FM Shelf
conditions to get an X-ray
- malleolus tenderness (specifically POSTERIOR medial or lateral malleolus) - navicular tenderness - 5th metatarsal tenderness (bump on the lateral/outside portion of your foot) - can't bear weight (for 4 steps)
open angle glaucoma
A condition in which pressure is elevated in the eye because of obstruction of the outflow of aqueous humor. Gradual loss of peripheral vision, resulting in tunnel vision. Ophthalmoscopy shows pathologic cupping of the optic disc. (vs macular degeneration which affects central vision. Have grey, black, blurry or blind spot in the middle of one's vision)
biceps tendonitis
Most patients with biceps tendinitis have a history of repetitive throwing, pulling, or lifting, and usually present with anterior shoulder pain. Injury to the long head tendon is more common than injury to the short head given its anatomic location. On examination, patients will have pain upon palpation of the tendon within the intertubercular groove located along the anterior humerus. Additionally, as the biceps muscle is primarily responsible for flexion of the arm during supination, conducting these movements against resistance often reproduces the pain. Conservative management should focus on adequate rest and gradual reintroduction of activity. "Examination shows tenderness to palpation over the right bicipital groove. Flexion at the right elbow against resistance produces pain." Don't do PT -> can make injury worse
fixed and widely split S2 that does not vary w/ respiration
ASD (normally, S2 splits on inspiration). Are silent ASDs, can remain asymptomatic for a long time - they are frequently picked up on routine exam. Because the pressure in the left atrium is slightly higher than the pressure in the right atrium, there is a net movement of blood from left-to-right. Over time, this overloads the pulmonary circulation and leads to pulmonary hypertension. Eventually, the pressure in the pulmonary vascular bed gets so high that the shunt reverses, causing a right-to-left shunt. This is the dreaded Eisenmenger syndrome, in which a left-to-right shunt reverses flow and turns into right-to-left shunt. Left-to-right shunt causes chronic volume overload in the right side of the heart --> RVH & pulmonary HTN to compensate (Eisenmenger syndrome). Can lead to volume overload on the RV leading to RV enlargement, dilated pulmonary artery, and increased pulmonary vascularity
cervical cancer screening
Terminating Pap tests at age 65 may not be appropriate for women with cervical cancer risk factors (eg, immunosuppression, high-risk sexual activity, tobacco use, diethylstilbestrol exposure). irregular vaginal bleeding and cervical mass are classic for invasive cervical cancer, which typically presents in patients who have not had routine Pap test screening. On examination, patients typically have cervical friability (eg, bleeding with manipulation) and a raised, exophytic mass. Other risk factors include immunosuppression, tobacco use, and multiple sexual partners.
conjunctivitis treatment
Viral conjunctivitis - gritty sensation (from watery discharge), mostly caused by adenovirus, associated w/ URI symptoms. The majority of patients improve with conservative symptomatic treatment only, including lubricating eye drops and cool compresses. Bacterial conjunctivitis - purulent discharge, unremitting discharge (reaccumulates within minutes) Allergic conjunctivitis - ocular pruritis is characteristic. Eyelid edema (due to histamine release and rubbing) is common The presence of severe pain, photophobia, or blurry vision should raise concern for a diagnosis other than conjunctivitis.
hoarse cough in 2 year old boy, labored respirations, and inspiratory strider
laryngotracheobronchitis (croup) also can be described as a barking cough
Subscapularis
medially rotates arm have issue w/ it if pain and relative weakness when pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back.
acne at which age group should prompt detailed endocrine laboratory testing for possible underlying systemic disease?
mid-childhood (like 5 years old) As many as 20% of newborns will be affected by neonatal acne, usually in the form of pustules confined to the cheeks, chin, eyelids, and forehead. This is typically mild, self-limited, and best managed by reassuring the parents. Acne can also appear in infants, typically males 6-12 months of age, and is also usually self-limited and not associated with underlying endocrine pathology in the absence of any other findings suggesting hormonal abnormalities such as clitoromegaly, breast or testicular development, pubic hair growth, hirsutism, or a growth abnormality consistent with increased muscle development.
"midsystolic click"
mitral valve prolapse The auscultory finding of a midsystolic click followed by a late systolic murmur heard best at the apex of the heart is characteristic.
if gonorrhea positive,
treat also for chlamydia as gonorrhea is much less prevalent than chlamydia and patients w/ gonorrhea are likely co-infected w/ chlamydia (reverse is less true since chlamydia is easier to acquire) one time injection of ceftriaxone and one time dose of azithromycin Treating gonorrhea with a one-time ceftriaxone injection in the office ensures compliance. Several of the fluoroquinolones (like ciprofloxacin, ofloxacin, and levofloxacin) are acceptable alternatives and are orally dosed. (Remember, though - no fluoroquinolones for pregnant women (fetal toxicity) or the pediatric population (possible link with arthrotoxicity). The USPSTF recommends screening for gonorrhea/chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection.
topical permethrin
treatment for scabies
primary ovarian insufficiency
type of hypergonadotropic hypogonadism (eg, menopause) in women age <40 that causes anovulation and subsequent abnormal uterine bleeding. In contrast to this patient, those with primary ovarian insufficiency have vasomotor symptoms (eg, hot flushes) and an elevated FSH level (>40 mIU/mL). Also have vaginal atrophy and is typically associated w/ a concomitant autoimmune disorder or Turner syndrome
starting at age 4 (or 3)
visual acuity testing is performed routinely at every well-child visit as early detection of eye abnormalities can prevent long-term vision loss (depression screening starts at age 12; autism screening performed at age 18 months and 2 years)
work-up for short stature in an otherwise normal child
Short stature is defined as 2 standard deviations below normal the mean height for children of the same sex and. The most important initial factor to consider is whether the growth velocity is normal or not. If a child has a very low growth velocity (<5th percentile) or "falls off" the growth curve, you should investigate causes for short stature like endocrinopathies, growth hormone deficiency, malnutrition or abuse, or malignancy. However, the two most common causes of short stature are familial short stature and constitutional delay of growth, and both of these present with a normal growth velocity. The best test to differentiate familial short stature from constitutional delay is bone age. For familial short stature, bone age should match chronological age, while in constitutional delay, bone age will lag behind chronological age. Bone age is obtained by taking radiographs of the hand and wrist
migraine management
Sumatriptans abort migraines, Beta Blockers and TCAs are prophylactic against future recurrence!
