infections (giardiasis).
Post coronary stenting rhythm indicative of good reperfusion
regular wide complex rhythm with no clearly discernible atrial activity accelerated idioventricular rhythm (AIVR)
the standard outcome measure for a cohort study is
relative risk. Relative risk is the ratio of the probability of developing a specific outcome (in this case, erectile function score) in a group with an exposure or risk factor present (treatment with tadalafil) to the probability of developing the specific outcome in a group without the exposure or risk factor present (no treatment with tadalafil). A relative risk that is greater than or less than 1 indicates a more likely or less likely outcome, respectively, of the measured variable in the exposure or risk factor group compared with the group without the exposure or risk factor present.
Invasive adenocarcinoma arising in a pedunculated or sessile polyp may be adequately treated by endoscopic polypectomy alone if the lesion is
removed en bloc, invades only the submucosa, possesses no adverse histologic features (poorly differentiated, lymphovascular invasion), and has clear margins
Invasive adenocarcinoma arising in a pedunculated or sessile polyp may be adequately treated by endoscopic polypectomy alone if the lesion is
removed en bloc, invades only the submucosa, possesses no adverse histologic features (poorly differentiated, lymphovascular invasion), and has clear margins. These polyps containing invasive cancer should be followed up with colonoscopy 3 to 6 months after removal.
Treat a patient with struvite nephrolithiasis by
removing the stone
Acquired cystic kidney disease is associated with a large number of small bilateral kidney cysts, reduced kidney size, and a markedly increased risk for developing
renal cell carcinoma.
After an initial negative evaluation, the underlying cause of obscure gastrointestinal bleeding can often be found by
repeating either upper endoscopy or colonoscopy depending on presenting features.
Middle East respiratory syndrome should be suspected in any person presenting with
respiratory illness following travel in or around the Arabian Peninsula. After an average incubation period of 5 days, patients report a typical viral-like syndrome. In severe illness, the patient often progresses to pneumonia and significant respiratory distress, often necessitating mechanical ventilation
Achilles tendinopathy tx
rest, activity modification, and application of ice. NSAIDs can be used for pain control
Initial therapy for acute meniscal tears
rest, ice, and physical therapy to strengthen the quadriceps and hamstring muscles. Consideration for surgical intervention for acute meniscal tears is typically limited to patients who have significant mechanical symptoms that persist beyond 4 weeks. MRI is reserved for patients in whom surgery is being considered and in patients with persistent locking and catching despite appropriate initial management.
The diagnosis of Parkinson disease can be made on the basis of clinical findings and requires the presence of bradykinesia and at least one of the other cardinal features of
resting tremor, rigidity, or postural instability. BRIT (bradykinesia, rigidity, instability, tremor)
When a vaccine series is interrupted, the most appropriate approach is to
resume rather than restart the series. Typically, the vaccine series is administered as a three-dose regimen over a 6-month time period, with doses administered at 0, 1, and 6 months
Patients with stage II nonseminomatous germ cell tumors
retroperitoneal lymph node dissection if retroperitoneal lymph nodes are small, with possible adjuvant chemotherapy depending on the extent of disease identified at surgery. For patients with bulky retroperitoneal lymphadenopathy identified on CT, cisplatin-based chemotherapy is recommended. Treatment of advanced disease depends on both histology and risk assessment based on clinical extent of disease and tumor marker levels. All patients with advanced disease receive chemotherapy, most commonly bleomycin, etoposide, and cisplatin, given for three to four cycles. Following treatment, patients are observed closely with periodic history, physical examination, and imaging and tumor marker assessments. For patients with residual radiographic abnormalities following treatment, surgery is sometimes recommended. Patients with relapsed or refractory disease are treated with salvage chemotherapy, and sometimes, autologous hematopoietic stem cell transplantation.
Felty syndrome is characterized by what triad
rheumatoid arthritis, splenomegaly, and neutropenia.
In ostium secundum atrial septal defect, the electrocardiogram (ECG) demonstrates
right axis deviation and incomplete right bundle branch block
Gold standard dx PAH
right heart cath
Treat amyotrophic lateral sclerosis with
riluzole
treatment for Waldenström macroglobulinemia
rituximab as monotherapy or combined with chemotherapy the chemotherapy regimen may consist of an alkylating agent base (such as cyclophosphamide) or purine analog base (such as fludarabine).
Standard therapy for all patients with diffuse large B-cell lymphoma, regardless of disease stage or prognosis, is
rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) Involved-field radiation therapy is added for patients with bulky disease Autologous HSCT is used as salvage therapy in patients with recurrent, chemotherapy-sensitive disease who experienced a disease-free interval of longer than 1 year from initial therapy.
