Gastrointestinal and Ranson's Criteria

Gastrointestinal

• Gold standard serology markers for Hepatitis A include HAV-IgM.
• Objective exam findings in Crohn's Disease include abdominal tenderness with a tubular tender mass in the RLQ, anal fissures, perianal fissures, nausea, vomiting, transmural inflammation, and focal involvement of the colon with skip lesions.

Ranson's Diagnostic Criteria for Pancreatitis

• On admission or diagnosis, these criteria apply:
  • Age older than 55 years
  • White blood cell count greater than 16,000
  • Blood glucose greater than 200
  • Base deficit greater than 4
  • Serum lactate dehydrogenase (LDH) greater than 350
  • Aspartate transaminase (AST) greater than 250
• During the initial 48 hours:
  • Hematocrit (Hct) drop of more than 10 percentage points
  • Blood urea nitrogen (BUN) rise of greater than 5
  • Arterial PO2 less than 60
  • Serum calcium (Ca) of less than 8
  • Estimated fluid sequestration of greater than 6L
• Number of Diagnostic Criteria vs Mortality Rate % include:
  • 0-2 = 1
  • 3-4 = 16
  • 5-6 = 40
  • 7-8 = 100

Treatment for Mild Diverticulitis

• A patient presenting with mild symptoms can be managed at home with rest and a clear liquid diet.
• Antibiotics are not recommended because diverticulitis is more of an inflammatory process.
• Diverticular disease can be managed with a high fiber diet or daily fiber supplementation.

GERD: Risk Factors and Signs/Symptoms

• Signs and symptoms include heartburn ranging from mild to severe, regurgitation, water brash, dysphagia, sour taste in the mouth in the mornings, belching, coughing, hoarseness, wheezing, and chest pain.

Grading of Internal Hemorrhoids

• First degree hemorrhoids protrude into the lumen of the anal canal, usually without the sensation of protrusion.
• Second degree hemorrhoids protrude beyond the anal canal during defecation but spontaneously reduce when defecation is completed.
• Third degree hemorrhoids protrude beyond the anal canal during defecation but must be manually reduced after the completion of the bowel movement.
• Fourth degree hemorrhoids protrude beyond the anal canal and are permanently prolapsed despite attempts at manual reduction.

Risk Factors Associated with Cholelithiasis

• Cholesterol stones are associated with:
  • Female gender
  • Obesity
  • Pregnancy
  • Increased age
  • Drug-induced causes (oral contraceptives, clofibrates)
  • Cystic fibrosis
  • Rapid weight loss
  • Spinal cord injury
  • Ileal disease with extensive resection
  • Diabetes mellitus
  • Sickle cell anemia
• Pigmented stones are associated with:
  • Hemolytic diseases
  • Increasing age
  • Hyperalimentation
  • Cirrhosis
  • Biliary stasis
  • Chronic biliary infections
• *six F's- female, fat, forty, flatulent, fertile, fat-intolerant

Colorectal Cancer Screening Guideline Recommendations

• Average risk: beginning at age 50 through age 75 years and for African Americans, begin screening at age 45 years.
• Screening Recommendations include: Colonoscopy every 10 years, annual fecal immunochemical test (FIT), flexible sigmoidoscopy every 5-10 years, computed tomography colonography every 5 years, and annual Hemoccult Sensa or fecal DNA testing every 3 years.
• Higher risk: family history of colorectal cancer or polyps before age 60 years and those with a family history of a hereditary colorectal cancer syndrome.
• Recommendations: colonoscopy every 5 years starting at age 40 or 10 years younger than the age at diagnosis of the youngest affected relative.

Exam Findings for Appendicitis

• Include guarding and rebound tenderness.
• Rovsing's sign involves deep palpation over the left lower quadrant with sudden release, causing right lower quadrant (RLQ) tenderness, which is a positive finding.
• Psoas sign involves the patient trying to lift the right leg against resistance or extending the right leg at the hip, with increased pain indicating an inflamed appendix irritating the psoas muscle.
• Obturator sign involves flexing the right hip and knee and internally rotating the leg, with RLQ pain indicating irritation of the obturator muscle.
• McBurney's sign involves applying pressure to McBurney's point, located halfway between the umbilicus and the anterior spine of the ilium; pain indicates a positive response.

