Acute coronary syndrome

Systemic Causes:

• Dec. O2 delivery (2)
• Increased O2 consumption (2)

• • Severe anemia
  • Hypotension
• • Sepsis
  • Thyrotoxicosis

1. ACS
2. Stable Angina
3. Panic disorder (30%, often coexisting with others)
4. GERD (also PUD, biliary, pancreatic)
5. Musculoskeletal (36% in outpatient setting)
6. Pleural (PE, infection, neoplasm, spontaneous pneumothorax)

Rapid evaluation for potential ACS:

• Hx (2)
• EKG findings by decreasing + LR (5)

1. Onset and character of pain
2. Prior Hx of CAD

1. ST elevation (>0.5 mm) in 2+ consecutive leads [6-54]
   
2. New LBBB [6.3]
   
3. New Q waves, in 2+ leads (not aVR) may not be until 24+ hrs later [3.9]
   
4. T wave hyperacuity or inversion in 2+ leads (not aVR) [3.1]
   

1. depression (>1mm) in 2+ consecutive leads [more ischemia than infarction] [2.1-39]
   

Cardiac Injury Markers

Onset, Peak, Duration, and Use

CK (total and MB)

Troponin

LDH

Aspirin for ACS

1. Indication

2. Contraindications

3. NNT to prevent death or MI

4. Alternative Tx

1. 325 mg ASA for all suspected ACS, continued daily indefinitely
2. Anaphylaxis, current active GI bleeding
3. prevents 3-10 per 100 treated ACS patients
4. Clopidogrel 300 mg load; 75 mg qd thereafter

Thrombolysis for ACS

1. Indications
2. Contraindications (7)
3. Timing

1. Onset of pain w/i 6 hours of presentation, PLUS
   1. ST elevation >2 contiguous leads
   2. New LBBB
2. Contraindications
   1. Active GI or non menses GU bleeding
   2. Abdominal or thoracic surgery in past 1 month
   3. Head trauma
   4. Recent stroke
   5. HTN crisis
   6. Aortic dissection
   7. Pancreatitis
3. Within 30 minutes of presentation

Acute Therapy for ACS

-For ACS in general (5)

-Additionally For UA/NSTEMI (1)

-Additionally For STEMI (2)

1.  
   1. Aspirin or clopidogrel for antiplatelet action
   2. Oral beta blockers (metoprolol) w/i 24 hours of diagnosis in patients without CHF or low cardiac output
   3. Nitroglycerin for pain relief as long as not hypotensive or bradycardic
   4. Morphine for pain control
   5. O2 for physiologic rationale
2. For UA/NSTEMI
   1. Heparin for unstable Angina or NSTEMI to decrease infarction and need for PTCA
3. For STEMI
   1. Reperfusion therapy
   2. ACEi for patients with large anterior infarcts, LV dysfunction, or EF<40%

Therapy for CAD

1. Single most important intervention?
2. Tx For symptoms
3. Tx For MI/death prevention
4. Criteria for revascularization

1. Smoking cessation!
2. Nitroglycerin for pain
3. Aspirin, beta blockers, and statins 
4. One of the following
   • >50% left main stenosis
   • 3 vessel disease plus dec. LV function
   • 2 vessel disease involving LAD artery
   • Failure of medical therapy

*note: for diabetics, CABG > angioplasty

Therapy for Panic disorder

1. Psychotherapy
2. Medications

1. CBT proven to work, relaxation therapy hasn't
2. Medical therapy for 6+ months
   1. SSRI's first line
   2. Daily benzos (alprazolam and lorazepam)
   3. Trycyclics (Nortryptiline)
   4. Possibly buspirone

NYHA and Specific Activity Scale

1. Class I
2. Class II
3. Class III
4. Class IV

1. Indications for Coronary Angiography (5)

1. High pretest probability of left main or 3 vessel CAD
2. Patient unable to undergo noninvasive testing (stress test)
3. Inconclusive results from noninvase testing
4. Occupation requires definitive testing
5. To Dx suspected vasospam via provocation

1. Antiplately (ASA or cloprigodel)
2. Beta blockers
3. Lipid lowering agents
4. ACE inhibitors

1. Fatigue
2. Lower extremity edema
3. DOE --> Paroxysmal nocturnal dyspnea --> orthopnea --> dyspnea at rest

1. Diastolic heart failure (2)

DDx of ACUTE leg pain and swelling

How common?

