CASE 1: HEALTH MAINTENANCE IN GENERAL

52 year old man with no active medical problems being evaluated during an annual physical
exam. No complaints on history, normal exam.

1. What is a health-maintenance exam? Preventative care for patients prior to development

of disease (primary)
2. What are the three parts of an adult health maintence exam? Screening for common
diseases (CV), screening for cancers, immunizations
Screening tests:
1. Cardiovascular disease:
a. HTN - check BP (everyone > 18)
b. Fasting lipid panel (Nonfasting lipids are accepatable in most primary prevention
patients who are not on lipid lowering theraphy since risk assessment doesn’t
include LDL; LDL measurements require fasting, whereas total cholesterol and
HDL change change minimally with fasting or nonfasting)
2. Cancer:
a. Colorectal cancer screening begins at age 50 - FOBT, flexible sigmoidoscopy (+/-
FOBT), colonoscopy, double contrast barium enema
b. Don’t offer PSA - insufficient evidence!

Immunizations:
1. Tdap (tetanus, diptheria, acellular pertussis) every 10 years or if he needs booster
protection against pertussis (many adults have waning immunity to whooping cough
leading to occasional outbreaks)
2. Influenza every year in fall or winter

HMEs generally:
● The goals are to identify the patient’s concerns, manage the current medical conditions,
identify risks for future conditions, perform rational and cost-effective screening, and
promote a healthy lifestyle
● Emphasis on prevention:
○ Primary prevention - prevent disease before it occurs, usually by managing risk
factors (eg statins to lower LDL and prevent CVD, removal of colon polyps)
○ Secondary prevention - reduce recurrence or exacerbations of disease

CASE 2: COPD

Summary: Man with long history of smoking presents with dyspnea, increased sputum
production, change in sputum character, coughing and wheezing

Most likely an acute exacerbation of COPD. Defined by three things: increase in coughing,
change in sputum character (producing sputum or change in color), and something else.

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Exam:
● Must assess oxygenation (pulse ox, ABG) and watch for signs of hypoxemia (cyanosis)
● Test for reversibility = increase in FEV1 of > 12% or 200 mL. Signals asthma instead
of COPD.

Appropriate acute treatment:

● Bronchodilator (act fast - albuterol, ipratropium is an anticholingeric that may be
synergistic),
● Systemic corticosteroids (need hours to work, but reduces length of exacerbation and
relapses).
● Give oxygen to keep PaO2 > 60 mm Hg and SaO2 > 90%.
● Antibiotic if increased or purulent sputum - pneumococcus, H flu, moraxella catarrhalis.
If severe, think klebsiella or psuedomonas.

Management of acute asthma and COPD exacerbation both include oxygen,

bronchodilators, systemic steroids

Interventions to reduce exacerbations:

● Smoking cessation - won’t reverse existing COPD, but will reduce rate of worsening
● Long-acting bronchodilator,
● Inhaled corticosteroid,
● Influenza and pneumococcal vaccine

COPD generally
● Consider alpha 1 antitrypsin deficiency in caucasians with emphysema before age 45
● Earliest symptom is cough with white sputum. Becomes yellow or green with bacterial or
viral infection.
● Dyspnea is the primary presenting symptom - by the time it starts, FEV1 is at 50% and
COPD has been present for years.
● Normal FEV1/FVC > 0.7 With COPD, FEV1/FVC < 0.7. - both are reduced, but FEV1 is
especially reduced.

Stage Class Findings Treatment

0 At risk cough and sputum Vaccines and risk factors

Normal spirometry

1 Mild COPD FEV1/FVC < 0.7 Short acting

FEV1 is still > or = 80% bronchodilator (albuterol
predicted. + ipratropium, an
+/- symptoms anticholinergic)

2 Moderate FEV1/FVC < 0.7 Short acting bronchodilator

FEV1 50-80% + long acting

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 +/- symptoms bronchodilator
(salmeterol + tiotropium,
oral methylxanthines)

3 Severe FEV1/FVC < 0.7 Short acting bronchodilator

FEV1 30-50% + long acting
+/- symptoms bronchodilator + inhaled
steroids (fluticasone,
triamcinolone,
mometasone) - fewer side
effects than systemic.
Reduces frequency of
exacerbations, won’t help
decline.

Think Steroids for Severe

COPD.

4 Very severe! FEV1/FVC < 0.7 Short acting bronchodilator

FEV1 < 30% or < 50% w/
chronic hypoxemia
(PaO2 < 55 mm Hg or
SaO2 < 88% at rest or
PaO2 < 60 if polycythemia
or signs of right heart
failure)
+ long acting
bronchodilator + inhaled
steroids + long term
oxygen - must be worn 15
hrs/day. The only
intervention that improves
mortality!