key features of post-streptococcal GN
<7 years old, dark brown colored urine (representing hematuria), and periorbital and peripheral edema. There is also a latent period of around 10 days following pharyngitis before symptoms of glomerulonephritis occur, although for glomerulonephritis following streptococcal impetigo, the latent period can be as long as 3-4 weeks. Will see dysmorphic RBCs and occasional RBC casts When you see casts in the urine sediment - whether WBC, RBC, or granular - you have glomerular disease. This is a useful pearl to remember - it's only when cells get squeezed through the glomerulus that they will form casts. Dysmorphic RBCs (especially acanthocytes) are also highly suggestive of glomerular disease. Patients with bleeding from sources other than the glomerulus- such as a patient with renal stones, bladder cancer, or a urinary tract infection - should have RBCs with normal morphology, since those cells are not being squeezed from the glomerulus intothe collecting tubule. Henoch-Schonlein purpura (IgA vasculitis) is a systemic vasculitis that commonly affects children. The classic triad of HSP is abdominal pain; a vasculitic, raised skin rash; and renal involvement. Questions that describe "palpable purpura" usually give away the diagnosis. The renal findings are variable, but include hematuria, proteinuria, and rising creatinine
initial workup of suspected cognitive impairment
AD, the most common form of dementia in older patients, is inevitably progressive and irreversible. However, before a definitive diagnosis is made, all patients should undergo a workup for potentially reversible causes of cognitive impairment. No matter which subtype is suspected, the initial evaluation of suspected dementia is similar. Evaluation involves neuropsychological testing (eg, Montreal Cognitive Assessment), laboratory testing (complete blood count, vitamin B12, TSH, complete metabolic panel), and neuroimaging. Folate and vitamin D levels are not routinely obtained; they are indicated only in specific risk groups. For example, patients with alcohol use disorder may have folate deficiencies that can contribute to cognitive impairment. Some conditions may place a patient at risk for vitamin D deficiency (eg, celiac disease, chronic kidney disease) and may also justify targeted testing.
focal headache, fever, and early-morning vomiting in the setting of a sinus infection (rhinorrhea, sore throat, cough)
Acute bacterial rhinosinusitis (ABRS) is a common infection of the paranasal sinuses that typically presents with ≥10 days of upper respiratory symptoms (eg, cough, congestion, sore throat) with or without fever. It is a common complication of viral upper respiratory infection (URI). Untreated ABRS can lead to life-threatening complications such as periorbital/orbital cellulitis due to orbital extension as well as meningitis or brain abscess due to intracranial extension. Intracranial complications should be suspected in patients with persistent headache and early-morning vomiting, which occurs due to increased intracranial pressure in the recumbent position. Other findings may include altered mental status (eg, drowsiness), neck pain (suggestive of meningeal irritation), and focal neurologic deficits. Do CT first Oral antibiotics (eg, amoxicillin, amoxicillin-clavulanate) are indicated for uncomplicated ABRS (unless patient w/ mild course/not worsening symptoms).
allergic rhinitis
Allergic rhinitis is characterized by IgE-mediated inflammation (type I hypersensitivity) of the nasal mucosa. Patients commonly experience nasal or sinus congestion, rhinorrhea, sneezing, nasal pruritus, conjunctivitis, and tearing. Common inciting allergens include plant pollens, animal dander, dust, and mold, whose presence may be seasonally dependent. Patients with allergic rhinitis may display signs of atopic disease processes, such as asthma or eczema. First-line treatment is with inhaled nasal corticosteroids (eg, fluticasone); other options include inhaled leukotriene receptor antagonists and oral antihistamines (can also use OTC antihistamines like diphenhydramine). Second-generation antihistamines, such as cetirizine, may be preferable for many patients because of their reduced central nervous system effects, such as somnolence.
febrile seizures vs meningitis
Although febrile seizures are the most common cause of seizure in children with fever, this condition must be distinguished from meningitis, a life-threatening infection. Simple febrile seizures are typically benign and triggered by fever due to a viral illness in children age 6 months to 5 years. Generalized tonic-clonic movements last <15 minutes, with a brief postictal period (<10 min). Laboratory evaluation and imaging are not required; the diagnosis is clinical.
Lambert-Eaton Syndrome
Antibodies against presynaptic calcium channels at the neuromuscular junction that leads to decreased acetylcholine release and subsequent weakness. Approximately 50% of cases are associated with an underlying malignancy, mostly small cell lung cancer. Patients initially have progressive symmetric proximal limb muscle weakness (eg, standing from a chair, combing hair, putting dishes in overhead cabinets). Deep tendon reflexes are reduced/absent, although vigorous muscle activity can improve reflexes and muscle strength temporarily. Autonomic dysfunction (eg, dry mouth, erectile dysfunction) is also common. The diagnosis is confirmed by checking for autoantibodies against voltage-gated calcium channels and by electrophysiological studies. Differences w/ myasthenia gravis - patients with myasthenia gravis typically present with fatigable ocular (eg, ptosis, diplopia) and bulbar (eg, dysarthria) muscle weakness. No loss of reflexes with MG and it is classically associated w/ thymoma rather than lung mass
Atopic Dermatitis (Eczema) vs psoraisis
Atopic dermatitis (eczema) causes a thickened, lichenified, erythematous skin. Whereas psoriasis causes a silverly scaley plaques with bleeding that's worsened in dry cold weather. Atopic Triad (Asthma, Atopic Dermatitis (aka Eczema), and Allergic Rhinitis). The chronic rash on her extremities that is on flexural regions than is likely Eczema (Eczema on flexural regions, Psoriasis on Extensor regions
gray, thin, watery, malodorous vaginal discharge
Bacterial vaginosis Treat w/ oral or vaginal topical metronidazole or topical clindamycin will see clue cells - epithelial cells of the vagina that get their distinctive stippled appearance by being covered w/ bacteria
developmental milestones of toddlers
By age 12 months, an infant's weight triples and height increases by 50%. Expected motor milestones at age 12 months include pulling to a standing position and walking while holding onto furniture for support (cruising); walking independently is a skill expected by age 15 months, although some infants age 12 months or younger may achieve this milestone earlier. In addition, a 12-month-old infant typically uses a 2-finger pincer grasp (ie, thumb and first finger) to pick up objects and eat table foods, as seen in this patient. Language milestones for a 12-month-old infant include calling a parent by name (eg, "mama," "dada").
