MC Missed PACKRAT/EOR Exams

Fluid Resucitation

100 mL/kg for the first 10 kg of body weight 50 mL/kg for the next 10 kg of body weight 20 mL/kg for the weights above 20 kg For this question, a 24-kg child would require: 100 mL/kg × 10 kg = 1,000 mL for the first 10 kg 50 mL/kg × 10 kg = 500 mL for the next 10 kg 20 mL/kg × 4 kg = 80 mL for the next 4 kg Total = 1,580 mL 24 kg

Endocrinology : Diagnostic Studies, Thyroid nodule

A thyroid uptake scan, choice (E), is not indicated since there is no indication of abnormal thyroid testing suggesting hyperthyroidism, or examination stated findings suggestive of a thyroid nodule. The correct choice is A, serum calcitonin. Both calcitonin and CEA are secreted by medullary thyroid cancer cells, and are used both in diagnosis and monitoring of patients after treatment. papillary thyroid cancer, commonly presents with either a local non-tender thyroid nodule or as lymph node metastasis. Thyroid carcinoma often presents as an asymptomatic thyroid nodule. The most common histologic form is papillary carcinoma, representing more than 80% of cases.

• Orthopedics/Rheumatology : Clinical Intervention, Radial head fracture

The majority of patients with a radial head fracture will not require operative management. Radial head fractures are typically caused by indirect trauma (e.g. fall on an outstretched hand). There are 4 types of radial head fractures ranging from the more common type I (undisplaced fracture) and type II (marginal fracture with minimal displacement) to the rarer type III (comminuted fracture) and type IV (fracture with dislocation). Type I and II injuries are usually treated with a sling and range of motion exercises

TB: Diagnostic Studies

The most definitive diagnostic tests for confirmation of tuberculosis are mycobacterial culture (C) which requires at least 2 weeks to grow mycobacterium, and nucleic acid amplification (D) of a respiratory specimen that can be completed in a matter of hours. AFB smear (A) has a sensitivity of only 40-60%, but positive results help establish a presumptive diagnosis. Work-up to Diagnose Active TB ● CXR ● 3 sputum specimens for AFB smear and culture at 8 to 24 hour intervals with at least one in the early morning ● Nucleic acid amplification may be used for confirmation ● Cultures are the definitive diagnosis but take time for results

• Orthopedics/Rheumatology : Diagnostic Studies, Rheumatoid arthritis

Diagnosis is made using a combination of modalities including laboratory studies, imaging, and clinical judgment. Helpful lab tests include rheumatoid factor assay (sensitive, but not specific), anti-cyclic citrullinated peptide antibodies (most specific for RA), erythrocyte sedimentation rate, C-reactive protein level, complete blood count, and antinuclear antibody assay. Radiography of affect joint spaces may show osteopenia, symmetrically narrowed joint space, and erosions. MRI, ultrasound, and joint aspiration can also provide useful information. Prompt initiation of disease-modifying antirheumatic drugs reduces permanent joint damage.Methotrexate is first line. NSAIDs and corticosteroids are often used in conjunction with disease-modifying antirheumatic drugs for pain and symptom control.

• Gastrointestinal/Nutritional : Clinical Intervention, Mallory Weiss tear

Most tears heal spontaneously. Patients may need injection with epinephrine to stop the bleeding. Epinephrine causes vasoconstriction and edema; it therefore decreases arterial blood flow

ENT/Ophthalmology : Scientific Concepts, Otitis externa

Pseudomonas aeruginosa infections of the ear are associated with swimming ("swimmer's ear"), an external otitis. Injury, wet humid conditions, inflammation, and maceration can predispose the external auditory canal to Pseudomonas aeruginosa infections. External otitis due to Pseudomonas aeruginosa is common in humid southern climates.

Endocrinology : Scientific Concepts, Hypothyroid

Patient will be complaining of generalized weakness, fatigue, facial swelling, constipation, cold intolerance, and weight gain PE will show periorbital edema, dry skin and coarse brittle hair. Symptoms of hypothyroidism include weight gain, pretibial myxedema, and generalized weakness. Hypothyroidism is frequently associated with and is a common secondary cause of dyslipidemia and thyrotropin level measures are indicated (Measure a thyroid stimulating hormone, or thyrotropin level) Labs will show high TSH and low free T4, antithyroid peroxidase and antithyroglobulin autoantibodies Most commonly caused by Hashimoto's thyroiditis Treatment is levothyroxine Comments: Takes about 6 weeks to see treatment effects. Monitor TSH

Cardiovascular : Clinical Intervention, Paroxysmal supraventricular tachycardia

Paroxysmal supraventricular tachycardia (PSVT). The mechanism of PSVT is most often reentry involving the AV node. When administered via IV, adenosine is recommended as the first-line agent due to its brief duration of action and minimal inotropic activity

Cardiovascular : Scientific Concepts, Coronary vascular disease

The "Metabolic Syndrome" significantly increases risk for atherosclerotic disease. Defined as having at least 3 or more of the following: ○ Central obesity (apple shaped vs. pear shaped) ○ TG > 150 ○ HDL < 40 (or < 50 in women) ○ Fasting glucose > 110

• Pulmonology : Diagnostic Studies, Acute asthma exacerbation

The first step in treatment of an acute asthma exacerbation includes oxygen and beta-2-agonist nebulizers, such as albuterol. Ipratropium is often added to the first three doses of albuterol in those with a severe exacerbation. Response to treatment is monitored by clinical appearance, physical examination, and peak-flow measurements. A mnemonic for the ED treatment of asthma is: BIOMES - Beta-agonists, ipratropium, oxygen, magnesium sulfate, epinephrine, and steroids. In between and even during an acute asthma attack, chest X-ray findings are usually normal. During severe exacerbations, the most common finding is lung hyperinflation. Asthma exacerbation should involve airway hyperresponsiveness in relation to a trigger exposure, and would demonstrate bilateral hyperinflation with diaphragm flattening on x-ray.

• Orthopedics/Rheumatology : Diagnosis, Polymyositis

gradual progressive proximal muscle weakness and elevation of creatinine phosphokinase level. The finding of lymphoid inflammatory infiltrates on muscle biopsy confirms the diagnosis. Initial treatment of choice in this condition is the use of a corticosteroid (prednisone). Patients who do not respond to prednisone may then benefit from the use of methotrexate or azathioprine. Patients usually experience progressive, symmetric, proximal muscle weakness with fatigue, malaise, and morning stiffness. Muscles often affected are those of the shoulder, neck, and pelvic girdle. Muscle biopsy can also be helpful in diagnosis. Prednisone, 1 mg/kg/day for up to several months, is the drug of choice; the earlier started in the disease process, the more effective it is. If prednisone is not sufficient, methotrexate, azathioprine, or another immunosuppressant is added.

• Orthopedics/Rheumatology : Clinical Therapeutics, Osteomyelitis

2 weeks IV, at least 4-6 weeks Abx total. Infants (Naficillin/Oxacillin or Ancef)(Clinda or Vanco if PCN allergy) Everyone else Vanco Newborn (CTX or Nacifillin) Salmonella concern for SCD patients (CTX or FQs) Pseudomonos then Cipro or Levo or Ceftazidime or Cefepime In children, acute osteomyelitis commonly occurs with hematogenous spread or direct contamination, as in stepping on a nail. Pain, edema, erythema, warmth and generalized malaise are common symptoms of acute osteomyelitis. It can enter the bone through multiple mechanisms including by direct inoculation during an open fracture or during surgical intervention following a fracture (most common mechanisms for adults) Lumbar vertebrae are most often affected, followed by thoracic and cervical vertebrae. Osteomyelitis of the sternoclavicular bones and pelvic bones are not uncommon sites, but these tend to be most frequent amongst IV drug abusers.

Gastrointestinal/Nutritional : Clinical Intervention, Intussusception

A barium enema is a good choice in suspected intussusception cases An air contrast barium enema may be able to reduce intussusceptions in children. Intussusception is more common in men but presents with colicky abdominal pain with subsequent development of vomiting and bloody diarrhea Reduction by contrast enema and observation for spontaneous reduction would not be beneficial in a child with a lead point presenting late. In cases of childhood intussusception, the most common location is in the right colon. Dance sign refers to the emptiness in the right lower quadrant in intussusception

Cardiology : Diagnosis, Malignant hypertension

A macular star results from punctuate exudates that radiate from the fovea in a star pattern; this is seen is patients who are experiencing malignant hypertension Secondary cause of elevated blood pressure should be suspected in patients with severe or resistant hypertension, in patients younger than 30 years without risk factors for hypertension, in patients with malignant hypertension, or hypertension onset before the age of puberty.

