Final Study Guide - EENT PDF

FINAL STUDY GUIDE EENT Allergic Rhinitis Types -​ Seasonal Variation (intermittent) -​ Year round perennial type (Chronic -​ Mixed rhinitis - combined allergic and nonallergic rhinitis (most common type) -​ Nonallergic rhinitis with multiple causes History -​ a/c asthma, atopic d...

FINAL STUDY GUIDE EENT Allergic Rhinitis Types -​ Seasonal Variation (intermittent) -​ Year round perennial type (Chronic -​ Mixed rhinitis - combined allergic and nonallergic rhinitis (most common type) -​ Nonallergic rhinitis with multiple causes History -​ a/c asthma, atopic derm, fam, triggers, known allergens Symptoms (atopic condition) -​ Nasal congestion -​ Clear rhinorrhea -​ Sneezing -​ Nasal pruritus -​ Post-nasal drip -​ Non-productive cough -​ Chronic sinusitis Clinical Presentation -​ Periorbital edema -​ Allergic shiners -​ Dennies lines Physical Exam -​ General inspection of face - dennie’s lines and allergic shiners -​ Examine nose for mucosal edema and thin, clear secretions, noting any nasal polyps/obstruct -​ Palpate sinuses for tenderness → sinusitis will hurt -​ Mouth breathing, erythema -​ Frequent sniffling/clearing throat -​ Eyes - allergic conjunctivitis -​ Ears - eustachian tube dysfunction -​ Breath sounds - wheeze/asthma -​ Skin - dermatitis -​ Neck - lymphnodes Dx testing -​ Formal dx based on skin allergy testing or serum testing UpToDate -​ Mild or episodic symptoms -​ Minimally sedating oral antihist. -​ Antihist nasal spray - azelastine or olopatadine -​ Glucocorticoid nasal spray -​ Cromolyn nasal spray - ideally 30 min before an exposure -​ Persistent or moderate-to-severe symptoms -​ Gluco nasal spray + antihistamine spray -​ Addition of minimally sedating oral antihist/decongest -​ Injection immunotherapy Pharyngitis Pathogensis -​ Viral common pathogens -​ Adenovirus -​ Parainflueza -​ Coronavirus  -​ Coxsackie virus (hand/foot/mouth) -​ EVB and CMV -​ Bacterial common pathogen -​ Group A -​ Gonorrhea -​ Fusobacterium -​ Non Injection cause -​ Allergic Rhinitis/post nasal drip -​ Gerd -​ Mouth breathing History CC & HPI -​ Determin onset/duration -​ Cough/rhinorrhea -​ Fever/systemic sx (GABHS) -​ Difficult swallowing/drooling → peritonsilar abscess -​ Known strep -​ Sexual practice Viral Pharyngitis Streptococcal Pharyngitis CM ​Coryza (nasal & Lacrima edema and congestion) ​Tender, swollen anterior cervical lymph ​Pharyngeal erythema nodes (uni or bi) ​Tonsillar edema ​Patchy tonsillar exudate ​Pharyngeal erythema ​Tonsillar edema Features ​ Subacute onset of sore throat ​ Acute onset of sore throat ​ A/c URI sx (cough, congest, conjunction, ​ Absence of Other URI sx hoarse) ​ Pharyngeal erythema and tonsillar edema ​ Pharyngeal erythema and tonsillar edema ​ Fever ​ Low-grade or absent fever ​ Tonsillar exudates Other Findings ​ Pharyngeal/tonsillar exudates ​ Known GABHS ​ Oral Ulcers ​ Palatal petechiae ​ Viral exanthem ​ Scarlatiniform rash ​ Strawberry tongue ​ No single clinical Features distinguishes ​ Highly suggest Strept if ○​ Acute onset pharyngitis w/ tonsillar exudate ○​ Fever ○​ Cervical lymphadenopathy ○​ Absence of other URI sx ​ RADT ​ Tx w/ Antibiotic Pharyngitis - Viral Clinical presentation - Gradual onset -​ URI -​ Cough -​ Conjunctivitis - lot of viral leak via eyes in kids -​ Afebrile but occasional low grade temp 101, HA -​ Sore throat w/ dysphagia w/o cold type sx -​ Abd pain + vomiting -​ Beefy throat w/exudate on tonsils -​ Pharyngeal edema -​ Patchy tonsillar exudates -​ Lymphadenopathy Diagnostic tests - Possible serious complications if left untreated -​ RADT, CBC w/diff, Mono Treatment -​ Penicillin VK 500mg PO BID for 10 days -​ IF PCN allergic (skin rash no anaphylaxis) → Cephalexin 500 mg PO BID x 10 days -​ IF PCN Anaphylaxis → Azithromycin 500 mg/day 1st day then 250 mg po daily 4 days -​ Symptomatic relief -​ NSAIDS, Tylenol -​ Decongestants (Afrin, mucinex) -​ Gargle w/ warm water, lemon -​ Lozenges Pharyngitis - N.gonorrhea Treatment -​ Single injection of Cetriaxone 500 mg IMx1 Pharyngitis - Allergic Clinical Presentation - intermittent symptoms -​ Does not present w/ fever -​ A/c w/ persistent PND -​ Sneezing, itchy watery eyes, rhinorrhea and mild sore throat that worsens w/ lying down Treatment - Symptomatic relief -​ Avoid allergens -​ Antihist. -​ Lozenges -​ Hydration Rhinosinusitis Inflammation of the mucous membrane that line the paranasal sinuses → Blockage of normal drainage pathways -​ Results in Mucus retention -​ Decrease mucus clearance -​ Predisposes to bacterial growth Can receive Abx if fit 1 of the following: -​ Onset w/ persistent sx or signs of acute rhino. Lasting ≥10 days w/o improvement -​ Onset w/ severe sx of signs of high fever + purulent nasal discharge or facial pain lasting for 3-4 consecutive days at beginning of illness  -​ Onset with worsening sx or signs characterized by the new onset of fever, HA, or increase in nasal discharge following typical viral URI that lasted 5-6 days and were initially improving (double sickening) Causes -​ Infectious - Bacterial, or viral -​ Viral - Adenovirus -​ Bacterial Pathogen -​ Strep pneumonia -​ H. Influenzea -​ Morazella -​ Noninfectious - Allergic Predisposing Factors -​ Recent URI or influenza -​ Allergic rhinitis -​ Environmental pollutants -​ Abnormalities -​ Hormone -​ Meds Clinical Presentation -​ Nasal congestion/obstruction -​ Nasal discharge -​ Anosmia -​ Dental pain -​ Increased Head pressure -​ Sore throat -​ Cough -​ Throbbing facial pain or pain above eye brows -​ Bad breath -​ Fatigue and malaise History CC & HPI -​ OLDCART -​ Fever? -​ Recent URI/hx -​ Treatment? Diagnostic test -​ Clinical findings suggest sinusitis → radiograph not needed -​ Sx are orbital, intracranial, or soft-tissue abscess, radiographic imaging should/can be done -​ Imaging (films, CT, US) -​ Facial swelling -​ Acute rhinosinusitis unresponsive to 48 hrs abx -​ Toxic appearance -​ Chronic or recurrent rhinosin. -​ Chronic unrespons. Asthma Acute Bacterial Rhinosinusitis Management -​ Adults general well treat for 5-7 days -​ Amoxicillin-Clauvulante 875/125 mg PO BID x 5-7 days -​ Amoxicillin 500 mg TID or 875 mg BID PO -​ IF PCN allergy → Doxyclycline 100 mg PO BID x 5-7 days -​ IF Response SLOW → Change diff class -​ Fail to improve 48 hrs → resistant organisms or mis-daignosis (ENT Referral) Supportive Management -​ Saline irrigation  -​ Pain management → ibuprofen and acetaminophen -​ Saline drops irrigation -​ Neti pot Patient Education -​ Return if not improving 48 hrs -​ No smoking avoid 2nd hand smoke -​ Avoid allergen/irritants -​ Increase fluids -​ Humidify air -​ Elevate head of bed -​ Avoid swimming/diving and flying during acute period -​ Avoid antihist unless there is allergic basis for sx Acute Otitis Media (AOM) Etiology -​ Bacterial pathogen S. Pneumonia, H.flu -​ Viral pathogen -​ Fungal Ssx -​ Earache, fever may or may not be present -​ Hearing loss or muffled, stuffiness, fullness -​ Vertigo PE -​ Sig. objective findings -​ Cloudy, opacified, full, red, bulging TM -​ Red TM is NOT definitive Dx Criteria -​ Decreased mobility TM -​ Decreases or abset bony landmark -​ Distorted or absent light reflex -​ Increase vascularity of TM Treatment -​ Pt has not had abx in past 1 month -​ Amoxicillin 1000 mg TID x 10 days -​ If pt has had abx in past 1 month -​ Amoxicillin clavunant 875/125 mg bid x10days Management -​ Education -​ Med admin, normal process, risk factors, follow up -​ Sx treatment -​ Fluid + Rest -​ Analgesics/antipyretics: -​ Tylenol, Ibuprofen Otitis Externa aka “Swimmers Ears” Cause -​ Fungal or bacterial S&S -​ Pruritus -​ Purulent discharge w/ crusting -​ Tenderness of tragus, Pinna -​ Diffuse canal -​ Edema  -​ Erythema or both, pain may radiate to face/neck Objective Findings -​ Erythema and edema of canal -​ Weeping secretions, purulent otorrhea, exudate or crusting of the skin -​ Degree of tenderness upon movement of pinna Externa Management -​ Gentle Cleaning - ⅓ white vinegar, ⅔ rubbing alc after swimming -​ PLUS -​ ABX ear drops for mod to severe disease. NB expesnive -​ Ciprofloxacin + hydrocortisone -​ Cirpo + dexamethasone Cardio/ECG Eval Basic ECG interpretation ECG (EKG) Basic Principles -​ 12 “Views” or leads -​ 6 limb - I, II, III, aVR, aVL, aVF -​ 6 Chest (precordial) - V1, V2, V3, V4, V5, V6 -​ Vertical = Amplitude mV -​ Horizontal = time mSec -​ Upward = positive -​ Downard = negative -​ Each block = 0.04 seconds Cardiac Conduction Cycle -​ Start at sinus node -​ A. Fib no clear P. wave ECG interval -​ PR interval: 0.12 - 0.20 sec -​ QRS Complex: 0.06 - 0.12 sec -​ QT Interval: 0.46 seconds Torsades de Pointes (type of V.Fib) -​ Give Magnesium  Ventricular Fibrillation Ectopic Beats (PACs & PVCs) Benign PAC -​ Early P wave -​ Missing QRS? PVC -​ Pt feels skip beat -​ QRS unrecognizable Bundle Branch Block -​ Easiest place to see BBB bunny ears (V1) -​ V1 Septum  Brugada Pattern -​ Almost mirror RBBB -​ V1 V2 -​ Pattern + sx → ED Atrial Fibrillation -​ Uncoordinated and disorganized atrial activation -​ Ineffective atrial contraction -​ Atrail are “fibrillating” -​ Look at V1 (Septum) AF Classification -​ Paroxysmal: Recurrent (>1 ep ≥ 30 seconds in duration) term spont. Within 7 days -​ Persistent: Sustained > 7 days or 48 hrs -​ 3 weeks of therapeutic AC -​ TEE confirm absence of LAA thrombus -​ Thromboembolism risk increase 1st 3-4 wks after DCCV A.Flutter → antithrombotic therapy Anticoagulation -​ Reduces risk of ischemic stroke by ⅔ -​ ASA not adequate prevention -​ Major consideration - BLEEDING!!! Non-Warfarin Oral Anticoagulation Eliquis (Apixaban) -​ Dose: 5 mg BID -​ Renal adjustment: 2.5 mg BID -​ 2 or more of the following: -​ ≥80 years -​ ≤ 60 kg -​ Creat ≥ 1.5 mg/dL -​ Half life: 12 hours -​ Time to Peak: 3-4 Hours -​ Direct factor Xa inhibitor Xarelto (rivaroxaban) -​ Dose: 20 mg QD w/ 500 calories -​ Renal Adjustment: -​ CrCl 15-50: 15 mg QD -​ CrCl 10% experience GI distress -​ Capsule must be taken intact -​ Half Life: 12-17 hrs. Up to 28 with renal impairment -​ Time Peak: 1-2 hours -​ Direct Thrombin Inhibitor Savaysa (edoxaban) -​ Renal Dose: 60mg daily -​ GFR 50-95 mL/min -​ GFR>95 mL/min Contraindicated -​ Half Life: 10 to 14 hours -​ Time to peak: 1-2 hours -​ Factor Xa Inhibitors Coumadin (Warfarin) -​ Dose Individually titrated -​ Half Life: 20-60 hours -​ Full therapeutic effect: 5-7 days -​ Vitamin K Antagonist CHECK FIRST -​ Baseline PT/INR -​ Establish target INR -​ 2-3 for AF -​ 2.5-3.5 for mech valve -​ First INR check on day 3-4  Reversal Agents Warfarin -​ Vitamin K 2.5-10 mg IV/PO -​ IV Peak effect: 12-14 hours -​ PO Peak effect: 24 hours -​ Not SQ or IM Pradaxa (dabigatran) -​ Praxbind (idarucizumab) 5g IV -​ 2.5g no more than 15 min apart -​ Neutralizes anticoagulant effect w/in min -​ Neutralizes anticoagulant effect w/in minutes Eliquis (apixaban) and Xarelto (rivaroxaban) -​ Andexxa 400mg-800mg IV bolus followed by IV infusion for up to 2 hrs -​ Rapid onset Rate Control -​ Beta Blockers -​ CCB -​ Digoxin Musculoskeletal System Neurovascular Assessment -​ Circulation -​ Sensation -​ Motion Back Pain History -​ Location, duration, and severity of the pain -​ Localized or with radiculopathy -​ Prior back pain and past remedies that helped Red Flag symptoms -​ Fever -​ Unintentional wt loss -​ Incontinence -​ Bilateral leg weakness -​ Perineal anesthesia Symptoms that suggest underlying systemic disease -​ Hx cancer -​ Age >50 yrs -​ Unexplained wt loss -​ Duration >1 mo -​ Nighttime pain -​ Unresponsive to previous therapies PE -​ Neurologic exam -​ Dermatomes -​ Strength -​ Reflexes -​ Gait -​ Foot drop: heel and toe walk Examination continued -​ Muscle strength testing: grade 1-5 -​ Special maneuvers -​ Straight leg raise (SLR)/Tripod Sign -​ Assesses for irritation of spinal nerves L5-S1 -​ Pt supine, examiner raises the pt extended leg 70-90 degree of hip flexion w/ foot dorsiflexed -​ + if pain elicited between 30-60 degrees -​ Contralateral Straight leg raise: -​ + when unaffected side is raised and sx are reproduced on affected side -​ Femoral stretch: assess L2-4 Differentials Mechanical -​ Strain/sprain -​ Herniated disc -​ Sciatica: union of 5 nerve: butt→food -​ Spondylolysis or spondylolisthesis -​ Listhesis: slip forward -​ Lysis: stress fracture -​ Spinal stenosis -​ Compression factor Systemic -​ Spinal/cauda equina compression -​ Metastatic cancer -​ Spinal epidural abscess -​ Vertebral osteomyelitis -​ Inflammatory spondyloarthropathy -​ Connective tissue disease Referred -​ Pancreatitis -​ PUD -​ Nephrolithiasis -​ AA -​ Uterine fibroid/PID -​ Prostate Treatment Conservative Measures -​ Ice/heat -​ NSAIDs, Acetaminophen -​ Caution against opioids/muscule relaxant -​ Low back pain stretches -​ PT -​ Orthopedics referral if severe or not improving w/ tx Imaging -​ MRI, CT or plain radiographs -​ Not recommended for nonspecific low back pain -​ Image if severe or progressive neuro deficit, or serious underlying issue Hand/Wrist Carpal Tunnel Syndrome Compression of median nerve -​ Due to repetitive movement that flex or extend wrist or raise arm -​ Sx: Intermittent pain or numbness/tingling in 1st 3 fingers radial half of 4th -​ Sx worst at NIGHT Phalen’s Maneuver -​ + if pain/paresthesia after 1 min wrist flex Tinel’s Test -​ + if percussion over median nerve at wrist produces pain/paresthesia Dx -​ Hx and Exam → Nerve conduction studies and electromyography to support dx Conservative Management -​ Reduce repetitive motion -​ Wrist splinting at night or full time -​ PT/OT referral -​ Glucocorticoid injection or short term oral glucocorticoid -​ Surgery if evidence of ongoing nerve damage De Quervain’s Tenosynovitis -​ Inflammation of tendons that innervate thumb -​ Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis Symptoms -​ Pain moving thumb, making fist, turning wrist, and lifting w/ thumbs pointed upward Risk Factors/Causes -​ RA -​ Pregnancy and Breast feeding -​ Repetitive motions -​ Gender: Female -​ Age: 40-50s Treatment -​ Immobilization -​ NSAIDS -​ Modify Activity -​ Corticosteroid Injection Elbow Lateral Epicondylitis - “Tennis Elbow” -​ Tenderness over lateral epicondyle and proximal wrist extensor muscles -​ Pain w/ resided wrist extension or passive wrist flexion w/ elbow in full extension -​ Absence of warmth/erythema/edema Medial epicondylitis - “Golfer’s elbow” -​ Tenderness over medial epicondyle and proximal wrist flexor muscles -​ Pain w/ resisted wrist flexion or passive wrist extension w/ elbow in full extension -​ Absence of warmth/erythema/edema Management: rest, counterforce brace, NSAIDs, physical therapy  -​ If no improvement: 3 view x-ray series, glucocorticoid injections Olecranon Bursitis -​ Either an inflammatory or non-inflammatory filling of the bursa w/ excess fluid Causes -​ injury, prolonged leaning on elbow, overuse, inflammatory arthritis, infection Symptoms -​ Tenderness over the bursa and w/ flexion of elbow Management -​ Joint protection, NSAIDS, Ice/Heat -​ Fluid aspiration and analysis if suspect infection Ulnar Nerve Entrapment (Cubital Tunnel Syndrome) -​ Compression of ulnar nerve -​ Caused by prolonged bending or leaning on elbow -​ Direct blow to elbow = hitting funny bone Symptoms -​ Pain on inside of elbow or numbness/tingling on ulnar side of 4th finger and 5th finger (distribution of ulnar nerve) -​ Motor weakness and sensory loss if severe Dx: -​ Xray and nerve conduction studies to support dx Management: -​ Avoid provoking factors, NSAIDS, brace/splint to keep elbow straight at night, nerve hliding exercise -​ Surgery - if evidence of ongoing nerve damage Shoulder Rotator Cuff Tendinitis -​ Athletes and ppl reach overhead -​ Presents as pain w/ lifting or reaching overhead, pain may be localized to lateral deltoid Physical Exam -​ ROM -​ Drop arm test -​ Apley Scratch Test Treatment -​ Rest, Ice/Heat -​ NSAIDs -​ PT -​ Glucocorticoid injection -​ Refer to ortho if no relief after 6 months Rotator Cuff Tear Cause -​ Acute trauma or degenerative tear from repetitive stress to shoulder Symptoms -​ Pain over lateral deltoid that is worse w/ overhead activities and at night -​ Weakness Multiple tests to elicit weakness, impingement, strength  -​ Active painful arc test -​ Drop arm test -​ Weakness in external rotation Imaging -​ X-ray -​ MRI Treatment -​ Ortho referral -​ Rest, Activity modification, NSAIDS, PT, Steroid injection HIP -​ Large ball-in-socket joint -​ Major wt bearing joint -​ Common conditions -​ Osteoarthritis -​ Trochanteric Bursitis -​ Hip Fracture -​ Avascular NEcrosis: ETOH and steroid use Osteoarthritis/degenerative joint disease (OA/DJD) Causes -​ Increasing age, fam hx, previous injury to hip joint, obesity CM -​ Progressively worsening pain, aching, stiffness, and restricted movement Sx -​ Pain usually deep anterior groin, but can radiate to buttocks, thigh or knee -​ Pain worse w/ standing form seating position and walking, and first thing in the morning Dx -​ Based on sx, x-ray to confirm Additional Testing -​ Younger individuals w/ symptoms of OA (25 -​ Fam hist/ Ethnicity Screening -​ Risk assessment at first pre-natal visit -​ Women high risk: obese; hx; glycosuria; PCO; fam -​ If no GDM initially → retest 24-28 at week -​ Women at normal risk → test between 24-28 week -​ GDM OGTT + if -​ Fasting ≥92 -​ 1 hr ≥180 -​ 2 hr ≥153 -​ Women w/ GDM screen 6-12 wk postpartum and f/u for 3 yrs Juvenile Diabetes T1DM T2DM Age Onset All ages Gender Equal Female Race/Ethnicity Non-hisp whites AA, Asians,Native,Hisp Obesity N/A >90% Fam Hx of DM 5-10% >80% Insulin Secretion Very low Low, normal, or high Insulin sensitivity Normal Decreased Onset Acute, Severe Suble ot severe Ketosis/DKA ~30% present DKA Uncommon HTN Uncommon Common Acanthosis Nigricans Rare Common POS Rare Common Islet Autoimmunity Present Uncommon T2DM Presentation -​ Polydip/Polyphag/PolyUria -​ Nocturia -​ Dehydration -​ Obesity -​ Acan Nigrican -​ Yeast (thrush) -​ PCOS -​ HTN  Screening -​ BMI >85 + 2 of any of following -​ Fam Hx -​ Race -​ Sign of insulin resist -​ Maternal hx GDM -​ Screen Q3yrs ADA Guidelines -​ A1C primary target -​ Lowering A1C below or around 7% -​ Pre-Prandial 80-130 -​ Peak Post 300 mg -​ Renal failure -​ ESRD Management of CKD in DM All patients -​ Annual measurements of Cr, Urinary albumin excretion, K+ GFR 45-60 -​ Refer - neph -​ eGFR q 6 mo -​ Monitor Electro and panal -​ Vit D -​ Bone density GFR 30-44 -​ eGFR q3mo -​ Monitor electrolight n stuff 3-6 mo eGFR 9% Obesity Screening + Treatment Meal plan -​ Reduce calorie -​ ~500-750 cal deficit Phsyical activity -​ >150 min/week performed on 3-5 separate days -​ Resistant training Behavioral -​ Self-monitoring -​ Goal setting -​ Education -​ Psychological Metabolic Surgery -​ Sleeve Gastrectomy 60% -​ Roux-en-Y gastric bypass Post surgery -​ AVOID NSAIDS -​ Avoid prego 12-24 mo -​ Measure Bone density w/ DEXA 2 yrs post -​ Labs: A1C, CBC, complete metabolic, copper, PTH, lipid, Thiamine, TSH, Vit A, B12, Zinc Older Adults + Diabetes -​ Higher risk of cognitive decline -​ Poor glycemic control → decline cognitive fx -​ Goal -​ Decrease risk of hypoglycemia -​ Simplify medication list Screening for Cognitive Decline -​ Mini mental state examination -​ Mini-Cog -​ Monteral Cognitive Hypoglycemia -​ Increase risk for hypoglycemia due to age + renal dysfx -​ Ensure no repeat dose/no skip meals Respiratory Illness Cough Hx -​ Duration -​ Dyspnea at rest or exertion -​ Other a/c sx -​ Vitals (Tells the ACUITY of the cough) -​ PE Acute vs Chronic -​ Acute (3 wks) -​ Smoker: COPD, Cancer -​ Non-smoker: Normal CXRE not on ACEI most common cause PND, asthma and GERD Acute, Subacute, Chronic -​ Acute: asthma attack, Pulmonary edema, bacterial PNA, pneumothorax, Pulmonary embolism -​ Subacute: suggest exacerbation of preexisting airway disease -​ Chronic: Slow progression of disease w/ periods of time sx are minimal or absent -​ Paroxysmal nocturnal dyspnea: attack of severe shortness of breath that occur at night and usually awaken the patient from sleep A/c sx/exam findings to help w/ differential -​ Dyspnea (at rest/w/ exertion) reflect more serious condition -​ Cough-variant asthma: consider in adults w/ prominent nocturnal cough -​ Pneumonia: tachycardia, tachypnea, fever, rales, decreased breath sounds, tactile fremitus, egophony -​ Chronic sinusitis: PND, sore throat, facial pain -​ Presence of post-tussive emesis or inspiratory whoop, increases likelihood of pertussis; absence Paroxymal cough decrease likelihood in cough lasting more than 1 week -​ COPD: cough w/ phlegm production, abnormal match test -​ HF: symmetric basilar rales, elevated jugular venous pressure Test to consider -​ CBC, TB, BNP, pertussis -​ CXR for abnormal vitals/exam findings, if unexplained cough lasts >6 wks -​ Chest CT for PE r/o -​ PFTs if concern fro or known hx of asthma /COPD Dyspnea Overview -​ Subjective sensations -​ Cant take deep breaths -​ Running out of breath -​ Air hunger -​ Breathing fast Differential by system -​ Cardiac -​ Pulmonary -​ Obstructive -​ Restrictive  -​ Mixed cardiac & pulmonary -​ Non cardiac/ non pulmonary -​ Considered in pt w/ minimal risk factors for Pulmonary disease and no clinical evidence of cardiac or pulmonary disease Cardiac Pulmonary Mixed Cardiac-Pulmonary Non Cardiac-Non Pulmonary -​ CHF -​ COPD -​ COPD w/ -​ Metabolic acidosis -​ CAD -​ Asthma Pulmonary HTN -​ Pain -​ MI -​ Pneumothorax -​ Deconditioning -​ Neuromuscular -​ Cardiomyopathy -​ Pneumonia -​ Pulmonary disorders -​ Valve dysfx -​ Restrictive lung embolism -​ Laryngeal disorders -​ LVH disorders -​ Trauma -​ Upper airway -​ Pericarditis -​ Hereditary lung obstruction -​ Arrhthmias disorders -​ Prego -​ Obesity -​ Anxiety; panic; hyperventilation Differential by Duration -​ Acute Dyspnea -​ Need to determine if emergency room is needed/stabilization/O2 -​ ED if: Severe dyspnea; New dyspnea at rest; sudden onset of chest pain -​ Look at vitals -​ Chronic Dyspnea -​ Lasting more than 1 month -​ Vitals maybe abnormal, but this may be patient’s baseline if dyspnea has been longstanding Acute Dyspnea Assessment -​ Must be able to recognize unstable patients: -​ Hypotension, alterned mental status, hypoxia, unstable arrhthmia -​ RR >40, retractions, cyanosis, low O2 sat -​ Upper airway obstruction: stridor, trying to breath w/o actual air movement -​ Tension Pneumothorax: Tracheal deviation, hypotension, unilateral breath sounds Histroy Sx (including Dyspena) Possible diagnosis Cough Asthma, Pneumonia Severe sore throat Epiglottitis Pleuritic chest pain Pericarditis, pulmonary embolism, pneumothorax, pneumonia Orthopnea, nocturnal paroxysmal dyspnea, edema Congestive heart failure Tobacco Use Chronic obstructive pulmonary disease, congestive heart failure, pulmonary embolism Indigestion, dysphagia Gastroesophageal reflux disease, aspiration Barking cough Croup Dyspnea on exertion/during rest Cardiac/pulmonary  Medications Beta blockers HTN LVH,CHF Anxiety Hyperventilation, panic attack Physical Wheezing, pulses paradoxus, accessory muscle use Acute asthma, COPD exacerbation Clubbing, barrel chest, decreased breath sounds COPD exacerbation Fever, Crackles, increased fremitus Pneumonia Edema, neck vein distention, S3 or S4, murmurs CHF Lower extremity swelling Pulmonary embolism Absent breath sounds, hyperresonance Pneumothorax Inspiratory stridor, rhonchi, retractions Croup Stridor, drooling, fever Epiglotittis Stridor, wheezing, persistent pneumonia Foreign body aspiration Wheezing, flaring, apnea Bronchiolittis, Dyspnea dx First line tests -​ Blood work -​ CBC (anemia) -​ TSH ( Hyperthyroidism) -​ Metabolic panal/anion gap (metabolic acid) -​ ABG (inpt) -​ CXR (FIRST LINE) -​ Skeletal abnormalities -​ Lung masses -​ PNA -​ Increase cardiac silhouette -​ EKG -​ Ischemia -​ Arrhythmias -​ Ventricular