Hydrophilic statins, such as ________, are less likely than lipophilic statins to cause statin-induced myopathy.
rosuvastatin
tx of systemic sclerosis-associated Malabsorption due to bacterial overgrowth
rotating courses of antibiotics
Bartter Syndrome mimics what diuretic use
s Bartter and Gitelman syndromes. These rare autosomal recessive genetic disorders of renal sodium and chloride transporters clinically mimic loop diuretic and thiazide diuretic use, respectively
Hypersensitivity pneumonitis (HP)
s the result of an immunologic response to repetitive inhalation of antigens. The most common sources of antigens are thermophilic actinomyces, fungi, and bird droppings. Antigens, however, are not limited to these origins and can include bacterial, protozoal, animal, or insect proteins, and even small molecular chemical compounds. The acute form of HP presents within 48 hours of a high-level exposure and will often be associated with fevers, flulike symptoms, cough, and shortness of breath. Radiographic imaging can demonstrate bilateral hazy opacities, while HRCT imaging of the chest shows findings of ground-glass opacities and centrilobular micronodules that are upper- and mid-lung predominant (Figure 8). Symptoms typically wane within 24 to 48 hours after removal from the exposure. Recurrence of symptoms with exposure to the respiratory antigen is the hallmark of this disorder, and careful attention to the history will help identify the cause.
Massive PE
sBP < 90 or drop in sBP >= 40mmHg for > 15min
The hallmark of FSGS is the presence of
segmental scars in some glomeruli. Electron microscopy shows visceral epithelial cell foot process effacement but no immune deposits. There are several variants of FSGS, but the "collapsing" form is diagnosed when there is severe podocyte hyperplasia leading to collapse of the glomerular tuft. HIV infection is typically associated with collapsing FSGS.
Women with BRCA1/2 mutations should undergo Ovarian cancer screening at age 30 years with
semiannual pelvic examinations, pelvic ultrasonography, and serum CA-125
Meniere disease is typically characterized by the triad of
sensorineural hearing loss, tinnitus, and vertigo
Patients with isolated hematuria with a family history of hematuria may require
serial measurements of kidney function and urine protein because kidney failure may occur later in life.
Owing to the increased risk of false-negative endoscopic and fecal antigen test results in patients with bleeding PUD, ____________ should also be performed as a second test in this clinical setting, and treatment should be pursued if either test modality is positive.
serologic antibody testing
Noninvasive H. pylori testing modalities include
serology, the fecal antigen test, or the urea breath test Serum testing for IgG antibodies to H. pylori does not identify active infection in populations with low prevalence of disease; however, it remains popular given its ease of administration, rapidity of results, and low cost. Given its marginal sensitivity (85%) and specificity (79%), antibody testing should not be used when there is a low background prevalence of H. pylori (prevalence <20%).
IgA deficiency is defined as a serum
serum IgA level less than 7 mg/dL (0.07 g/L). A low level should be confirmed by repeat measurement.
In patients taking an interferon beta as a disease-modifying therapy for multiple sclerosis, _______ levels should be measured every 3 to 6 months to monitor for autoimmune hepatitis.
serum aminotransferase
Pseudohyponatremia is caused by a laboratory error in the measurement of serum sodium due to the presence in the serum of elevated
serum lipid levels (pancreatitis) or abnormal paraproteins such as myeloma proteins.
The diagnosis of drug-induced lupus erythematosus is typically confirmed when symptoms resolve after how long after discontinuation of the offending agent.
several weeks to months
Which 2 objects in the esophagus need to be retrieved
sharp objects and batteries
treatment for hormone receptor negative breast cancer
single-agent chemotherapy
important imagine as a part of the initial evaluation of multiple myeloma
skeletal survey; An MRI or CT is more sensitive at detecting bone lesions than plain radiographs and should be considered when bone pain is present and radiographs are unrevealing MRI should also be performed to assess for spinal cord impingement if back pain is present or a compression fracture is seen on radiographs.
In older patients who require posthospital rehabilitation but cannot tolerate active, intensive therapy (3 hours per day, 5 days per week), rehabilitation services may be performed in a
skilled nursing facility Rehabilitation services can be provided on an outpatient basis, either in the patient's own home if the patient is homebound or at an outpatient rehabilitation clinic in patients who are more functional. However, because this patient's family is not able to provide adequately extensive care in the home, rehabilitation services in this setting are not appropriate.
Disseminated blastomycosis most commonly manifests as
skin lesions
Diagnose allergic bronchopulmonary aspergillosis
skin test reactivity to Aspergillus antigens; this is often used as an initial diagnostic test ;aboratory studies show peripheral eosinophilia (usually greater than 1000/µL [1 × 109/L]), serum IgE levels greater than 1000 U/mL (1000 kU/L), and precipitating serum antibodies to Aspergillus
the prothrombin time (PT) and aPTT in vWD
slight prolongation of the activated partial thromboplastin time (aPTT), although typically the prothrombin time (PT) and aPTT are normal. Hemorrhagic manifestations of vWD are characterized by mucocutaneous bleeding, not hemarthroses as in hemophilia.