• Dermatology : Diagnosis, Basal cell carcinoma

A pearly border is more consistent with a basal cell carcinoma. These lesions often begin as a pearly papule with telangiectasias. These lesions will present as pink or flesh-colored nodules with a pearly or translucent quality. A classic description is that these lesions have a pearly or a rolled border Basal cell carcinoma is the most common form of skin cancer, usually affecting fair-skinned individuals with a history of cumulative sun exposure, such as this patient. Treatment is often surgical, and Mohs micrographic surgery is now preferred for lesions with a high risk of recurrence. Does smoking increase the risk of basal cell carcinoma? Answer: Yes. Clinically: pearly/waxy papule, easy bleeding, central crater with rolled border, "Rodent ulcer" ● Diagnose: clinical appearance and biopsy ● Treatment: excision, cryotherapy, topical therapies like Imiquimod, 5-FU

Cardiology : Scientific Concepts, Amyloidosis

ACEIs and angiotensin II inhibitors are poorly tolerated in patients with amyloidosis. Even small doses may result in profound hypotension. Transudates are usually associated with some cardiac disease, such as congestive heart failure, or hepatic disease, such as cirrhosis. Other causes of transudative effusion include nephrotic syndrome, hypothyroidism and amyloidosis This patient's most likely diagnosis is restrictive cardiomyopathy. The goal of treatment in this form of cardiomyopathy is to reduce symptoms by lowering elevated filling pressures without significantly reducing cardiac output. Low to medium dose diuretics, such as furosemide (Lasix), lower preload and may provide symptomatic relief. In addition, beta blockers and cardioselective calcium channel blockers, such as verapamil and diltiazem, may be of benefit; they increase left ventricular filling time, improve ventricular relaxation, and decrease compensatory sympathetic stimulation. Restricted cardiomyopathy also may have only slight or even normal left ventricular function and size. Causes include amyloidosis,

• Pulmonology : Clinical Therapeutics, Acute bronchitis

Acute bronchitis is an inflammation of the bronchi caused by upper respiratory infection. It is a self-limiting condition that is most commonly of viral etiology. Patients with acute bronchitis generally have few systemic symptoms. The most common clinical presentation is a cough lasting up to 10-20 days. The cough may be productive and patients often mistakenly attribute purulent sputum in acute bronchitis with a bacterial infection. The symptoms of acute bronchitis are less severe than those of influenza or pneumonia and help determine diagnosis and course of treatment. Symptomatic treatment with acetaminophen or NSAIDs and other supportive care measures are recommended as initial management of patients with acute bronchitis. Acute bronchitis is the most common cause of minor hemoptysis in the Emergency Department. Acute Bronchitis Viruses > bacteria Most common cause of minor hemoptysis Hallmark: cough (usually productive), <1week Symptomatic treatment, bronchodilators Routine ABX therapy not indicated Treatment ● Supportive: hydration, analgesics, bronchodilators, cough suppressants

Neurology : Clinical Intervention, Intracranial hemorrhage

Additionally, any valsalva maneuver decreases cerebral venous return and will worsen the headache. Patients will often have visual complaints including transient vision loss secondary to ischemia of the visual pathways. Other typical symptoms include nausea, vomiting and lightheadedness. Fundoscopic examination reveals papilledema. Diagnosis is made based on an increased opening pressure found on lumbar puncture. Treatment focuses on decreasing CSF production initially with acetazolamide Acute onset of weakness from a brain tumor would likely occur in the setting of concomitant intracranial hemorrhage which would be diagnosed by completion of head CT or MRI and not with a bedside test hypertensive intracranial hemorrhage occurs most frequently in deep cerebral locations such as in the putamen. Hemorrhage in this area can result in hemiplegia, hemisensory loss, homonymous hemianopsia, gaze palsy and coma.

• Pulmonology : Diagnostic Studies, Alpha-1 antitrypsin deficiency

Alpha-1-antitrypsin deficiency (α1AT) is a genetic risk factor for early-onset COPD, but it would not account for the gastrointestinal pathology associated with CF. Alpha-1-antitypsin deficiency (A) may cause respiratory symptoms seen in this patient (persistent coughing, wheezing, and shortness of breath), however it does not classically cause the symptoms of carcinoid syndrome. alpha-1 antitrypsin deficiency based on family history and lack of smoking history and young age.

Neurology : Scientific Concepts, Delirium

An important distinction between delirium and dementia is the time of onset. Delirium is characterized by its rapid onset and fluctuating course. It leads to acute changes in mental status, marked by inattention, poor concentration, and fluctuating levels of consciousness. It commonly occurs in hospitalized elderly patients. Delirium, dementia, and depression can coexist within the same patient. When an acute change in mental status occurs, however, the diagnosis of delirium should be presumed until proven otherwise.

Cardiovascular : Scientific Concepts, Bicuspid aortic stenosis

Aortic dissection is more common in patients with hypertension, connective tissue disorders, congenital aortic stenosis or bicuspid aortic valve, and in those with first-degree relatives with history of thoracic dissections. CoA Associations ● Bicuspid aortic valve The notch in the aorta signifies the coarctation and the LVH is the result of hypertension and aortic stenosis. Common physical exam findings in patients with the disorder include hypertension, higher blood pressures in the upper extremities than in the lower extremities, a delay between the brachial and femoral pulses, and a systolic ejection murmur as a result of a bicuspid aortic valve (1).

Cardiovascular : Clinical Therapeutics, Atrial fibrillation

Atrial fibrillation is the most common chronic arrhythmia, frequently developing in the course of hyperthyroidism. The initial steps in the management of atrial fibrillation is to control the ventricular response and prevent the risk of stroke. A short acting beta-blocker (e.g., esmolol) is a good choice for the rapid management of heart rate. Other drugs used in the management of atrial fibrillation include: Calcium channel blockers (e.g., verapamil or diltiazem) Digoxin when calcium channel blockers and beta-blockers are not suitable Electric cardioversion should not be performed prior to anticoagulation in patients with atrial fibrillation that has been present for more than 48 hours. Ibutilide is mainly used for the conversion of atrial fibrillation or flutter. The initial management in a hemodynamically stable patient (i.e., no hypotension or angina) with atrial fibrillation involves control of ventricular rate (goal <100 beats/min) by administering diltiazem or other rate-controlling drugs (e.g., verapamil, metoprolol, esmolol, or propranolol). If there is spontaneous conversion to sinus rhythm, the patient can be discharged after assessment for the cause of AF; otherwise, the patient requires anticoagulation and electrical/chemical cardioversion at a later date. Amiodarone and propafenone are the pharmacological agents used in chemical cardioversion. AV nodal ablation and permanent pacemaker implantation are highly effective in improving symptoms in patients with AF who are experiencing symptoms related to a rapid ventricular rate, and who cannot be adequately controlled with anti-arrhythmic or negative chronotropic medications.

• Gastrointestinal/Nutritional : Health Maintenance, Hepatitis A virus

Both hepatitis A and E can be transmitted via fecal-oral route while hepatitis B, C, and D are transmitted parenterally and sexually. ANTI-HAV IgM(+) Acute ANTI-HAV IgG(-) Chronic

Neurology : Clinical Intervention, Subdural hematoma

Burr holes over the hematoma to evacuate the clot A subdural hematoma involves the collection of venous blood in the space between the inner and the outer membranes covering the brain, generally following trauma. Symptoms include loss of consciousness, drowsiness, headache, impaired vision, enophthalmos, unilateral eyelid drooping, decreased sensation or numbness, unilateral paralysis, confusion and delirium, changes in personality, decreased memory, slow thought process, impaired speech, and anhidrosis on one side of the forehead. Focal neurological deficits and abnormal reflexes may be present

Complex regional pain syndrome

CRPS is indeed a complex syndrome often occurring in a limb; patients exhibit vasomotor and neurologic symptoms out of proportion with objective findings. It often occurs following some type of event, such as a surgery (note the patient's recent ipsilateral knee surgery), fracture, stroke, or myocardial infarction. Most of the time, there is no nerve lesion. CRPS is classified into 3 stages, and symptoms can vary depending on the stage. It is characterized by persistent burning and/or throbbing pain in an extremity. Swelling, redness, and increased hair/nail growth occur in stage I; it may progress to cool, pale skin and even osteoporosis in the latter 2 stages. Allodynia, the phenomenon in which a normally painless stimulus produces significant pain response, is a common finding. No single exam finding or test is diagnostic of CRPS, which is a clinical diagnosis. Complex regional pain syndrome is a form of chronic pain in a body region, but it most commonly affects the extremities. It is characterized by pain, swelling, skin changes, vasomotor instability, limited range of motion, and patchy bone demineralization. It frequently occurs after a soft tissue injury, surgery, or vascular event such as a myocardial infarction or stroke. The pathophysiology of complex regional pain syndrome is incompletely understood and most of the time there is no definable nerve lesion. Symptoms of complex regional pain syndrome include pain that is described as burning, tingling, throbbing or aching. The pain can be quite severe and out of proportion to physical exam. Many patients experience allodynia, which is pain from a stimulus that does not usually provoke pain. Other symptoms include sensitivity to cold or touch, swelling, skin changes such as thickened, rough skin, or muscle atrophy. A diagnosis of complex regional pain syndrome requires the presence of regional pain and sensory changes following a noxious event. It is usually made clinically as there is no laboratory or radiologic testing that alone is diagnostic.