hypertrophy -​ Obstructive lung disease -​ Spirometry -​ Differentiate between Obstructive vs restrictive -​ Obstructive: COPD, Asthma -​ Restrictive: -​ Intrapulmonary - interstitial lung disease secondary to RA, lupus, fibrosis -​ Extrapulmonary - obesity, skeletal disorder, MS, muscular dystrophy If cause not identified progress to Second line tests: -​ Echo -​ Cardiac valve issue (murmur on exam) -​ Pulmonary function test -​ Stress tests  -​ Exercise Treadmill: order if hx suggest ischemia/CAD -​ Cardiopulmonary exercise test: Reserve for cases when dx still unclear -​ Chest CT -​ Soft tissue/blood vessels Dyspnea Management -​ Goals of tx: stabilization & improvement of sx, QOL -​ Specific management guided by underlying etiology -​ Supplemental O2 -​ Cardio-pulmonary rehabilitation -​ Smoking cessation if applicable Respiratory Illness ​ Acute Bronchitis Overview -​ Viral -​ Cough due to acute inflammation of trachea w/o evidence of PNA -​ May or may not have sputum or wheezing -​ Exam: wheezes/rhonchi that improve w/ cough -​ Prevention: vaccine-flu, RSV, Covid -​ Management -​ Sx care -​ Void OTC cold in children 2-3 wks consider testing for pertussis Indication for CXR -​ Dyspnea, bloody sputum, or rusty sputum color -​ Pulse >100 -​ RR > 24 -​ Oral Body Temp >100 -​ Focal consolidation, egophony, or fremitus on chest examination Strategies to reduce ABX use -​ Use delayed prescription strategies such as asking pt to call or pick up abx or to old on abx prescription -​ Address pt concerns in compassion -​ Discuss expected course of illness and cough duration (2-3 wks) -​ Expalin abx do not sig. Shorten illness duration Pneumonia Overview -​ Exam: Cough/SOB, fever, rales, rhonchi, tactile fremitus, increased vitals -​ Prevention: vaccines-PCV, flu, RSM, Covid -​ Management: abx: Amoxicillin or Doxycycline -​ Rule of thumb: broader spectrum fro more risk factors/co-morbiditis -​ Complications → death -​ Give abx even if viral to cover your ass Asthma Overview  -​ Exam: Exacerbation - high pitched wheezes, cough/SOB, may have increased vitals. Absent lung sounds if severe → ED! -​ PFTs: Decreased FEV1 or FEV/FVC ratio -​ Management -​ Goal: improve QOL, understand/manage triggers, reduce exacerbation -​ 2 pronged approach: rescue and prevent ​ Evidence based diagnosis and treatment: GINA -​ All pt need inhaled corticosteroid - even if mild/intermittent asthma sx -​ Albuterole-only PRN increases risk of death -​ GINA advocates for SMART therapy: single Maintenance and Reliever therapy -​ Combined ICS + LABA (symbicort): 1 inhaler used for both rescue and prevention Management -​ Spacer w/ inhaler -​ Peak flow home monitoring -​ Allergy testing -​ PCV, Covid, flu, RSV vaccines COPD Overview -​ Umbrella term w/ chronic bronchitis and emphysema; occur separately or together -​ Obstructive lung disease (asthma) where expiratory airflow limitation and bronchial hyper-responsiveness -​ But it is irreversible or only partially reversible -​ Exam: Exacerbation - Increased sputum amount, increased purulence of sputum, increased dyspnea, wheezes/crackles/rhonci, O2 sat decreased from baseline -​ PFTs: decreased FEV1 or FEV/FVC ratio -​ FEV/FVC 21 days (surgery maybe) Full thickness - 3rd degree Extends through and destroys all layers of dermis and often injure underlying subQ -​ Waxy white to leathery gray to charred black -​ Dry and inelastic to pressure -​ Blisters DO NOT develop -​ No blanching -​ Painful w/ deep pressure ONLY -​ Healing → surgery Impetigo Highly contagious, superficial bacterial infection most frequently found in children ages 2-5 Transmission -​ Infection is carried in the fluid that oozes from blisters -​ Spread by direct contact -​ PRedisposing factors: Warm temp, high humidity, poor hygiene, skin trauma. Microbiology -​ Staphylococcus aures -​ Streptococcus A -​ Combo of both Types -​ Nonbullous -​ Bullous Classification -​ Primary - direct invasion of normal skin -​ Secondary - infection at site of minor trauma Clinical presentation -​ Self-limited condition last 2-3 wks -​ Lesions may ich and/or burn -​ Regional lymphadenopathy -​ Systemic sx unlikely -​ Complications rare Nonbullous Clinical presentation -​ Red, crusting rash that begins w/ maculopapular lesions, expand in size and progress to thin walled vesicles -​ Vesicles → pustules that enlarge → break → form crust (honey-combed) appearance  -​ Occurs 2-3 wks and usually face and extremities Bullous Clinical Presentation -​ Large, fragile bullae that rupture -​ Ooze clear yellow turbid fluid -​ Ruptured bullae leave thin brown crusting of skin -​ Young children -​ Rarer -​ Trunk and face Diagnosis -​ Typical Clinical presentation dx and tx started w/o culture -​ DDX - herpes simplex/ varicella zoster/ insect bite/ contact derm/ atopic derm/ thermal burns Labs -​ Not generally done initially -​ Culture of pus Pharmacologic treatment -​ Topical abx -​ Mupirocin ointment 2% affected area TID x5 days -​ Oral abx -​ OTC abx ointment - bacitracin/neomycin/polymyxin Tick Borne Disease -​ Greatest risk of being bitten exists throughout spring, summer and fall. However, unless temperature below freezing, ticks are alive and capable of transmitting disease Conditions caused by Ticks -​ Lyme disease -​ Tularemia -​ Ehrlichiosis -​ Rocky mountain spotted fever -​ Anaplasmosis -​ Babesiosis Other conditions -​ Colorado tick -​ Powassan virus -​ Southern tick-a/c rash illness -​ Tick paralysis -​ Spotted fever -​ Relapsing fever -​ Heartland virus Clinical presentation -​ Fever/chills. All tick borne disease can cause fever -​ Rash. Lyme disease, southern tick-associated rash illness (STARI), Rocky Mountain spotted fever (RMSF), ehrlichiosis, and tularemia can cause distinctive rash -​ Aches and pains. Tickborne disease can cause HA, fatigue, and muscle aches. Ppl w/ lyme disease may also have joint pain Early Stage tick bite  -​ Early stage: small bump or redness at site of tick bite that