lichen planus
Can be drug-inducedpruritic, purple/pink, polygonal papules and plaques on the skin of the extremities and trunk (cutaneous LP), but lesions may also appear on the genitalia (genital LP) or oral mucosa (oral LP). The lesions often have white, lacy markings known as Wickham striae and can form along the lines of minor trauma (Köbner phenomenon). often associated with hepatitis C (elevated aminotransferases like SGOT, SGPT but normal alkaline phosphatase). Treatment includes topical high-potency glucocorticoids (eg, betamethasone). The disorder is self-limited and typically resolves within 2 years.
acute urticaria
Clinical Presentation - well circumscribed + raised, erythematous plaques - lesions can be oval, round, serpiginous up to several centimeters in diameter - *intense pruritis* - *lesions worsen over mins to hours then disappear within 24 hours* Etiologies - infections -viral, bacterial, parasitic - IgE mediated - antibiotics, insect bites, latex, food, blood products - Direct mast cell activation - narcotics, muscle relaxers, radiocontrast medium - NSAIDs - idiopathic Initial management includes a second-generation H1 blocker (eg, cetirizine)
rib notching on x-ray, short 2/6 midsystolic murmur is heard at the left paravertebral interscapular area
Coarctation of the aorta common cuase of secondary hypertension association w/ Turner's syndrome - short, squat, female with a webbed neck, a shield shaped chest, orwidely-spaced nipples. Primary amenorrhea
Eustachian Tube Dysfunction
Condition in which the Eustachian tube does not adequately equalize middle ear pressure. Symptoms: ear fullness/discomfort, tinnitus, conductive hearing loss, "popping" sensation. Can see a middle ear effusion Otoscopic exam shows a retracted right tympanic membrane. Diagnosis is clinical, with treatment aimed at relieving the underlying cause (eg, antibiotics for acute bacterial rhinosinusitis, antihistamines for allergic rhinitis).
4 y/o with 1-2 bowel movements per week composed of small lumps of hard stool. She strains to have the bowel movements, and they are painful.
functional constipation Daily use of polyethyleneglycol (PEG) solution has been found to be more effective than lactulose, senna, or magnesium hydroxidein head-to-head studies. Evidence does not support the use of fiber supplements in the treatment offunctional constipation.
mass that is firm, mobile, nontender to palpation, and transilluminates on penlight examination
ganglion cyst Most common at wrist Most ganglion cysts resolve spontaneously and require no treatment.
increased FSH and LH, low testosterone
Klinefelter's syndrome (XXY) Gynecomastia, elevated risk of breast cancer associated with tall stature, small testes, and signs of decreased virilization (eg, decreased body hair)
risk factors for endometrial hyperplasia/cancer
Excess estrogen: - obesity - chronic anovulation/PCOS - nulliparity - early menarche or late menopause - tamoxifen use
approach to the straining infant
Features warranting further evaluation include severe abdominal distension, abnormal rectal tone or sacral findings, a history of delayed passage of meconium, or failure to thrive. This otherwise healthy infant with straining and crying prior to passing normal soft stool (soft, yellow, and seedy stools) most likely has infant dyschezia, a common, benign functional stooling disorder. Infant dyschezia - crying, turning red in the face, and straining for greater than 10 minutes, followed by passage of a soft, nonbloody stool. Reassurance alone Switching to soy formula can be considered for straining from food protein-induced proctocolitis due to milk. Unlike this infant, these patients have loose stools containing mucus and blood. Hirschsprung disease, caused by an aganglionic colonic segment and diagnosed by barium enema, can cause straining in infants due to lack of internal sphincter relaxation. Typical findings include severe abdominal distension, increased rectal tone, and a history of delayed passage of meconium. A sweat chloride test evaluates for cystic fibrosis, which can cause straining and constipation due to improper intestinal development (ie, microcolon) in the setting of meconium ileus. Delayed passage of meconium in the newborn period is typical in cystic fibrosis.
male presenting w/ serum testosterone revealing hypogonadism - next step?
Further evaluation with FSH and LH levels is advised as the initial workup to distinguish between primary and secondary hypogonadism. If secondary hypogonadism is indicated by low or inappropriately normal FSH and LH levels, prolactin and serum iron levels and measurement of total iron binding capacity are recommended to determine secondary causes of hypogonadism, with possible further evaluation to include other pituitary hormone levels and MRI of the pituitary. If primary hypogonadism is found, karyotyping may be indicated for Klinefelter's syndrome.
hepatitis
Hep A which is self-limiting, with no carrier state or chronic state - if positive hep A antibody, immune Negative hep B surface antigen + positive hep B surface antibody = no current hep B infection and patient has immunity. Hep C = IV drug users Hepatitis C is more likely to become a chronic infection (75-85%) whereas fewer than 5% of those who contract Hepatitis B will develop a chronic infection
hypertensive medication to use for African Americans
thiazide diuretics (ie chlorthalidone) and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or β-blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs.
idiopathic thrombocytopenic purpura (ITP)
ITP is a diagnosis of exclusion made by finding low platelets and ruling out other diseases and toxic exposures that result in decreased platelet counts. It is an autoimmune disease caused by antibody-mediated destruction of platelets, so first line therapies are high-dose corticosteroids like prednisone as well as intravenous immunoglobulin (IVIg). Patients refractory to these treatments may require more high-powered immunosuppressant drugs or splenectomy. A few teaching points about ITP and thrombocytopenia: 1) There are two groups of patients who get ITP: children from 2-4, and adults (usually women) in their 20s-40s. Children in general do much better with the disease: over 80% of children will have a spontaneous remission of their disease, while only 20% of adults have a sustained remission. It is extremely important to rule out other diseases before you make the diagnosis of ITP. Here, the patient's CBC is normal with the exception of low platelets - thus, you don't have to worry about leukemia, which would be another common cause of this presentation in a young child. DIC and TTP should also be excluded by looking at a peripheral blood smear for schistocytes or laboratory evidence of microangiopathic hemolytic anemia (increased LDH or bilirubin or decreased haptoglobin and hematocrit). Patients with ITP generally look like this patient - otherwise well except for their thrombocytopenia. Up to 85% of pediatric patients will have a history of an antecedent infection.