• Pulmonology : Diagnosis, Bacterial pneumonia

Chest X-ray is the most appropriate next step in the evaluation of this patient who has a history and physical exam suggestive of community-acquired bacterial pneumonia (CAP). It is the most common infectious cause of death in the United States. Patients may present with productive cough, fever, shortness of breath, and sometimes pleuritic chest pain. Symptoms may came on suddenly. Clinical findings include tachypnea, tachycardia, fever or hypothermia, and altered breath sounds such as the auscultation of rhonchi or rales, dullness, increased fremitus, or egophony. Bacterial pneumonia patients typically present with high temperatures and associated pleural effusions, along with a high percentage of band forms on lab study. Most commonly, it is secondary to acute viral bronchitis occurring during minor upper respiratory infection, or it is complicating an underlying chronic illness. Bacterial pneumonia will have an acute history of 2-4 days with fever and a nonproductive cough. The X-ray will show lobar infiltrate; it is rarely found throughout the lung. Staphylococcus aureus pneumonia is classically associated with causing post-influenza bacterial pneumonia. On Gram stain this is seen as Gram positive cocci in clusters

Dermatology : Clinical Therapeutics, Rosacea

Chronic skin disorder of papules and pustules ● Intermittent facial flushing ● Telangiectasia ● Rhinophyma (large bulbous, red nose) ● Blepharitis (inflammation of lids), conjunctivitis ● Distinguished from acne: middle age and older, no comedones, telangiectasia ● Tx: avoid triggers (hot beverages, Ethanol, sunlight) ○ Hydrocortisone topical ○ Metronidazole topical ○ Oral antibiotics ○ Retinoid

Cardiovascular : Clinical Intervention, Peripheral arterial disease

Cilostazol and clopidogrel both inhibit platelets. Clopidogrel is used in CAD and CVA prevention, as well as post-ST-segment MI. Cilostazol lowers lipid levels and is indicated in peripheral arterial disease. This patient has peripheral arterial disease (PAD). This can be treated with antiplatelet agents, including aspirin and/or clopidogrel. Evaluation & Treatment of PAD ● Ankle-Brachial Index (ABI): bedside test; <0.9 is abnormal; implies disease in leg with low ABI ● Imaging: Arterial duplex, CTA, MRI, angiography - what you use depends on what is available and on patient presentation ● Treatment: revascularization via embolectomy - IR-guided vs surgical. Patients require urgent vascular surgery evaluation.

Pulmonology : Clinical Therapeutics, Aspiration pneumonia

Clindamycin (B) is generally given for aspiration pneumonia Anaerobic bacteria can cause pneumonia in patients with poor dental hygiene or aspiration. An alveolar space infection resulting from the inhalation of pathogenic material from the oropharynx. Aspiration Pneumonitis Inflammatory chemical injury Inhalation of gastric contents Can lead to aspiration pneumonia Depressed level of consciousness Unilateral focal/patchy consolidations in dependent lung segments Prophylactic antibiotics NOT recommended Aspiration pneumonia. Lung Abscess Patient will be complaining of several weeks of cough, fever, pleuritic chest pain, weight loss, and night sweats CXR will show area of dense consolidation with an air-fluid level inside a thick-walled cavitary lesion Most commonly caused by aspiration pneumonia Treatment is clindamycin Aspiration pneumonitis is an inflammatory chemical injury of the tracheobronchial tree and pulmonary parenchyma produced from the inhalation of regurgitated gastric contents. Aspiration pneumonitis can lead to aspiration pneumonia due to the breakdown of the pulmonary defense mechanisms caused by the chemical irritation The elderly and those patients with a history of stroke are also at increased risk for aspiration pneumonitis. Clinically, patients may have minor symptoms (nonproductive cough and tachypnea). With larger aspirations, patients may develop tracheobronchitis with bronchospasm, bloody or frothy sputum, and respiratory distress. The chest radiograph usually shows unilateral focal or patchy consolidations in the dependent lung segments.

Cardiology : Clinical Therapeutics, Hypercholesterolemia

Colesevelam (WelChol) is considered a Category B pregnancy risk. Both lovastatin and rosuvastatin (statins) are considered Pregnancy Category X and should be avoided in pregnancy. Ezetimibea and fenofibrate are both Pregnancy Category C. Colesevelam, a bile acid sequestrant, decreases cholesterol absorption by forming insoluble complexes of bile acids that can then be eliminated through feces. Bile acid sequestrants include cholestyramine, colestipol, and colesevelam. Bile acid sequestrants interrupt reabsorption of bile acids, resulting in lowered intrahepatic cholesterol. Maximum benefit is typically seen within 3 weeks.

Diagnosis, Third-degree atrioventricular block

Complete, or third-degree AV block, advanced second-degree AV block, symptomatic Mobitz I or Mobitz II second-degree AV block are all indications for pacemaker placement This patient has a third-degree AV block that is symptomatic, with syncope and mild shortness of breath. The treatment for this patient is pacemaker insertion. Third degree, or complete, heart block is characterized by absent conduction of all atrial impulses and complete electrical AV dissociation. The hallmark findings of third-degree AV heart block are regular PP intervals unrelated to regular R-R intervals with P waves that appear to march through the QRS-T complexes.

Seizures

Complex partial seizures typically have impaired consciousness with focal motor symptoms or somatosensory symptoms, and they do not have the 3 phases. Grand mal seizures are characterized by a tonic phase, which includes a sudden loss of consciousness and rigidity that typically lasts less than a minute. A clonic phase follows, which is characterized by jerking motions usually lasting for a few minutes. The clonic phase is followed by a flaccid coma state.

• Gastrointestinal/Nutritional : Clinical Therapeutics, Acute diverticulitis

Conservative treatment with rehydration is used in acute diverticulitis. A low fiber diet is recommended after an episode of acute diverticulitis until the patient remains asymptomatic for 6 weeks. A low fiber diet is especially effective in cases of acute diverticulitis, because it helps reduce the frequency of stools and allows the affected portion of the colon to adequately heal. Steady pain is the most common symptom in acute diverticulitis, not colicky pain. Most cases in the United States start with vague and generalized pain that localizes to the left lower quadrant. Bowel habits are commonly altered with diverticulitis, with constipation being more common than diarrhea, although an alternation between the two is also common. Colonoscopy is contraindicated in acute diverticulitis due to the risk of bowel perforation. Acute diverticulitis typically presents with constipation or diarrhea along with LLQ tenderness. CT is the preferred diagnostic imaging in suspected acute diverticulitis.

Dermatology : Health Maintenance, Celiac disease

Dermatitis herpetiformis an intensely pruritic papulovesicular rash, is pathognomonic for Celiac disease. It most commonly occurs at the extensor surfaces of the elbows and knees as well as buttocks, and may occur even in patients who appear to have no gastrointestinal problems. Diagnosis of dermatitis herpetiformis is made by visualizing granular IgA deposition on immunofluorescence of a skin biopsy. As with the gastrointestinal manifestations of Celiac disease, dermatitis herpetiformis typically resolves with full elimination of gluten from the diet.

Dermatology : Clinical Intervention, Diaper dermatitis

Dermatophyte infections Dermatophyte infections ● Erythematous, annular patch with distinct border and central clearing ● Itching, stinging, ± burning ● Superficial fungal infections, affects hair, nails, skin ● 3 most common organisms: ○ Trichopyton ○ Microsporum ○ Epidermophyton Tinea : Pedis (foot), Cruris (groin), Corporis (trunk, legs, arms), Unguium (nails), Facialis (face) ● KOH prep ● Tx: antifungal creams, ointments (avoid steroids), oral antifungal o Griseofulvin - avoid EtOH (antabuse), o Itraconazole - careful with liver dz o Terbinafine

Cardiology : Diagnostic Studies, Hypertrophic cardiomyopathy

Doppler Echocardiography is test of choice: demonstrates septal hypertrophy, normal systolic function, poor diastolic function, degree of mitral regurgitation The murmur is a loud, harsh systolic murmur present along the left sternal border. The gradient and the murmur may be enhanced by maneuvers that decrease ventricular volume, such as an upright posture, standing, or Valsalva maneuver Reducing the LV volume increases obstruction and the murmur intensity; whereas, in valvular aortic stenosis, reducing the stroke volume across the valve decreases the murmur Hypertrophic cardiomyopathy occurs when the myocardium is abnormally thickened, causing impaired contractile function. It is associated with a hereditary syndrome. It typically presents with dyspnea, chest pain, and syncope. Echocardiogram will reveal left ventricular hypertrophy. A bisferiens pulse is a pulse with two systolic peaks, commonly seen in patients with aortic regurgitation or hypertrophic cardiomyopathy. The ECG is abnormal in 90% of cases and abnormalities include left ventricular hypertrophy, "dagger-like" Q waves in the inferior and lateral leads, and nonspecific ST segment changes. The diagnosis is made by echocardiogram.

Neurology : Diagnostic Studies, Guillain-Barre syndrome

Elevated protein with only a mild pleocytosis on cerebrospinal fluid analysis (termed albuminocytologic dissociation) is highly specific in the clinical setting of suspected GBS. Albuminocytologic dissociation, which is an elevation in CSF protein (>0.55 g/L) without an elevation in white blood cells Lumbar puncture characteristically reveals elevated CSF protein content. Other results are normal, although the white blood cell count may be somewhat elevated. The results of the lumbar puncture demonstrate a markedly elevated protein and mild pleocytosis. Pleocytosis, which is an increased number of lymphocytes Measuring the vital capacity or negative inspiratory force (NIF) is critical to assessing respiratory effort. These easily repeated tests predict developing diaphragmatic weakness and the need for prophylactic intubation. It is often preceded by a viral illness, infection with Campylobacter jejuni, or vaccination. In the classic presentation of GBS, a viral illness is followed by an ascending symmetric weakness or paralysis with decreased or absent deep tendon reflexes. Common organisms implicated include Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus, and Mycoplasma pneumoniae.