• Vascular (2
• Dermatologic (2)
• Traumatic (1)

DDx of CHRONIC leg pain and swelling

How common?

• Vascular (4)
• Endocrine/Metabolic (2)

• DVT:
• Tests (2) with good PPV in patients with high pretest probability (high risk)
• Test high good NPV in patients with low pretest probability (low risk)

• Impedance plethysmography and duplex venous ultrasound have excellent PPV to rule IN a DVT in the high-risk patient, 
• D-dimer testing has an excellent NPV to rule OUT the diagnosis in the low-risk patient.
  • Note: D-dimer has poor PPV

Evaluating a potential DVT

1. Low Risk Patient?
2. Moderate/high Risk?

• Low Risk--> D-dimer
  • Negative--> no DVT
  • Postive --> Ultrasound
    • Negative--> no DVT
    • Positive --> Treat

• Mod/High Risk --> Ultrasound
  • Positive --> treat
  • Negative --> D-dimer
    • Negative --> no DVT
    • Positive --> contrast venography or repeat US in 1 week

Pulmonary Embolism:

Good PPV test in high risk patient?

Good NPV test in low risk patient?

• Helical computed tomography has an excellent positive predictive value to rule in PE in the high-risk patient,
• D-dimer testing has an excellent negative predictive value to rule out the diagnosis in the low-risk patient.

How to make the diagnosis of:

• Diabetes (3)
• Impaired Fasting Glucose (1)
• Impaired Glucose Tolerance (1)

1. Diabetes
   1. Symptomatic + random glucose >200 OR
   2. Two separate fasting glucose >125 OR
   3. Two hour 75g GTT >200 (rare to do this)

1. IFG: Fasting glucose 100-125 mg/dl

1. IGT: Two hour 75g GTT 140-199 mg/dl

Diabetes Treatment

                           *Goal         *NNT (10 yr)           *Benefits

• HTN
• Tobacco use
• Endothelial dysfxn
• Hypercholesterolemia
• Hyperglycemia

After a diagnosis of diabetes is made, what should be ordered? (7)

1. Hb A1c
   
2. fasting lipid profile for cardiac risk stratification.
3. ECG to look for LVH
   
4. Urinalysis to test for ketones and protein
   
5. Microalbumin/creatinine test for risk of renal disease.
   
6. Serum creatinine for those with proteinuria
7. Opthomalogy referral (and maybe podiatry)

• Also TSH in Type 1's
  

Metformin

• Mechanism?
• Expected decrease in HbA1c
• Benefits (2)
• Side effects
• Contraindications (5)

• reducing hepatic glucose production and increasing peripheral glucose utilization
• 1.5–2.0%
• Lowest rate of hypoglycemia. Weight neutral/decrease
• Dose increase related GI upset most common
• Renal disease (renal excretion), pregnancy/lactation, active liver disease, alcoholism, and COPD

Sulfonylureas (Glypizide, glyburide, glimepride)

• Mechanism?
• Expected decrease in HbA1c
• Benefits
• Side effects
• Contraindications

• stimulating insulin secretion and increasing tissue sensitivity
• 1.5 - 2.0%
• Less renal excretion (50-80%); can be renal dosed
• Hypoglycemia is main risk; thus stick to shorter half lives (glipizide) and withhold if unable to eat
• ?

• decreasing peripheral insulin resistance in skeletal muscle and adipose tissue.
• 1.0 to 1.5%.
• Lower triglycerides slightly and increase HDL
• Increase LDL, fluid retention, monitor LFT's during first year
• Active liver disease, Class III/IV CHF

Hypothyroidism

• Diagnosistic steps?
• Treatment?
• Monitoring Treatment?
• Complications?