Consider surgery

Unites States Preventative Task Force Guidelines:

1. Level A: High certainty of substantial net benefit
2. Level B: High certainty of moderate benefit or moderate certainty of moderate-to-
substantial benefit
3. Level C: May be worthwhile to provide the service to an individual patient. Moderate or
high certainty that there is no net harm.
4. Level D: Moderate or high certainty that there is no net benefit or that harms outweigh
benefits
5. Level I: Insufficient evidence to make recommendations

CASE 3: JOINT PAIN

Major causes: Crystal induced arthritis, infection, osteoarthritis, rheumatoid arthritis

Diagnosis: Must do joint aspiration to identify crystals and rule out infection - sepsis can
damage cartilage w/in 24 hours. Don’t go based on fluid appearance - both crystals and
infection can be chalky/yellow.

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Differential for Nontraumatic Joint Pain? Crystal-induced arthritis, infection, osteoarthritis, RA
Treatment of acute vs chronic gout? Acute = NSAIDs, colchicine, glucocorticoids (in elderly give
steroid injections/ice packs/low dose colchicine due to GI a/es). Chronic maintains low serum
uric acid with allopurinol or probenecid.

1.) Crystals
● Diagnosis: WBC = 2k to 60k with less than 90% neutrophils (contrast infection ~100k).
See crystals.
● Different kinds:
○ Classic monosodium urate. Serum uric acid can be normal or even low during
acute attacks (b/c of deposition) but useful to monitor therapy btwn attcks. Men
30-50 y/o, post-menop women 50-70 y/o. Treat acute attacks w/ steroids,
NSAIDs, colchicine (be careful of GI side effects in elderly). Chronic treatment w/
allopurinol or probenecid to decrease uric acid levels.
○ Calcium pyrophosphate dehydrate - rod shaped, rhomboid, weakly positive
birefringence. Causes psuedogout
○ Calcium hydroxyapatite - electron microscopy to see cytoplasmic inclusions,
not birefringent
○ Calcium oxalate - bipyramidal appearance, strongly positive birefringence.
Mostly ESRD.

2.) Joint infection

● Becomes septic via blood innoculation, contiguous infection, or direct innoculation from
trauma or surgery
● Must exclude the diagnosis first w/ joint aspiration! Can destroy cartilage w/in 24 hrs
● One joint → bacterial. Chronic + 2-3 joints → suspect fungus or TB. Acute + > 3 joints →
think endocarditis or disseminated gonoccocal infection.
● Signs/symptoms: limited range of motion is characteristic (due to pain, effusion, fever),
unlike cellulitis or osteomyelitis. Positive culture in 90%.
● Risk factors for joint infection:
○ RA (most common) b/c of chronic inflammation + steroids → staph aureus
○ HIV → strep pneumo, salmonella, H flu
○ IV drugs → strep, staph, gram negatives, psuedomonas
● Treatment: Drain joint, give IV abx. Use vancomycin for MRSA but should be culture
specific.

3.) Osteoarthritis
● Associated w/ obesity (knee), trauma, repetitive joint use.
● Symptoms/signs: dull deep aching pain, gradual onset, worse w/ use. Bony crepitus w/
passive ROM. xrays are usually normal at first.
● Treatment: mobility exercises to maintain ROM, weight loss if appropriate. Intra-articular
cortisol injections every 4-6 months (not too soon to avoid cartilage damage). Joint
replacement for severe disease.

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4.) Rheumatoid Arthritis
● Swelling in at least one joint, often multiple joints involved (especially small joints), can
have RF/ anti-CCP (citrullinated protein): more specific and may precede disease by
years, and low albumin - correlates w/ disease severity.
● Treatment:
○ exercises, physical + occupational therapy.
○ Meds = NSAIDs, glucocorticoids, DMARDs (sulfasalazine, methotrexate),
anticytokines (etanercept & infliximab both target TNF), topical analgesics.
○ Monitor hepatoxicity

CASE 4: PRENATAL CARE

Date the pregnancy = LMP start date - 3 months + 7 days. Refer to a high risk provider if
diabetes, asthma, thyroid disease, HTN, lupus, thromboembolism, seizures

Ultrasound is not mandatory - only truly need it to evaluate uncertain gestational age,
size/date differences, vaginal bleeding, multiple gestations, placental location, and other high-
risk situations.
● Ultrasound dating is accurate within 1 week if performed in 1st trimester, w/in 2 weeks in
2nd trimester, 3 weeks in 3rd trimester.