• Pulmonology : History and Physical, Emphysema

Emphysema is a chronic obstructive airway disease; it is characterized by abnormal, permanent enlargement of the airways distal to the terminal bronchioles and destruction of their walls. Cigarette smoking is a major contributor in the development of emphysema. Other causes include air pollution, alpha-1 antitrypsin deficiency, and occupational exposure. The classical symptomatology includes prolonged progressive dyspnea with late-onset non-productive cough, occasional mucopurulent relapses, and eventual cachexia and respiratory failure. The patients are usually thin and have a barrel-shaped chest. There is tachypnea with pursed-lip breathing and use of accessory muscles; they may also adopt a tripod sitting position. A chest X-ray shows hyperinflated lungs with bullae, tubular heart, and flattened diaphragm. Forced expiratory spirometry quantifies airway obstruction. Pulmonary function tests (PFT) reveal a decrease in forced expiratory volume in 1 second (FEV1) along with reduction of FEV1/FVC (forced vital capacity) ratio. alpha-1 antitrypsin deficiency,

Dermatology : Diagnosis, Erysipelas

Erysipelas ● Superficial bacterial skin infection that involves lymphatics ● Classically on face, common on legs ● Organism: strep pyogenes ● Sharp, demarcated borders, edematous, indurated, pruritic, painful First-line treatment is an oral penicillin such as amoxicillin. For patients with systemic symptoms, intravenous ceftriaxone or cefazolin is indicated. Erysipelas is a cutaneous infection characterized by marked superficial dermal lymphatic involvement. The most common cause of erysipelas worldwide is Streptococcus pyogenes (group A beta-hemolytic Streptococcus). Facial erysipelas is frequently associated with streptococcal pharyngitis. Another common location for this infection is the lower legs. Clinical manifestations include raised, bright salmon-red colored lesions above the level of the surrounding skin with a clear line of demarcation between involved and uninvolved skin. Plaques may develop vesicles or bullae. In facial erysipelas, one or both eyes are frequently swollen shut. Erysipelas is a soft tissue skin infection characterized by deeply erythematous, indurated skin with sharply demarcated borders. It typically involves the upper dermis, superficial lymphatics and the superficial subcutaneous tissue. Patients are often very young or 50- to 60-year olds presenting with a prodrome of fever, chills and malaise followed by the eruption of cellulitic skin changes. Erysipelas is most often seen on the lower leg (90%) followed by the arm (5%) and the face (2.5%). Tx: Amoxicillin/Kelfex CTX or Cefazolin if

Dermatology : Diagnosis, Erythema multiforme

Erythema multiforme "minor" ● Hypersensitivity reaction to infection ● Target lesions ● Palms and soles, then moves centrally ● Causes: o Herpes simplex o Mycoplasma pneumonia ● Treatment: treat underlying cause Patients present with a rash consistent with erythema multiforme (EM) and should be started on systemic corticosteroids. EM is an acute disease caused by the sudden appearance of erythematous violaceous macules and papules. It is usually self-limiting. The rash is commonly found on the soles of the feet and the palms of the hands. Lesions are target-like with a central dark papule surrounded by a pale area and a "halo" of erythema. In patients with coexisting or recent HSV infection, early treatment with oral acyclovir may lessen the number and duration of cutaneous lesions. More severe cases (significant mucous membrane involvement) should be treated with systemic corticosteroids

Cardiovascular : History and Physical, Aortic stenosis

Exertional dyspnea, angina pectoris, and syncope are the 3 cardinal symptoms Aortic stenosis is characteristically an ejection (mid) systolic murmur that commences shortly after the S1, increases in intensity to reach a peak toward the middle of ejection, and ends just before aortic valve closure. It is characteristically low-pitched, rough and rasping in character, and loudest at the base of the heart, most commonly in the 2nd right intercostal space. It is transmitted upward along the carotid arteries.

ENT/Ophthalmology : Health Maintenance, Allergic rhinitis

First-line treatment is to prescribe an intranasal corticosteroid or antihistamine. Nasal corticosteroids shrink hypertrophic nasal mucosa. Patients should be educated that noticeable efficacy may take approximately two weeks. This patient could be started on an intranasal steroid spray now and use it seasonally for a few months each fall. Although it likely would be effective for symptoms, it would be inappropriate to prescribe a first-generation oral antihistamine (such as diphenhydramine or chlorpheniramine). The patient gave a history of trying such medications (which are available over-the-counter) and experiencing excessive sedation. Some of the newer, second-generation antihistamines would be a preferable choice, especially if the patient was experiencing allergy symptoms in his eyes. An over-the-counter nasal saline spray is often recommended for various nasal conditions. In cases of allergic rhinitis, these sprays can mechanically flush allergens out of the nasal cavity; however, their role is more of an adjunct treatment, not a primary treatment. First-line treatment is with glucocorticoid nasal sprays including fluticasone, or second-generation antihistamines. Nasal decongestant sprays are not recommended as monotherapy in the treatment of allergic rhinitis as their continued use can lead to rebound nasal congestion, also referred to as rhinitis medicamentosa. This condition typically exhibits nasal secretions that are rich in eosinophils, which are the specific type of leukocytes that are involved in allergic reactions. Neutrophila would be seen in excess in the case of infection. Lymphocytes would be seen in excess in the case of an immune reaction. Allergic rhinitis is a hypersensitivity reaction to specific allergens that is mediated by immunoglobulin (Ig)E antibodies in sensitized patients resulting in inflammation Classic findings of pale, bluish nasal mucosa, enlarged or boggy turbinates, clear nasal secretions, and pharyngeal cobblestoning may or may not always be seen. Antihistamines are the drugs that have major applications in treating the symptoms of allergic rhinitis and urticaria. Seasonal (allergic) rhinitis (hay fever)

• Pulmonology : Scientific Concepts, Solitary pulmonary nodule

Greater than 3 cm (mass) CT again in 3 months, then in 6 months for up to 2 years, beyond 2 years=Benign Pulmonary hamartoma is the most common benign lung tumor, although it is a relatively uncommon lesion. It is likely an acquired lesion from peribronchial mesenchyme. The patients are generally asymptomatic. The lesion is almost always solitary and is usually peripheral; hence, it does not reveal any cells on fine-needle aspiration. Histologically, hamartomas are composed of both mesenchymal and epithelial elements. The differential diagnosis of a solitary coin lesion includes: Lung carcinoma (most commonly an adenocarcinoma) Granuloma Hamartoma A small cell carcinoma (or oat cell carcinoma) tends to spread very quickly and does not remain localized. Moreover, it is most common with a history of smoking. Pulmonary nodule ● Rule out cancer: bronchogenic, lymphoma, carcinoid ● DDx: benign tumor (hamartoma), infectious, inflammatory ● If likely benign, may re-image at 3-6 months ● If suspicious, need TISSUE! ● CT guided biopsy

Dermatology : History and Physical, Psoriasis

Guttate psoriasis (A) presents with small, erythematous plaques that have coarser scales than pityriasis rosea. Guttate psoriasis does not have a preceding herald patch. In addition, a streptococcal infection frequently precedes guttate psoriasis Plaque psoriasis (D) presents with raised, inflamed plaques and papules with silvery scales. Pinpoint bleeding after removal of a scale from a psoriatic plaque (Auspitz sign) is a common clinical finding of plaque psoriasis. Many patients with psoriasis have a positive family history of the disorder. Psoriasis is an autoimmune condition with peak incidence in the early 20's. It occurs equally in males and females, and has a hereditary component. Stereotypical lesions are chronic, relapsing, thick silvery and scaly papules and plaques that overly an erythematous base. It is a chronic disorder but certain triggers such as infection, drugs, and trauma can cause flares. The Koebner phenomenon occurs when physical trauma elicits new growth of psoriatic patches. The most common areas affected are the extensor surfaces of the extremities (elbows and knees), lower back, palms and soles, scalp, gluteal cleft, and genital regions.

ENT/Ophthalmology : Diagnosis, Hyphema

Hyphema is defined as hemorrhage into the anterior chamber. A hyphema (B) is an internal hemorrhage within the anterior chamber of the eye. Hyphema is an accumulation of blood in the anterior chamber of the eye. They are frequently traumatic in nature, but also occur post intraocular surgery Immediate ophthalmologic consultation is required to decrease the chance of vision loss, and to evaluate intraocular pressure and optic atrophy. Treatment consists of analgesics, dilating drops, steroids, head of bed elevation, controlling intraocular pressure and nightly use of an eye patch Blood in anterior chamber, "8-ball" hyphema when completely covers iris,

Endocrinology : Scientific Concepts, Diabetes insipidus

Labs will show increase in plasma osmolality and a decrease urine osmolality Central DI: Most commonly caused by ↓ ADH production Diagnosis is made by water deprivation test: > 50% increase in urine osmolality Treatment is intranasal DDAVP Nephrogenic DI: Patient with a history of taking lithium Most commonly caused by renal unresponsiveness to ADH Diagnosis is made by water deprivation test: no change in urine osmolality Treatment is HCTZ, amiloride, indomethacin

ENT/Ophthalmology : Diagnosis, Labyrinthitis

Labyrinthitis often includes hearing loss and or tinnitus, with episodes often lasting days or weeks. The classic clinical picture of labyrinthitis is acute, profound, incapacitating vertigo, with nausea, vomiting and nystagmus. Tinnitus and hearing impairment usually accompany the onset of vertigo. These symptoms resemble those of Meniere's disease, however in Meniere's disease, symptoms are intermittent and possibly less severe. Labryinthitis is inflammation of the inner ear or nerves with unilateral loss of auditory function. Labrynthitis is usually associated with an ear infection that is caused from bacteria or a virus Labyrinthitis presents with an acute onset of continuous vertigo, hearing loss, and tinnitus. Symptoms gradually improve over several weeks, though hearing may remain impaired following recovery. Acoustic neuroma has a gradual onset, and symptoms will not improve until the tumor is treated. Treatment of suspected viral labyrinthitis includes bed rest, hydration, antiemetics and vestibular depressants. Treatment with corticosteroids during the acute period of vertigo has been shown to improve the recovery of peripheral vestibular function in patients with acute labyrinthitis. Benzodiazepines are also effective. ● Can happen after a viral illness or an otitis media ● Treatment: Treat the vertigo symptomatically

Endocrinology : Clinical Intervention, Pheochromocytoma

Management of hypertensive emergency in patients with pheochromocytoma is a two-step process. You must obtain α-blockade prior to β-blockade. This is classically done by administering phenoxybenzamine, which is an α1- and α2-blocker, or phentolamine, a nonspecific α-blocker, followed by a beta blocker, such as labetalol or propranolol. Definitive management is by surgical resection of the tumor.

