1. Potassium replenishment
- K-lor capsules are very large, for many people they sit at the LES and cause erosive esophagitis. Doxycycline does the same thing. If someone needs K, you're better off giving liquid K (although it tastes bad).
- 0.1 mEq K below = 20-40 mEq deficit. For a 1 mEq deficit, replenish with 40-60 mEq PO q4-6 or 10 mEq IV q1 hour if its urgent.
2. Syphillis
- in the CSF, the VDRL is specific but not sensitive (70% false negative), while FTA-ABS is sensitive. It's the opposite of the serum pattern. A negative csf VDRL does not rule out neurosyphillis!
- In the US, >50,000 cases diagnosed every year
- primary syphilis - 10-90 day incubation period, chancres
- secondary syphilis - weeks to months later, diffuse symmetric rash (although can take any form except vesicular) plus general malaise symptoms- fever, anorexia, etc. many people will have spirochetes in their csf at this point.
- latent syphilis
- late syphillis occurs 1-30 years after initial presentation will occur in 25-40% of people with untreated syphilis - cardiac (aortitis), Neuro (transient meningitis, cranial neuropathies ESP optic, facial, menigovascular - arteritis of vessels in subarachnoid space leading to thromboses)
- otosyphilis, oculosyphilis can occur too
- tabes dorsalis can present with lancing pain,
3. Fourniers gangrene
- 100% mortality with antibiotics alone, 40-80% mortality even with surgery
- "Localized infection adjacent to a portal of entry is the inciting event in the development of Fournier gangrene. Ultimately, an obliterative endarteritis develops, and the ensuing cutaneous and subcutaneous vascular necrosis leads to localized ischemia and further bacterial proliferation. Rates of fascial destruction as high as 2-3 cm/h have been described.... testicles usually spared because they have a separate blood supply (testicular arteries, from aorta)" (medscape)
4. Anti-Xa levels
- Lovenox levels are monitored with anti-Xa (all heparin-based a/c can be monitored with this); lovenox only needs monitoring in people who need dose adjustments, like people with ESRD
- Adjustment for renal function: increase the interval, rather than decrease the dose.
- Anti-Xa test: put antithrombin and factor Xa in a tube, add patients' serum; if there is a lot of lovenox in the serum, it will cleave all the factor Xa and there will be little remaining (this measured with chromophores that are cleaved upon enzymatic cleavage). This is then plotted on a concentration-activity curve to determine the amount of "anti-Xa" activity within the patient's serum
- Therapeutic anti-Xa levels: lovenox (0.5-1.2), unfractionated heparin (0.3-0.7)
- Prophylactic anti-Xa levels: lovenox (0.2-0.5), unfractionated heparin (0.1-0.4)
5. Low molecular weight heparins:
- Lovenox comes in 80 mg pens
- Dalteparin does not accumulate even in people with renal failure
6. Antibiotics medley
- Keflex is good for wound infections, but it must be taken 3-4 times a day. Covers from MSSA to non-resistant GNR
- Augmentin has similar coverage, but is only BID. Better coverage of resistant GNR, coverage of anaerobes (no cephalosporins have any anaerobic coverage)
- Bactrim can cause a pseudo-type 4 RTA (decreased response to aldosterone, hyperkalemia) even at low doses. Especially relevant in ESRD patients.
- Many antibiotics affect warfarin metabolism in the liver - bactrim, cipro, macrolides (clarithro, erythro), flagyl! There are differences from what is seen in case reports (bad times) and what is seen when you co-administer warfarin and these antibiotics in healthy volunteers (not so bad!)
- "Some investigators advise that the hypothrombinemic response to warfarin can increase when acetaminophen is taken in a dosage of more than 2 g per day for longer than one week.3(pp7–8) Recent information suggests that the warfarin-acetaminophen interaction may be clinically significant at even lower dosages of the pain reliever. One case-control study identified acetaminophen as a cause of 30 percent of INR values greater than 6.0 in patients taking warfarin.4 This response occurred with as few as seven 325-mg tablets of acetaminophen. The proposed mechanism is a reduced capacity of cytochrome P450 enzymes caused by acetaminophen and resulting in decreased metabolism of warfarin." (from above article.... interesting)
7. Premature beats
- PAC: p-wave comes early, then the pacemaker resets. Comes from ectopic foci-- P wave morphology and PR interval are different. The PAC can be conducted normally or blocked through AV node.
- PVC: p-wave comes early, pacemaker resets. Wide QRS. Can be experienced as a "skipped heart beat", because the ventricles contract before they can adequately fill with blood.
- Atrial bigeminy: every normal sinus beat is followed by a PAC. Often due to mild irritation of atria: try stopping caffeine, checking electrolytes. Usually harmless
- Ventricular bigeminy: every normal sinus beat followed by PVC. The "true" heart rate will be half as fast as the measured heart rate-- because the PVC beats are not good beats, as the ventricles don't fill completely so the cardiac output is bad during those beats. Can occur in young healthy people and be fine-- they may be able to sit at an effective rate of 30 BPM. Can cause fatigue though, for decreased CO. If its severe enough you can treat this with ablation.
8. Escape rhythms/beats
- "escape" = higher levels of pacing have failed, now relying on downsteam pacemakers (junction, ventricular fascicles)
- Junctional escape rhythm: usually 40-60 bpm, narrow complex, may or may not have a p-wave (may conduct sightly retrograde and have an inverse form, may have no P wave.
- Ventricular escape rhythm: 20-40 bpm, wide complex, no p-wave for sure.
9. AV node blocks
- First degree: PR > 0.2 ms (one large box)
- Second degree type I wenckebach's: PRs lengthen than QRS drops; the ratio can be 1:2 - 1:10.