community-acquired pneumonia in school-aged children
In school-aged children (age ≥5), bilateral pneumonia is most commonly caused by atypical bacteria, including Mycoplasma pneumoniae and Chlamydia pneumoniae. These pathogens are referred to as "atypical" to distinguish them from "typical" bacteria such as Streptococcus pneumoniae, which is the most common cause of focal, lobar pneumonia The presentation of atypical bacterial pneumonia is generally more gradual and less severe than that of pneumococcal pneumonia. Patients often have low-grade fever, malaise, headache, and sore throat, in addition to a prolonged and slowly worsening cough. Chest pain, hypoxia, and respiratory distress are unusual, and patients do not typically appear ill and can continue daily activities (ie, "walking pneumonia"). Auscultation of the chest may reveal bilateral crackles, wheezes, or rhonchi, and chest x-ray, if performed, frequently reveals interstitial infiltrates bilaterally. Treatment of atypical bacterial pneumonia in children is usually with a macrolide (eg, azithromycin).
screening for 2 year old AA male w/ history of sickle cell disease
Individuals with sickle cell disease are at increased risk for vascular disease, especially stroke. All sickle cell patients 2-16 years of age should be screened with transcranial Doppler ultrasonography (SOR A).
first step in workup of anemia
Microcytic --> ferritin Normocytic --> reticulocyte count Macrocytic --> blood smear
bladder cancer
Most cases arise in adults age >40 who have chronic exposure to chemical carcinogens such as cigarette smoke or industrial chemicals. Common manifestations include hematuria, voiding symptoms (dysuria, frequency, urgency), suprapubic pain (indicates a more advanced tumor that has penetrated the muscle and invaded the surrounding soft tissue or nerves). Urinalysis is generally the first test of choice to confirm hematuria (≥3 RBCs/hpf) and to rule out other common causes of hematuria such as infection (eg, significant pyuria, bacteriuria, leukocyte esterase) or glomerulonephritis (eg, red cell casts, dysmorphic RBCs). Cystoscopy with biopsy and urinary tract imaging (eg, CT urogram) is then required if no clear cause is evident. "Rectal exam reveals a smooth, firm enlargement of the prostate w/ no tenderness, induration, or asymmetry" Prostate cancer is generally asymptomatic and discovered on prostatic examination (nodule) or with prostate-specific antigen testing. Because prostate cancer usually grows in the periphery of the gland, hematuria and voiding symptoms are uncommon (as the tumor does not impinge upon the central periurethral area).
fatigable muscle weakness (symptoms worsen throughout the day), double vision, ptosis, dysarthria, and difficulty chewing
Oculobulbar myasthenia gravis is the most common type, resulting in the signs and symptoms presented Myasthenia gravis has a bimodal age distribution, so there are two classic groups of patients who get MG: young women in their 20s or 30s with autoimmune disorders (RA, SLE, hyperthyroidism, etc.), and men in their 70s or 80s. Caused by autoantibodies that bind to postsynaptic ACh receptors The easiest way to confirm the diagnosis in a patient such as this one with overt ptosis is to administer i.v. edrophonium. Edrophonium is an acetylcholinesterase inhibitor with a short onset of action and half life. If you give the medication and the patient's symptoms immediately improve, you have essentially confirmed the diagnosis. Alternatively, can diagnose w/ EMG - can diagnose MG ifyou see a decremental response to repetitive nerve stimulation The treatment of myasthenia gravis begins with anticholinesterase drugs like neostigmine or pyridostigmine, which increase the amount of ACh in the synapse, overcoming the antibody blockade. Myasthenia gravis almost always have some abnormality of the thymus: 75% will have thymic hyperplasia, and 15% will have an overt thymoma. Since the disease is mediated by T cells, removal of the thymus can be curative in patients who fail medical therapy.
Osteonecrosis (avascular necrosis)
Osteonecrosis is a common complication of SCD secondary to red blood cell sickling, microinfarctions, and bone hyperplasia. The most common sites are the humeral and femoral heads. Clinical features typically include chronic groin, buttock, or thigh pain that initially occurs with weight bearing but progresses to occurring at rest. Because it is a chronic, noninflammatory process, avascular necrosis does not present with erythema or warmth of the joints, leukocytosis, or elevated inflammatory markers. X-rays of the hip may appear normal early in disease, and MRI should be performed to confirm the diagnosis. Legg-Calvé-Perthes disease refers to idiopathic avascular necrosis of the femoral head that most commonly occurs in younger boys from 4 to 9 years old. The classic presentation includes the slow onset of hip pain which is worsened by activity and associated with a limp. It does not present with fever or leukocytosis.
painless scrotal masses
Painless scrotal masses are most commonly due to a hydrocele, inguinal hernia, or varicocele and less commonly caused by malignancy. soft, irregular mass ("bag of worms") directly above the testis that increases in size with Valsalva and does not transilluminate. These findings are consistent with a varicocele. Varicoceles typically present in adolescent and young adult males and are more common on the left side Like varicoceles, indirect inguinal hernias (caused by a patent processus vaginalis) also increase in size with Valsalva maneuver. However, unlike varicoceles, hernias are often reducible with manipulation; in addition, palpation reveals a soft-tissue mass, unlike the characteristic "bag of worms" texture of a varicocele. A scrotal ultrasound can be useful if the diagnosis remains unclear after clinical examination. Hydroceles are peritoneal fluid collections between the parietal and visceral layers of the tunica vaginalis. Although communicating hydroceles can change size with positioning, the fluid within a hydrocele is easily transilluminated. Incision and drainage is occasionally required to treat hydrocele, a collection of fluid between the parietal and visceral layers of the tunica vaginalis;
patients being treated w/ amiodarone should be monitored periodically with serum levels of...
Patients on amiodarone can develop either hyperthyroidism or hypothyroidism. It is recommended that a patient on amiodarone have baseline thyroid function tests (free T4, TSH) with follow-up testing every 6months to monitor for these conditions. Pulmonary toxicity is a serious adverse effect of long-term amiodarone use and can occur months to several years after the initiation of therapy. Interstitial pneumonitis due to amiodarone presents with progressive dyspnea, nonproductive cough, and new reticular or ground-glass opacities on chest radiograph.
febrile neutropenia
Patients with febrile neutropenia should be started on empiric broad-spectrum antibiotics as soon as possible after blood cultures are obtained. Empiric monotherapy with an antipseudomonal agent (eg, cefepime, meropenem, piperacillin-tazobactam) is recommended for initial management - provides both gram-negative and gram-positive coverage
dermatitis, diarrhea, dementia
Pellagra ("rough skin" in Italian vernacular) is due to niacin (vitamin B3) deficiency and is characterized by the "3 Ds" Dermatitis = sun-exposed areas of body, characterized by rough, hyperpigmented, scaly skin Dementia is due to neuronal degeneration in the brain and spinal cord and can lead to memory loss, affective symptoms (eg, depressed mood in this patient), and psychosis. Prolonged isoniazid therapy can interfere with niacin metabolism and occasionally cause pellagra.