• High TSH --> Low T4--> anti-thyroperoxidase antibodies
• Levothyroxine (T4)
• T4 half life is ~ week so takes 3-6 weeks to reach new steady state after dosage adjustment.  Thus measure TSH 6 weeks after any dosage changes.
• Untreated: cardiac dysfunction, depression, elevated cholesterol levels, and persistent symptoms.

Hyperthyroidism

1. Top 4 causes by prevalence
2. Diagnostic steps?

1. Graves (60-80%), Toxic nodular goiter (5%), Solitary nodule/adenoma, Transient Thyroiditises (viral, lymphocytic, and postpartum)
2. Low TSH -->Free T4
   1. Normal--> T3 to distinguish T3 toxicosis from others
   2. High-->Thyroid Uptake
      1. High: Diffuse=Graves, hot spot is TNG or adenoma
      2. Low-->Thyroglobulin
         1. Low--> exogenous hormone
         2. High --> thyroiditis, iodide exposure, ectopic production.

Hyperthyroidism Management

1. Short term symptoms?
2. Who gets radioiodine?
   1. Cure rates
   2. side effects
3. Who gets PTU/methimazole?
   1. Cure rates
   2. side effects
4. Who gets surgery?
   1. Cure rates
   2. Risks
      

1. Symptoms managed with beta blockers (CCB's 2nd line)
2. Radioiodine for Graves and patients over 40 with TNG or MNG. Must avoid pregnancy for 6-12 months and pregnant woman/children for 2-3 days.
   
   1. 80% cure at 2-6 months.  85% hypothyroid in 25 years
3.  Pregnant patients (PTU preferred), children, or in cardiac/elderly patients to normalize thyroid before surgery
   1. 40-50% cure at 18 months. High antithyrotropin Ab's and smoking have higher relapse rate, ~3-6 months.
   2. Polarythritis (1-2%), Agranulocytosis (0.5%, mostly PTU and during first 3 months)  Elevated LFT's (30% on PTU)
4. Subtotal thyroidectomy 
   
   1. for pregnant women or children who cannot tolerate ATDs, patients with compressive symptoms TNG in healthy patients younger than 40,  noncompliant patients, failed ATDs but does not want RAI,
      
   2. 92% curative. 25% risk of hypothyroidism
5. Total thyroidectomy
   
   1. curative and is indicated for patients with severe disease or large goiters.
6. Both surgeries 1-2% risk of hypoparathyroidism and/or recurrent laryngeal nerve damage

Manning Criteria for Irritable Bowel Syndrome (IBS)

Name the 5:

1. Pain relief with bowel action
2. More frequent stools with the onset of pain
3. Looser stools with the onset of pain
4. Passage of mucus
5. Sensation of incomplete evacuation
6. Abdominal distention as evidenced by tight clothing or visible appearance

Irritable Bowel syndrome:

• Tx for diarrhea predominant (2)
• Tx for pain predominant (2)
• Tx for constipation predominat (1)

• Diarrhea:
  
  • loperamide (peripheral mu-opiod antagonist)
  • Alosetron (5-HT3 antagonist)
• Pain:
  
  • dicylcomine (antimuscarinic and antispasmodic) amityripline (tricylclic)
• Constipation:
  • Tegaserod (5-HT4 agonist) *pulled from market*

Dyspepsia

Top 4 diagnoses and their frequency

1. 60% Functional dyspepsia
2. 20% Peptic ulcer disease
3. 10% GERD
4. <2% Gastric or esophageal cancer

Functional dyspepsia

List 3 major potential pathophysiologic mechanisms:

1. 30% Delayed gastric emptying--> pp fullness, n/v
2. 40% Impaired gastric accomodation --> early satiety
3. 37% Hypersensitivit to distention --> pp pain, belching, wt loss

Red flags for further work up of dyspepsia

(hints)

1. regarding food (2)
2. swallowing (2)
3. puking (2)
4. longstanding... (1)
5. stool (2)
6. history item (1)
7. age (1)
8. PE finding (2)
9. lab finding (1)