Prenatal visits: every 4 weeks through week 28, then every 2 weeks through week 36,
then weekly.
● First prenatal visit:
○ CBC. Repeat at 28 weeks if at risk of anemia. If Hgb < 10.5, risk of preterm
delivery, low fetal iron stores, might have thalassemia. Treat mild anemia w/ iron.
Moderate - check ferritin and Hb electrophoresis.
○ Disease testing:
■ Hep B surface antigen - if +, check LFTs and hepatitis serology to
determine active hepatitis vs. chronic carrier. Baby will need Hep B
immune globulins and Hep B vaccination.
■ HIV ELISA and follow with PCR or western blot. If positive, offer anti-HIV
meds, elective cesarean, and IV zidovudine during labor → reduce
transmission from 25% to 2%.
■ Syphillis w/ rapid plasma reagin (RPR), then specific antibody test like
MHA-TP if positive. Must stage the disease. Repeat at 28 weeks if at risk.
■ PAP smear for gonorrhea (blindness, preterm delivery - treat w/
ceftriaxone) and chlamydia (blindness, pneumonia - treat w/
azithromycin or amoxicillin).
● If ASC-US - repap post partum, LGSIL or HSIL → colposcopy
■ Group B strep - culture lower vagina, rectum, and perineal area at 35-37
weeks. 10-30% are positive. Treat w/ IV penicillin at the time of labor
or rupture of membranes to reduce GBS infection - if not available, can

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 use IV ampicillin. If allergic to penicillins, can do cephalothin,
erythromycin, clindamycin, and vancomycin. If bacteriuria, give abx during
pregnancy.
○ Immunity testing:
■ Rubella antibody - if not immune, vaccinate after delivery.
■ Blood type and Rh status. If Rh negative, follow with antibody screen
(indirect Coombs test). Lewis lives , Kell kills, Duffy dies
● If negative, there is no isoimmunization. Give Rho(D) immune
globulin at 28 weeks, at delivery, and if any risk of 0.1 mL of blood
mixing - trauma, bleeding, CVS, amiocentesis, etc. Can give
before 12 weeks if threatened abortion.
○ Otherwise, first pregnancy will make IgM antibodies - do
not cross placenta, so no risk to baby.
○ Later pregnancies will take place with IgG → do cross
placenta. Risk of extravascular hemolysis in the baby →
(1) elevated BR and risk of kernicterus; (2) anemia → high
output heart failure and myocardial ischemia; (3)
extramedullary hematopoeisis → decreased liver
production of plasma proteins → decreased oncotic
pressure → ascites, pericardial effusion, pleural effusion,
subcutaneous edema.
● If positive antibody screen and it’s confirmed as Rh (anti-D), then
assess titer to learn fetal effect. Low titer → observe, high titer →
further testing w/ ultrasound (look at Middle Cerebral Artery
velocity - increased with anemia) and maybe amniocentesis.
● Screen for other RBC antibodies: Lewis doesn’t cross placenta,
Kell suppresses erythropoeisis.”Lewis lives, Kell kills”
○ Urinalysis + culture to look for asymptomatic bacteriuria (100k+ bugs/mL) -
increased risk of pyelonephritis, preterm birth, low birth weight. Must treat.
● Tests at every visit: weight, BP, fundal height, fetal heart tones w/ Doppler, urinalysis for
protein, glucose, and infection.
○ Screen for gestational diabetes at 24 to 28 weeks, unless very low risk.
■ Start w/ 1 hour 50g glucose challenge - abnormal if > 140. If positive, 3 hr
glucose tolerance test - get fasting, 1 hr, 2 hr, and 3 hr values. Positive if
2/4 are positive.
● Induce between 41 and 42 weeks.

Genetic screening for trisomies

● 1st trimester:
○ Ultrasound for nuchal translucency.
○ At 10-13 weeks, can add hCG & PAPP-A (pregnancy associated plasma protein)
● 2nd trimester during weeks 15-20:
○ Triple screen = hCG, AFP, estriol. 95% specific, but higher false negative rate -
approximately 65% sensitive.

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 ○ Quadruple screen = hcg, AFP, estriol + inhibin A. 95% specific, quadruple is
80% sensitive.
● Increased risk of aneuploidy if mom is > 35 yrs w/ singleton or > 32 yrs with multiples.
Offer:
○ 10-12 weeks: CV sampling with AFP testing. Has 1-1.5% risk of miscarriage,
risk of limb deformity is 1 in 1000 to 1 in 3000
○ 15+ weeks: amniocentesis. Has 0.5% risk of miscarriage.

Vitamins: Should take 400-800 micrograms of folic acid.

● DM or Epilepsy → 1 mg. Epileptics should continue to take anticonvulsant meds, but
might change type. Eg., valproic acid has a high risk of neural tube defects.
● Previous neural tube defect → 4 mg.

Vaccinations: Can give killed influenza and tetanus during pregnancy. Do not give varicella,
rubella, or live influenza during pregnancy.