infectious genital ulcers
Primary syphilis - Bilateral inguinal lymphadenopathy, ("nontender enlargement of the inguinal lymph nodes measuring 2.5 cm on the left and 2 cm on the right"), is common. Doxycycline is the first-line treatment for lymphogranuloma venereum caused by Chlamydia trachomatis. Small (2-3 mm), painless genital ulcers appear and then resolve before the development of painful, suppurative inguinal nodes. Azithromycin or ceftriaxone may be used to treat a chancroid (caused by Haemophilus ducreyi), which is a painful ulcer with an exudative base that may be accompanied by tender, suppurative lymphadenopathy.
jerking movements first in one hand and then the other, but when the patient is distracted the symptom resolves.
Psychogenic tremor is characterized by an abrupt onset, spontaneous remission, changing characteristics,and extinction with distraction. Contrast with... Parkinsonian tremor is noted at rest, is asymmetric, and decreases with voluntary movement. Bradykinesia, rigidity, and postural instability are generally noted. Patients who have essential tremor have symmetric, fine tremors that may involve the hands, wrists, head, voice, or lower extremities. This may improve with ingestion of small amounts of alcohol. There is no specific diagnostic test but the tremor is treated with propranolol or primidone. Enhanced physiologic tremor is a postural tremor of low amplitude exacerbated by medication. There is usually a history of caffeine use or anxiety.
young child not using left arm - holding it slightly pronated, flexed, and close to her body. tenderness near the lateral elbow and resists your attempts to examine that area. There is no ecchymosis, swelling, or deformity of the elbow.
Radial head subluxation, or nursemaid's elbow, is the most common orthopedic condition of the elbow inchildren 1-4 years of age, although it can be encountered before 1 year of age and in children as old as 9 years of age. The mechanism of injury is partial displacement of the radial head when the child's arm undergoes axial traction while in a pronated and fully extended position. The classic history includes a caregiver picking up (or pulling) a toddler by the arm. In half of all cases, however, no inciting event is recalled. As long as there are no outward signs of fracture or abuse it is considered safe and appropriate to attempt reduction of the radial head before moving on to imaging studies. With the child's elbow in 90° of flexion, the hand is fully supinated by the examiner and the elbow is then brought into full flexion. Usually the child will begin to use the affected arm again within a couple of minutes. If ecchymosis, significant swelling, or pain away from the joint is present, or if symptoms do not improve after attempts at reduction, then a plain radiograph is recommended.
Kawasaki disease
The diagnosis of Kawasaki disease is a clinical one, requiring fever of at least 5 days duration and at least four of the following: peripheral edema, desquamation (especially of the fingertips, palms, and soles), bilateral conjunctivitis; polymorphous, non-vesicular rash; cervical lymphadenopathy (often unilateral); dry or fissured lips; or "strawberry tongue." "Strawberry tongue" is characteristic of scarlet fever or Kawasaki disease, so whenever you see it (or a description of it) think of these two things first. Scarlet fever is an exotoxin-mediated complication of Group A strep infection. The key diagnostic features include a history or physical exam findings consistent with strep infection(especially streptococcal pharyngitis), a "strawberry tongue," and the famous rash. The rash of scarlet fever is - as its name implies - scarlet, and may resemble a "boiled lobster" or sunburn. Later, punctate lesions the size of pinheads give the skin a rough, sandpaper-like texture. There can be skin peeling as well, but this is a late occurrence The most serious and feared complication of Kawasaki disease is the formation of coronary artery aneurysms, and all patients need serial echocardiograms to monitor for the formation of aneurysms. Treatment of Kawasaki disease includes intravenous immunoglobulin (IVIg) and corticosteroids, as well as aspirin to prevent thrombosis
differential diagnosis of heel pain
This patient likely has a calcaneal stress fracture, which is caused by repetitive microtrauma in high-impact activities (eg, running, jumping). It typically follows an abrupt increase in exercise or a transition of activities to hard surfaces. Calcaneal stress fracture is more common in women, and the risk is increased by obesity. Calcaneal stress fracture presents with heel pain that is worse with ambulation, especially during the first steps of the morning or after rest; this can be misdiagnosed as plantar fasciitis.
differential diagnosis of dementia subtypes
This patient's relatively abrupt cognitive decline over the past 3 months, combined with focal neurologic findings suggestive of prior unrecognized stroke (eg, left-sided hemiparesis/weakness and pronator drift, Romberg sign), is strongly suggestive of vascular dementia (VaD). For a diagnosis of dementia (eg, Alzheimer disease, dementia with Lewy bodies), a patient must have impairment in activities of daily living (eg, meal preparation, shopping, bathing) as a result of cognitive impairment. Pseudodementia often presents with a relatively rapid onset in comparison to dementia. Pseudodementia describes the cognitive deficits associated with major depressive disorder in elderly patients. It can also be distinguished from dementia by poor cooperation and effort on exam, apathy, a preponderance of mood symptoms rather than neurologic symptoms, and absence of other findings suggestive of dementia, such as word finding difficulty, dyspraxia, and worsening of cognition at night. Pseudodementia typically responds well to treatment with antidepressants, including selective serotonin reuptake inhibitors.