occurs immediately that goes away in 1-2 days is not sign of lyme disease -​ Erythema migrains (EM) rash -​ Approx 70-80% -​ Begins at site 3 to 30 days avg about 7 days -​ Expands over several days reaching up to 12 in -​ Warm to touch but rarely itchy or painful -​ Clears as it enlarges: bull’s eye -​ Does not always appear classic erythema migrain rash Later signs and symptoms (days to months) -​ Severe headaches and neck stiffness -​ Additional EM rashes on other areas of body -​ Facial Palsy -​ Arthritis w/ severe joint pain and swelling of knee -​ Intermittent pain in tendons, muscles, joints and bones -​ Heart palpations or irregular heartbeat -​ Episodes of dizziness or SOB -​ Inflammation of brain and spinal cord -​ Nerve pain -​ Shooting pain *later signs of Lyme → swollen knees, irregular heartbeat, facial palsy* Lyme Disease -​ Lyme disease most common vector-borne disease -​ Caused by borrelia burgdorferi-I. Scapularis ticks are carriers -​ Prevention aimed at avoiding bites Treatment goal -​ Prescribe abx prophylaxis selectively Post Exposure Prophylaxis Treatment -​ High risk: All 3 must be present -​ Ixodes vector (black leg) -​ bite occurred in high endemic area -​ tick attached > 36 hrs Treatment -​ Administer tx w/in 72 hrs of tick removal -​ Adult: Doxyclycline 200 mg po x1 dose w/ food prophylaxis -​ Child: Doxycycline 4mg/kg not to exceed 200 mg Po x 1 dose Serologic Testing Obtain serological testing if patient -​ Resides or travel to area endemic -​ Risk factor for exposure to ticks -​ Sx consitent w/ early disease or late lyme Testing -​ Enzyme-linked immunoassay (ELISA): common and rapid test to identify Lym disease antibodies, is most sensitive screening -​ Indirect fluorescent antibody (IFA): Screens for Lyme antibodies -​ Western blot test Seborrheic Keratosis Clinical Presentation -​ Harmless, but unsightly -​ Stuck-on appearache, waxy and dulled surface -​ Friable, vascular, bleed relatively easily -​ Predilection for the face, neck and trunk, but can occur on the extremities -​ Many variations in pigmentation Treatment -​ Lesions removed because of irritation or for cosmetic reasons -​ Curettage or cryotherapy Actinic Keratosis Clinical Presentation -​ Easily palpated than inspected -​ Rough textured, Keratin scale -​ Few mm 1-2 cm -​ May be pink, erythematous, grey, brown -​ Occur in fair skinned folks w/ other signs of sun damage (liver spot) Treatment -​ Refer to Derm -​ Topical -​ 5-fluorouracil (5FU) twice daily for 3 weeks and can result in skin becoming raw, tender and red so noncompliance is an issue -​ Retinoids -​ Cryotherapy Dysplastic Nevi/Atypical Nevi Clinical Significance -​ A/c w/ increased risk of melanoma -​ Individuals w/ atypical nevi have 3 to 20 fold higher risk of melanoma Clinical Significance -​ Found in Trunk, extremities, rarely in sun exposed area Early detection skin cancer: Melanoma -​ Asymmetry -​ Border -​ Color -​ Diameter -​ Evolving Skin Cancer Screening -​ Self examin -​ No fam hx skin exam per routine visit -​ Derm surveillance if -​ Fam hx of melanoma -​ Presence of atypical moles -​ Presense of numerous actinic keratosis  -​ Mole mapping Squamous cell Carcinoma Basal Cell Carcinoma (most common) Malignant Melanoma - Most deadly -​ Arises in epithelium -​ Nodular, superficial, pigmented -​ Malignant neoplasm -​ Common in middle-aged and elderly varieties -​ Able to metastasize populations -​ Pearly surface -​ Incidence rising -​ Appear as papules, plaques or -​ Rolled edge nodules that are skin colored, pink -​ Central umbilication or erosion or red -​ Friable -​ May be smooth, keratotic, ulcerated or indurated painful, pruritic or friable Herpes zoster (Shingles) -​ Acute vesicobullous eruption seen in dermatomal distribution w/ sharp demarcation -​ Reactivation of varicella virus -​ Increased in elderly + immunosuppressed -​ Triggered via stress, chemo, xrt (radio therapy) -​ Pre-eruptive phase 4-5 days prior -​ Pain, pruritus, burning, tender, flu, lymphadenopathy -​ Presents w/ red swollen vesicles of various sizes spread along dermatome -​ Spread only when vesicular rash Treatment -​ Antiviral tx for pts fulfilling any of these criterias -​ >50 yo -​ Moderate severe rash or pain -​ Involvement of face/eye -​ Acute complication of infection -​ Immunocompromised state -​ Mild to moderate -​ Valacyclovir 1000 mg po tid x 7 days -​ Severe -​ Acyclovir 10 mg/kg IV Q8h 7-14 days Shingle Vaccine -​ 2 doses of RZV to prevent ≥50 yo -​ CDC recommends 2 doses RZM aged ≥19 who may be immunosuppressed Atopic Dermatitis (AD) -​ Overreactive immune response → produce proteins → trigger inflammation (red, dry, unbearable itch) -​ Scratching → weaken skin barrier: bacteria, virus and allergens enter -​ Common neck, arms, inside elbows, back of knee Physical Exam Findings  -​ Skin may manifest any following -​ Acute: vesicles, intense redness, blisters -​ Sub acute: red, scale, fissuring, parched to scalded appearance -​ Chronic: thickened skin, lichenification, excoriations, fissuring Treatment -​ Moisturize w/ ceramides -​ Topical corticosteroids: 1st TX reduce infalm, itch and infection -​ Topical Phosphodiesterase 4 inhibitor (PDE-4): crisaborole (eucrisa) ointment: reduce inflam, itch, and infection -​ Topical janus kinase inhibitor: Ruxolitinib (opzelura): short term tx for reduce infla,, itch for mild to mod >12 yo If no responde well ^ -​ Dupilumab -​ Phototherapy, cyclosporine, methotrexate -​ DO NOT RECOMMEND: SYSTEMIC CORTICOSTEROIDS Psoriasis -​ Chronic, genetic -​ Dysregulation of T cells -​ Trigger cytokine release which causes chronic inflammation -​ Trigger rapid accumulation of epidermal cells -​ Leads to raised, scaly, cutaneous plaques -​ Itching. Bleeding, burning, stinging, pain flares are triggered by physical or emotional stress Distribution -​ Favors: -​ Elbows, knees, scalp, gluteal cleft, fingernails, toe nails -​ Extensor surface, more than flexor surfaces -​ Can occur w/ or proceed