- Second degree type II: PRs same length, QRS randomly drops. vs PAC-- second degree blocks are sinus rhythms, so the P-P intervals are symmetric (ie not premature).
- Third degree: complete block. Frequently occurs after inferior wall MIs, as the RCA supplies the SA and AV node with blood. These people need a pacemaker, although the urgency varies; if they're healthy and compensating well, they might be able to stay on the floor and move to the OR at a leisurely pace to get the pacemaker (although should be within a day or so). If they're old and not able to compensate, they will need an ICU admission, an urgent temporary venous-catheter-placed-pacemaker and a trip to the OR as soon as feasible. Remember: in third degree block you are relying on ventricular escape rhythms, and those are really slow. An old person with lots of comorbidities may not be able to adequately perfuse at 20 bpm.
10. Bundle branch blocks:
- Most of the heart depolarizes R to L, but the septum depolarizes L to R
- RBBB: AV node to L fascicle is normal, and septum is able to depolarize normally. On the L lateral leads (V5, V6) you'll see a small Q (from the septal depolarization), a sharp R, and a widened S. On the right-side (V1, V2), you'll see a small R from the septal depolarization, a sharp S from the L ventricle depolarizing, and then a large R from the R side depolarizing (visible because the L ventricle is already done, so the direction of the vector will be very clearly towards the R) -- rabbit ears, rsR'. T wave inversions is normal.
- LBBB: AV node to R fascicle is normal, but septal depolarization and L side depolarization are both messed up. L lateral leads will see a widened R wave as the L ventricle depolarizing in a slow, inefficient way. R lateral leads will see a big widened S wave for the same reason-- L ventricle depolarizing.
- Hemi-blocks: Left bundle branch has anterior and posterior fascicle.
- L Anterior fascicular block is most common because it is supplied by the LAD. You get left axis deviation, Q1S3 (small Q in lead 1/avL, S wave in lead III), prolonged QRS
- L posterior fascicular block is less common because it has a dual blood supply- LAD and RCA. If you have ischemia of both, then you have bigger problems. Exact opposite EKG findings: R axis deviation, Q3S1, QRS prolonged.
- Combined blocks: L Anterior fascicular + RBBB because they are both supplied by LAD -- these have a high rate of progression to third degree AV block.
Friday, April 18, 2014
Wednesday, April 16, 2014
1. B12 deficiency
- Neuropsych signs (~33%, can occur w/ normal CBC): paresthesias, then ataxia with loss of vibration/position, then severe weakness, spasticity, clonus, paraplegia, incontinence, delirium/dementia.
- Homocysteine & MMA: they both need B12 to be converted to breakdown products, so they will increase in cases of B12 deficiency. Sensitivity of both tests are 85-95% sensitive. Homocysteine is less specific, can be elevated in vascular dx, some other processes.
- Anemia in ~75%, macrocytosis in ~80%. Normal CBC does NOT rule out B12 deficiency.
- B12 protien bound & released by acid digestion in stomach, binds IF in jejunum, absorbed in terminal ileum.
- Dietary deficiency rare bc 4 years of stores in liver.
- Old people who don't have stomach acid (atrophic gastritis, PPI, metformin) can have trouble absorbing B12.
- B12 level can be falsely low in folate deficiency, pregnancy, OCPs
- B12 deficiency: when to treat: when B12 is very low, when the B12 is borderline but either Homocysteine or MMA are low.
- Can treat with IM B12, or PO B12-- if you give huge doses, you can overcome even pernicious anemia.
2. Folate deficiency
- Drugs that interrupt the DHFR pathway: methotrexate, phenytoin, sulfasazlaine, alcohol
- People who need extra folate: chronic hemolytic anemia (like sickle cell), pregnancy, increased growth periods -- these people should always be taking folate
- Red cell folate reflects status over 3 months; sens/spec ~70%
3. Anemia of chronic disease
- Iron studies all slightly low, with high ferritin, low RPI
- Common causes: CKD, autoimmune dx, endocrinopathies, cancer, acute/chronic infection
- Cytokines change iron processing
- Hb <8 suggest additional cause
- Look for iron, B12, folate
- Should not be pancytopenic
4. TTP-HUS:
- fever, thrombocytopenia, hemolytic anemia, kidney injury, neuro sx
- w/u with smear, coags to r/o DIC
- tx with plasmapharesis to get off the anti-ADAMSTS13 antibodies
5. When someone walks in with AKI, consider the following first:
- Look at volume status => replenish volume
- Stop NSAIDs and other nephrotoxins
- Obstruction (older male, anticholinergics, urine problems) => bladder scan/straight cath => if the residual volume is high, get a renal u/s then relieve the obstruction
6. Prerenal (low FeNa)
- Dehydration, blood loss
- CHF/Cirrhosis
- NSAIDs
- Vascular - thrombi, severe b/l RAS
7. Intrarenal
- Glomerular: Nephritic syndrome (ie. red cell casts) , nephrotic
- Tubular: ATN from toxins (most common are contrast - muddy brown casts, and post-operative), prolonged hypotension
- Interstitial: 85% caused by meds: NSAIDs, antibiotics, diuretics (thiazides), anticonvulsants, PPIs, penicillins, cipro, 10% from infections (pyelo)
- Vascular
- TTP-HUS: vascular risk factors, DIC, TTP-HUS
8. Post-renal
- Prostate
- Stones
- Cancer obstructing all kidneys
- Neurogenic
- Once you relieve obstruction, there will be post-obstructive diuresis - keep up with IVF
9. Workup:
- Urine dipstick and microscopy
- Urine electrolytes
- Straight cath
10. FeNa/FeUrea
- FeUrea more sensitive and specific than FeNa in people on diuretics, perhaps in everyone
- FeNa <1%, FeUrea <35% suggestive of pre-renal cause; higher suggest non-pre-renal cause.