gout treatment/management
Treat acute gout first with 1. NSAIDS (except aspirin; ex: Indomethacin) 2. Colchicine 3. GCS if there are any contraindications to the first two. Urate lowering medications such as allopurinol are of no benefit during an acute attack and should not be initiated but should not be discontinued if already being taken. Initiating urate lowering medications during an acute attack can actually worsen symptoms transiently. Patients should avoid triggering risk factors such as alcohol and purine-rich meals (Note that hydroxychloroquinine used for treatment of RA and SLE)
screening test for diabetes
USPTF recommends screening of those 40-70 years of age if overweight (>25 BMI) for DM. glucose challenge test, A1C, or fasting glucose NOT with glucose tolerance test
contraindications to combined estrogen/progestin contraceptive pills
Women with uncontrolled hypertension, hypertension with associated end-organ damage, or who are age ≥35 and use tobacco should not take combined OCPs because the compounding of these factors results in an increased risk of myocardial infarction and stroke. antiphospholipid antibody syndrome is an absolute contraindication to estrogen/progestin hormonal contraception due to increased risk of arterial and venous thrombosis - should get copper IUD or permanent ligation
intussusception
a condition in which part of the intestine telescopes on itself, resulting in bowel edema, ischemia, obstruction, and ultimately perforation. Thepatient usually presents with a history of sudden onset severe, crampy abdominal pain that is accompanied by drawing the legs up toward the abdomen and inconsolable crying. These episodesusually last 20 minutes and pain-free periods can follow. Usually the episodes become more severe and spaced closer together over time. Non-bilious vomiting can become bilious as the obstruction worsens. "Currant jelly" stool is a common description of the blood and mucus mixed stool that can occur with intussusception. Palpation of a "sausage-shaped" mass is also classic(especially on the USMLE), but is not always appreciated on physical exam. Ultrasound imaging is not mandatory for diagnosis, but if performed, it may reveal pathognomonic "bull's eye" or"coiled spring" lesions. Prompt treatment is necessary to avoid irreversible intestinal ischemia or bowel perforation. An air contrast enema (answer B) is not only diagnostic, but can also betherapeutic by reducing the telescoped bowel. A handful of extra teaching points... 1) The child's age is an important clue when you're considering a diagnosis of intussusception. Intussusceptionis the most common cause of intestinal obstruction in ages 6 months to 36 months, but is very rare before 3 months and after 6 years of age. 2) Based on history and physical, if you have a high index of suspicion for intussusception, it is appropriate to make the diagnosis using contrast enema, skipping other imaging modalities
actinic keratosis
a precancerous skin growth that occurs on sun-damaged skin Premalignant lesion that may progress to SCC. Are light pink, ill-defined macules w/ a gritty texture in areas of prolonged sun exposure. May be treated w/ topical medications like 5-fluorouracil or imiquimod, excision, cryotherapy, or dermabrasion. Lack of response to topical therapy should raise suspicion for possible SCC and should prompt an excisional biopsy
adenomyosis
abnormal endometrial tissue within the uterine myometrium - accumulation of endometrial glands and stroma w/i the myometrium Dysmenorrhea (abdominal cramps), heavy menstrual bleeding, chronic pelvic pain, diffuse uterine enlargement, +/- uterine tenderness Risk factors: multiparity, age > 40, prior uterine surgery MRI/ultrasound - thickened myometrium Treat w/ hysterectomy As repeated menstrual cycles continue to cause endometrial shedding within the myometrium, patients often progress from dysmenorrhea to chronic, dull pelvic pain. vs fibroids - irregularly enlarged uterus (while adenomyosis is diffusely enlarged, tender uterus) Endometriosis is characterized by the presence of endometrial tissue outside of the uterus and classically presents with symptoms of abdominal and pelvic pain, dysmenorrhea, dyspareunia, and dyschezia. Infertility is a common complication because of inflammation and scarring of the fallopian tubes.
conditions anterior uveitis is seen in
can be associated with systemic inflammatory diseases such as certain infections (eg, herpesviruses, toxoplasmosis), sarcoidosis, spondyloarthritis (eg, ankylosing spondylitis, reactive arthritis), and inflammatory bowel disease (IBD). cornea is spared. painful, red eye associated with photophobia, tearing, and diminished visual acuity.
hyperprolactinemia
caused by prolactin-secreting pituitary adenomas, other hypothalamic or pituitary masses, or antidopaminergic medications (eg, antipsychotics). Symptoms in men include decreased libido, erectile dysfunction, gynecomastia, and infertility.
urinary incontinence (overactive bladder)
characterized by sudden, strong involuntary detrusor contractions causing an urge to void, followed immediately by urine leakage. Initial treatment for urgency urinary incontinence is with behavior modification and pelvic floor exercises; however, if symptoms persist, pharmacotherapy can be initiated with medications that help prevent bladder contractions - oxybutynin (an antimuscarinic that blocks M3 receptors at the bladder and prevent detrusor contractions) and mirabegron (a beta-3 receptor agonist that causes detrusor smooth muscle relaxation and allows increased urine storage. (Bethanechol, a cholinergic agonist, can be used to help treat urinary retention in patients with neurogenic bladder (ie, detrusor underactivity) by increasing detrusor contractions.)
treatment of dementia
cholinesterase inhibitor like donepezil - will increase the amount of synaptic ACh
iron deficiency anemia in a male is...
colorectal cancer until proven otherwise! This patient presents with a microcytic anemia: his hemoglobin and MCV are both low. Thedifferential diagnosis of microcytic anemias is fairly broad, and includes a number of "zebras." (A useful mnemonic to remember the differential of microcytic anemias is "TAILS" - Thalassemias,Anemia of chronic disease (which can sometimes be normocytic), Iron deficiency anemia, Lead poisoning, and Sideroblastic anemia) Far and away the top cause of a microcytic anemia is irondeficiency anemia brought about by blood loss. Any male or postmenopausal woman who presents with iron deficiency anemia should be evaluated for an occult GI source of their bleeding,preferably with upper and lower endoscopy
Tuboovarian abscess (TOA)
complication of pelvic inflammatory disease and may present with pelvic pain and an ovarian mass. It typically appears on ultrasound as a complex, multicystic adnexal mass with enhancing rims.
UPSTF recommendations for depression screening
depression screening for all adolescents 12-18 years of age The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years.
maternal serum alpha feto-protein
done as part of maternal screening for fetal birth defects. It is offered to women between 15-20 weeks gestation. Elevated levels can indicate multiple gestations, neural tubedefects, or abdominal wall defects like gastroschisis or omphalocele Grossly, you can think of an increased AFP as being caused by any defect in which the fetal body cavity is left open. These include neural tube defects like anencephaly or myelomeningocele and abdominal wall defects like gastroschisis or omphalocele. Obviously, of course, a larger fetus produces moreA FP than a smaller one, so the interpretation of MSAFP results depends on having accurate gestational dates. Therefore, the two most common non-pathological reasons for an elevated MSAFP are multiple gestations and inaccurate dates. Finding a DECREASED MSAFP is also a sign of diseases - usually chromosomal abnormalities. Both trisomy 18 and Down's syndrome or trisomy 21 are associated with decreased AFP (usually <0.5 MoM).
posterior testicular swelling and tenderness that improves w/ elevation of the testes
epididymitis in age <35, caused by STIs and have minimal urinary symptoms Age > 35, bladder outlet obstruction (eg, benign prostatic hypertrophy) and are caused by coliform bacteria (eg, Escherichia coli). Patients generally have urinary symptoms and significant pyuria (eg. >25 leukocytes/hpf) on urinalysis. Levofloxacin alone (for enteric pathogens) is generally curative.