CASE 5: WELL CHILD EXAM

Screening in infants:
● All states require PKU and hypothyroid. Other common screening includes Hgb-
opathies, galactosemia, other inborn errors of metabolism
● Lead poisoning: Screen at 1 year and 2 years when > 25% of homes were built before
1950 or when >10% of kids have venous lead concentrations of > 10 micrograms/mL.
Also target high risk kids.
● Anemia: Screen at 6 months, 1 year, and annually. Use Hct or Hgb. Risk factors: drink >
24 oz cow’s milk, iron restricted diet, low birth weight or preterm, mom is iron deficient.
○ Try an iron supplement, dietary modification - if fail to respond, investigate
further.
● Hearing: Newborns - auditory brainstem response or evoked otoacoustic emission.
Older infants/toddlers - question parents, snap fingers. > 4 yrs - office based audiometry.
○ Risk factors: FH, neurofibromatosis, bacterial meningitis
● Vision: Infants - red reflexes → r/o congenital cataracts and retinoblastoma. Screen for
strabismus with symmetric reflection from the cornea, cover/uncover test - if strabismus,
uncovered eye deviates to focus on the object. Refer to ophthamology to avoid
amblyopia! After 3 yrs, use vision chart (E’s, etc).
● TB: Screen kids who were born or who live in areas with high TB prevalence, or who live
with someone who has TB. Do PPD.
● Hyperlipidemia: Screen between 2-10 yrs w/ serum fasting lipid panel if FH of
dyslipidemia, FH or premature CV dz, unknown FH, other CV risk factors, overweight
(85th-95th) or obese (95th), HTN (> 95th percentile), cigarette smoking, or DM

Physical development
● Head circumference: plotted in kids < 3 yrs
● BP in kids > 3 yrs

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 ● Failure to thrive: weight below the 3rd or 5th percentile for age, or decelerations in
growth that have crossed two major growth percentiles in a short period of time.

Skills Development:
● Gross motor
● Fine motor/adaptive
● Language
● Social/personal skills

Leading causes of death:

● < 1 yr: SIDS. Sleep on back!
● > 1 yr: accidents and injuries - especially car accidents.
○ Kids should ride in back seat. If no back seat, only ride in front if no air bag or air
bag is disabled. Rear facing car seat until 1 year AND > 20 lbs. Forward car
seat until 40lbs, then booster seat. Can stop using the booster when can sit
with back at the seat and legs over the front - at least 4’9” and 8-12 years.
Don’t ride in the front seat until > 13 y/o.
○ Set hot water heater < 120 degrees.

Nutrition
● Introduce cereal, baby foods, and water between 4-6 months
● Whole cow’s milk at 1 year. Continue until 2 yrs, then switch to 2%.

Vaccinations:
● True CI: severe illness (not minor), history of anaphylactic rxn to a specific vaccine or
a component (wheezing, hypotension).
● Specific vaccinations:
○ HepB x3: 3 doses between birth and 1.5 years.
■ Birth, 1-2 months, 6 months - 1.5 years
○ Rotavirus (x2 if rotarix, x3 if rotateq): 3 doses between 2 months and 6
months
■ 2, 4, 6 months
○ Hib x3, maybe a booster: 3-4 doses between 2 months and 15 months
■ 2, 4, 6 months, then booster 12-15 months
○ DTap x5: 5 doses between 2 months and 6 years, then switch to Tdap 11-12
years.
■ 2, 4, 6 months, 12-18 months, 4-6 yrs. Then Tdap at 11-12 yrs.
○ Inactivated polio (NOT ORAL) x4: 4 doses between 2 months and 6 years
■ 2, 4, 6-18 months, then 4-6 years
○ MMR and varicella x2: once at one year, then once at 4-6 years
■ 12-15 months, 4-6 yrs
○ Hep A x2: 2 doses between 1-2 years
○ Meningococcus (x1) and HPV (x3 over 6 months): 11-12 yrs. The antibodies
are stronger when it's given younger.

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 CASE 6: ALLERGIC DISORDERS

Allergic rhinitis:
● Signs and symptoms: Itchy eyes, nasal congestion and discharge, often seasonal but
not always. Mucosa of nasal turbinates is swollen (boggy) w/ pale blue-gray color.
Secretions are thin and watery, but can be purulent like a bacterial infection. Can have
fatigue, malaise, allergic shiners.
● Mechanism: Exposure to foreign proteins → IgE produced and coats mast cells → 2nd
exposure causes mast cell degranulation → immediate release of histamine, production
of leukotrienes and prostaglandins.
● Treatment:
○ Avoid allergens if at all possible
○ Meds:
■ Antihistamines: NOT FOR ASTHMA - only for allergies
● First generation includes diphenhydramine, chlorpheniramine,
and hydroxyzine - can cause sleepiness and anticholingeric
effects (dry eyes, dry mouth, blurred vision, urinary retention). Be
careful with elderly patients.
● Second generation = loratadine, desloratadine, fexofenadine,
and cetirizine - less penetration into CNS, so less sedation
(except cetirizine)
■ Decongestants - oral or intranasal, constrict blood vessels. Usually
psuedoephedrine. Oral - can cause sympathetic side effects. Can also
get rebound hyperemia and worsening of symptoms with chronic use or
discontinuation.
■ Corticosteroid nasal sprays: Most effective treatment for long term
management of mild-moderate symptoms. Side effects = pharyngitis,
nose bleeds, URIs. Require 2-4 weeks to kick in.
■ Leukotriene inhibitors: for both allergic rhinitis and persistent asthma.
■ Oral corticosteroids: Only for severe allergies
■ Desensitization therapy: requires lots of shots

Conjunctivitis: caused by bacteria or viruses (most), or allergies or chemicals.