- Neuropsych signs (~33%, can occur w/ normal CBC): paresthesias, then ataxia with loss of vibration/position, then severe weakness, spasticity, clonus, paraplegia, incontinence, delirium/dementia.
- Homocysteine & MMA: they both need B12 to be converted to breakdown products, so they will increase in cases of B12 deficiency. Sensitivity of both tests are 85-95% sensitive. Homocysteine is less specific, can be elevated in vascular dx, some other processes.
- Anemia in ~75%, macrocytosis in ~80%. Normal CBC does NOT rule out B12 deficiency.
- B12 protien bound & released by acid digestion in stomach, binds IF in jejunum, absorbed in terminal ileum.
- Dietary deficiency rare bc 4 years of stores in liver.
- Old people who don't have stomach acid (atrophic gastritis, PPI, metformin) can have trouble absorbing B12.
- B12 level can be falsely low in folate deficiency, pregnancy, OCPs
- B12 deficiency: when to treat: when B12 is very low, when the B12 is borderline but either Homocysteine or MMA are low.
- Can treat with IM B12, or PO B12-- if you give huge doses, you can overcome even pernicious anemia.
2. Folate deficiency
- Drugs that interrupt the DHFR pathway: methotrexate, phenytoin, sulfasazlaine, alcohol
- People who need extra folate: chronic hemolytic anemia (like sickle cell), pregnancy, increased growth periods -- these people should always be taking folate
- Red cell folate reflects status over 3 months; sens/spec ~70%
3. Anemia of chronic disease
- Iron studies all slightly low, with high ferritin, low RPI
- Common causes: CKD, autoimmune dx, endocrinopathies, cancer, acute/chronic infection
- Cytokines change iron processing
- Hb <8 suggest additional cause
- Look for iron, B12, folate
- Should not be pancytopenic
4. TTP-HUS:
- fever, thrombocytopenia, hemolytic anemia, kidney injury, neuro sx
- w/u with smear, coags to r/o DIC
- tx with plasmapharesis to get off the anti-ADAMSTS13 antibodies
5. When someone walks in with AKI, consider the following first:
- Look at volume status => replenish volume
- Stop NSAIDs and other nephrotoxins
- Obstruction (older male, anticholinergics, urine problems) => bladder scan/straight cath => if the residual volume is high, get a renal u/s then relieve the obstruction
6. Prerenal (low FeNa)
- Dehydration, blood loss
- CHF/Cirrhosis
- NSAIDs
- Vascular - thrombi, severe b/l RAS
7. Intrarenal
- Glomerular: Nephritic syndrome (ie. red cell casts) , nephrotic
- Tubular: ATN from toxins (most common are contrast - muddy brown casts, and post-operative), prolonged hypotension
- Interstitial: 85% caused by meds: NSAIDs, antibiotics, diuretics (thiazides), anticonvulsants, PPIs, penicillins, cipro, 10% from infections (pyelo)
- Vascular
- TTP-HUS: vascular risk factors, DIC, TTP-HUS
8. Post-renal
- Prostate
- Stones
- Cancer obstructing all kidneys
- Neurogenic
- Once you relieve obstruction, there will be post-obstructive diuresis - keep up with IVF
9. Workup:
- Urine dipstick and microscopy
- Urine electrolytes
- Straight cath
10. FeNa/FeUrea
- FeUrea more sensitive and specific than FeNa in people on diuretics, perhaps in everyone
- FeNa <1%, FeUrea <35% suggestive of pre-renal cause; higher suggest non-pre-renal cause.
Tuesday, April 15, 2014
1. Pancytopenia:
- primary process: aplastic anemia,
- secondary process:
- any infiltrative process
- sarcoid, lupus
- B12 deficiency (17% of people)
- acute alcohol
- overwhelming sepsis
- aplastic anemia
- hypersplenism
2. Anemia + thrombocytopenia:
- microangiopathic (TTP-HUS, DIC, HELLP)
- autoimmune
- hypersplenism
- HIV
3. Anemia alone
- RPI to differentiate between underproduction and overconsumption.
4. Hemolysis:
- Check coombs to diagnose autoimmune, look for schistocytes on smear to determine microangiopathic hemolysis
- Think of others: hereditary (sickle cell, g6pd) and acquired (hypersplenism, toxin, infection like malaria)
5. MCV
- not specific: cannot be used to rule out etiology.
- if its slightly elevated, reticulocytes are big, so many hemolytic anemias will cause slightly increased MCV
6. Iron deficiency anemia
- Causes PICA
- Can give trial of iron and measure H&H at 4-6 weeks, or measure retics in 7-10 days
- Iron sulfate - can cause nausea/constipation: to avoid, titrate up to 325 TID, take with food, try other forms of iron which are easier to digest but have lower bioavail so it will take longer.
- Blood loss is #1 cause (menstrual, GI)
- Inadequate intake (less bioavail from veggies than from meat, so vegetarians/vegans)
- Increased demand (pregnancy, rapid growth, epo use)
- Malabsorption (celiac, crohns, post-gastrectomy)
- Ferritin is the best test in patients without inflammation (in al patients, low ferritin rules IN iron deficiency, LR+51 for ferritin <15, LR+25 for ferritin <32).
- TIBC next best test, TIBC < 5% LR +10 for iron deficiency
7. Who needs a workup for iron deficiency anemia?
- All dudes
- Women over 50
- People at increased risk of colon cancer
- With malabsorption: 12% of patients with celiac dx present with iron deficiency
8. GI bleed:
- Even low dose aspirin can cause peptic ulcer dx
- GI AVMs can be easily missed on colonoscopy
- SBFT is not sensitive at all for GI bleed
- Video capsule is test of choice for looking @ small bowel, unless someone has a history of stricture.