Drug-induced AIN is characterized by a
slowly increasing serum creatinine 7 to 10 days after exposure; however, it can occur within 1 day of exposure if the patient has been exposed previously. Drug-induced AIN can also occur months after exposure, often with NSAIDs and proton pump inhibitors (PPIs).
Sitagliptin is a dipeptidyl peptidase-4 (DPP-4) inhibitor that
slows gastric emptying and suppresses glucagon secretion.
Malignancy, especially ________, is found in as many as 60% of patients with Lambert-Eaton myasthenic syndrome.
small cell lung cancer
Mechanical stone removal is appropriate for patients with large (>10 mm) kidney stones or those with
smaller stones who have failed medical management or have complicated nephrolithiasis (urosepsis, acute kidney injury, anuria, refractory pain).
In patients with ascites associated with cirrhosis, management consists of
sodium restriction (<2 g/d) and spironolactone with furosemide.
Diagnose COPD with
spirometry, which measures the FEV1 and FVC, and the FEV1/FVC ratio to assess for and quantify any degree of airflow obstruction present. Patients with COPD have a FEV1/FVC ratio of less than or equal to 70%. Spirometry is reproducible and provides an objective measurement of airflow obstruction
Patients with severe community-acquired pneumonia should have _________ cultures performed as part of further diagnostic testing.
sputum and blood cultures
gastroesophageal cancer stages
stage I disease is a superficial lesion that has not spread and does not penetrate the full thickness of the esophagus or stomach wall, whereas stage II disease is a full-thickness lesion. Stage III disease is defined by spread to locoregional lymph nodes, and stage IV disease is defined by the presence of distant metastatic disease.
Diagnose knee osteoarthritis with
standing plain radiography. In patients with suspected osteoarthritis, confirmatory plain radiographs with standing views are appropriate to solidify the diagnosis and rule out less common findings such as avascular necrosis, fractures, and malignancies.
In patients with interstitial nephritis, the hallmark findings on urinalysis are
sterile pyuria and leukocyte casts.
Patients with unruptured intracranial aneurysms should be counseled to
stop smoking because of the increased risk of aneurysmal rupture.
For patients with parkinson's in whom the motor benefits of medication wear off quickly
strategies include either using a greater frequency of immediate-release levodopa dosing or using sustained-release levodopa. Other options include adding a dopamine agonist, a catechol-O-methyltransferase inhibitor, or a monoamine oxidase type B inhibitor. In patients with dyskinesia, adding amantadine may help a subset of patients. In patients with prominent tremor, anticholinergic medications may provide some additional benefit, but their high adverse effect profiles limit their use, especially in patients with cognitive impairment and in older patients.
Indications for Immediate radiation therapy in SVC syndrome
stridor, laryngeal edema, or mental status decline.
The serum-ascites albumin gradient (SAAG) should be calculated by
subtracting the ascitic fluid albumin level from the serum albumin level
Patients taking AEDs should be regularly screened for
suicidal thoughts
A positive drop-arm test is suggestive of
supraspinatus tear
Rectal cancer treatment
surgery, with a total mesorectal excision being the preferred procedure. If local lymph node metastases or full-thickness tumor penetration is found after surgery in those patients thought to be stage I preoperatively, then postoperative chemotherapy and radiation therapy are indicated. Otherwise, if pathology confirms stage I cancer, no further therapy is needed.
In patients with an adnexal mass without ascites, diagnosis of ovarian cancer is usually established by
surgical exploration, as there is survival benefit from intact removal of the adnexal mass in early-stage disease. If ovarian cancer is confirmed at surgery, appropriate procedures include peritoneal washings for cytology, total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, full abdominal and pelvic exploration with biopsy of any masses suspicious for cancer, lymph node evaluation, and, for patients with advanced ovarian cancer, debulking of the tumor by removing as much of the cancer as possible.
glioblastoma multiforme
surgical resection followed by combined modality therapy of radiation and chemo (Temozolomide)
Patients with colon cancer without preoperative evidence of metastatic disease should undergo
surgical resection of the primary tumor and the regional lymph nodes.
patients with stages I, II, and III gastroesophageal cancer are typically treated
surgically, and with neoadjuvant chemotherapy or chemoradiation therapy Treatment of metastatic (stage IV) gastroesophageal cancer remains unsatisfactory and palliative.
After SVR, patients with cirrhosis or with stage 3 fibrosis should undergo
surveillance for hepatocellular carcinoma twice annually for an indefinite duration. Patients with cirrhosis should also undergo endoscopic screening for esophagogastric varices.
eosinophilic esophagitis tx
swallowed aerosolized topical glucocorticoids (fluticasone or budesonide); if symptoms are not responsive, oral prednisone should be used. Esophageal dilation should be considered in patients with a persistent esophageal stricture despite medical therapy.
Treatment of cerumen impaction is indicated only in
symptomatic patients or if the tympanic membrane needs to be visualized Ceruminolytic agents, manual removal, and irrigation are all effective means to remove cerumen in symptomatic patients.