1. anorexia, unexplained recent weight loss,
2. dysphagia, odynophagia,
3. persistent vomiting, hematemesis,
4. longstanding GERD,
5. melena, blood in the stool,
6. previous gastric surgery,
7. new onset over age 55
8. a palpable abdominal mass, jaundice
9. anemia, 

Dyspepsia and suspected GERD:

Workup and management in patient without any red flags

• Empiric PPI treatment to see if symptoms improve
  
  • Yes--> continue PPI, consider eventual step down
  • No--> Endoscopy
    • Positive --> higher dose PPI; +/- biopsy
    • Negative --> esophageal pH study

Dyspepsia and supsected Peptic Ulcer Disease

Workup and management in patient w/o red flags

"Test and Treat"

• Urea breath test or stool antigen for H. Pylori ( if unavailable or recent PPI use --> serum ELISA)
  • Positive --> eradicate: PPI+clarithromycin+amoxicillin for 7-14 days
    
    • No symptoms? Yay
    • Symptoms? Retest
      • Positive --> quadruple therapy
      • Negative --> unlikely PUD, more likely GERD or functional dyspepsia
  • Negative --> try PPI 4-8 weeks 
    • No good? --> possibly endoscopy or consider alternate diagnosis.

Contraceptive mechanisms of

• Progestins (4)
• Estrogens (2)

• progestins 
  
  •  thickened cervical mucus that blocks sperm from the uterus,
    
  • inhibition of capacitation (ability of sperm to fertilize an egg),
    
  • interference with transport of the egg and sperm
    
  • endometrial changes that interfere with implantation.

• Estrogen: block ovulation via
  
  • decreases the follicle stimulating hormone (FSH) levels
    
  • decreasing the Luteinizing hormone surge

Pros and Cons of

1. Combined OCP's
2. Progestin only OCP
3. Patch
4. Ring
5. Depo injection
6. IUD
7. Diaphragm with spermicide
8. Sponge
9. Sterilization

Starting OCP's

Describe the 3 methods and when backup protection is needed:

• First-day start—the OC can be started on the first day of menses. When the OC is begun within the first 5 days after a period begins, contraceptive protection begins immediately and use of a back-up method is not necessary.

• Sunday start— the first OC tablet is taken on the first Sunday following the beginning of menses. A back-up method of contraception should be used for the first 7 days the OC is taken when beginning the OC with a Sunday start.

• Immediate Use—the OC can be started at any time after a negative pregnancy test. If the OC is started mid-cycle vs. during days 1–7 (the first week) of the cycle then a back-up method of contraception should be used for 7 days.

Emergency contraception

1. mechanism
2. Two regimens
3. Side effects
4. Patient education points

1. prevention/delay of ovulation/fertilization. Tiny hypothetical chance of inhibition of implanation.
2. Plan B (2 x 0.75 mg levonorgestrel) and Yuzpe regimen (2x 0.2 mg EE and 0.5 mg levonorgestrel)
3. Yuzpe: 50% nausea, 25% vomiting
   Plan B: 25% nausea, 12% vomiting
   *advise dimenhydrinate or meclizine 1 hour before
4. May delay ovulation, increasing risk of pregnancy immediately after use.  May delay menses up to 1 week.  If longer, get pregnancy test.

Risk factors for osteoporosis

• Nutrition related (3)
• Genetic (1)
• Lifestyle (2)
• Hormonal related (3)

Screening for osteoporosis

• When?
• At what intervals?
• How do you diagnose it?