Endocrinology : Diagnosis, Primary aldosteronism

Mineralocorticoid (D) excess (hyperaldosteronism) causes hypertension, headaches and polydipsia. Clinically, patients present from complications of hypertension and hypokalemia (weakness, ileus). Treatment is with high-dose spironolactone or eplerenone (aldosterone antagonist) to normalize potassium levels. Side effects include gynecomastia, rash, impotence, and GI discomfort. Unilateral adrenalectomy is also an option in patients with a single adenoma. Hyperaldosteronism can stem from a variety of sources and most commonly leads to secondary hypertension. The most common cause is due to a aldosterone-producing adenoma, also referred to as Conn disease. Hypertension and hypokalemia are classically found, although the potassium can be normal. The workup begins with checking plasma aldosterone concentration and plasma renin activity.

Cardiology : History and Physical, Mitral valve prolapse

Mitral valve prolapse occurs when the mitral valve protrudes back into the left atrium. It is most frequently found in young, thin women. Patients may be asymptomatic, or they may experience dyspnea, fatigue, palpitations, and chest pain. Mitral valve prolapse will produce a mid-systolic click on auscultation. Mitral valve prolapse and pulmonic stenosis are examples of systolic murmurs Women with no significant past medical history presents with a history of recurrent palpitations. These episodes occur primarily upon exertion. She recalls periodic bouts of anxiety, panic attacks, and lightheadedness. The cardiac exam revealed a high-pitch late systolic click at the apex. The valsalva maneuver and a standing position result in prolongation of the murmur Activities that reduce end-diastolic volume, such as Valsalva maneuver or a standing position, cause an earlier click and a prolonged murmur. In the supine position, especially with the legs raised for increased venous return, left ventricular diastolic volume is increased, resulting in a click later in systole and a shortened murmur.

Neurology : Diagnosis, Brain tumor

Obtaining a contrast-enhanced MRI of the brain will demonstrate an intracranial mass lesion. MRI scans have a much higher resolution for soft tissue over CT scans and are preferred for looking at brain parenchyma. Brain tumors are associated with headaches, but they typically do not follow the above pattern. Headaches occurring with brain tumors may become more severe over time, and they usually do not resolve spontaneously. The most common causes of a cranial nerve VI palsy include increased intracranial pressure, brain tumor, and stroke.

• Neurology : Diagnosis, Simple partial epilepsy

One important hallmark of a simple partial seizure is that the patient does NOT lose consciousness. Focal seizures without dyscognitive features (formerly termed simple partial seizures) can cause motor, sensory, autonomic, or psychic symptoms without impairment of cognition. Simple partial seizures are due to focal brain cortex stimulation. The seizure symptoms will be related to the specific region of the brain cortex involved, and may include motor, sensory, and autonomic changes. Partial seizures are differentiated as simple versus complex, based on the alteration or lack of alteration of consciousness, A transient focal deficit (usually unilateral) following a simple or complex focal seizure is referred to as Todd paralysis, and it should resolve within 48 hours. Simple partial seizures are seizures that usually affect the temporal lobes and/or hippocampi. Simple partial seizures are usually followed by larger seizures later in life; the abnormal electrical activity spreads to a larger area of the brain (usually), resulting in a complex partial seizure or a tonic-clonic seizure Eye deviation with facial twitching that lasts 1-2 minutes' is the correct answer. Simple partial seizures can vary depending on what portion of the cortex has been effected. Patients may display isolated tonic or clonic activity or may have transient altered sensory perception. Clonic movements are jerks that may involve a specific body part or may spread to adjacent body parts, known as "Jacksonian march." Tonic activity is stiffening or sustained posturing, such as eye deviation in this case.

Pulmonology : Health Maintenance, Pertussis

PCR assay and antigen detection are increasingly used to assist in diagnosing pertussis Bordetella pertussis is a fastidious Gram-negative bacillus that is the causative agent of whooping cough. The organism is difficult to recover in cultures; PCR testing and DFA are the tests of choice, especially because results are acquired within hours instead of days What is a potential neurologic complication of pertussis infection? Seizures. A special medium culture plate (such as a Bordet-Gengou agar) is required for the nasopharyngeal swab for the diagnosis of pertussis. C. Ampicillin may be used for macrolide-intolerant patients however it is not the drug of choice. Can use Erythromycin and Clarithyromycin or Bactrim Acellular pertussis vaccine given in combo with diphtheria and tetanus toxoid, and for adults in TdAP

• ENT/Ophthalmology : Clinical Therapeutics, Otitis externa

Patients present with a painful, pruritic ear, sometimes accompanied by a discharge. On physical exam, these patients have a swollen, erythematous auditory canal. Manipulation of the tragus or the pinna of the affected ear elicits pain. This differentiates the condition from otitis media, where pain is not elicited. Malignant external otitis is also an infection of the outer ear, but it spreads to involve the skull, most often the temporal bone. This infection is life-threatening, and it is most often seen in diabetics and immunocompromised patients. Usually caused by organisms such as Pseudomonas aeruginosa, S. epidermidis, and S. aureus. In uncomplicated cases, treatment is with oral antianalgesics (e.g., ibuprofen) plus topical agents aimed at cleaning and drying the ear canal and treating the infection. These include 2% acetic acid and fluoroquinolone ear drops. Topical corticosteroids, such as hydrocortisone, can also be used to reduce inflammation

ENT/Ophthalmology : Clinical Therapeutics, Orbital cellulitis

Patients should be started on broad-spectrum intravenous antibiotics that are antistaphylococcal and antistreptococcal such as ceftriaxone. Vancomycin is added to cover MRSA. A CT scan can be obtained to evaluate for postseptal extension or abscess. If there is concern for associated cavernous sinus thrombosis, an MRI with venous phase is indicated. Ophthalmology and ENT consultation should also be obtained. Can use: 2nd/3rd Generation Cephalosporin +FQs, or Naficillin and Metro (or Clinda) Orbital cellulitis is a life-threatening infection of the tissues posterior to the orbital septum. It occurs most commonly in children. The causative organisms include S. aureus, S. pneumoniae, H. Influenzae, and S. pyogenes. An afferent pupillary defect is often present. Pain with extraocular muscle movement is the key distinguishing feature of orbital cellulitis. Other key distinguishing features of orbital cellulitis include chemosis, proptosis, fever, and ophthalmoplegia. Loss of vision is a late finding.

ENT/Ophthalmology : Clinical Intervention, Sialolithiasis

Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone. Palpable stones may also be "milked" from the duct, if they are distal enough, by gentle stroking in a posterior to anterior direction He states that he gets swelling on the right side of his jaw that begins while eating and subsides within 2 hours after eating. On physical exam, there is no edema noted, but a palpable mass is noted on the right side of the jaw, near the TMJ;The clinical picture is suggestive of sialolithiasis, or a calculus formation within the Stensen's duct of the parotid gland. A patient may note swelling and pain while eating or after eating. A palpable lump or visible swelling in the area of the gland is often noted.

• Orthopedics/Rheumatology : Health Maintenance, Ankylosing spondylitis

Physical Therapy (swimming), NSAIDs, TNF- inhibitors

Endocrinology : History and Physical, Pituitary adenoma - prolactin

Pituitary Tumors Prolactinoma: (most common), amenorrhea, impotence Many medications cause hyperprolactinemia, including SSRIs, tricyclic antidepressants, and antipsychotics

Pulmonology : Health Maintenance, Strep Pneumo

Prevention ● Pneumococcal conjugate vaccine (PCV13) ["Prevnar 13"]: 4 doses for pediatrics (2, 4 & 6 mos, and between 12-15 mos); adults ≥ 65yo, 1 dose if never received PCV13 ● Pneumococcal polysacharide vaccine (PPSV) ["Pneumovax 23"] ○ Ages 2yo-64yo with chronic illnesses that increase the risk of pneumonia, like cardiovascular disease, sickle cell, asplenia, and liver disease ○ Adults ≥ 65yo ○ Booster after 5 years for: children and adults < 65yo who are at high risk, and for adults ≥ 65yo who received their 1st dose when they were younger than 65yo ○ Some sources recommend vaccination for anyone requesting it

• Pulmonology : History and Physical, Pneumonia

Progressive purulent cough, tachypnea, tachycardia, pleuretic chest pain, fevers, rigors, SOB, dullness to percussion if effusion

Diagnostic Studies, Pulmonic stenosis

Pulmonic Stenosis Rare & associated with congenital heart defects Pulmonic stenosis can present with symptoms of right heart failure in the later stages. Patients may exhibit symptoms similar to aortic stenosis, including dyspnea with exertion, angina, fatigue and syncope, and evaluation through echocardiogram is recommended. Mitral valve prolapse and pulmonic stenosis are examples of systolic murmurs Congenital pulmonic valve stenosis tends to be asymptomatic. If symptoms do occur, they present with right-sided heart failure, abdominal fullness, and pedal edema in advanced disease. On exam, a prominent a wave is present, and a right ventricular heave is palpated. The murmur is a loud, late-peaking crescendo decrescendo systolic ejection murmur heart at the upper left sternal border. The patient likely has pulmonic stenosis as noted by his dyspnea on exertion and loud ejection click heard to precede the high-pitched systolic ejection murmur. These murmurs characteristically decrease with inspiration (the only right heart auscultatory event that decreases with inspiration, as all others increase). This is due to increased RV filling from inspiration prematurely opening the valve during atrial systole. Delayed and soft P2 and a thrill at a second left intercostal space are also signs of pulmonic stenosis. Most notably for the patient 50% of Noonan Syndrome patients have congenital heart disease and is often associated with pulmonary stenosis.