psoriatic arthritis DDX -​ Atopic dermatitis -​ Contact dermatitis -​ Seborrheic dermatitis -​ Tinea -​ Candidiasis -​ Pityriasis rosea -​ Drug eruption Treatment -​ Cream/Systemic therapies/phototherapy Eczema vs Psoriasis -​ Eczema (in folds) → flexor surface -​ Psoriasis found in extensor surface GI Abdominal Pain Acute Abdomen  -​ Acute abdomen is defined as a sudden onset of severe abdominal pain developing over a short time period Location abd pain DDX Epigastric -​ PUD -​ GERD RUQ LUQ -​ Cholecystitis/Cholelithia ​ RLQ LLQ -​ Diverticulosis/Diverticulitis -​ Diverticulosis/Diverticulitis -​ Appendicitis All -​ Diarrhea/Constipation -​ Acute Abdominal pain Acute abdomen in Geriatrics -​ Older adults less likely to have pain and fever more likely to have sx of lethargy, hypotension and confusion Dx studies -​ CBC -​ Serum electrolytes -​ Amylase -​ Lipase -​ UA -​ Stool for occult blood -​ EKG -​ CXR -​ Flat plate and upright abd film to look for obstruction, ileus, perforation, biliary or renal stone Management & Special Considerations -​ Refer for surgical eval in acute sit. Appendicitis Cause -​ Blockage of appendiceal lumen, leading to distention of appendix → accumulate intramural fluid w/ secondary bacterial infection Signs -​ Early s/sx -​ Pain starts in epigastrium or periumbilical area then migration of pain to LQ -​ Abd rigidity -​ Acute onset of pain -​ After acute onset of pain you see: -​ Anorexia -​ N/V/C -​ Rarely diarrhea Physical exam -​ Physical assessment -​ McBurney point -​ Point on abd -​ Rovsing Sign -​ Palpate LLQ → pain RLQ -​ Obturator Sign -​ Rotation of right flexed hip while supine  -​ guarding/rebound tender = + -​ Psoas Sign -​ Hip extension laying sideways and extending leg on top -​ guarding/rebound tender = + Pediatric Consideration -​ Less common overall -​ Less prevalent in preschool children than children >5 -​ Same signs as adult Diagnosis -​ Diagnostic -​ CBC w/ diff (elevated white) -​ C reactive protein -​ HCG if appropriate (prego) -​ Sickle dx test -​ Stool guaiac -​ Imaging -​ Abd US or CT scan w/ contrast Management -​ Immediate ED/Surgery -​ Abx if uncomplicated GERD -​ Retrograde movement of gastric contents from stomach to esophagus -​ PPI help decrease acid BUT also decrease BMD -​ Max 8 wks Symptoms -​ Burning sensation in chest (heartburn/indigestion) -​ Pain temp goes away w/ antacid, milk, or baking soda -​ Sx often occur or worse after meal (food is trigger) -​ Older pt present w/ atypical or extrasophageal manifestation w/o heartburn -​ Dyspepsia, epigastric pain, Nausea, bloating, belching, asthma, chronic cough, and laryngitis -​ Those w/ atypical sx delay seeking care and first present w/ alarming sx like: -​ Dysphagia, odynophagia or vomiting Risk Factors -​ Eating large meals or lying down w/in 3 hrs after eating -​ Wearing tight clothes -​ Obesity -​ Anxiety -​ Smoking -​ Opioid/ETOH use -​ Tomato based foods,spicy food Agents that lower Esophageal sphincter tone -​ Anticholinergi -​ Nitrates -​ Chocolate cs -​ Nicotine -​ Citrus/Spicy/ -​ Morphine -​ Alc high fat -​ Theophylline -​ Caffeine -​ Aspirin -​ CCB -​ Benzos Physical Assessment -​ History -​ Heart burn (30-60 min after eating -​ Exacerbated by lying supine or bending over  -​ Regurgitation -​ Sour stomach -​ Atypical sx -​ Dysphagia -​ Odynophagia -​ Chest pain -​ Hoarseness -​ Cough -​ Sore throat -​ Nausea -​ Asthma Physical Exam -​ Oral exam -​ Poor dentist -​ Loss of emmanuel -​ Halitosis -​ Mild epigastric tenderness Diagnostic Studies -​ Usuualy not required -​ Barium radiography poor screening test for GERD -​ EGD if sx persist on PPI -​ PH testing DDX -​ Esophageal motility disorders -​ PUD -​ Esophageal tumor -​ Cholelithiasis -​ Angina -​ Pill -​ Barrett Management -​ Promote sustained sx control and prevent complications such as stricture, Barrett esophagus and adenocarcinoma Complications -​ Respiratory -​ Aspiration pneumonitis -​ Asthma -​ Laryngeal granulomas -​ Subglottic stenosis -​ Other -​ Hemorrhage -​ Esophageal stricture -​ Barrett’s Esophagus -​ Adenocarcinoma FIRST LINE TREATMENT -​ Nonpharm -​ Decrease meal size/wt loss, raise HOB, Reduce ETOH, carbs, fatty, smoking, eliminate any food triggers -​ Medications -​ Antacids, alginic acid, or OTC histamine (H2RAs) - PRN -​ OTC = cimetidine (Tagamet), Famotidine (Pepcid), and Nizatidine (Axid) -​ Avoid meds that lower esophageal spingter tone or acidify gastric content -​ Anticholinergics  -​ Aspirins -​ Benzos -​ Opiates -​ Nitrates -​ Calcium channel antagonists 2nd LINE - PPI Therapy for GERD -​ Started when pt has more days than w/o sx -​ Tx of choice for moderate to severe GERD or GERD w/ any complications -​ PPIs: Omeprazole, Esomeprazole, Lansoprazole (OTC) -​ There is no clinically important diff in sx relief w/ any PPIs -​ 8 wk course once daily PPI -​ PPIs should be taken 30-60 min BEFORE MEAL PPI Therapy for GERD -​ Pt for whom acute medical therapy alleviates sx - a trial off med can be considered -​ Recurrance of sx is common after therapy stopped -​ Pt only partially respond to PPI - dosage increase or change in PPI can be tried -​ Pt who do not respond to PPI → endoscopy. pH monitoring Peptic Ulcer Disease ​ 2 common causes -​ H.Pylori -​ NSAIDs Clinical presentation -​ Epigastric pain-upper abdominal -​ Sharp, burning, aching or gnawing pain -​ Dyspepsia Assessment -​ History -​ Pain gnawing or dull ache -​ Pain relieved after meal → Duodenal -​ Pain worsen w/ meal → gastric -​ N/anorexia/wt loss -​ Physical -​ Nothing sig on abd exam -​ Mild, localized epigastric tenderness to deep palpation -​ Diagnostic Studies -​ CBC w/ diff -​ Serum chemistries -​ H pylori testing -​ Stool for occult blood -​ Barium radiography -​ DDX -​ GERD -​ Cholecystitis -​ Pancreatitis -​ Biliary Tract disorder -​ Gastric Carcinoma -​ CV disease Medication - H.Pylori -​ Pt risk factor for macrolide resistance -​ Bismut, metronidazole, tetracycline, and PPI -​ Reserve