Indications for mitral valve surgery include
symptomatic severe mitral regurgitation with left ventricular (LV) ejection fraction greater than 30% asymptomatic severe mitral regurgitation with mild to moderate LV dysfunction (ejection fraction of 30%-60% and/or LV end-systolic diameter ≥40 mm)
Patients with malignant pleural mesothelioma most commonly present with
symptoms of a slowly enlarging pleural effusion
The diagnosis of drug-induced lupus erythematosus is typically confirmed when
symptoms resolve several weeks to months after discontinuation of the offending agent.
An extensive evaluation for cancer is not indicated in patients with membranous glomerulopathy beyond age-appropriate cancer screening except for those with
symptoms suggestive of a cancer diagnosis or significant risk factors for specific malignancies.
High risk features of syncope
syncope during exertion palpitations at the time of syncope family history of sudden death abnormal electrocardiographic findings severe structural or coronary heart disease (heart failure low ejection fraction previous myocardial infarction comorbidities (severe anemia, electrolyte disturbances)
High-grade poorly differentiated neuroendocrine tumors of unknown primary site often respond rapidly to
systemic platinum-based chemotherapy, such as the regimens used to treat small cell lung cancer.
American College of Chest Physicians (ACCP) recommends thrombolytic therapy for patients with PE if they have
systolic blood pressure less than 90 mm Hg and without contraindications (for example, high bleeding risk)
immunosuppression for liver transplant
tacrolimus or cyclosporine
The recommended adjuvant endocrine therapy following breast cancer treatment for a premenopausal patient is
tamoxifen for at least 5—preferably 10—years.
breast cancer prophylaxis
tamoxifen prior to menopause and with tamoxifen, raloxifene, or exemestane after menopause.
febrile neutropenia, which is generally defined as
temperature >38.3 C (>101 F) and an absolute neutrophil count <500/mm
A rising epigastric sensation is the most common epileptic aura that originates in the ______ lobe of the brain
temporal lobe
Iliotibial band syndrome on examination
tenderness to palpation of the lateral femoral epicondyle, which is approximately 2 to 3 cm proximal to the lateral joint line, accompanied by weakness of the hip abductor muscles and the knee extender and flexor muscles. Pain is reproduced when the examiner repeatedly flexes and extends the supine patient's knee while the examiner's thumb is on the lateral femoral epicondyle (positive Noble test).
HIV infection and hepatitis B can both be treated with
tenofovir (either tenofovir disoproxil fumarate or tenofovir alafenamide), emtricitabine, and lamivudine including two of these agents in the medication regimen is crucial for managing coinfection.
PrEP
tenofovir-emtricitabine
Treatment for patients younger than 50 years with dyspepsia without alarm features
test-and-treat approach for Helicobacter pylori
For patients younger than 50 to 55 years who present with dyspepsia without alarm features, testing and treating for ______ should be pursued before any further testing is done.
testing and treating for H. pylori infection or a trial of proton pump inhibitor (PPI) therapy should be pursued before any further testing is done
What order should all immunocompromised person receive the pneumococcal vaccinations
the 13-valent pneumococcal conjugate vaccine first, followed 8 weeks later by the 23-valent pneumococcal polysaccharide vaccine
Criteria that have been suggested for a successful spontaneous breathing trial in patients requiring intubation and mechanical ventilation include
the ability to tolerate a weaning trial for 30 minutes; maintain a respiration rate of less than 35/min; and maintain an oxygen saturation of at least 90% without arrhythmias, sudden increases in heart rate and blood pressure, or development of respiratory distress, diaphoresis, or anxiety.
A TIPS can be considered for patients with refractory ascites WITH
the absence of HE, heart failure, and pulmonary hypertension when the serum bilirubin level is less than 4 mg/dL (68.4 µmol/L) and the MELD score is less than 15 to 18.
Hemoglobinuria is distinguished from true hematuria by
the absence of erythrocytes on urine microscopy.
surgery for patients with an asymptomatic intracranial aneurysm in the posterior circulation when
the aneurysm shows rapid growth to greater than 7 mm in size and clinical signs consistent with an enlarging aneurysm.
Neurosurgical evacuation is clinically indicated for hematomas located in
the cerebellum
First-line treatment options in stable patients with MG include
the cholinesterase inhibitor pyridostigmine, glucocorticoids, and immunosuppressant agents. Pyridostigmine monotherapy may be sufficient in patients with mild disease but should be avoided in those with acute respiratory failure because the drug increases respiratory secretions. Glucocorticoids can transiently worsen any weakness and should be started at a lower dosage with slow upward titration in the presence of moderate weakness. In patients with severe weakness, initiation of acute treatment with IVIG or plasmapheresis must precede any glucocorticoid treatment. Glucocorticoid-sparing disease-modifying medications, such as azathioprine, mycophenolate mofetil, and cyclosporine, are mainstays of long-term maintenance therapy in patients with advanced disease.
