High Yield 

Diabetes (Type 2)

Hypertension

• BP > 180 systolic or > 120 diastolic is hypertensive crisis

• Elevated BP & stage 1 HTN with a 10-year risk < 10% or without ASCVD 

  • Lifestyle modification first, reassess 3-6 mo

• Stage 1 HTN with ASCVD or 10-year risk > 10% 

  • Gets medication & lifestyle modification, reassess in 1 mo

• TX

  • < 50yo monotherapy: ACEi/ARB

  • Black pts:

    • Monotx: Amlodipine (dihydropyridine CCB) or chlorthalidone (thiazide-like)

    • Dualtx: ACEi/ARB and CCB or (ACEi/ARB and thiazide if ssx of hypervolemia)

  • HF, MI, DM, CKD: ACEi first line

  • A-fib, post-MI, angina: β-blockers added to ACEi in 

  • Osteoporosis: thiazides (↑ Ca reabsorption) 

  • Preg: Labetalol, methyldopa, nifedipine  

  • Avoid: Thiazides in gout, β-blockers in COPD/bronchospasm and DM, CCB in HF

VTE

Hyperlipidemia

• Patho

  • Studies show high blood cholesterol is a major risk factor for atherosclerosis cardiovascular disease (ASCVD) 

  • ASCVD is MCC of death among chronic dz

  • RCTs show lowering cholesterol levels ➔ ↓ risk of ASCVD ➔ ↓ risk of death  

• DX/screening/starting stain

  • Get lipid panel if > 20yo and new pt or hx family hx of ASCVD/genetic hyperlipidemia 

  • Start statin if any manifestation of ASCVD (after a stroke, MI)

  • Start statin if 40 - 75yo and diabetic (regardless of ASCVD risk) and aim for LDL of 70

  • Start statin and aggressive lifestyle modification immediately if LDL ≥190

  • If LDL < 190:

    • 20 - 39yo without ASCVD

      • Emphasize lifestyle's role in development of ASCVD 

      • Informal CVD risk estimate (HTN, ↑ BMI, family hx of CHD, smoking) to determine statin initiation 

    • 40 - 75yo - Formal ASCVD risk assessment 10 year risk > 7.5% ➔ start statin 

    • Who wouldn't get a statin?

      • 40-75yo with LDL < 70 and ASCVD risk < 7.5%, pregnant or breastfeeding, liver disease, on amiodarone or protease inhibitors (HIV)

• Addicted to grapefruit juice (like more than a cup a day) or crossfit

• TX

  • Lifestyle modifications

  • Want Low LDL (< 100) - Use Statin (CI in pregnancy, BOLO for myositis)

  • Get baseline CK (but myositis may not ➔ ↑ CK), recheck LDL in 6-12 wks, can add ezetimibe if needed 

  • Want High HDL (> 40) - Use niacin (CI PUD/GI bleeding, avoid in DM/gout, BOLO hyperglycemia/uremia)

  • Want Triglycerides (< 150) - Use fibrates (CI in hx of biliary obstruction, renal dz, BOLO myositis esp. with statins)

  • Total (< 200)

  • LDL/HDL ratio♂< 3.5 ♀ < 3.0 

Thyroiditis 

Subacute (granulomatous thyroiditis/de Quervain's thyroiditis)

• • • Breakdown of follicular thyroid cells ➔ release of T3/T4

      • Hyperthyroidism ➔ hypothyroidism ➔ euthyroid

      • Neck pain/tender goiter

    • DX

      •  ↑ T4/T3 ➔ ↓TSH ➔ RAI UPTAKE STUDY

        • LOW UPTAKE (unlike Grave's which has high uptake with low TSH)

    • TX

      • NSAIDs or prednisone for pain

      • Propanalol for hyperthyroid sx 

        • Thionamides ↓ T3/4 synthesis and are not needed (because synthesis is already suppressed by elevated TSH)