9. Macrocytic anemia:
- Megaloblastic: B12, folate
- Non megaloblastic: alcohol, hypothyroid, liver disease
10. Microcytic anemia:
- Iron deficiency, thalassemia, sideroblastic anemia (defect in heme synthesis leads to accumulation of iron in mitochondria around nucleus of developing RBC instead of being incorporated into heme)
- primary process: aplastic anemia,
- secondary process:
- any infiltrative process
- sarcoid, lupus
- B12 deficiency (17% of people)
- acute alcohol
- overwhelming sepsis
- aplastic anemia
- hypersplenism
2. Anemia + thrombocytopenia:
- microangiopathic (TTP-HUS, DIC, HELLP)
- autoimmune
- hypersplenism
- HIV
3. Anemia alone
- RPI to differentiate between underproduction and overconsumption.
4. Hemolysis:
- Check coombs to diagnose autoimmune, look for schistocytes on smear to determine microangiopathic hemolysis
- Think of others: hereditary (sickle cell, g6pd) and acquired (hypersplenism, toxin, infection like malaria)
5. MCV
- not specific: cannot be used to rule out etiology.
- if its slightly elevated, reticulocytes are big, so many hemolytic anemias will cause slightly increased MCV
6. Iron deficiency anemia
- Causes PICA
- Can give trial of iron and measure H&H at 4-6 weeks, or measure retics in 7-10 days
- Iron sulfate - can cause nausea/constipation: to avoid, titrate up to 325 TID, take with food, try other forms of iron which are easier to digest but have lower bioavail so it will take longer.
- Blood loss is #1 cause (menstrual, GI)
- Inadequate intake (less bioavail from veggies than from meat, so vegetarians/vegans)
- Increased demand (pregnancy, rapid growth, epo use)
- Malabsorption (celiac, crohns, post-gastrectomy)
- Ferritin is the best test in patients without inflammation (in al patients, low ferritin rules IN iron deficiency, LR+51 for ferritin <15, LR+25 for ferritin <32).
- TIBC next best test, TIBC < 5% LR +10 for iron deficiency
7. Who needs a workup for iron deficiency anemia?
- All dudes
- Women over 50
- People at increased risk of colon cancer
- With malabsorption: 12% of patients with celiac dx present with iron deficiency
8. GI bleed:
- Even low dose aspirin can cause peptic ulcer dx
- GI AVMs can be easily missed on colonoscopy
- SBFT is not sensitive at all for GI bleed
- Video capsule is test of choice for looking @ small bowel, unless someone has a history of stricture.
9. Macrocytic anemia:
- Megaloblastic: B12, folate
- Non megaloblastic: alcohol, hypothyroid, liver disease
10. Microcytic anemia:
- Iron deficiency, thalassemia, sideroblastic anemia (defect in heme synthesis leads to accumulation of iron in mitochondria around nucleus of developing RBC instead of being incorporated into heme)
Monday, April 14, 2014
1. Viral causes of polyarticular arthritis
- Rubella (can get with vaccine administration), rash
- Hep B
- HIV
- Parvo (kids don't get the arthritis, just fever and rash - lacy macular lesion ie nonspecific viral exanthem)
2. DDx Monoarticular arthritis
- Inflammatory: infectious, crystalline, trauma
- Infectious: septic joint (staph/GC), osteomyelitis, lyme
- Crystalline: gout, pseudogout/CPPT
- Non-inflammatory: osteoarthritis, trauma.
3. DDx Inflammatory polyarticular arthritis
- Rheum: Lupus, Sarcoidosis, Rheumatoid arthritis/JRA, Seronegative spondyloarthropathies (Reactive arthritis/Reiters, Psoriatic, IBD, Ankylosing spondylitis), most of the other autoimmune diseases (Mixed connective tissue disease, dermatomyositis, sjogrens)
- Infectious (bacterial): bacterial endocarditis, lyme disease.
- Infectious (viral): rubella, hep B, HIV, parvo (adults)
- Post-infectious: enteric, urogenital, rheumatic fever.
4. Common causes of joint pain (non-OA) at...
- Neck: cervical radiculopathy, cervical sprain
- Shoulder: rotator cuff injury, impingement
- Elbow: olecranon bursitis, lateral epicondylitis (tennis elbow); overuse injury from extensor tendons... the tendon distal to the insertion is hypovascular and more prone to microtears from overuse. Likely the extensor carpi radialis brevis is implicated, among others. Medial epicondylitis is the same, but at the medial (all of the major wrist/finger flexors and arm pronators attach at one tendon on the ulna); more rare than lateral epicondylitis.
- Hand: carpel tunnel
- Hip: trochanteric bursitis (lateral), meralgia paresthetica (thigh)
- Knee: patellar tendonitis (pain directly on patellar tendon, often inferior), patellofemoral pain syndrome (pain under patella from friction), meniscal/ligamentous injuries
- Foot: achilles' tendonitis, plantar fasciitis
5. Metatarsalgia vs metatarsal stress fx
- Line up their toe with their foot, push in, that really hurts if they have a stress fx
- Tell them to take a week off, come back, if it still hurts then you'll xray-- gives time for metatarsalgia to resolve, also by then you'll actually see the fracture on x-ray
6. Acute, fluctuating confusion- delirum
- (Acute, non-fluctuating confusion - "acute confusional state" - look for another CNS insult: stroke, toxin, infection, hypoglycemia)
- To diagnose delirium, use confusion assessment method: AIDA
- Acute onset, fluctuating course
- Inattention (can't focus, easily distractible)
- Disorganized thinking (illogical, incoherent, rambling, rambling)
- Altered level of consciousness (lethargy, stupor, hypervigilant/climbing walls)
7. Workup of delirium
- H&P
- Basic labs
- CXR
- UA
- EKG
- Review meds
8. When to get further testing for delirium:
- EEG- delirium will show you diffuse slowing c/w toxic encephalopathy every time so there is usually no point. Only get this in someone with a hx of seizures. Non convulsive seizures are rare, usually at least they have eye deviation or something.