Babesiosis is a protozoal infection that is primarily spread through Ixodes ticks and is most commonly found among residents or travelers to ______
the coastal northeastern United States.
prophylactic bilateral salpingo-oophorectomy is recommended in women who have
the deleterious BRCA1/2 mutations between ages 35 and 40 years, once childbearing is complete.
The ARR is
the difference in rates of events between the treatment group and control group
Diagnose eosinophilic esophagitis
the finding of greater than 15 eosinophils/hpf on esophageal endoscopic biopsy and by exclusion of GERD. GERD must be excluded because it can also cause esophageal eosinophilic infiltration. This can be done with a therapeutic trial of a proton pump inhibitor (PPI) for 8 weeks. Clinical response to PPI therapy should be assessed based on improvement of clinical symptoms and even repeating the upper endoscopy with biopsies to demonstrate mucosal healing. Endoscopy often reveals characteristic findings of EoE such as rings, longitudinal furrows, and sometimes strictures. Medical therapy consists of swallowed aerosolized topical glucocorticoids (fluticasone or budesonide).
Diagnosis of thin glomerular basement membrane disease is usually based on
the history of persistent hematuria, normal kidney function, and positive family history of hematuria without kidney failure. thin glomerular basement membrane (GBM) disease, an inherited type IV collagen abnormality that causes thinning of the GBM and results in hematuria. Long-term prognosis is excellent, with rare progression to CKD. Blood pressure control with agents to decrease proteinuria is of benefit.
A reactive HIV-1/2 antigen/antibody combination immunoassay followed by negative result on confirmatory testing indicates that
the initial combination assay result was a false positive.
In patients with underlying Graves disease, thyroid storm may be precipitated by
the iodine content found in contrast media. also by infection, surgery, myocardial infarction, trauma, or parturition.
IgG4-related disease is characterized by
the lymphoplasmacytic infiltration and enlargement of various structures, including the pancreas, lymph nodes, salivary glands, periaortic region leading to retroperitoneal fibrosis, kidneys, and skin.
Travelers' diarrhea is defined as
the occurrence of 3 or more unformed stools per day with abdominal pain or cramps, nausea or vomiting, bloody stools, or fever
Parapneumonic pleural effusions require thoracostomy tube drainage when:
the pH is less than 7.2 or the pleural fluid glucose level is less than 60 mg/dL (3.3 mmol/L).
Endoscopic retrograde cholangiopancreatography (ERCP) and biliary sphincterotomy are indicated in the presence of cholangitis or nonresolving biliary obstruction unless
the patient is not a surgical candidate for cholecystectomy. Obstruction is typically indicated by a dilated bile duct and persistently elevated liver enzyme levels.
diagnosis of ADPKD in at-risk individuals 30 to 59 years of age
the presence of at least two cysts in each kidney is required for diagnosis; this increases to four cysts in each kidney for those older than 60 years.
diagnosis of ADPKD In 15- to 29-year-old at-risk individuals with a family history of ADPKD,
the presence of at least two kidney cysts (unilateral or bilateral) is sufficient for diagnosis.
neuroendocrine tumors that have demonstrated somatostatin receptors and are hormonally symptomatic or show clear growth under observation may be treated with
the somatostatin analogues octreotide or lanreotide Mechanical interventions, such as hepatic arterial embolization, radiofrequency ablation, or surgical debulking, may be used to reduce symptomatic tumor bulk in the liver or to decrease hormone production.
All adults, including immunocompromised patients, should receive a one-time booster immunization with
the tetanus-diphtheria-acellular pertussis vaccine.
Patients taking aromatase inhibitors (anastrozole, letrozole, and exemestane,) should have the following monitoring
their bone density monitored, and if the T score falls below -2.5, bisphosphonate treatment can be initiated.
Patients with gastroesophageal reflux disease with no alarm symptoms who have a partial response to once-daily proton pump inhibitor therapy should have
their dose increased to twice daily.
Transthoracic echocardiography in a patient with valvular heart disease is appropriate when
there is a change in clinical symptoms.
indications for inpatient management of PE
they require supplemental oxygen, intravenous pain medications, or management of comorbid conditions that may contribute to rapid clinical deterioration or if home circumstances make outpatient therapy unfeasible.
Manage upper gastrointestinal bleeding caused by a high-risk ulcer.
they should be treated endoscopically with hemostatic clips, thermal therapy, or injection of sclerosants.
If repeat pleural fluid cytology is negative and the suspicion for malignancy is high in an exudative effusion, the next step in the evaluation is
thoracoscopy; it has a diagnostic sensitivity for malignant disease of greater than 90%.
recurrent urinary tract infections (UTI) is defined as
three UTIs in the previous 12 months or two UTIs in the previous 6 months The initial duration of prophylaxis is generally 6 months; however, 50% of women experience recurrence by 3 months after discontinuation of prophylaxis. If this occurs, prophylaxis should be reinstated for 1 or 2 years with reassessment after that time.