● Bacterial: usually strep, staph, H flu, moraxella, and psuedomonas. No blurring of vision,
only minor discomfort. Usually resolves within 2 weeks but can give sulfonamides.
● Viral = epidemic keratoconjunctivitis (pink eye): most often adenovirus. Usually have
fever, malaise, pharyngitis, and preauricular lymphadenopathy. Red eyes, lots of watery
discharge. Give sulfonamides to prevent secondary bacterial infection. Maybe weak
topical steroids to treat corneal infiltrates. Usually lasts 2 weeks.
● Allergic: itching, tearing, redness, stringy discharge, sometimes photophobia. Treat w/
oral or topical antihistamines or anti-inflammatory eye drops.
● Chemical

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 CASE 7: TOBACCO

Pregnancy category B = reassuring but uncertainty remains: No harm to animal fetus but
human studies aren’t available OR harm to animal fetus but human fetus has been fine

Pregnancy category C = be worried: Harm to animal fetus and no studies in humans OR no

human or animal studies
● Includes buproprion and varenicline - haven’t been studied in pregnancy! Pregnant
smokers should be encouraged to quit without any meds.

Pregnancy category D = bads news: Human studies showed potential harm, but benefits of
treatment might outweigh (nicotine replacement products)

Tobacco use is the #1 cause of preventable death!

Discuss tobacco using the 5 A’s:

1. ASK about tobacco use
2. ADVISE to quit through clear personalized messages - let the patient know of his
specific risks and connection to health
3. ASSESS willingness to quit - what does the patient think about quitting? Ready to
proceed?
4. ASSIST: individual, group, or telephone counseling and pharmacologic treatment.
5. ARRANGE follow up and support

If no desire to quit, provide interventions that increase future quit attempts (motivational
interviewing, 5 R’s enhancing motivation)
● 5 R’s: Discuss the specific RELEVANCE of smoking cessation, RISKS of ongoing use,
REWARDS to quitting (financial, health, social), ROADBLOCKS to quitting (withdrawal,
discouragement because of past failed attempts, enjoyment of smoking), and
REPETITION (reminding at every visit, reminding that most people have to try several
times before being successful)

Meds: Two classes - nicotine replacement and non-nicotine meds (buproprion and varenicline).
Insufficient evidence for use in smokeless tobacco users, light smokers (< 10 cigarrettes/day),
teens, pregnant women.
● Buproprion: blocks norepi and dopamine reuptake. CI’ed in patients with eating
disorders, MAO use in the past two weeks, or seizure. Start two weeks before quitting,
continue for up to 6 months. Can use solo or with nicotine replacement. Success = 30%
vs. 17% in placebo group. Can cause insomnia, dry mouth.
● Varenicline (Chantix): nicotinic receptor partial agonist that can reduce cravings,
withdrawal, and block nicotine binding from smoking. Similar efficacy to bupoprion.
Hasn’t been studied w/ nicotine replacement. Start 1 week before quit date. Risk of
agitation, depression, suicidal behavior, nausea, trouble sleeping and weird dreams
(“patient reports makes you go crazy”)

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 ● Nicotine replacement: patch + as needed replacement is best. Can do any
combination.
○ Nasal inhaler has the highest peak level, greatest risk of dependence
○ Nicotine gum delivers more nicotine than the nasal spray.
○ Acidic drinks (Coffee, soda, juice) can reduce absorption of nicotine from the
buccal mucosa - avoid ingesting w/in 15 mins of these things.
○ Patch - 8 weeks is as effective as longer periods.

CASE 8: MEDICAL ETHICS

STDs
● Must report communicable disease to the Dept of Health - can use an agent (staff
member). Federal mandate to report - failure to do so → legal, civil, criminal penalties. In
TX, failure to report is a class B misdemeanor.
● Must inform partners by either: (1) patient referral or (2) dept of health staff. If patient is
unwilling to inform the partner, the physician must inform the partner if they know the
person

Teen Pregnancy
● Considered emancipated in some states - can make all decisions about pregnancy
related health except abortion. Emancipation ends the parents’ duty to support the
minor.