Renal

• Stages of Chronic Kidney Disease include:
• Stage 1: persistent albuminuria with normal GFR greater than 90
• Stage 2: albuminuria with GFR between 60-89
• Stage 3: GFR between 30-59
• Stage 4: GFR between 15-29
• Stage 5: ESRD defined as GFR less than 15

Major Causes of Acute Kidney Injury

• Prerenal Acute Kidney Injury:
  • Fluid and electrolyte depletion
  • Hemorrhage
  • Septicemia
  • Cardiac failure
  • Liver failure
  • Heat stroke
  • Burns
• Intrarenal Acute Kidney Injury:
  • Ischemia
  • Toxins
  • Radiocontrast agents
  • Hemoglobinuria
  • Myoglobinuria
  • Acute glomerulonephritis
  • Arterial or venous obstruction
  • Tubulointerstitial nephritis
  • Pyelonephritis
  • Papillary necrosis
  • Precipitation from hypercalcemia
  • Urates
  • Myeloma protein
• Postrenal Acute Kidney Injury:
  • Prostatism (hypertrophy or malignancy)
  • Bladder tumor
  • Pelvic tumor
  • Retroperitoneal tumor
  • Renal calculi

Urine Specific Gravity Findings: Increased and Decreased Specific Gravity

• Increased urine specific gravity may be caused by:
  • Dehydration
  • CHF
  • Adrenal insufficiency
  • Diabetes
  • Nephrosis
  • Antidiuretic hormone
• Decreased urine specific gravity may be caused by:
  • Diabetes Insipidus
  • Pyelonephritis
  • Glomerulonephritis
  • Excess Fluid intake

Pyelonephritis Treatment

• Treatment includes oral vs IV antibiotics, dependent on local antibiogram and drug-resistance rates for the community and patient population with evaluations for sepsis and hospitalization.

Management of Stress Incontinence

• Includes pelvic floor re-education with biofeedback (Kegels), weight loss if obese, electrical stimulation, hormone replacement therapy (estrogen), alpha-adrenergic agonist, surgical correction of hypermobile bladder neck, and periurethral bulking injections.

Management & Prevention of Kidney Stones

• Includes pain management, intake of 64 oz of water daily for prevention, may require extracorporeal shock-wave lithotripsy due to inability to pass stones, and ureteral stents.

Instructions for Patients with Nephrolithiasis

• Increase fluid intake to six to eight 8-ounce glasses per day unless contraindicated.
• Monitor intake and output and strain the urine for passed stones.
• Avoid over-the-counter drugs that contain phosphorus or calcium and most vitamin supplements, especially vitamin D3.
• Avoid caffeine, beer, and wine and consume a low-oxalate diet to prevent calcium oxalate stones.
• A low-phosphorus diet for calcium phosphate or struvite stones should eliminate milk products and cola drinks.
• A low-purine diet is often effective in reducing stones formed from excess uric acid.

Side Effects of Anticholinergic/Antispasmodic Medications for Incontinence

• Include dry mouth, drowsiness, and blurred vision.

Dietary Management in Chronic Kidney Disease

• Include restricted protein intake, restricted sodium intake, adequate caloric intake, and restriction of phosphate and potassium.

Contraindications to Bactrim in UTI

• Hypersensitivity to trimethoprim or sulfonamides, allergy to sulfa, folate-deficiency megaloblastic anemia, and pregnancy are contraindications.

Men's Health

• Diagnostic gold standard for diagnosis of Epididymitis is an ultrasound of the scrotum.
• Prehn's sign in epididymitis is pain relieved on testicular elevation.

Benign Prostatic Hypertrophy Signs and Symptoms

• Obstructive-decreased force of stream and urinary hesitancy. Further symptoms include:
  • Postvoid dribbling
  • Sensation of an incomplete bladder after emptying
  • Overflow incontinence
  • Inability to voluntarily stop the urinary stream
  • Urinary retention
  • Double voiding and draining
  • Irritative-nocturia
  • Urinary frequency
  • Urgency
  • Dysuria
  • Urge incontinence

Treatment of BPH Medications & Side Effects

• Alpha1 adrenergic antagonists and 5-alpha-reductase inhibitors can be used.
• Possible side effects include decreased libido and erectile dysfunction.