Patients who have experienced a significant HIV exposure should immediately begin postexposure prophylaxis with
three-drug regimen of tenofovir-emtricitabine and raltegravir.
According to new guidelines, preeclampsia can also be diagnosed in patients without proteinuria if the hypertension is accompanied by one of the following conditions:
thrombocytopenia (platelet count <100,000/µL [100 × 109/L]), kidney dysfunction (serum creatinine concentration >1.1 mg/dL [97.2 µmol/L] doubling of the serum creatinine concentration in the absence of other kidney disease), impaired liver function (elevated blood concentrations of liver aminotransferases to twice the normal concentration), pulmonary edema, cerebral or visual symptoms.
CT of the chest should be obtained in patients with MG to screen for
thymoma
MRI is contraindicated in patients with ferromagnetic metal implants, although MRI is allowable in patients with implants made of
titanium
iliotibial band syndrome tx
tivity modification, ice application, and NSAIDs to reduce inflammation. Once inflammation subsides, stretching and then strengthening exercises are indicated.
The first step in management of shift work sleep disorder is
to address sleep-related behaviors and the sleep environment, referred to as sleep hygiene.
The first step in managing secondary hyperparathyroidism is
to correct 25-hydroxy vitamin D deficiency and normalize the serum calcium and phosphorus, thus eliminating the stimulus for PTH secretion. If PTH levels remain elevated after correction of 25-hydroxy vitamin D deficiency, calcitriol or calcitriol analogues can be used to further suppress PTH, but monitoring for hyperphosphatemia and/or hypercalcemia due to increased absorption of phosphorus and calcium is necessary.
conversion chemotherapy
to shrink visible metastatic disease away from critical vascular structures to facilitate resection.
Older patients with osteoarthritis who require NSAID therapy to control pain should be considered for
topical NSAID therapy to manage gastrointestinal toxicity. Discontinuing naproxen and adding celecoxib would reduce the risk of gastrointestinal toxicity to an extent similar to that of adding a proton pump inhibitor (PPI) to naproxen but would be unwarranted in the setting of a good response to topical naproxen. In patients with particularly high risk who require therapy with oral NSAIDs, simultaneously switching to celecoxib and adding a PPI could be considered.
For patients who have Sjögren syndrome with prominent keratoconjunctivitis sicca that has not responded to environmental measures, artificial tears, and lubricants, the most appropriate next therapy is
topical cyclosporine.
Menopausal genitourinary symptoms that do not respond to vaginal lubricants are best treated with
topical low-dose vaginal estradiol.
Treatment of HIV infection leads to increases in
total cholesterol and LDL cholesterol levels
Technetium-labeled nuclear scans are used in patients with active bleeding (melena or hematochezia) who are
transfusion dependent and hospitalized.
Patients with Balkan endemic nephropathy are at increased risk for
transitional cell carcinomas of the renal pelvis, ureters, and bladder.
Diagnosis of Follicular lymphoma is confirmed by biopsy of a palpable lymph node and cytogenetic analysis identifying
translocation [t(14:18)] that causes an overexpression of the BCL2 oncogene.
In postmenopausal women, any vaginal bleeding requires assessment to exclude malignancy. Initial evaluation may be with either
transvaginal ultrasonography or endometrial biopsy
Diagnose acalculous cholecystitis
trasound findings of acute cholecystitis or a radionuclide biliary scan that fails to visualize the gallbladder
Imaging is indicated for neck pain following
trauma or if a structural abnormality, such as a compression fracture, is suspected. Imaging may also be indicated in patients who have weakness or clinical evidence of spinal cord involvement as a cause of neck pain. Additionally, imaging may be useful in those with a clinical presentation suggestive of malignancy or infection as a cause of neck pain. T
Management of infection-related glomerulonephritis consists of
treatment of the underlying infection.
In patients with ankylosing spondylitis, treatment with __________ is currently recommended if first-line therapy with NSAIDs is inadequate.
tumor necrosis factor α inhibitor (adalimumab)
Treat ankylosing spondylitis that has not responded to NSAIDs
tumor necrosis factor α inhibitor etanercept
patients with active ankylosing spondylitis who do not respond to treatment with NSAIDs should be started on
tumor necrosis factor α inhibitor.
Breast-conserving therapy is effective for patients with invasive breast cancer with tumors...
tumors 5 cm or less involving a single quadrant of the breast and clear margins after excision.
Indications for breast conserving therapy in patients with breast cancer
tumors 5 cm or less involving a single quadrant of the breast and clear margins after excision.
Chest wall radiation therapy after mastectomy is recommended in patients with invasive breast cancer with tumors...
tumors greater than 5 cm, positive tumor margins, skin or chest wall involvement, inflammatory breast cancer, and for patients with any positive axillary lymph nodes.
Indications for radiation after mastectomy
tumors greater than 5 cm, positive tumor margins, skin or chest wall involvement, inflammatory breast cancer, any positive axillary lymph nodes.