Infectious (suppurative) thyroiditis 

• Acute infection spreads to thyroid ➔ abscess 

  • Sudden unilateral (MC) neck pain/tenderness with fever/ssx of infection

• DX

  • TSH, T3/4 usually normal (but ↑ T3/4 may occur)

  • Thyroid US can differentiate abscess 

• TX

  • IV abx (can drain surgically if needed)

Anemia

Fe overload

• ↓ RBC production or ↑ destruction

  • Thalassemia

  • Hemochromatosis

  • X transfusions

  • Supplements

Fe deficiency

• • Pregnancy, bleeding, malnutrition

  • ↓ Fe & ↓ Ferritin 

    • (depleted stores) 

  • ↑ Transferrin/TIBC 

    • floating around looking for more Fe

• Anemia of chronic dz

  • SLE, RA, CKD

  • ↑ hepcidin ➔ ↓ Fe absorption

  • ↓ Fe & ↓ Transferrin 

  • ↑ Ferritin (storing but not using)

TX

• PO Fe with orange juice on empty stomach in AM (deficiency)

  • ADR: constipation, N/V (can do IV Fe)

• CKD

  • TSAT ≤25&% and ferritin ≤500 ng/mL Fe before ESA

Headache

Migraines

• Severe headache associated with dilation of intracranial blood vessels

  • Triggers: stress, hormone (PMS/oral contraception), poor sleep, etOH

• DX clinical

• TX

  • Keep diary to track triggers and limit them, exercise, healthy diet

  • First line: NSAIDs/acetaminophen ± caffeine

    • ACUTE

      • 5-HT agonist (triptans or ergotamine)

        • BOLO: serotonin syndrome

        • CI pregnancy, cardiac hx

      • Tx nausea/vomiting with antiemetics 

        • (DA antagonist like metoclopramide or prochlorperazine can be used as monotx)

    • Prophylaxis

      •   β-blockers, topiramate, valproate, TCA 

Arthritis

Osteoporosis

• ↓ bone mass with abnormal structure ➔ ↑ risk of fractures

• Bone mineral density is one of the factors in ↓ bone strength

• MCC in postmenopausal women is related to estrogen deficiency   

  • Secondary osteoporosis hyperPTH, hypogonad/premature menopause, GI malabsorption

• SSX

  • ASX vertebral fractures, hip, distal radius (FOOSH ➔ Colles fx)

• Screening

  • Women > 65 or < 65 with:

    • hx/family hx of fracture, glucocorticoid steroids, ↓ BMI, smoking/etOH, rheumatoid arthritis

    • Men with radiographic evidence, ↓ height over short time, family hx and meds (steroids, androgen inhibitors)

• DX

  • Get serum Ca, phosphate, PTH, urine Ca/Cr & cortisol

  • Fragility fracture (spontaneous or minor trauma)

  • BMD via DXA: T-Score < - 2.5 at any site (2.5 SDs below) - (T-score is comparing to young adults)

    • Z-score < - 2 (2 SDs below) ➔ investigate reversible causes of osteoporosis (Z-score is comparing to age matched)

      • Drugs (steroids, anti-seizure)

      • Endo (including DM)

      • GI (absorption issues)

      • Marrow/blood disorders

      • Genetic (osteogenesis imperfecta)

  • X-ray ➔ ↑ radiolucency 

• TX

  • Bisphosphonates (⊣ bone resorption) for T-Score < - 2.5 or -2.5 to -1 with ↑fracture risk  

  • Take first thing in AM on empty stomach with full glass of water and wait 1 hr til eating/meds

    • Alendronate, risedronate; IV zoledronic acid (annual) for pts that have difficulty with bisphosphonates 

    • ADR: hypoCa (BOLO paresthesias, spasms, cardiac arrhythmias), esophagitis (stay upright for 1hr after taking), jaw osteonecrosis

  • Lifestyle (diet, exercise, fall prevention)

    • Total of 1200 mg of Ca (daily)