- LP- get it if they have a fever, delirium, and no source
- CT- get it if you have reason to believe there may be a subdural. Don't get it to "rule out stroke" if you can get a decent neuro exam; stroke almost always has focal neurological findings.
- Neuro consult
9. Delirium is persistent-- it tends to go on for months, so if someone is ready for discharge and still delirious, keeping them more days will not help resolve the issue.
10. Preventing onset of delirium in hospitalized patients
- Let them sleep
- Reorientation (family members, make sure they have glasses/hearing aids/etc to prevent sensory deprivation)
- Early ambulation (i.e. get the nasal cannula, foley, IVs out)
- Keep them hydrated.
- Rubella (can get with vaccine administration), rash
- Hep B
- HIV
- Parvo (kids don't get the arthritis, just fever and rash - lacy macular lesion ie nonspecific viral exanthem)
2. DDx Monoarticular arthritis
- Inflammatory: infectious, crystalline, trauma
- Infectious: septic joint (staph/GC), osteomyelitis, lyme
- Crystalline: gout, pseudogout/CPPT
- Non-inflammatory: osteoarthritis, trauma.
3. DDx Inflammatory polyarticular arthritis
- Rheum: Lupus, Sarcoidosis, Rheumatoid arthritis/JRA, Seronegative spondyloarthropathies (Reactive arthritis/Reiters, Psoriatic, IBD, Ankylosing spondylitis), most of the other autoimmune diseases (Mixed connective tissue disease, dermatomyositis, sjogrens)
- Infectious (bacterial): bacterial endocarditis, lyme disease.
- Infectious (viral): rubella, hep B, HIV, parvo (adults)
- Post-infectious: enteric, urogenital, rheumatic fever.
4. Common causes of joint pain (non-OA) at...
- Neck: cervical radiculopathy, cervical sprain
- Shoulder: rotator cuff injury, impingement
- Elbow: olecranon bursitis, lateral epicondylitis (tennis elbow); overuse injury from extensor tendons... the tendon distal to the insertion is hypovascular and more prone to microtears from overuse. Likely the extensor carpi radialis brevis is implicated, among others. Medial epicondylitis is the same, but at the medial (all of the major wrist/finger flexors and arm pronators attach at one tendon on the ulna); more rare than lateral epicondylitis.
- Hip: trochanteric bursitis (lateral), meralgia paresthetica (thigh)
- Knee: patellar tendonitis (pain directly on patellar tendon, often inferior), patellofemoral pain syndrome (pain under patella from friction), meniscal/ligamentous injuries
- Foot: achilles' tendonitis, plantar fasciitis
5. Metatarsalgia vs metatarsal stress fx
- Line up their toe with their foot, push in, that really hurts if they have a stress fx
- Tell them to take a week off, come back, if it still hurts then you'll xray-- gives time for metatarsalgia to resolve, also by then you'll actually see the fracture on x-ray
6. Acute, fluctuating confusion- delirum
- (Acute, non-fluctuating confusion - "acute confusional state" - look for another CNS insult: stroke, toxin, infection, hypoglycemia)
- To diagnose delirium, use confusion assessment method: AIDA
- Acute onset, fluctuating course
- Inattention (can't focus, easily distractible)
- Disorganized thinking (illogical, incoherent, rambling, rambling)
- Altered level of consciousness (lethargy, stupor, hypervigilant/climbing walls)
7. Workup of delirium
- H&P
- Basic labs
- CXR
- UA
- EKG
- Review meds
8. When to get further testing for delirium:
- EEG- delirium will show you diffuse slowing c/w toxic encephalopathy every time so there is usually no point. Only get this in someone with a hx of seizures. Non convulsive seizures are rare, usually at least they have eye deviation or something.
- LP- get it if they have a fever, delirium, and no source
- CT- get it if you have reason to believe there may be a subdural. Don't get it to "rule out stroke" if you can get a decent neuro exam; stroke almost always has focal neurological findings.
- Neuro consult
9. Delirium is persistent-- it tends to go on for months, so if someone is ready for discharge and still delirious, keeping them more days will not help resolve the issue.
10. Preventing onset of delirium in hospitalized patients
- Let them sleep
- Reorientation (family members, make sure they have glasses/hearing aids/etc to prevent sensory deprivation)
- Early ambulation (i.e. get the nasal cannula, foley, IVs out)
- Keep them hydrated.
Nuclear imaging
Few absolute contraindications for nuclear imaging:
Few absolute contraindications for nuclear imaging:
-renal fxn irrelevant, allergic reactions don't happen, metal OK
-Pregnancy is a relative CI for all ionizing imaging modalities, absolute CI with I-131 as it crosses the placenta, irradiates fetal thyroid, causes cretinism
Nuclear medicine:
- Diagnostic (gamma rays) imaging - cardiac scan, bone scan, PET scan, (real GFR, RBC mass/volume, Schillings test), radioiodine, V/Q, HIDA, tagged RBC, tagged WBC, relative organ perfusion (how many counts are in R vs L kidney, etc), organ emptying-- GB/heart (EF)/stomach comparing counts within and outside.