tarsal tunnel syndrome
etiology: trauma (fracture, dislocation), overuse injury, inflammatory disorder like RA Patients have burning, numbness, and aching at the distal plantar surface of the foot or toes that may radiate to the calf. The pain is reproduced by percussion over the nerve ie tap the nerve inferior to the medial malleolus (Tinel sign) or by dorsiflexion-eversion and plantar flexion-inversion of the ankle which stress and compress the nerve Initial treatment includes nonsteroidal anti-inflammatory drugs, shoe orthotics, and activity modification.
elevated LDH, decreased haptoglobin, elevated bilirubin, and jaundice indicate
glucose-6-phosphate dehydrogenase deficiency, an X-linked recessive disease that tends to affect men of Mediterranean or African descent. G6PD is an enzyme in glycolysis that is responsible for the production of NADPH, which maintains glutathione in its reduced state and protects cells from oxidative stress. Since red blood cells are dependent on glycolysis and thus G6PD to produce their NADPH and glutathione, deficiency of G6PD results in RBCs that are exquisitely susceptible to oxygen radicals. Anything that increases oxidative stress results in hemolysis and an acute hemolytic anemia. The most common culprits include: viral or bacterial infections, fava beans, nitrofurantoin, quinine, dapsone, and sulfonamides. Here, the culprit was sulfamethoxazole, so that drug should be discontinued Treatment is supportive Note that darbopoietin injections are for the treatment for anemia due to chronic kidney disease, where the kidneys are not producing enough erythropoietin to stimulate the bone marrow to produce more RBCs. If you were to check a reticulocyte count on this patient, however, it would be elevated - his anemia is not from inadequate production of RBCs, it's from hemolysis of RBCs, as shown by the increased LDH and decreased haptoglobin
benign prostatic hyperplasia
months of progressive urinary urgency, hesitancy, nocturia, and weak urinary stream. Digital rectal exam reveals a smooth, firm, and enlarged prostate w/o induration or asymmetry. BPH is from bladder outlet (neck) obstruction. Prostate-specific antigen is normal. Urinalysis shows no proteinuria or hematuria. Serum creatinine is elevated from his baseline lower urinary tract symptoms (LUTS) (eg, urinary urgency, hesitancy, nocturia, weak urinary stream) with a smooth, enlarged prostate on examination consistent with benign prostatic hyperplasia (BPH). Can also get urinary retention. Initial evaluation of patients with LUTS should include a urinalysis (to exclude infection and hematuria) and serum prostate-specific antigen (PSA) to assess risk for prostate cancer. Chronic outlet obstruction leads to urinary retention and may cause hydronephrosis or urinary tract infection. Can get increase in creatinine from BILATERAL obstruction such in patients w/ severe outlet obstruction due to BPH - require imaging (renal ultrasound) to assess for hydronephrosis BPH - symmetrically enlarged and smooth prostate; prostate cancer - asymmetrically enlarged, nodules, and firm prostate Best next step to relieve a bladder outlet obstruction involves catherization to decompress bladder and prevent complications of prolonged bladder outlet obstruction such as UTI, bladder rupture, urothelial cell atrophy or necrosis, hydroureter, hydronephrosis, post-renal azotemia, and/or renal failure Treatment is with supportive care, α-blockers (eg, tamsulosin), 5-α-reductase inhibitors (eg, finasteride), or surgery. Urinary tract infections associated with BPH are treated with antibiotics (eg, trimethoprim, sulfamethoxazole, or nitrofurantoin)
IV drug user + fever w/o clear source
must evaluate for infective endocarditis - obtain blood cultures IE in people who inject drugs is more likely to be right-sided, specifically involving the tricuspid valve.Right-sided IE is less frequently associated with systemic findings of endocarditis such as Janeway lesionsor Roth spots. Patients often do not have a heart murmur.
contraindications to HRT
personal history of coronary heart disease, thromboembolism, transient ischemic attack or stroke, breast cancer, and endometrial cancer. Patients with contraindications to HRT are typically managed with nonhormonal therapy (eg, selective serotonin reuptake inhibitors). The estrogen component of HRT treats menopausal symptoms, but if unopposed (ie, no progesterone), it can result in endometrial proliferation and hyperplasia. Therefore, in patients with a uterus, HRT with a progestin component is required for endometrial protection.
rotator cuff tear
often follow an injury (eg, fall on outstretched hand) and typically cause weakness with active shoulder abduction and rotation. Palpation of shoulder, collarbone, and neck reveal no step-off deformities or point tenderness MRI can visualize the soft tissues around the humeral head and can accurately diagnose a rotator cuff tear. Treatment of an acute tear usually involves surgery, with best results if performed within 6 weeks of the injury. Rotator cuff (primarily supraspinatus) tendonitis is an overuse syndrome characterized by painful abduction and external rotation (eg, heavy lifting above the shoulder). Patients with these disorders may resist manipulation of the arm because of pain, but passive ROM is normal. Have subacromial tenderness
greater trochanteric pain syndrome
one-sided lateral hip pain, pain is burning, worse w/ activity and prolonged standing and when lying on that side, as well as hip flexion (like climbing stairs, walking uphill) presents w chronic lateral hip pain worsened w/ repetitive hip flexion. It is an overuse syndrome involving the tendons of the gluteus medius and minimus where they run over the greater trochanter. Physical examination shows local tenderness over the greater trochanter during flexion
indications for bariatric surgery
patients w/ BMI > 40 who have failed diet and exercise (with or without drug therapy) or >35 with comorbid conditions like HTN, T2DM
basal cell carcinoma
pearly, flesh- or pink-colored nodule with telangiectatic vessels and is usually found on the head or neck. (vs squamous cell carcinoma - asymptomatic, scaly, well-demarcated, erythematous plaque that enlarges. The lesions often become keratinized (with a thickened, rough surface) or ulcerate with crusting and bleeding. In addition, SCC can display early perineural invasion, causing regional neurologic symptoms (eg, numbness, paresthesias). SCC is especially common in patients who have a history of organ transplant and are on chronic immunosuppressive therapy.)