• routinely at age 65 and at 60–64 years with risk factors.
• Must be >/ 2 years between tests to see change
• T score (compared to young women)
  • -1 to -2.5 SD = osteopenia
  • Less than -2.5 SD = osteoporosis

1. Smoking cessation
2. Weight bearing exercise
3. +1000 mg Calcium
4. 400-800 IU Vitamin D
5. Bisphosphonates for high risk women

1.  change in size and force of urinary stream,
2. sensation of incomplete emptying
3.  enlarged prostate on digital rectal examination

BPH Initial evaluation

• DRE
  • feel of prostatitis?
  • of BPH?
  • of malignancy?
• Definite tests to order?
• Optional tests to order? (3)

• DRE
  • tender, boggy
  • enlarged and rubbery.
  • Any area of firm induration, nodularity, or asymmetry
• Urinalysis for
  • hematuria--> go to cystoscopy
  • leukocytes--> prostatitis or cystitis
• PSA--> elevated in 25% of BPH. have a discussion
• Urine cytology --> if smoker/bladder cancer concern
• PVR/urodynamics

BPH Medical Treatment

• 1st line treatment?
• Side effects?
• Second line?
• Side effects?

• alpha1 blockers (the -z/sosins):
  
  • relieve dynamic compnent of BOO
  • titrate gradually to avoid orthostasis, dizziness
• 5-alpha reductase inhibitors (finasteride, dutasteride):
  
  • add in combination to block testosterone to DHT conversion.  relieve fixed component of BOO.  Take 3-6 months before benefit
  • erectile dysfunction, decreased libido, gynecomastia

Risk factors for prostate cancer:

• Age
• Ethnicity
• Genetics
• Diet

• Increases with age. rare before 45
• African american more than caucasian or hispanic
• 1st degree relative 2X risk.  BRCA increases risk too
• High in animal fat/low in veggies

Chlamydia as STI

• Manifestations
• Diagnosis
• Treatment (3)
• Follow up (3)

• Cervicitis, urethritis, and occasionally epidydymitis
• Nucleic acid amplification (85% sen, 99% spec)
• Tx: All plus ceftriaxone for GC
  • Azithromycin 1g once
  • or Doxycyline 100 mg bid x 7 days
  • Pregnant:
    
    • Amoxicillin 500 mg tid x 7
    • or Erythromycin 500 mg qid x 7
• Follow up
  
  • No sexual contact for seven days
  • Women, rescreen in 3-4 months for reinfection
  • Pregnant, test for cure in 3 weeks by culture

Gonorrhea as STI

• Manifestations (5)
• Diagnosis
• Treatment
• Follow Up

• Cervicitis, urethritis, proctitis, epidimytis, pharyngitis
• Nucleic acid amplification 95% sens, 97% spec (in children must use culture)
• Ceftriaxone 125 mg IM x1 or Cefexime 400 mg po x1

Bacterial vaginosis

• symptoms
• Diagnostic criteria (4)
• Treatment (2)

• Fishy odor worse after sex.  Often asymptomatic. Rarely itchy.  Creamy discharge
• Amsel's criteria (3 of 4 is 70% sens 94% spec)
  
  • homogenous discharge
  • pH > 4.5
  • Positive whiff test
  • Clue Cells
• Oral or vaginal
  • metronidazole x 5-7 d
  • clindamycin x 7 d

Candida vulvovaginitis

• symptoms
• Diagnostic criteria
• Treatment

• white curd like discharge.  Erythema of vagina/vulva.  +itchy
•  KOH prep microscopy
• -azole antifungal; per vagina x 3d or PO

Ottowa Rules for Ankle X-Rays

Acute ankle injury and has "____" and one of the following 4 findings

Pain in the Malleolar or Midfoot zones and:

1. Bone tenderness at poster edge of lateral or medial malleolus
2. Bony tenderness over navicular (1st medial midfoot bone)
3. Bony tenderness at base of 5th (lateral) metatarsal
4. Inability to bear weight (4 steps) immediately and in ED

1. Age 55 years or older
2. Tenderness at the head of the fibula
3. Isolated patella tenderness
4. Inability to flex to 90 degrees
5. Inability to bear weight both immediately and in the emergency department (four weight transfers onto each leg, regardless of limping)

Herniation of L3-L4 disc

1. Nerve root affected
2. Sensory loss
3. Motor Weakness
4. Screening exam
5. Reflex

1. L4 nerve root
2. Medial foot sensory loss
3. Knee extension weakness
4. Squat and rise test
5. Diminished Patellar reflex