• Orthopedics/Rheumatology : Clinical Intervention, Spinal stenosis

Question: What is first line therapy for spinal stenosis? Answer: Adequate pain management, physical therapy, exercise, and weight loss Spinal stenosis usually occurs at cervical and lumbar segments. Patients with cervical stenosis present with radiating arm pain, numbness, paresthesia, and motor weakness. The common symptoms with lumbar stenosis are gradual onset low back pain, leg pain, and numbness. The pain is most often bilateral, The classic presentation is radiating leg pain (burning or cramping) that begins or worsens with walking and standing and is relieved by sitting or lying down with hips and knees drawn up in a sitting posture (neurogenic claudication). Bending forward diminishes pain.

• Cardiology : Clinical Intervention, Thrombophlebitis

ROSH: Phlebitis is the counterpart to vasculitis, in that phlebitis is inflammation of a vein. Thrombophlebitis is vein inflammation due to thrombus (blood clot). These commonly occur in the superficial veins of the lower extremities, whereas, deep venous thrombosus (DVT) is the term used when a clot lodges in the deep veins. ymptoms include painful, palpable cord-like veins, distal edema and possibly localized erythema. Causes include a predilection to clotting, vein injury, incompetent venous valves (varicosity), Behcet's syndrome and prolonged travel or immobility. Evaluation usually includes Doppler ultrasonography and blood clotting studies. The key to treatment is driven by where the disorder is located. Below-the-knee superficial thrombophlebitis is usually treated with NSAIDs, compressive support and leg elevation. Above-the-knee superficial thrombophlebitis is commonly associated with deep venous thrombus. As such, dislodgement of the deeper clot can cause a life-threatening pulmonary embolus. Therefore, it is important to ascertain whether or not an above-the-knee superficial thrombophlebitis occurs with a deep venous clot (via Duplex ultrasound). If it does, then anticoagulation is recommended as part of the treatment plan. If it isn't, the recommended treatment is less clear. Enoxaparin is a low molecular weight heparin (LMWH) that is used to prevent and treat deep vein thrombosis or pulmonary embolism. Superficial thrombophlebitis is an inflammation of a vein and can be related to a septic condition. One risk factor for superficial thrombophlebitis is presence of an IV catheter, which this patient would have due to being an inpatient and post-operative.

Cardiology : Clinical Intervention, Constrictive pericarditis

ROSH: Treatment includes NSAIDs, corticosteroids and colchicine. Drainage and antibiotics are usually necessary if an infectious etiology is found. PA EASY: Transthoracic echocardiography, would allow for monitoring of a patient with acute pericarditis, to determine if a pericardial effusion and/or cardiac tamponade develops. Exam Master: Most cases are due to viral infections with the treatment being rest and non-steroidal agents, e.g. aspirin or indomethacin. If this pericarditis progressed to tamponade, pericardiocentesis would be indicated. Symptoms of tamponade are not seen in this patient (dyspnea, elevated jugular venous pressure, hypotension, paradoxical pulse, and muffled heart sounds). Treatment ● High-dose ASA or NSAIDs (naproxen, ibuprofen) for 1-3 weeks (for idiopathic, viral infection) ● Treat underlying cause (for uremia, bacterial infection) ● Colchicine: decreases duration of symptoms and frequency of recurrences ● Steroids are controversial - may increase recurrences (always AVOID on exams!)

• Orthopedics/Rheumatology : Health Maintenance, Osteoporosis

Recommendations for patients diagnosed with osteoporosis without a fracture is every 2-3 years (C). This guideline is approved based on age, risk factors, or previous fractures. A post-menopausal woman at age 64 without a presenting fracture can be followed every 2-3 years with bone density imaging (DXA scan). Performing a DXA at intervals less than two years has not shown of benefit Recommendations for calcium carbonate are 1,000-1,500 mg once daily orally. Vitamin D increases calcium absorption in the gastrointestinal tract, making calcium more available for reabsorption and circulation. Recommendations for Vitamin D are 800-2,000 international units once daily orally. Z scores indicate how the patients bone density compares to peers and T scores compare the patient to young, health individuals. Proximal humerus fractures are most commonly seen in elderly patients. The most common type of fracture occurs at the surgical neck (the epiphyseal-diaphyseal junction, just inferior to both tuberosities). Osteoporosis is a condition characterized by low bone mass, which increases the fragility of bones and leads to an increased risk of fracture. Osteoporosis is defined as being either primary or secondary and primary osteoporosis is further broken down into Type 1 and Type 2. Type 1 is related to decreased hormone levels - estrogen in women and testosterone in men, and is sometimes referred to as "postmenopausal osteoporosis." It is six times more common in women and results in loss of trabecular bone. Type 1 primary osteoporosis often presents with vertebral compression fractures or fractures of the distal radius after a fall. Type 2 primary osteoporosis is sometimes referred to as "senile osteoporosis" and generally occurs in patients over 70 years of age. It is twice as common in women as men and occurs due to a diminished capacity to make new bone. The most common types of fractures found in this type of osteoarthritis are hip and pelvic fractures. Secondary osteoporosis occurs at a somewhat higher rate in men versus women and is caused by some other medical condition that produces bone loss. Common causes include long-term steroid use, various endocrine abnormalities, and neoplastic diseases such as multiple myeloma.

• Gastrointestinal/Nutritional : Clinical Intervention, Small bowel obstruction

Small bowel obstruction typically presents with localized high-pitched bowel sounds with crampy abdominal pain, nausea, and vomiting. The bowel sounds will diminish if complete obstruction occurs. The most common causes of small bowel obstructions are postoperative adhesions, followed by neoplasms, Crohn's disease, and hernias.

Neurology : Clinical Therapeutics, Multiple sclerosis

Starting interferon therapy in a patient with optic neuritis who has multiple white matter lesions can prevent development of multiple sclerosis in a percentage of patients. Otherwise Symptomatic: Amantadine for fatigue, baclofen/diazepam for spasticity, oxybutnin for incontinence Medications, such as the glucocorticoids, are utilized for acute exacerbations or initial episodes of MS, to decrease exacerbation severity. Additionally, they are used for associated conditions, such as optic neuritis. Steroids have not been shown to decrease MS progression or impact the relapse rate. MRI of the brain of cervical cord will reveal the pathology that is typical in MS; usually, the presence of multiple hypointense 'black holes' representing areas of permanent axonal damage is strongly suggestive of MS as the diagnosis. the distinguishing characteristics; spasticity (what she describes as restless legs), diplopia, unsteadiness, numbness, tingling, and urinary urgency/hesitancy (sphincter abnormalities).

• Orthopedics/Rheumatology : History and Physical, Osteosarcoma

Sunburst Pattern on XR Osteosarcoma also has a metaphyseal predilection, however, it occurs with lytic and blastic lesions in the second decade, with chondrosarcoma having calcified lesions and fibrosarcoma having lytic lesions. Osteosarcoma is a type of primary bone cancer. Fortunately this is a rare cancer, accounting for only 1% of the cancers diagnosed each year in the USA for patients of all ages. Osteosarcomas are more common in the pediatric population, accounting for 5% of all childhood cancers and 56% of all cancers of the bone in patients less than 20 years old. Osteosarcomas have a bimodal occurrence rate with the highest prevalence between ages 11-13 and over the age of 65.