Indications for mastectectomy
tumors involving the skin, chest wall, or more than one quadrant of the breast inflammatory breast cancer
Mastectomy is recommended for patients with invasive breast cancer with tumors...
tumors involving the skin, chest wall, or more than one quadrant of the breast and for inflammatory breast cancer.
Rapid streptococcal antigen test or GAS throat culture is indicated to confirm the diagnosis in patients who meet _____of the Centor criteria
two or three Centor criteria Patients who meet the four criteria are at highest risk and can be treated empirically with antibiotics. Penicillin is the first-line agent; a macrolide antibiotic is indicated for penicillin-allergic patients.
bedtime ingestion of hypertension medication (especially an ACE inhibitor, angiotensin receptor blocker, or β-blocker) may help to reduce the risk of new-onset
type 2 diabetes mellitus.
Patients with __________ typically present with hyperkalemia, a normal anion gap metabolic acidosis, and impaired urine acidification, but with the ability to maintain the urine pH to <5.5.
type 4 (hyperkalemic distal) renal tubular acidosis.
Type I autoimmune pancreatitis (AIP)
typically presents in older men, with a mean age of onset in the fifth decade of life. This patient has evidence of type 1 AIP based on the presence of three diagnostic criteria: imaging features (focal pancreatic enlargement with a featureless rim and a nondilated pancreatic duct), increased serum IgG4 level, and extrapancreatic organ involvement (sclerosing cholangitis or IgG4-associated cholangitis). Almost all patients (>90%) enter clinical remission in response to glucocorticoids, but relapse is common.
Fine needle aspiration, generally reserved for what kind of breast lesions
ultrasound-confirmed cystic lesions, requires an experienced cytopathologist for interpretation
Pharmacologic stress testing with imaging is indicated for patients who are
unable to exercise
Imaging modality for breast lump for those <30 and those >= 30
under 30 do U/S, 30 and above are mammography
Diagnose essential thrombocythemia.
undergo JAK2 V617F mutational analysis A patient with iron deficiency and isolated thrombocytosis that persists after correction of iron deficiency should undergo JAK2 V617F mutational analysis as part of the evaluation for essential thrombocythemia. BCR-ABL testing, then bone marrow aspiration and biopsy, would be performed if the platelet count remained persistently elevated after correction of serum iron levels with a negative JAK2 mutation status, because myeloproliferative neoplasms other than ET can less commonly elevate the platelet count. In ET, general hypercellularity and megakaryocyte hyperplasia would be seen on the bone marrow examination.
The triad of hypoxemia, new pulmonary infiltrates on chest radiograph, and decreasing hematocrit associated with systemic lupus erythematosus is highly predictive of
underlying diffuse alveolar hemorrhage associated with systemic lupus erythematosus
migraine attacks should last between 4 and 72 hours if untreated, and the pain must possess two of the following four features
unilateral location, throbbing nature, moderate or severe intensity, aggravation with physical activity.
Patients with cholangitis should receive immediate broad-spectrum antimicrobial therapy; if rapid improvement is not seen then
urgent endoscopic stone removal should be performed (ERCP)
Nephrolothiasis with stones that have rhomboid \ rosette shape
uric acid
Prevention of pressure ulcers
use of advanced static mattresses and overlays (such as foam, gel, or air mattresses/overlays)
treatment of Bacterial conjunctivitis
usually caused by Staphylococcus aureus infection Treatment of bacterial conjunctivitis involves broad-spectrum topical antibiotics (erythromycin ophthalmic 0.5% ointment, bacitracin/polymyxin B ophthalmic ointment), which should be used for 5 to 7 days.
The characteristic finding on physical examination is circumferential redness around the border of the sclera and cornea (corneal limbus), termed ciliary flush, which represents dilated conjunctival vessels
uveitis, which is inflammation involving the middle structures of the eye (iris, ciliary body, and choroid).
Stress test of choice with a LBBB or ventricular pacing?
vasodilator study using an agent such as adenosine or dipyridamole is necessary instead of an exercise study. This is because perfusion defects that are not related to obstructive coronary artery disease (CAD) can be seen in the septum with exercise. vasodilators produce hyperemia and a flow disparity between myocardium supplied by the stenotic vessel as compared with the unobstructed vessel that is not affected by the delay in septal contraction related to LBBB
Preventative therapy for cluster headache
verapamil is the drug of choice for cluster headache prevention.
Active surveillance is the postponement of definitive local therapy coupled with surveillance using serum PSA measurement, DRE, and repeat prostate biopsy is only appropriate for men with
very low-risk or low-risk prostate cancer with a life expectancy of at least 10 years.
The initial test of choice for evaluation of oropharyngeal dysphagia is
videofluoroscopy
Unilateral then bilateral conjunctivitis with morning crusting of the eye and daytime watery or mucoid discharge
viral conjunctivitis
In a patient successfully treated with thrombolysis for an acute ischemic stroke caused by a probable large artery occlusion, recent guidelines recommend
visualization of the occlusion by CT angiography to determine the appropriateness of endovascular therapy.