Chlamydia Treatment Recommendations

• Adults and adolescents: doxycycline 100mg orally BID for 7 days or azithromycin 1G orally in single dose or levofloxacin 500mg orally daily for 7 days
• Pregnancy: azithromycin 1G orally in single dose or amoxicillin 500mg TID for 7 days

Genital Herpes Treatment

• Acyclovir 400mg TID 7-10 days or famciclovir 250mg TID 7-10 days or valacyclovir 1G BID 7-10 days (CDC 2021 STD Guidelines)

Prostate Cancer Screening Recommendations

• Annually for men with no symptoms and in relatively good health and can expect to live at least 10 more years begins at Age 50
• Men that are African American or men who have a father or brother with prostate cancer should begin screening before the age of 65, age 45

Chronic Prostatitis Treatment

• Is a 4-6 weeks of treatment with Levaquin currently being the best cure rates

Hydrocele Exam Findings

• Include; swelling in the groin or upper scrotum, perform transillumination with a penlight in a darkened room to see trapped fluid which appears light pink, yellow, or red

Women's Health

• Three of the following are required to diagnose bacterial vaginosis; Include:
• Homogenous, thin, grayish-white discharge that smoothly coats the vaginal walls
• Vaginal pH greater than 4.5
• Positive whiff-amine test
• Clue cells on the saline wet mount

Breast Cancer Signs/Symptoms & Differentials

• Indicative of breast cancer: palpable mass is usually persistent, unilateral, solitary, discrete, firm, irregularly shaped, nontender
• Breast distortion and skin changes such as erythema, edema, peau d'orange, dimpling, nipple retraction, or nipple ulceration
• Nipple discharge is spontaneous, persistent, unilateral, localized to a single duct, watery or sticky
• Malignant lymph nodes are large, firm, or fixed
• Differentials:
  • Benign breast masses
  • Fibrocystic changes
  • Fibroadenomas
  • Hamartomas
  • Diabetic mastopathy
  • Intraductal papilloma
  • Duct ectasia
  • Ductal hyperplasia

Signs & Symptoms of Mastitis

• Complaints of fatigue, flu-like symptoms, fever, breast pain, nipple discharge, nipple retractions
• Varying degrees of erythema with a V-shaped distribution
• Purulent nipple discharge

Causes of Secondary Amenorrhea

• Pregnancy is most common cause
• Pituitary tumor
• Adrenal insufficiency
• Hyperprolactinemia

Treatment Options in Dysmenorrhea

• Anti-inflammatories, heating pad, consideration of combined oral contraceptives

Pap Smear Screening Guidelines

• Normal cytology: repeat Pap test every 3 years (ages 21-29 every 3 years; 30-65 every 3 years or every 5 years with HIV cotesting).
• Unsatisfactory for evaluation: repeat Pap test in 2-4 months.
• If HPV positive and older than 30 years, colposcopy is acceptable.
• Infection: treat infections that present with symptoms or identified with cytology results, or test to confirm the organism.
• Low-grade squamous intraepithelial lesion indicates mild dysplasia: refer to gynecologist and colposcopic examination is likely
• High-grade squamous intraepithelial lesion indicates moderate or severe cervical intraepithelial neoplasia but does not necessarily mean the presences of cervical cancer: REFER TO GYNECOLOGIST Squamous cell carcinoma: REFER TO GYNECOLOGIST
• Glandular cell abnormalities:
• Atypical glandular cells: refer to gynecologist
• AGC-not otherwise specified: refer to gynecologist
• AGC-favor neoplasia: refer to gynecologist
• AIS (adenocarcinoma in situ): refer to gynecologist
• Adenocarcinoma: refer to gynecologist

Breast Mass Differentials

• Benign breast disorders such as; fibrocystic disease (fibroadenoma; lumps are normally tender and bilateral and may have rapid fluctuation in size, tenderness, and size may increase before menses), or mammary dysplasia