• Pulmonology : Clinical Therapeutics, Chronic bronchitis

Supplemental O2 in Patients with <55mHg and <88%O2 Sat, Anticholinergics > SABA for bronchodilation, SABA could be prescribed, Abx frequently needed, steroids are effective but use with caution, consider alpha anti-trypsin replacement therapy Patients with acute exacerbations of chronic bronchitis should be treated with trimethoprim/sulfamethoxazole or amoxicillin/clavulanate combinations. They should also receive an annual influenza vaccination. Spirometry reveals an FEV1 of 2 L (40% of predicted), an FVC of 4 L (80% of predicted) and an FEV1/FVC of 50% Treatment (acute exacerbation): o O2 via Venturi mask o Beta-agonists o Anticholinergics o Corticosteroids o Magnesium o BiPAP ● Treatment (long term): o stop smoking (improves prognosis) o vaccine (pneumococcal polysaccharide vaccine 23 [PPV-23])

Scientific Concepts, Congestive heart failure

Symptoms of congestive heart failure (S3, pulmonary edema, crackles, mitral regurgitation) or an ejection fraction < 40%. ACE inhibitors are primarily used in the treatment of hypertension and congestive heart failure. Overall, digoxin use usually is limited to CHF patients with left-ventricular systolic dysfunction in atrial fibrillation or to patients in sinus rhythm who remain symptomatic despite maximal therapy with ACE inhibitors and β-adrenergic receptor antagonists. Although digoxin does not confer a survival benefit, it has reduced the number of hospitalizations that occur as a result of worsening heart failure. Those with congestive heart failure or pulmonary congestion may benefit from the cautious use of digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. Severe anemia, may result with progression of gastric ulcers, and is the only high-output cause of congestive heart failure among the choices offered Congenital heart diseases, such as malformations of the heart—patent ductus arteriosus (D) and ventricular septal defects, are the most common causes of heart failure in infants-toddlers Transthoracic echocardiogram, is usually necessary in patients demonstrating symptoms suggestive of congestive heart failure Bicuspid aortic valve, would be the most likely finding on echocardiogram given the patient's history and physical exam findings. The patient is demonstrating symptoms suggestive of congestive heart failure at a relatively young age, with relatively few cardiac risk factors. A congenital bicuspid aortic valve does not usually cause symptoms until the fifth or sixth decade Signs and symptoms of congestive heart failure can lead to hepatic congestion and hepatomegaly

Cardiovascular : Scientific Concepts, Lateral wall myocardial infarction

The EKG shows an elevation of ST segment in leads V3 and V4, which reflect the anterior wall of the left ventricle. The diagonal branch of the left anterior descending artery-LAD (a branch of left coronary artery) supplies this anatomic area. The LAD-septal branch supplies the septum, represented by leads V1 and V2. The LCA-circumflex branch supplies the high lateral wall of left ventricle, represented by V5, V6, DI, and aVL. The RCA (right coronary artery) posterior descending branch supplies the inferior and posterior wall of left ventricle, represented by leads DII, DIII, and aVF. The RCA-proximal branch supplies the right ventricle, inferior, and posterior wall of left ventricle, represented by leads V4R, DII, DIII, and aVF.

• Orthopedics/Rheumatology : Scientific Concepts, Scaphoid fracture

The appropriate management of a scaphoid fracture is immobilization in a thumb spica cast. Scaphoid fractures are at risk of non-union due to the potential interruption of blood supply from the palmar carpal branch of the radial artery to the proximal pole of the scaphoid. The most common mechanism of injury is a fall on an outstretched hand. These fractures often do not show up on X-rays taken immediately after the causative injury. Therefore, any patient with a suspicious mechanism of injury and snuffbox tenderness should be treated as a scaphoid fracture, regardless of radiographic finding Patients with snuff box tenderness or suspicion for scaphoid fracture should be placed in a thumb spica splint with repeat radiographs in 2-3 weeks. The scaphoid bone is the most commonly fractured carpal bone. Patients with missed fractures that are not immobilized are at an increased risk for fracture nonunion and long-term chronic arthritis. How long should a scaphoid fracture be immobilized? Answer: At least 6 - 12 weeks. Because of this tenuous blood supply, scaphoid fractures have a tendency to develop avascular necrosis (AVN). The more proximal the fracture, the greater the likelihood of developing AVN.

Neurology : History and Physical, Spinal cord injury

The central cord syndrome involves loss of motor function that is more severe in the upper extremities than in the lower extremities, and is more severe in the hands. There is typically hyperesthesia over the shoulders and arms. Anterior cord syndrome presents with paraplegia or quadriplegia, loss of lateral spinothalamic function with preservation of posterior column function. Brown-Séquard syndrome consists of weakness and loss of posterior column function on one side of the body distal to the lesion with contralateral loss of lateral spinothalamic function one to two levels below the lesion.

Endocrinology : Clinical Intervention, Graves disease

The classic triad of Grave's disease includes the presence of a diffuse goiter, exophthalmos and pretibial myxedema. Exophthalmos is not the result of excess thyroid hormone (which causes other eye findings such as lid lag and lid retraction) but rather is due to cellular inflammation and the accumulation of hydrophilic glycosaminoglycans in the extraocular muscles and retroorbital tissues

• Pulmonology : Diagnostic Studies, Sarcoidosis

The diagnosis can be made confidently from the clinical and radiological feature, and it can be confirmed histologically from the biopsy of a superficial lymph node or skin lesion What is the most useful test to confirm a diagnosis of sarcoidosis?Biopsy of the affected organ. African-Americans, females Primary target organ: lungs Parotid enlargement Hypercalcemia CXR: bilateral hilar adenopathy Biopsy: noncaseating granulomas Steroids Sarcoidosis is an idiopathic inflammatory disorder that may cause noncaseating granuloma formation in the lungs. Some patients report symptoms such as cough but others are asymptomatic. Elevated levels of serum angiotensin converting enzyme (ACE) are typically elevated in about 75% of patients with sarcoidosis. Sarcoidosis is a multisystem granulomatous disease. Histologically, it is characterized by the presence of non-necrotizing granulomas and hilar lymph node involvement occurs in 100% of the cases. Any infection has to be ruled out. 30% of the patients of sarcoidosis are asymptomatic, and the disease is commonly detected by an abnormal chest radiograph revealing bilateral hilar lymphadenopathy in an asymptomatic patient. However, with extensive lung involvement, there may be exertional dyspnea or cough. Erythema nodosum (EN) may occur in up to 39% of sarcoidosis cases, characterized by tender erythematous nodules most commonly located on the anterior tibial areas. Sarcoidosis has a number of lab abnormalities associated with it including hypercalcemia. Sarcoidosis is a multisystem inflammatory disease that involves non-caeseating granulomas composed of collections of T-helper cells and other inflammatory cells. It predominantly affects the lungs and intrathoracic lymph nodes but can involve a number of systems including cardiac, skin and neurologic. Chest radiography often reveals hilar adenopathy in early stages and progresses to pulmonary fibrosis. Patients may present with a host of non-specific symptoms including fever, fatigue, weight loss and polyarthritis. Other symptoms depend on end organ involvement. The granulomas secrete 1,25 vitamin D leading to hypercalcemia and hypercalciuria. Name two steroid-sparing alternative medications used for pulmonary sarcoidosis. Azathioprine and methotrexate.

• Gastrointestinal/Nutritional : Scientific Concepts, Phenylketonuria

The disease phenylketonuria (PKU) results from decreased levels of the enzyme phenylalanine hydroxylase that is part of the phenylalanine degradation pathway. Untreated, PKU leads to intellectual disability Phenylketonuria is an autosomal recessive metabolic disorder, which causes abnormal metabolism of phenylalanine, resulting in elevated serum phenylalanine. Phenylketonuria is an extremely well-known amino acid metabolism disorder that can be found in newborns. In classic phenylketonuria, there is decreased activity of phenylalanine hydroxylase, which is the enzyme that converts phenylalanine to tyrosine; this leads to excessively high levels of phenylalanine accumulating in the patient. Elevated serum phenylalanine provides the diagnosis and treatment is dietary restriction of phenylalanine. The recommended uniform screening panel for newborns in the United States includes screening for PKU to allow for early intervention in patients with the disorder.

• Orthopedics/Rheumatology : History and Physical, Osteoarthritis

The earliest sign of the development of osteoarthritis of the hip is often the loss of internal rotation Distal interphalangeal joints of the hand are rare locations for either gout or pseudogout, but are classic locations to see signs and symptoms of osteoarthritis. Osteoarthritis is a progressive, irreversible disease that leads to loss of articular cartilage in the joints. Osteoarthritis can affect the weight bearing joints in the lower extremities and spine, but can also be commonly found in the hands and other joints. The occurrence and severity of the condition can be affected by history of past trauma to a joint, long-term wear and tear on a joint, as well as obesity, genetics, and progressive aging. The condition can produce pain, swelling, stiffness, decreased range of motion, joint deformity, crepitus and decreased ability to do tasks of daily living. Osteoarthritis does tend to lead to direct damage to tissues like fascia (which is a fibrous connective tissue that surrounds muscles), muscles or tendons (tendons connect muscles to bones). As osteophytes form and joints become distorted, this could have a secondary impact on ligaments that are responsible for providing joint stability, but ligaments are not primarily affected by osteoarthritis Osteoarthritis can affect all of the joints mentioned, but generally has the highest prevalence in the DIP joints, especially the second DIP joint. Osteophyte formation at the DIP joints produce enlargements referred to has Heberden's nodes.