In some patients on warfarin with fluctuating INRs, daily supplementation with ____ can stabilize the INR
vitamin K (100-150 µg/d)
best vent setting mode
volume-controlled continuous mandatory ventilation setting to minimize risk for ventilator-induced lung injury is recommended as the best strategy for initial mechanical ventilation.
cost-effective way to risk stratify obese patients
waist circumference
positive direct antiglobulin (Coombs) test
warm autoimmune hemolytic anemia (WAIHA)
Diagnose lithium-induced nephrogenic diabetes insipidus using a
water restriction test. An inadequate response to water restriction (urine osmolality does not rise despite rising plasma osmolality) suggests either central or nephrogenic diabetes insipidus.
Treatment for NAFLD
weight loss
Manage gout with dietary modifications
weight loss if appropriate, reduction of high-fructose and high-purine foods, alcohol restriction, and increased low-fat dairy intake
When to get right heart cath for PAH
when PH is believed to be related to underlying lung disease.
Patients with multiple brain metastases typically are treated with
whole-brain radiation
In a patient with severe neuropathic pain due to diabetes mellitus, treatment is
with a serotonin-norepinephrine reuptake inhibitor, such as duloxetine A notable benefit also was seen with pregabalin and gabapentin
In severe microscopic colitis, treatment
with an anti-tumor necrosis factor agent such as infliximab may be effective. However, this expensive, potent immune-suppressing medication should be used only if budesonide is unsuccessful.
patients at high risk for recurrence after treatment for stages 1, 2, or 3 colorectal cancer,
with poorly differentiated histology, lymphatic or vascular invasions, or positive resection margins
When to stop Pap smears
women age 65 years and older who: 1.) 3 consecutive negative cytology results 2.) 2 consecutive negative cytology results and HPV testing within the past 10 years, with the most recent test performed within 5 years) 3.) Women who have had a hysterectomy with removal of the cervix with no history of a precancerous lesion.
Fingolimod hould not be used by
women who are pregnant or planning to become pregnant. An oral disease-modifying therapy for multiple sclerosis (MS), fingolimod is a sphingosine-1-phosphate receptor modulator that restricts activated lymphocytes to lymph nodes and may also have direct neuroprotective effects. Fingolimod significantly reduces the relapse rate, risk of disability progression, and accumulation of new lesions on MRI. This drug has been associated with rare but potentially harmful side effects, including increased rates of serious herpesvirus infection, hypertension, bradycardia, lymphopenia, liver function abnormalities, and macular edema.
When to screen for HIV
x1 age 15-65
organisms transmitted via the airborne route
zoster, tuberculosis, measles, and chickenpox
Uncomplicated type B acute aortic injury is best treated medically, initially with
β-blockade followed by a parenteral arterial vasodilator to control blood pressure.
he treatment of stress cardiomyopathy is supportive, including the use of
β-blockers and ACE inhibitors
CAP tx: inpatient, non-ICU
β-lactama plus a macrolide or doxycycline; or respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)
CAP tx inpatient ICU
β-lactamb plus either azithromycin or a fluoroquinolonec; if penicillin allergic, a respiratory fluoroquinoloned plus aztreoname
Hemolytic anemia, microcytosis, and target cells are typical of
β-thalassemia
slightly increased hemoglobin A2 and some residual hemoglobin F
β-thalassemia
useful tools for determining the prognosis of multiple myeloma requiring therapy
β2-microglobulin and lactate dehydrogenase
Stage 2 hypertension:
≥140 mm Hg systolic or ≥90 mm Hg diastolic
Pre-eclampsia dx
≥140 mm Hg systolic or ≥90 mm Hg diastolic on two occasions at least 4 hours apart after 20 weeks of pregnancy in a woman with a previously normal blood pressure OR ≥160 mm Hg systolic or ≥110 mm Hg diastolic, hypertension can be confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy -----AND Proteinuria defined as----- ≥300 mg/24 h (or this amount extrapolated from a timed collection) OR Urine protein-creatinine ratio ≥300 mg/g OR Dipstick reading of 1+ (used only if other quantitative methods are not available)
volume overload (manifested by an increased pulmonary capillary wedge pressure, usually
≥18 mm Hg) and reduced cardiac output.
PPI ppx in ICU
●platelet count <50,000 per m3 ●[INR] >1.5 ●partial thromboplastin time [PTT] >2 times the control value ●Mechanical ventilation for >48 hours ●History of GI ulceration ●GI bleeding within the past year ●Traumatic brain injury ● traumatic spinal cord injury ●burn injury ●On NSAID ● on anti-platelet agents ●Two or more of the following minor criteria: - sepsis - an ICU stay more than one week - occult GI bleeding for six or more days - glucocorticoid therapy (more than 250 mg hydrocortisone or the equivalent)