Diagnostics for Secondary Amenorrhea

• Urine pregnancy test, electrolyte panel, thyroid function tests, estrogen, FSH, LH, prolactin levels, total testosterone, and DHEA-S

American Cancer Society and Clinical Breast Exam Recommendations

• Screening mammogram beginning at age 45 years and performed annually in women 45 to 54 years with the opportunity to begin screening at age 40 years
• Biennial screening for women 55 years and older with the opportunity to screen annually while continuing screening as long as overall health is good and life expectancy is at least 10 years

Ovarian Cancer Diagnostics

• Bimanual pelvic exam
• Pelvis ultrasound
• Serum CA-125
• TVUS
• Intravenous pyelogram (IVP)
• Barium enema or colonoscopy especially if hemoccult is positive
• Laparoscopy
• Abdominal/pelvic CT or MRI

Menopause Diagnostic Testing & Hormone Levels Common in Menopause

• Pregnancy Test
• FSH and LH levels are elevated (FSH levels greater than 40 consistent with complete cessation of ovarian function)
• Estradiol level <30
• Menopausal status can also be determined by vaginal cytological examination
• Parabasal cells will predominate

Dermatology

• Acne Vulgaris Pharmacologic Management
• Mild acne is treated with topical medication
• *topical retinoids treatment with comedonal acne (Retin-A, Differin Gel)
• Inflammatory Acne
  • *topical antibiotics for inflammatory acne (erythromycin or clindamycin, benzoyl peroxide, or combination of benzoyl peroxide and erythromycin)
• Moderate to severe acne that is systemic can be treated with:
  • *systemic antibiotic and hormonal treatment of moderate to severe acne (doxycycline, minocycline)
• Severe acne can be referred to dermatologist for treatment with (Isotretinoin—previously Accutane)

Impetigo Patient Education

• Good handwashing and personal hygiene to stop the spread of bacteria
• Keep fingernails short
• Refrain from participation in any contact sport or activity that could spread infection
• Children should not attend daycare or school until 24 hours after the antibiotic therapy is started
• Instruct patient to gently clean the crust from the lesion with antibacterial soap before applying mupirocin cream or retapamulin

Onychomycosis Exam Findings

• Infected nail spears dry with opaque white patch with sharp borders
• Area under nail accumulates chalky material made up of hyperkeratotic debris

Tinea Corporis Exam Findings

• Classic "ringworm”- ringlike lesions with bright red elevated border covered with scales with central clearing

Rosacea Examination Findings and Subtypes

• Rosy hue to the forehead, cheek, nose, or chin
• • Subtype 1: erythematotelangiectatic rosacea-flushing and persistent redness, which may include visible blood vessels
• • Subtype 2: papulopustular rosacea-persistent redness with transient bumps and pimples
• • Subtype 3: phymatous rosacea-skin thickening usually with hyperplasia of the nose, resulting in a large, bumpy, and bulbous appearance
• • Subtype 4: ocular rosacea-ocular manifestations with dry eye, tearing and burning, erythematous eyelids, recurrent styes, and possible vision loss from corneal damage

Malignant Melanoma Diagnostic Tests

• Physical exam with full-body inspection, excisional biopsy

Candidiasis Diagnostics

• Exam findings: pruritis and burning, cutaneous candida infections are normally bright red rash with macules or satellite lesions on borders
• Diagnostic test: wet mount, KOH examination

Contact Dermatitis Signs and Symptoms

• Pruritis erythematous rash, may report exposure history

Scabies Treatment

• Treat the entire household, launder linens with hot water and detergents.
• Permetherin is the first-line treatment.
• Antihistamines and topical steroids for itching can be helpful.
• Trim fingernails to prevent reinfesting themselves.
• Treat home environment

Psoriasis Diagnostics

• Exam Findings: erythematous plaques surrounded by a thick, silvery scale (not easily removed) where if scales are removed, multiple small sites of bleeding appear (Auspitz's sign)
• Diagnostic Test: CBC w/ diff, serum chemistry panel, uric acid levels where
  • *uric acid levels are typically elevated and CBC and BMP are normal
  • *x-ray of hands to check for psoriatic arthritis