      • Ca in 8oz glass of milk ~300mg 

    • 800 IU of Vit D in postmenopausal women (daily)

    • ↓ etOH & smoking

  • FOLLOW UP DXA IN 2yrs 

Lupus

• Development of autoAB ➔ attack of healthy tissue - heart, lungs, kidneys, vasculature, neurological (psychosis, personality changes)

• Fatigue, fever, joints, skin (malar rash) - photosensitivity, oral ulcers

  • Cytopenias, serous membrane inflammation (pericarditis, pleuritis, peritonitis), myalgia

• DX

  • Anti-phospholipid ABs: anticardiolipin (tested with RPR/VDRL - also a test for syphilis) 

  • ↓ C3 and/or ↓ C4  

  • Lupus anticoagulant (➔ ↑ aPTT)

  • ANA  high sensitivity, low specificity for SLE

  • anti-dsDNA or anti-Smith most specific

• TX

  • Avoid sunlight, topical steroid for skin, NSAIDs for sx

  • Hydroxychloroquine (or MTX or azathioprine)

  • Glucocorticoids/cyclophosphamide for sever sx/organ involvement

Lyme

• Borrelia burgdorferi (obligate intracellular spirochete) via Ixodes scapularis (deer/black legged tick)

• Tick must be attached for 24-36hrs

  • STAGE 1

    • 7-14d after tick bite

    • Flu-like sx, erythema chronicum migrans - expanding red ring with central clearing

  • STAGE 2 

    • 3-10 weeks after bite:

      • Migratory arthralgia 

      • Neuro sx: facial nerve palsy, meningitis

      • Carditis ➔ AV block 

      • ± eythema migrans lesions

  • STAGE 3

    • Months-years: chronic arthritis, lymphocytic meningitis

• DX

  • ELISA (initial test) confirm with Western Blot

• TX

  • Doxycycline if >8yo (amoxicillin if allergic, kid, pregnant)

  • IV ceftriaxone (severe neuro/carditis)

Colorectal Cancer

• Patho

  • Genetic (familial), polyps

  • IBD ➔ ↑ inflammation ➔ hyperplasia ➔ neoplasia (UC)

  • RF: ↑ BMI, processed meat, high-fat/low-fiber, family HX

• SSX

  • Cancer sx (weight loss, night sweats, fatigue)

  • RIGHT-SIDE (ascending) bleeding ➔ melena ➔ Fe deficiency anemia

  • LEFT-SIDE (descending) ➔ ∆ bowel habits, bloody stools, obstruction

  • RECTAL ➔ hematochezia, tenesmus, pencil-thin stool, rectal pain

    • Liver common site of mets

• Screening with FIT/FOBT

  • Screening: Annually at 50yo (10 years before dx in 1st ° relative)

  • Stool sample for occult blood (colorectal cancer), R/O anemia cause, GI bleeding

    • Can be from hemorrhoids (ask about constipation)

    • DRE ➔ colonoscopy (double contrast barium enema if incomplete colonoscopy)

      • Advise about prep and post sedation

• TX depends on staging

Incontinence

• Stress

  • Aging, obesity, pelvic trauma, prostate surgery

  • ↑ ABD pressure ➔ ↑ bladder pressure > sphincter can handle

    • TX with Kegel (pelvic floor exercise) and lifestyle mod, vaginal pessary

• Urge

  • Inflammatory (UTI) or neuro ➔ overactive bladder, overactive detrusor, or sphincter dysfunction

  • Sudden urge with involuntary leak

    • TX with antiAch (oxybuntynin) or β3 agonist (mirabegron)

• Overflow 

  • Weak detrusor or outlet obstruction (BPH) ➔ incomplete emptying

  • Over-filled bladder ➔ ↑ pressure ➔ dribbling/leaking (usually no urge prior to leakage). ↑ post-void residual urine volume 