- Minor procedures: lymphoscintillagraphy (inject breast, watch tracer drain with the lymphatics; drops in eyes to see whether tear ducts are patent
- Therapeutic: beta/alpha particles: medium dose I-131 (hyperthyroid), thyroid CA (high dose I-131), theraspheres (inject radioactive spheres into hepatic artery to get liver), radioactive seeds (bexxar, zevalin), painful bone mets (radium 223, strontium)
Bone scan:
- Advantages: can scan whole body, great for blastic lesions, better for following evolution of bone mets over time (i.e. s/p chemo) because CT scans see the scarring/sclerosis of bone, which will stay the same even after chemo, but bone scan will see the osteoblastic activity which reflects the true act
- Disadvantages: not specific (also lights up osteo, fractures, DJD), takes hours, not sensitive for lytic lesions (renal cell CA) because can only see blastic/remodeling activity, marrow processes (MM)
- Bone mets don't really go to bone-- they go to red marrow. When you're young, you have red marrow everywhere, but most of it is replaced by yellow marrow starting from the fingertips/toes out. Cancer goes to the red marrow first, then it goes to the adjacent bone-- once you have osteoblast activity, then and only then will the bone scan see it.
- Kids: neuroblastoma will metastasize to the ends of the bones.
Friday, April 11, 2014
1. Acute inflammatory monoarticular arthritis
- DDx: gout, pseudogout, septic joint, osteomyelitis, trauma (rarer: first episode of RA, reactive arthritis)
- Is an absolute indication for arthrocentesis, unless you're absolutely sure it's gout:
- Signs that point to gout:
>1 attack of acute arthritis (i.e. history of gout)
Maximal inflammation in <1 day ("thunderclap onset")
Monoarthritis
Joint erythema
1st MTP involvement ***
Unilateral MTP arthritis
Unilateral tarsal acute arthritis
Tophus
Asymmetric joint swelling
Hyperuricemia
Bone cysts without erosion on X-ray
Negative joint fluid culture
- 6 or more of the above criteria for diagnosing gout: Sens/Spec – 87%/96%, LR + 22, LR - 0.13
- 5 or more: Sens/Spec – 95%/89% LR + 8.6, LR - 0.005
2. Gout
-Acute: colchicine (dose to the major side effect, which is diarrhea), prednisone PO or joint injection, NSAIDs
-Chronic: allopurinol, febuxistat (if they can't tolerate allopurinol bc of renal insufficiency), probenicid (if they are underexcreters)
-Also affects kidney (urate nephropathy ie CKD without any cause other than gout)
3. CPPD/Pseudogout
- Clinically resembles OA, treat it as if it was OA
- Pseudo RA
- Affects the knee
- Xray: linear calcifications within joint space.
- Due to hypercalcemia (occult hyperparathyroidism is most common cause)
- Treat with colchicine, NSAIDs, treat hyperparathyroid if they have it
4. Septic joint
- Either GC or Staph
- GC: triad of septic joint, tenosynovitis (87%), fever (50%), skin lesion (90%), positive blood cx (43%), because its a higher grade bacteremia than staph.
- Tenosynovitis: back of hands, tendons all inflamed, can't bend hands.
- Staph: less risk of all of the above sx. usually in people with a reason to get staph in their blood (IV drug use, recent surgery, port/dialysis cath, etc)
- Hand and such you can just give IV abx
- Big joints (hip) need to be washed out either in the OR or at bedside.
5. Lyme disease
- Nymph form of ixodes tick is the one that carries lyme disease (Nymphs are much tinier than adult ticks)
- Single dose 100 mg doxy prevents lyme. However the % of lyme-carrying, nymph, ixodes/deer ticks are so rare that it'd be egregious overtreating to prophylax everyone.
- Acute lyme tx: 21 days of doxy.
- If you don't treat lyme, the next things that you get are heart (heart block), brain (headache, meningitis), then 1-6 months out then you get joint pain (knee most common)
- Anything after acute phase you need IV ceftriaxone
- Can also get jarisch-herxheimer reaction as well with initiation of treatment... so warn your patients they may feel a lot worse before they feel better.
- Endemic areas: coastal mideast, northwest wisconsin, some in california
- Lyme rash hurts
6. RA
- Metatarsals, wrists
- In a younger person, lupus can cause similar symptoms
- Workup: ESR/CRP, RF, anti-CCP (specific), x-ray (erosive joint), rheumatoid nodules (over bony joints like knuckles and olecranon, LR +22)
- Tx: acutely, steroids and NSAIDs, once you get a diagnosis then 20mg/week of methotrexate and as much steroids as you need to control symptoms. After you fail that, then biologics (like remicade). Recent NEJM study showed that people who failed mtx randomized to remicade vs plaquenil, that many people did well on plaquenil.
- 20 mg one time a week. Then you wean by 2.5 mg every 2 months or so. Most people need at least ~12.5 mg.
7. Psoriatic arthritis
- Psoriasis, nail findings, DIP involvement, "sausage digits" - where whole finger is inflamed. Because you get enthasopathy (inflammation of tendon insertions) as well as arthritis.
- Even if people say they don't have psoriasis, look closely (umbilicus, genitals, etc) for hidden psoriasis.
- Arthritis mutilans, telescoping digits -- destruction of joint with tendon still pulling down, so fingers shorten.