• Gastrointestinal/Nutritional : Diagnosis, Hirschsprung disease

The neonate probably has Hirschsprung's disease, a congenital motility disorder of the colon caused by lack of innervation in a short segment of the colon, usually the rectosigmoid. This results in failure of relaxation of that part and functional obstruction. Failure of passage of meconium in the first 48 hours is suggestive. If not treated quickly, sometimes enterocolitis can occur with fever, sepsis, and life-threatening toxic megacolon, as is the case in this patient. Barium enema shows a narrowed segment with a dilated proximal colon. Rectal biopsy is the standard and will reveal absence of ganglion cells in the affected segment. Treatment is surgical The disease is four times more common in boys than girls and is associated with Down's syndrome. Toxic megacolon is a complication of Hirschsprung disease The mainstay of treatment is bowel decompression with NG tube

Endocrinology : Diagnosis, Pituitary tumor

The patient is presenting with classic signs and symptoms of acromegaly. This disorder is caused most commonly by a growth hormone secreting pituitary adenoma. A patient presents with a several year history of developing coarse facial features, prognathism, widely spaced teeth, and sleep apnea. Upon exam, you also note oily skin and high blood pressure

Cardiovascular : Diagnosis, Coarctation of the aorta

The physical exam will reveal a higher BP in the upper extremities and absent or weak femoral pulses. There will be strong arterial pulsations in the neck and suprasternal notch and a harsh late systolic ejection murmur which is best heard at the base. An EKG may reveal left ventricular hypertrophy. A CXR may reveal rib notching and dilated L subclavian artery, however an echocardiogram is diagnostic. This patient has coarctation of the aorta. Balloon angioplasty of the abnormality is the correct answer, and is a corrective repair. Coarctation of the aorta typically presents with pulse lag in the lower extremities and a blowing systolic murmur heard best in the left axilla and back.

Cardiology : Clinical Therapeutics, Prinzmetal angina

This patient is exhibiting Prinzmetal's angina (vasoconstriction); she does not have any stenosis. The best therapy for her is a calcium channel blocker (e.g., nifedipine) Treatment is calcium channel blockers and nitrates Thiazide and loop diuretics, have no proven benefit in patients with Prinzmetal angina. Aspirin, may worsen episodes of prinzmetal angina, and thus is not recommended.

Cardiovascular : Clinical Intervention, Tetralogy of Fallot

Treatment and Disposition ● Immediate ○ Open ductus with PGE1 @ 0.1 mcg/kg/min ■ Hypotension ■ Apnea ■ Hyperpyrexia ○ Keep pulmonary pressures low with oxygen ○ Consider transfusion (to Hgb >10), bicarbonate, fluid ● Correction ○ Temporize with Blalock-Taussig (BT) shunt Echocardiography usually establishes the diagnosis by visualizing the large ventricular septal defect, the right ventricl infundibular stenosis, and the enlarged aorta.

Orthopedics/Rheumatology : Clinical Intervention, Fibromyalgia

Treatment is multifaceted. Patient education should emphasize that the disease is not progressive; exercise programs and cognitive behavioral therapy may be beneficial. Many medications (including amitriptyline, duloxetine, gabapentin, and muscle relaxants) show modest symptom relief; corticosteroids and opioids should be avoided as these have not be proven effective. Pregabalin (Lyrica) only FDA approved drug for Fibromylagia Points include the trapezius, medial fat pads of the knees, and lateral epicondyles of the elbows. Physical examination is normal except for "trigger points" of pain produced by palpation of various areas such as the trapezius, the medial fat pad of the knee, and the lateral epicondyle of the elbow.

Dermatology : Scientific Concepts, Impetigo

Tx: ○ Remove crusts with warm cloth ○ Mupirocin ointment ● Avoid scratching (can self inoculate) ● Oral abx: for more severe cases (dicloxacillin, cephalexin (MSSA), TMP/SMX, clindamycin (MRSA)

Dermatology : Clinical Therapeutics, Cellulitis

Tx: Amoxicllin, Kelfex, Dicloxcacillin PCN: Allergy: Clinda, Arithromycin, Erythromycin MRSA: Bactrim/Doxy {Doxy, Clinda, Bactrim} Why is trimethoprim-sulfamethoxazole (TMP-SMX) a poor choice as a single agent to treat cellulitis? Answer: TMP-SMX is active against most methicillin resistant Staphylococcus aureus but has poor coverage against group A streptococci; an organism often implicated in cellulitis Cellulitis is characterized by an expanding, erythematous, edematous and tender lesion often involving the lower extremity. The borders of the area involved are not elevated and not demarcated. Borders of erythema should be marked in order to track spread of infected tissue. Pain, chills, and fever are commonly present. ● Clinical presentation: erythema, warmth, pain, induration, edema, lymphadenopathy, lymphangitis, fever ● Dx and tx: clinical, on US: "cobblestoning,"

Diagnostic Studies, Abdominal aortic aneurysm

Ultrasonography is cost-effective and is the most commonly utilized screening modality for AAAs. It can be utilized for initial detection of a nonruptured AAA and for monitoring of progression. Anteroposterior and lateral abdominal radiographs may reveal calcification of an AAA as an incidental finding but are nonsensitive/nonspecific. ● Diagnosis ○ Can be diagnosed with US (bedside) if abdominal ○ Other modalities: CT, MRI Abdominal Aortic Aneurysm (AAA) ● 'Classic' AAA presentation: severe abdominal/hip/back pain, pulsatile abdominal mass, syncope ● **Beware that a kidney stone can present just like a AAA, including hematuria ○ Think worst first if patient has risk factors for AAA ○ Hematuria of AAA due to dissection into renal arteries

Cardiovascular : Health Maintenance, Aortic dissection

Useful agents in regards to aortic dissection include beta blockers to reduce the force of contraction and heart rate, as well as to lower blood pressure. Vasodilators can be used to reduce blood pressure. In all individuals with aortic dissections, medication should be used to control high blood pressure, if present. Intravenous beta blockers, such as labetalol, are effective at reducing blood pressure and heart rate. The target systolic blood pressure should be 100 - 120 mm Hg. The target heart rate should be below 60 beats/min.

Endocrinology : Diagnostic Studies, Diabetes insipidus

Water deprivation test. This test helps the practitioner determine if the patient can concentrate his/her urine with or without becoming hyperosmolar. The patient is restricted from liquids and food during the test, which must be done in a controlled environment. A patient with primary polydipsia will be able to concentrate his/her urine without becoming hyperosmolar. A patient with diabetes insipidus will become hyperosmolar without concentrating the urine.

• Orthopedics/Rheumatology : Clinical Intervention, Plantar fasciitis

What is the most appropriate first line treatment for plantar fasciitis?NSAIDs,The plantar fascia is a tough layer of the sole that is functionally significant during foot strike and the early stance phase of walking. Plantar fasciitis is an overuse injury of insidious onset that usually begins with pain on first weight bearing in the morning or after prolonged sitting. This progresses to persistent pain during gait. Pain and tenderness are localized to the medial aspect of the heel. Plain radiography is not diagnostic but shows a calcaneal spur in 50% of patients with plantar fasciitis. NSAIDs are considered first line treatment, along with rest, ice, and shoe inserts Which type of foot anomaly is plantar fasciitis common in? Answer: Cavus feet.

• Pulmonology : Clinical Therapeutics, Influenza

Zanamivir is an anti-viral agent that is active against the influenza virus. The Center for Disease Control recommends that neuraminidase inhibitors be prescribed for pregnant women and for those up to two weeks postpartum who have suspected or confirmed influenza. Women can continue to breastfeed while being treated with antivirals. Treatment with antiviral agents, should be started within 48 hours of symptom onset. The recommended treatment of influenza in pregnancy is one of the neuraminidase inhibitors, such as oseltamivir Although amantadine and zanamivir are approved for treatment of influenza infections, they have only been found to be helpful if treatment is begun within 48 hours of the initial symptoms. If prescribed within this period, the duration of illness can be shortened by about 1 day. The neuraminidase inhibitors, including oseltamivir and zanamivir, are associated with a reduction in duration of illness, and secondary complications for both influenza A and B viral strains. However, zanamivir, due to the oral inhalation delivery route, is relatively contraindicated in this patient, due to his history of asthma and an associated increased risk of bronchospasm. Amantadine is inactive against influenza B, as well as certain influenza A strains.

Neurology : Clinical Therapeutics, Migraine headache

o Acute treatment: ■ Dopamine antagonists (droperidol, prochorperazine, metoclopramide, chlorpromazine) ■ Triptans (sumatriptan) ■ NSAIDs (ASA, ibupr Prevention: o Antihypertensive (Ca+2-channel blockers, β-blockers) o Anticonvulsant (topiramate, gabapentin) o Antidepressant (SSRIs, TCAs) They are treated with a variety of medications, including dihydroergotamine (DHE), triptans, metoclopramide, chlorpromazine, and ketorolac. Placement of the patient in a dark, quiet room and administration of IV fluids can also be helpful. Migraines can present with neurologic symptoms such as visual disturbances (scotoma), paresthesias, and auras, which can make the diagnosis difficult Sumatriptan is commonly used for treatment of acute migraine attacks and can cause coronary vasospasms in 1-5% of patients. The vasospasms can be perceived as chest pain or discomfort.

Dermatology : Health Maintenance, Lice

● Nits located at the base of hair shaft o Unlike dandruff, unable to remove from hair shaft Pediculosis capitis is very common worldwide and most frequently affects children. The female louse lays eggs and attaches them to the base of the hair shaft. These eggs, or nits, are easily seen without magnification on physical exam. They are most commonly found behind the ears or at the posterior hairline. Nits take 8-9 days to hatch and 9-12 days to mature. The average lifespan of Pediculus humanus capitis is 30 days. What medication is indicated for the treatment and prevention of head lice and scabies? Answer: Permethrin. Treatment ● Primarily topical o Permethrin (Elimite®, Nix®) o Pyrethroids (A200®, RID®) o Malathion (Ovide®) o Lindane (Kwell®) ⇒ too toxic ⇒ seizure ● Oral Ivermectin - for severe cases Disposition/Follow Up ● Treat affected family members/close contacts ● Treat sexual partners ● Re-treat in 7 days to kill nits ● Launder clothing, bedding, etc. in hot water