  • TX with catheterization, timed voiding, lifestyle mod

  • TX BPH with ⍺1 blockers (-zosins) first line

Acute Kidney Injury

• Sudden ↓ kidney function ➔ ↑ BUN/Cr 

• Stage 1 - SrCr ↑ 0.3 in 2d or 1.5-2x baseline in 1wk

• Stage 2 - SrCr ↑ 2-2.9x baseline

• Stage 3 - SrCr ↑ 4 or > 3x baseline and or < 0.3ml/kg/hr urine

  • Oliguric/anuric phase lasts 1-3wks

    • < 50ml urine, azotemia (↑ BUN/Cr)

  • Polyuric phase lasts 2wks

    • GFR normalizes but reabsorption is still a problem ➔ lost electrolytes

  • Recovery phase can last mo-yrs

    • Kidneys back to functioning

• Pre-renal (MC) - ↓ renal perfusion

  • Hypovolemia, renal artery stenosis ➔ RAS & ADH ➔ ↑ Na, H2O, urea reabsorption ➔ ↑ urine mOsm

  • BUN/Cr > 20/1

  • ↓ Na excretion (< 20, FeNa < 1%)

• Intra-renal - Kidney dz/damage

  • Acute tubular necrosis (MC intra), glomerulonephritis ➔ ↓ Na, H2O, urea reabsorption ➔ ↓ urine mOsm

  • BUN/Cr <15/1

  • ↑ Na excretion (> 40, FeNa > 2%)

  • ATN ➔ muddy brown casts; glomerulonephritis ➔ RBC casts; nephrotic ➔ fatty casts

• Post-renal -↓ voiding/drainage

  • BPH, stones, neurogenic bladder ➔ ↑ hydrostatic pressure ➔ ↓ GFR 

  • BUN/Cr may be normal

Chronic Kidney Disease

• Na + H2O retention ➔ HTN, edema (pulm and peripheral), pH disorders, anemia

• Causes of CKD: DM nephropathy, HTN nephropathy, glomerulonephritis, polycystic kidney disease

• Stage 1 - eGFR > 90 but with kidney damage

• Stage 2 - eGFR 60-89 ± proteinuria

• Stage 3 - eGFR 30-59  ➔ problems with 

  • bone (kidneys make Vit D) ↓ Ca ➔ 2° hyperPTH ➔ osteodystrophy

  • blood (kidneys make EPO) anemia

  • Acidosis, HyperK, PO4, uremia ➔ pericarditis/pleuritis, encephalitis

• Stage 4 - eGFR 15-29 ➔ Start dialysis prep and talk about transplant 

• Stage 5 - eGFR < 15

• Stage 6 - eGFR < 15 on dialysis 

  • Dialysis indication: eGFR < 5 or 5-15 with ssx that aren't responding to medical tx

• Tx

  • ↑ renal perfusion (may have to stop ACEi/ARB, def stop NSAIDs)

  • Tx urinary tract obstruction

  • ⊣ RAS (ACEi/ARB), SGLT2 inhibitors 

  • Tx CKD complications

    • Volume overload (restrict Na, loops)

    • Dyslipidemia (statin)

    • HyperPO4 (restrict phosphate, CaHCO3 with meals) , anemia (EPO), HyperK, acidosis

Pediatric exanthem

Measles (rubeola)

• Cough, coryza, conjunctivits

• Koplik spots (blue/gray spots) on buccal mucosa

• One week later ➔ large sized spots blanchable rash starting on face with high fever

  • BOLO encephalitis, PNA, otitis media (superinfxn)

Rubella (German measles)

• Post-auricular LN, mild sx

• Forchheimer (sounds german) spots on soft palate

• 5d later ➔ Medium sized blanchable rash starting on face with polyarthritis

  • BOLO TTP

Roseola

• HHV 6

• High fever ➔ blanchable rash ➔ ↓ temp

  • FROM TRUNK TO FACE

• Nagayama (papular enanthem on uvula and palate

  • BOLO febrile seizures