8. Seronegative (ie ANA neg, RF neg) spondyloarthropathies (can affect spine)
- Often cause asymmetric inflammation (one knee, one ankle), enthasopathy is common
- Chronic, polyarticular
- Psoriatic, Ankylosing spondylitis, reactive arthritis/reiter's, IBD
9. Lupus
- Hold on immune workup until you have 3+ clinical sx (i.e. malar/discoid rash, cardiac/pulmonary serositis, renal disease, arthritis) to avoid overdiagnosing and sending ANAs on everyone, b/c ANA is so nonspecific
10. Erythema nodosum
- Seronegative spondyloarthropathies (esp IBD), sarcoid
- Rheumatic fever (JONES criteria are major - migrating polyarthritis, peri/myo/endocarditis, subQ nodules, erythema nodosum, syndenham's chorea, minor criteria - fever, joint pain, PR prolongation, elevated ESR/CRP)
- DDx: gout, pseudogout, septic joint, osteomyelitis, trauma (rarer: first episode of RA, reactive arthritis)
- Is an absolute indication for arthrocentesis, unless you're absolutely sure it's gout:
- Signs that point to gout:
>1 attack of acute arthritis (i.e. history of gout)
Maximal inflammation in <1 day ("thunderclap onset")
Monoarthritis
Joint erythema
1st MTP involvement ***
Unilateral MTP arthritis
Unilateral tarsal acute arthritis
Tophus
Asymmetric joint swelling
Hyperuricemia
Bone cysts without erosion on X-ray
Negative joint fluid culture
- 6 or more of the above criteria for diagnosing gout: Sens/Spec – 87%/96%, LR + 22, LR - 0.13
- 5 or more: Sens/Spec – 95%/89% LR + 8.6, LR - 0.005
2. Gout
-Acute: colchicine (dose to the major side effect, which is diarrhea), prednisone PO or joint injection, NSAIDs
-Chronic: allopurinol, febuxistat (if they can't tolerate allopurinol bc of renal insufficiency), probenicid (if they are underexcreters)
-Also affects kidney (urate nephropathy ie CKD without any cause other than gout)
3. CPPD/Pseudogout
- Clinically resembles OA, treat it as if it was OA
- Pseudo RA
- Affects the knee
- Xray: linear calcifications within joint space.
- Due to hypercalcemia (occult hyperparathyroidism is most common cause)
- Treat with colchicine, NSAIDs, treat hyperparathyroid if they have it
4. Septic joint
- Either GC or Staph
- GC: triad of septic joint, tenosynovitis (87%), fever (50%), skin lesion (90%), positive blood cx (43%), because its a higher grade bacteremia than staph.
- Tenosynovitis: back of hands, tendons all inflamed, can't bend hands.
- Staph: less risk of all of the above sx. usually in people with a reason to get staph in their blood (IV drug use, recent surgery, port/dialysis cath, etc)
- Hand and such you can just give IV abx
- Big joints (hip) need to be washed out either in the OR or at bedside.
5. Lyme disease
- Nymph form of ixodes tick is the one that carries lyme disease (Nymphs are much tinier than adult ticks)
- Single dose 100 mg doxy prevents lyme. However the % of lyme-carrying, nymph, ixodes/deer ticks are so rare that it'd be egregious overtreating to prophylax everyone.
- Acute lyme tx: 21 days of doxy.
- If you don't treat lyme, the next things that you get are heart (heart block), brain (headache, meningitis), then 1-6 months out then you get joint pain (knee most common)
- Anything after acute phase you need IV ceftriaxone
- Can also get jarisch-herxheimer reaction as well with initiation of treatment... so warn your patients they may feel a lot worse before they feel better.
- Endemic areas: coastal mideast, northwest wisconsin, some in california
- Lyme rash hurts
6. RA
- Metatarsals, wrists
- In a younger person, lupus can cause similar symptoms
- Workup: ESR/CRP, RF, anti-CCP (specific), x-ray (erosive joint), rheumatoid nodules (over bony joints like knuckles and olecranon, LR +22)
- Tx: acutely, steroids and NSAIDs, once you get a diagnosis then 20mg/week of methotrexate and as much steroids as you need to control symptoms. After you fail that, then biologics (like remicade). Recent NEJM study showed that people who failed mtx randomized to remicade vs plaquenil, that many people did well on plaquenil.
- 20 mg one time a week. Then you wean by 2.5 mg every 2 months or so. Most people need at least ~12.5 mg.
7. Psoriatic arthritis
- Psoriasis, nail findings, DIP involvement, "sausage digits" - where whole finger is inflamed. Because you get enthasopathy (inflammation of tendon insertions) as well as arthritis.
- Even if people say they don't have psoriasis, look closely (umbilicus, genitals, etc) for hidden psoriasis.
- Arthritis mutilans, telescoping digits -- destruction of joint with tendon still pulling down, so fingers shorten.
8. Seronegative (ie ANA neg, RF neg) spondyloarthropathies (can affect spine)
- Often cause asymmetric inflammation (one knee, one ankle), enthasopathy is common
- Chronic, polyarticular
- Psoriatic, Ankylosing spondylitis, reactive arthritis/reiter's, IBD
9. Lupus
- Hold on immune workup until you have 3+ clinical sx (i.e. malar/discoid rash, cardiac/pulmonary serositis, renal disease, arthritis) to avoid overdiagnosing and sending ANAs on everyone, b/c ANA is so nonspecific
10. Erythema nodosum
- Seronegative spondyloarthropathies (esp IBD), sarcoid
- Rheumatic fever (JONES criteria are major - migrating polyarthritis, peri/myo/endocarditis, subQ nodules, erythema nodosum, syndenham's chorea, minor criteria - fever, joint pain, PR prolongation, elevated ESR/CRP)
Thursday, April 10, 2014
1. Cavernous sinus thrombosis
-frontal/sinus pain
-waxing and waning
2. Migraines
POUNDing:
- Pulsatile
- Onset/duration 4-72 hours without treatment
- Unilateral
- Nausea
- Disabling - can't work through it
- classically: car sickness as a child
- neurological symptoms are from cerebral cortex and brainstem.