side effect of calcium channel blockers like amlodipine
peripheral edema
3-6 week old infant with projectile vomiting, and an olive-like mass on physical exam vomiting non-biliousmaterial immediately after each feeding, but then becomes fussy and demands to be fed again
pyloric stenosis Losing HCl in emesis leads to a hypochloremic, hypokalemic metabolic alkalosis. The initial test of choice when the diagnosis is unclear is abdominal ultrasound, which will reveal the hypertrophied pylorus Needs surgery
Cholelithiasis
refers to the simple presence of gallstones in the gallbladder. Biliary colic is pain caused by a stone temporarily obstructing the cystic duct. The pain from biliary colic goes away, unlike the unrelenting right upper quadrant pain of cholecystitis, in which obstruction of the cystic duct becomes fixed and leads to inflammation. Patients with cholecystitis also have increased WBC, fever, and signs of inflammation on ultrasound like gallbladder wall thickening. Choledocholithiasis refers to the presence of a stone in the common bile duct, which can be missed on ultrasound but will lead to abnormal LFTs. Cholangitis refers to a stone obstructing the biliary or hepatic ducts, which leads to inflammation and infection and the feared symptoms of Charcot's triad (fever/chills, RUQ pain, and jaundice) and Reynold's pentad (Charcot's triad plus hypotension and altered mental status). A positive Murphy's sign is the presence of RUQ pain and inspiratory arrest that occurs with palpation of the RUQ. It indicates acute cholecystitis. There ARE a few indications for cholecystectomy in an asymptomatic patient. Most surgeons will recommend a cholecystectomy on children with gallstones, just as they would for patients with cirrhosis or those waiting an organ transplant. Also, patients with sickle cell disease almost always develop pigment stones, and should have an elective cholecystectomy. Finally, patients with a calcified or "porcelain" gallbladder should have it removed, because this finding is associated with a high risk of malignancy.
causes of chronic low back pain
spondylarthritis - patients may show reduced spinal range of motion and tenderness at the sacroiliac joints and at tendon insertion sites (eg, along the vertebrae, hands, insertion of Achilles tendon). Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Lumbar disc herniation occurs most often following chronic disc degeneration combined with a minor traumatic event such as bending and lifting a heavy object causing an acute increase in the intradiscal pressure. Disc herniation typically presents as acute back pain along with symptoms of lumbosacral radiculopathy, including acute extremity pain or weakness in a dermatomal and myotomal distribution with respect to the impinged spinal nerve. The diagnosis of lumbar disc herniation is clinical and can be made through a combination of history and various examination maneuvers, including the straight leg raise test (in which flexion of the hip while the leg is held in extension at the knee reproduces pain in the lower back that generally shoots down the leg). Lumbosacral radiculopathy secondary to lumbar disc herniation is typically a self-limited process, with most patients demonstrating spontaneous improvement with conservative management, including analgesia, physical therapy, and normal activity as tolerated. Prolonged bed rest is not necessary for most patients and may worsen pain and prolong recovery. Red Flags (when to get imaging) Severe or progressive neurologic deficits (e.g., bowel or bladder function, saddle parasthesia) Fever Sudden back pain with spinal tenderness (especially with history of osteoporosis, cancer, steroid use) Trauma Serious underlying medical condition (e.g., cancer)
stress incontinence
the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing Results from urethral hypermobility, pelvic floor weakness, or intrinsic sphincter deficiency. Risk factors include mutiple vaginal deliveries, obesity, and prostate surgery. Stress incontinence is triggered by an increase in intra-abdominal pressure (eg lifting, sneezing, Valsalva) unopposed by counterpressure from the pelvic floor or urethral sphincters, resulting in leakage of urine
vulvar pruritis. Physical exam reveals slight vulvar erythema, and speculum exam shows moderate clumpy white discharge. Vaginal discharge pH is 4.0. Whiff test is negative. Wet mount results: KOH prep shows occasional budding yeast and hyphae.
vulvovaginal candidiasis, which is usually treated with a single dose of oral fluconazole or several days of miconazole or clotrimazole vaginal creams Metronidazole is the treatment for the other forms of vaginitis - both bacterial vaginosis (BV) or trichomoniasis. BV and trichomoniasis can presentwith similar symptoms, though classically BV discharge is usually described as malodorous, thin, and grey-white, while trichomoniasis is described as purulent, green-grey, or frothy. The vaginal pH for both of BV and trichomoniasis is >4.5 and the whiff test is often positive in both. The saline wet mount for BV often shows increased numbers of cocobacilli and the classic "clue cells," which are vaginal epithelial cells studded by adherent coccobacilli around the cell's edges. A saline wet mount for trichomoniasis will show motile trichomonads.
stress fracture
worsening forefoot pain, history of intense exercise, and tenderness on palpation of the metatarsal bone Female runners with low BMI and functional hypothalamic amenorrhea precipitated by intense exercise are more likely to develop stress fractures. Other potential causes of forefoot pain include muscular strain, arthritis, bursitis, or Morton neuroma (pain BETWEEN the metatarsal bones). A stress fracture can be distinguished from these causes with direct palpation or axial loading of the metatarsal joint, which usually causes sharp and localized pain over a bony surface (commonly the dorsal aspect of the metatarsals).
Pharmacologic options for benign prostatic hyperplasia and lower urinary tract symptoms (like nocturia)
α-adrenergic blocker, a 5-α-reductase inhibitor (if there is evidence of prostatic enlargement or a PSA level >1.5 ng/mL; finasteride), a phosphodiesterase-5 inhibitor, or antimuscarinic therapy.
42 y/o. gradual increase in shortness of breath, a chronic cough, and a decrease in her usual activity level over the past year. Chest radiograph shows panlobular basal emphysema. No history of smoking or occupational exposures. Decreased FEV1/FVC ratio w/ no change after bronchodilator administration
α1-Antitrypsin deficiency Association with liver disease Recurrent respiratory infections Inherited alpha-1 antitrypsin deficiency causes autoproteolysis of lung tissue, leading to panacinar emphysema ie lower lobes (meanwhile centriacinar emphysema ie upper lobes is more characteristic for smoking-induced COPD) and irreversible obstruction also can see flattened diaphragm on CXR Bronchiectasis (thickened, dilated bronchioles) would present with bronchial dilation and bronchial wall thickening on chest radiograph - typically results from chronic/recurring pulmonary infections, as seen in patients w/ CF or immunodeficiency syndromes. Interstitial lung disease would present with reticular or increased interstitial markings. Diffuse panbronchiolitis would present with diffuse small centrilobular nodular opacities along withhyperinflation.