Mature minors and confidentiality in general

● “Mature minor doctrine” or “judicial bypass” - judicial system can deem the minor to be
mature → exception to the need for parental consent for medical care. Must go through
the courts.
● Emancipation: Not living with parents, self-sufficient, married, pregnant or a parent, or
declared emancipated.
● Sometimes kids can consent to medical care based on the type of care they are seeking
- maternity services, contraception, STD care, drug/alcohol problems, sexual assault or
mental health.
● Only disclose medical information when the life of the adolescent is at risk
● Adolescents aren’t responsible for medical bills - have to keep this in mind and act in
their interest, just can’t just disclose to parents when trying to collect

CASE 9: GERIATRIC ANEMIA

● Anemia: Hgb < 12 g/dL in women and < 13 g/dL in men.

● 9-45% of patients over 65 are anemic! Especially non-hispanic blacks (biologic). Men >
anemia than women later in life.
● It’s a risk factor for increased morbidity and mortality and decreased QOL.

Symptoms: fatigue, dyspnea, weakness - can make underlying conditions worse

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Signs: conjunctival pallor - signals Hgb < 9 g/dL. Jaundice - hemolytic anemia, splenomegaly -
thalassemia or cancer
Treatment: Transfuse if Hgb < 7 g/dL. Can transfuse with higher Hgb if patient is
symptomatic or has a comorbid disease like CAD.

Normocytic
● Anemia of chronic disease: most common cause of normocytic anemia in the elderly.
Can also present as microcytic anemia. Iron stores (measure with ferritin) are normal.
Doesn’t improve with supplemental iron!
○ If b/c of CKD and on dialysis, goal Hgb is only 10-12! Otherwise increased risk of
death and CV events
● EPO deficiency: Can get normocytic anemia with renal failure

Macrocytic anemias:
● B12 deficiency: Neuro symptoms like dementia, confusion, decreased position and
vibration sense, ataxia, paresthesia AND glossitis, pearly gray hair at an early age.
○ Look for high homocysteine AND high methylmalonic acid!
○ Most often caused by pernicious anemia → no intrinsic factor to assist in B12
absorption. Check with gastric endoscopy to look for atrophic gastritis.
○ Also seen with gastrectomy, diseases associated with malabsorption (Crohn’s,
celiac, bacterial infection), veganism. Takes awhile to manifest, body stores
last 5 years.
● Folate deficiency: like B12 but no neuro signs! Look for high homocysteine!
Alcoholics at risk

Microcytic anemias
● Iron deficiency: koilonychias, glossitis, dysphagia. Can be a sign of GI cancer or other
GI bleeding.
○ Treat w/ oral iron. Use parenteral iron if GI absorption is poor and the patient
needs a lot of iron.
● Anemia of chronic disease
● Thalassemia

CASE 10: DIARRHEA

Suspect acute gastroenteritis → order fecal leukocytes. Worry about dehydration, electrolyte
imbalances
● 90% of acute diarrhea is infectious - viral >> bacteria, viral spreads especially easily
(wash hands, stay home from school). The rest caused by meds, ischemia, toxins.
○ Food:
■ Chicken → Salmonella or shigella
■ Raw seafood - vibrio, salmonella, hepatitis A
■ Undercooked hamburger → enterohemorrhagic e coli
■ Mayo → staph aureus, salmonella

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 ○ Timing
■ W/in 6 hours → staph aureus (think staph is phast!)
■ W/in 8-12 hours → Clostridium perfringens - “Clostridium after you’re
off the clock from a day’s work”
■ W/in 12-14 hours → E coli. “E colley slowly makes its way through the
colon”
○ Context:
■ Traveler’s diarrhea: Usually e coli
■ Day care: shigella, giardia, rotavirus (esp in winter)
■ Abx: c diff
● Type of diarrhea
○ Watery diarrhea: E coli, shigella, giardia, amebiasis
○ Bloody diarrhea: Invasive species like hemorrhagic or enteroinvasive e coli,
yersinia, shigella, entamoeba histolytica

Usually self-limited and does not require work up.

● Exceptions for complicated diarrhea and in certain patients: profuse, dehydration, fever
> 100.4 (38), bloody, severe abdominal pain, lasts longer than 48 hours, kids, elderly,
IC’ed
● Exam: vital signs, assessment of volume status (mucous membranes, skin turgor,
capillary refill), abdominal exam
● Labs: Stool culture usually takes several days, so not very useful in the acute setting.
Parasites are unlikely. C Diff after any antibiotic.