3. Treatment for migraines
- Abortive: NSAIDs (+/- antiemetics), Triptans (selctive sertotonin agonists)
- Corticosteroids are helpful to break a cluster of migraines (i.e. normally they come infrequently but they are getting them every day for a while and using abortive agents every day)
- Prophylactic: B-blockers, CCB, Topamax/neurontin/ARBs
4. GCA or temporal arteritis
- older white female
- 15% of those with PMR have GCA
- 60% of those with GCA have PMR
- Jaw claudication - sens 34%, spec 92%
- Diplopia - sens 9%, spec 97% (unknown why this happens-- direct inflammation of CN III/IV/VI, vs ischemia to nerve or muscles)
- Headache & jaw claudication LR +8
- Scalp tenderness & jaw claudication LR +17
- Beading, enlargemnt, prominence of TA LR >4
- Temporal aretery tenderness, loss of pulse LR >2
- Abnormal ESR has sensitivity of 96%
- NSAIDs will alleviate sx, but will not treat underlying dx so don't send someone home on NSAIDs if your suspicion is high.
- Treatment is high-dose steroids
5. SDH
- Classic: AMS, somnolence, not commonly associated with headache
- Associated symptoms (% frequency)
- Falls 74%
- Progressive neuro deficit 70%
- Head trauma 37%
- Transient neuro deficit 21% (hence scan someone you think has a TIA before anticoagulation to r/o SDH)
- Seizure
6. Pseudotumor: headache in young women with visual changes.
7. Upper extremity injury:
- 95% shoulder dislocations are anterior, 5% posterior, usually seizure or electrical shock
- Radial head fracture most common elbow fracture in adults
- FOOSH fractures:
4-10 y/o torus fracture (buckle fracture in radius)
11-16 : saltar harris II - through growth plate and metaphysis
17-40 scaphoid (risk for avascular necrosis in proximal pole
>40: colles (esp women distal radius fracture
8. IR procedures:
- procedures with low risk of bleed, and if it bleeds, it is easily detected and controllable
dialysis access, ivc filter, centreal line removal, drainage catheter
- procedures with significant risk of bleed; bleeds are difficult to detect and to control (i.e. need way stricter coagulation parameters)
TIPS, renal bx, nephrostomy tube placement, RFA
9. General guidelines for coagulation parameters before starting IR:
- Platelets > 50 PTT, INR <1.5
- heparin held for 3 hours
- aspirin held 5 days
- try to hold plavix
10. Contrast nephropathy
>25% increase in Cr or abs cr increase of 0.5 mg/dL
Risk fx: pre-existing renal insufficiency (cr <60)
Diabetes
Hypovolemia
Typical CT 60-120 cc contrast
intensive procedures w lots of angios/cath can be as high as 200-300 cc contrast
-frontal/sinus pain
-waxing and waning
2. Migraines
POUNDing:
- Pulsatile
- Onset/duration 4-72 hours without treatment
- Unilateral
- Nausea
- Disabling - can't work through it
- classically: car sickness as a child
- neurological symptoms are from cerebral cortex and brainstem.
3. Treatment for migraines
- Abortive: NSAIDs (+/- antiemetics), Triptans (selctive sertotonin agonists)
- Corticosteroids are helpful to break a cluster of migraines (i.e. normally they come infrequently but they are getting them every day for a while and using abortive agents every day)
- Prophylactic: B-blockers, CCB, Topamax/neurontin/ARBs
4. GCA or temporal arteritis
- older white female
- 15% of those with PMR have GCA
- 60% of those with GCA have PMR
- Jaw claudication - sens 34%, spec 92%
- Diplopia - sens 9%, spec 97% (unknown why this happens-- direct inflammation of CN III/IV/VI, vs ischemia to nerve or muscles)
- Headache & jaw claudication LR +8
- Scalp tenderness & jaw claudication LR +17
- Beading, enlargemnt, prominence of TA LR >4
- Temporal aretery tenderness, loss of pulse LR >2
- Abnormal ESR has sensitivity of 96%
- NSAIDs will alleviate sx, but will not treat underlying dx so don't send someone home on NSAIDs if your suspicion is high.
- Treatment is high-dose steroids
5. SDH
- Classic: AMS, somnolence, not commonly associated with headache
- Associated symptoms (% frequency)
- Falls 74%
- Progressive neuro deficit 70%
- Head trauma 37%
- Transient neuro deficit 21% (hence scan someone you think has a TIA before anticoagulation to r/o SDH)
- Seizure
6. Pseudotumor: headache in young women with visual changes.
7. Upper extremity injury:
- 95% shoulder dislocations are anterior, 5% posterior, usually seizure or electrical shock
- Radial head fracture most common elbow fracture in adults
- FOOSH fractures:
4-10 y/o torus fracture (buckle fracture in radius)
11-16 : saltar harris II - through growth plate and metaphysis
17-40 scaphoid (risk for avascular necrosis in proximal pole
>40: colles (esp women distal radius fracture
8. IR procedures:
- procedures with low risk of bleed, and if it bleeds, it is easily detected and controllable
dialysis access, ivc filter, centreal line removal, drainage catheter
- procedures with significant risk of bleed; bleeds are difficult to detect and to control (i.e. need way stricter coagulation parameters)
TIPS, renal bx, nephrostomy tube placement, RFA
9. General guidelines for coagulation parameters before starting IR:
- Platelets > 50 PTT, INR <1.5
- heparin held for 3 hours
- aspirin held 5 days
- try to hold plavix
10. Contrast nephropathy
>25% increase in Cr or abs cr increase of 0.5 mg/dL
Risk fx: pre-existing renal insufficiency (cr <60)
Diabetes
Hypovolemia
Typical CT 60-120 cc contrast
intensive procedures w lots of angios/cath can be as high as 200-300 cc contrast
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