Herniation of L4-L5 disc

1. Nerve root affected
2. Sensory loss
3. Motor Weakness
4. Screening exam
5. Reflex

1.  
   1. L5
   2. Dorsal foot
   3. Dorsiflexion ankle/great toe
   4. Heel walking
   5. None

Herniation of L5-S1 disc

1. Nerve root affected
2. Sensory loss
3. Motor Weakness
4. Screening exam
5. Reflex

1. S1
2. Lateral foot
3. Plantarflexion ankle/toes
4. Walking on toes
5. Achilles reflex

Low back pain Red Flags

1. General 3
2. Cancer 3
3. Infection 4
4. Fracture 5

• General
  • failure to improve after 4-6 wks conservative therapy
  • unrelenting night pain or pain at rest
  • progressive motor or sensory deficit
• Cancer
  • Age > 50
  • Hx of cancer
  • Unexplained weight loss
• Infection
  • IVDU
  • Recent UTI or skin infection
  • Immunosuppression
  • Fever or chills
• Fracture
  • Age > 50
  • Hx of osteoporosis
  • Chronic oral steroids
  • Substance abuse
  • Trauma

Cervical Radiculopathy at Level C4/5

1. Root affected
2. Motor weakness
3. Sensory loss
4. Parasthesia
5. Referred Pain
6. Reflex Loss
7. Subjective pain

1. C5
2. Deltoid,  biceps
3. Lateral upper arm
4. None in digits
5. Shoulder and upper lateral arm referred pain
6. Biceps reflex
7. Shoulder (but relatively pain free)
8. [image]

Cervical Radiculopathy at Level C5/6

1. Root affected
2. Motor weakness
3. Sensory loss
4. Parasthesia
5. Referred Pain
6. Reflex Loss
7. Subjective pain

1. C6 root
2. Brachioradialis (wrist extension), biceps (minor) weakness
3. Thumb and forearm proximal to thumb sensory loss
4. Thumb and index finger parasthesia (Okay sign)
5. Radial aspect of forearm referred pain
6. Brachioradialis and biceps (minor) reflex loss
7. Deltoid, rhomboid muscle areas

Cervical Radiculopathy at Level C6/7

1. Root affected
2. Motor weakness
3. Sensory loss
4. Parasthesia
5. Referred Pain
6. Reflex Loss
7. Subjective pain

1. C7 
2. Wrist flexor, digit extensors, Triceps weakness
3. Middle ring finger sensory loss
4. Middle finger parasthesia
5. Dorsal aspect of forearm referred pain
6. Triceps reflex loss
7. Dorsolateral upper arm, superomedial angle of scapula

[image]

Cervical Radiculopathy at Level C7/T1

1. Root affected
2. Motor weakness
3. Sensory loss
4. Parasthesia
5. Referred Pain
6. Reflex Loss
7. Subjective pain

Treatment of

• Tinea capitis
• Tinea corporis
• Tinea cruris
• Tinea pedis
• Tinea Versicolor
• Onychomycosis

• Capitis: griseofulvin, itraconazole, or terbinafine PO 2-8 weeks
• Corporis: topical miconazole, clotrimazole.  If big, tx like capitis.
• Cruris: Tx like corporis. may need to cover candida
• Pedis: treat like corporis. terbinafine best PO option
• Versicolor:
  
  • caused by yeast-like Pityrosporum spp.
  • topical ketoconazole, selenium/zinc shampoos
• Onchomycosis: terbinafine PO x 4 months

Red flags in Dizziness

5 red flags and suggested Dx

1. Cardiovascular sx's --> any acute cause of HF
2. CNS sx's --> stroke/tia/tumor/etc.
3. Gradual hearing loss/tinnitus --> acoustic neuroma
4. Fall/severe lightheaded on standing --> orthostasis, hypotension etc.
5. Presyncope, weakness, SOB, and bleeding risk factors --> UGI or lower GI bleed