Treatment:
● Fluids and electrolytes. If can tolerate oral rehydration, use something with electrolytes
(pedialyte, etc).
● Probiotics (lactobacillus, saccharomyces) can reduce the incidence of abx associated
diarrhea and the duration/severity of all cause infectious diarrhea (Level A evidence)
● Antimotility/antisecretory meds - slow frequency of stools, but won’t speed recovery and
can actually prevent the body from getting rid of some bugs
● Antibiotics - can help with parasites, sometimes with bacteria. Not with viral
○ Usually a fluoroquinolone = ciprofloxacin 1-3 days. CAN’T BE USED IN KIDS
OR PREGNANT WOMEN - use azithromycin instead.
○ Traveler’s diarrhea caused by E coli - can use cipro, azithromycin, or
rifamixin, but won’t work if fever or blood in the stool
○ C Diff: rifamixin or oral vancomycin
○ Antibiotic prophylaxis for traveler’s disease isn’t recommended unless the patient
is at increased risk for complications, such as with inflammatory bowel disease,
renal disease, or IC’ed. Use flouroquinolones.

CASE 11: HEALTH MAINTENANCE IN ADULT FEMALE

Cancer screening

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 1. PAP smears: Have decreased cervical cancer rates! Start at age 21 or within 3 years of
the onset of sexual activity. Stop at age 65 unless risk factors - new partner, recent
abnormal PAPs, etc.
a. Annually until have three normal annual PAP smears, then every 3 yrs, but
no strong consensus across different expert organizations.
b. Can be discontinued following hysterectomy for benign indication if cervix is
gone, too. But continue if cervical dysplasia was present and/or if cervix remains.
c. Most cervical cancer happens in women who haven’t been screened in 5 yrs or
who didn’t follow up on an abnormal PAP
d. HPV vaccine - recommended in kids ages 9 to 26. Does not affect PAP
screening intervals.
2. Mammogram: Most abnormalities found are NOT breast cancer! Every 2 years for
women over 50, individual decision for women over 40.
a. Clinical breast exam - insufficient evidence
b. Breast self exam - NOT recommended.
3. BRCA testing
a. First degree relatives
i. 2 with breast cancer, w/ one < 50 yrs old
ii. 1 with bilateral breast cancer
b. First or second degree relatives:
i. 3 with breast cancer at any age
ii. 2 with ovarian cancer
iii. Anyone with breast and ovarian cancer
iv. Male with breast cancer

Osteoporosis: HALF of all post menopausal women will have an osteoporosis related fracture!
Risk increases w/ age, smoking, weight, white/asian, family history, sedentary life, low calcium
intake.
● In men: risk factors include prolonged corticosteroids, diseases that alter hormone levels
(chronic kidney, lung), undiagnosed low testosterone levels
● Screening: DEXA scan is best for predicting hip fracture. Screen women over 65, or 60
if risk factors
○ Osteoporosis = T score < -2.5, osteopenia if -2.5 < T score < -1.0.
● Prevention: All women over 50 should take 1200 mg calcium and 400-800 mg
Vitamin D daily. Use supplements if diet isn’t enough. Do exercises.

Cardiovascular disease: number 1 killer of women in the US. Screening rec’s are similar as to
those for men.
● Blood pressure: all women over 18 yrs
● Lipids: all women over 45
● Hormone replacement is NOT recommended for prevention of chronic conditions -
increased rates of adverse CV outcomes, whether estrogen solo or estrogen +
progesterone.

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Domestic violence: USPSTF found insufficient evidence to recommend for or against
screening or that screening affects outcomes, but other groups recommend screening
● Risk factors: Young age, low income, pregnant, mental illness, alcohol or substance use,
separated or divorced, childhood abuse
● Reporting is mandatory in some states

CASE 12: MSK INJURY

Sprain: stretching or tearing of a ligament

Strain: stretching or tearing of a muscle or tendon (remember “sTrain a Tendon or muscle”)

MSK injuries generally

● Exam: inspect, palpate, active and passive ROM, strength, neurovascular status, special
tests
○ Dislocated joint or joint effusion can limit both active and passive ROM, but
torn tendon or muscle injury will only limit active ROM
○ If you suspect that limited ROM is because of pain, can numb the joint by
injecting lidocaine and then reexamine
● Initial imaging is always xray - even with rotator cuff tears. Include at least 2 views at
90 degrees to each other.
○ If xray is normal and patient still has symptoms, or if suspect ligament or tendon
injury → get MRI Sensitive and specific for articular and soft tissue abnormalities
- ligament, tendon, cartilage.
● Treatment of sprain and strains:
○ PRICE = protection, rest, ice, compression, elevation
○ Start ROM exercises within 48-72 hours
○ The most common cause of persistently stiff, painful, or unstable joints
following sprains is inadequate rehab - refer patients to PT. But then if that
doesn’t work, go with more advanced imaging like MRI.