Clarithromycin for pt w/ H.pylori who demonstrate known susceptibility to clarithromycin Management  -​ If anemia, GI bleed, Rigid abd, wtf loss or new onset of dyspepsia in 50+ → REFER TO ED/GI NSAID - induced Ulcer treatment -​ D/C NSAID if possible, add standard dose of PPI or H2 blocker -​ If D/C not possible → add a continuous PPI or H2 blocker or misoprostol (cytotec) Diarrhea -​Definition: increased stool freq >3 BM liquid a day -​Many causes - goal to distinguish acute vs chronic -​ Acute: loose stools last 4 wks Risk factors -​ Travel -​ Ingesting contaminated food or water; fecal oral route -​ Salmonella, Shigella, Giardia -​ Medical Disease -​ Hyperthyroidism -​ UC/Crohns -​ IBS Acute -​ Non-inflammatory -​ Watery, non-bloody stool -​ Abd cramping, bloating, N/V -​ Caused by virus or noninvasive bacteria -​ Inflammatory -​ Blood, pus, and/or fever -​ Smaller quantity, LLQ cramps, urgency, tenesmus (persistent feeling of needing to shit) -​ Caused by invasive toxin-producing bacterium -​ Dx required Chronic -​ Osmotic - r/t water retention -​ Secretory - Cholera -​ Inflammation - Crohns, colitis -​ Meds - Abx, antacids, PPI -​ Malabsorption syndromes - lactose intolerance -​ Motility disorder - peristaltic movement History -​ Normal pattern -​ Dirrhea that awakens someone from sleep (HUGE RED FLAG) -​ Sx relife w/ diet, OTC meds, RX meds -​ Magnesium antacids, laxatives, abx Physical Exam -​ Fever; wt loss -​ Signs of dehydration -​ Tachycardia, orthostatic hypotension -​ Poor skin turgor, decreased urine output -​ Abd exam may reveal hyperactive bowel sounds, generalized tenderness -​ Rectal exam, stool guaiac may be positive (fecal occult blood test) Diagnostic Studies -​ Pt mild, afebrile, acute diarrhea dx evaluation not indicated → viral or food borne (resolves by itself) -​ Acute inflammatory diarrhea -​ Stool culture, O&P, C.diff -​ Recent hosptialization -​ Fecal leukocytes  -​ Occult blood -​ CBC w/ diff -​ Chronic -​ Labs -​ CBC w/ diff, comp, glucose, LFTs, TSH -​ Imaging -​ KUB, CT abd, barium study, sigmoidoscopy, colonscopy w/ biopsy Treatment -​ Fluid + electro replacement -​ Nausea main complain -​ Zofran, Phenergan, Compazine -​ Antidiarrheal agents -​ Kaopectate, PeptoBismol, Loperamide -​ Chronic -​ Clonidine -​ Octreotide -​ Celiac avoid wheat Pediatric Considerations -​ Viral Gastroenteritis -​ Extraintestinal infection C diff or CDI -​ Severe diarrhea, usually after hospitalization w/ abx treatment -​ Treatment -​ Abx: Fidamoxin FIRST LINE -​ Avoid antiperistaltic agents (Loperamide) -​ Fecal transplant Older adults -​ Diarrhea → decrease QOL and sig death Constipation -​ Buttaro (bristol stool chart) -​ More common in women + elderly Pediatric Considerations -​ Fewer than 2 or fewer per week -​ Recent-onset if present 3 cultures positive episodes/year. Post menopausal person: >3 cultures positive + symptomatic UTIs in 1 yr or 2 UTIs in 6 mo -​ Complicated -​ DM/Immunosupp/reduced renal fx/ catheter UTI Acute age female> circum male -​ Dx requires culture (bagged urine) -​ Blood culture should be performed in infants w/ + UTI -​ Tx -​ IV abx -​ Dx -​ Abnormal UA and >50,000 cfu mL of urinary pathogen -​ Clean catch mid void only in older kids -​ Flank pain, persistent fever, other systematic sx suggest upper tract disease -​ Tx -​ IV if seriously ill -​ PO amoxicillin-Clavulanate 10-15 mg/kg UTI Acute Uncomplicated Female -​ Urine culture w/ recent UTI or areas high antimicrovial resistance -​ If STI risk and sx of urethritis, consider tx of chlamydia -​ Tx -​ Nitrofurantoin (Macrobid) 100 mg po bid x 5days UTI adult male -​ Dx w/ dysuria, frequency, urgency +/- suprapubic pain -​ If sexually active ro gonococcal cystitis and chlamydia infection -​ Any hint of obstruction evaluate via imaging ASAP -​ Tx -​ Adult: Cirpofloxacin 500 mg po bid x 5-7 days UTI complicated or catheter related -​ Complicated = obstruction, reflux, azotemia, transplant -​ Tx -​ Adult: ciproflaxicn 500 mg po bid or 400 mg IV q 12 x 7-14 days -​ Peds: Ciprofloxacin 6-10 mg/kg (400 mg max) IV q8 hours or 10-20 mg/kg (750 mg max) PO q 12h UTI Clinical Presentation -​ Adults -​ Frequency, urgency, burning on urination, nocturia, hematuria, low back or suprapubic pain, urinary incontinence or cloudy, foul smelling urine -​ Peds  -​ Nonspecific sx and signs (fever, irritability) UTI evaluation PEds -​ Not Toilet training → cath or suprapubic aspiration → NO COLLECTION BAG -​ Toliet Trained → clean voided specimen UTI eval female adult uncomplicated -​ Acute sx -​ Dysuria, Urinary freq. Or urgency and or suprapubic pain, particularly in the absence of vaginal sx (eg, vaginal pruritus or discharge) -​ If sx ^ → urine studies (clean catch, UA, dipstick, culture ) UTI eval male adult -​ Suspect if dysuria, urinary freq or urgency and/or suprapubic pain -​ Lab dx tools consist of urinalysis Urinalysis UTI Dipstick eval -​ Dipstick analysis -​ 88% sensitive but cheap and quicl -​ Leukocyte esterase -​ + = UTI but nonsepcific -​ Nitrate -​ + = UTI Urinalysis -​ Color → foods, meds, infection can alter -​ Specific gravity → hydration status and concetrating ability of kidneys -​ Increased → dehydration, glycosuria, SIADH -​ Decreased → Water intoxication, Diuretics, DM insip, adrenal insuff, aldosteronism, impaired renal fx -​ pH → 4.5-8 help identifying and manage UTI and Kidney stone -​ Protein → + indicated inflam kidney -​ Sugar → uncrontroleld sugar -​ Nitrates → specific but not sensitive not only indicate UTI -​ Leukocyte Esterase → neutrophils = infection/inflammation -​ Epithelial cell → contaminant -​ Ketons → sugar/DMII -​ Bilirubin → breakdown of hemoglobin -​ Urobilinogen → breakdown of bilirubin (hemolysis) -​ RBC → hematuria -​ WBC → infection Antibiotic Susceptibility -​ Determines wat abx will be effective -​ Susceptible → best choice -​ I​ ntermediate → may be effective give higher dosage or more freq. To achieve good effect -​ Resistant → not effective