Ankle injury
● Sprain: Most ankle sprains result from inversion on an ankle that is plantar flexed. The
anterior talofibular (ATFL) ligament is the most commonly injured, followed by the
calcaneofibular ligament (CFL)
● Grading:
○ Grade 1: Stretch ATFL → pain and swelling. No mechanical instability or
functional loss.
○ Grade 2: Partial tear of ATFL, stretch CFL→ severe pain, swelling, and
bruising. Mild/moderate joint instability, significant pain w/ weight bearing, loss of
range of motion.
○ Grade 3: Complete tear of ATFL and CFL, partial tear of PTFL → significant
joint instability, loss of function, inability to bear weight.
● Evaluation:

15
 ○ Ottawa ankle rules are 100% sensitive for ruling out significant malleolar
and midfoot fractures.
■ Apply to nonpregnant adults with normal mental status (not drunk) who
don’t have any other injuries.
■ Only get an xray if bony tenderness or if patient can’t bear weight
immediately or when examined
○ ATFL: Anterior drawer test - pull forward on heel while stabilizing lower leg with
the other hand - tests the ATFL
○ CFL: inversion stress test
○ Squeeze tibula and fibula together at midcalf - test syndesomotic injury (high
ankle)

Rotator cuff
● Large tear - can’t lower arm slowly from a raised position, arm drops down
● Supraspinatus
○ Empty can test
○ Hawkins test - bend elbow to 90 degrees and hold bent arm horizontal with
shoulder and internally rotate hand
● Teres minor and infraspinatus → arms at sides, flex elbows at 90 degrees, externally
rotate against resistance
● Subscapularis → (1) internal rotation version of teres minor/infraspinatus test; (2) lift
off test - can’t lift dorsum of hand off small of back

Knee injury
● Get an xray under the Ottawa knee rules if: > 55 yrs, isolated patella tenderness,
tenderness at the head of the fibula, inability to flex the knee to 90 degrees, inability to
bear weight for four steps (regardless of limping)

CASE 13: SKIN LESIONS

Terms:
● Vesicle < 0.5 cm, bulla > 0.5 cm
● Papule < 1.0 cm, nodule > 1.0 cm
● Plaque - raised, solid plateau that covers large area

Four kinds of melanoma

● Superficial spreading melanoma = most common. Spreads superficially, then goes
deeper. Men get it on upper torso, women most often on legs. Look for raised borders
and mixed colors - brown with mixed pink, white, gray or blue
● Lentigo melanoma - most often in the elderly, chronically sun-damaged skin. Tan to
brown with very irregular borders
● Acral lentiginous melanoma - most common melanoma found in African Americans
and Asians. Found under the nails, soles of the feet, palms of the hands. Flat, irregular,
dark brown to black lesions

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 ● Nodular melanoma - Most aggressive type of melanoma - grow fast and are usually
invasive at the time of diagnosis, and the 2nd most common. Brown to black lesions.

A,B, C, D - < or > 6 mm, E - elevated or evolving

Excise melanoma with at least 5 mm margins, excise other lesions with at least 2 to 3 mm
margins
Melanomas < 1 mm thick have a good prognosis - worse prognosis with thicker lesions

CASE 14: HEMATURIA

Hematuria in general
1. Glomerular: significant proteinuria, RBC casts, dysmorphic RBCs
2. Renal/nonglomerular: tubulointerstitial, renovascular, metabolic disorders. Often lots of
proteinuria but no RBC casts or dysmorphic RBCs.
3. Urologic: tumors, calculi, infections, trauma, and BPH. No proteinuria, no dysmorphic
RBCs or RBC casts

Gross hematuria: urine looks reddish or brownish. Must always do a full work up, including
urinalysis, urine culture, and imaging of the upper urinary tract by CT scanning

Microscopic hematuria: 3 or more RBCs per HPF on at least 2 properly collected urinalysis
specimens. Remember 3 or more from 2 or more.
○ Transient sources = menses, recent sex, recent DRE, heavy exercise (resolves
in 72 hours)

Evaluation of asymptomatic microscopic hematuria: Initial routine screening is not

recommended.
● Dipstick only has specificity of 65-99%, so follow up with microscopic evaluation of urine
sediment. Dipstick can’t distinguish between myoglobin or hemoglobin.
● Assess risk factors - for cancer, STDs, occupational exposures to chemicals, strenuous
exercise, drugs, medications, and herbal/nutritional supplements
● Initial approach: If risk factors, image the upper and lower urinary tract. If no risk factors,
then repeat urinalysis to see if the hematuria continues, and do imaging if it does.
○ Upper imaging: Give acetylcysteine or IV sodium bicarb to reduce risk of
contrast nephropathy
■ Intravenous pyelogram - x ray with contrast, can miss small lesions, not
great at solid vs. cystic
■ CT scan to see kidneys and ureters - can see masses, renal stones, renal
or perirenal infection, obstruction. Do noncontrast for stones, then
contrast.
■ If high risk of contrast nephropathy, can do retrograde pyelogram with
renal ultrasound - place catheter into bladder and inject dye. Little risk of
contrast nephropathy because no contrast given by IV

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 ○ Lower tract: cystoscopy - an endoscopic procedure to see bladder and urethra.-
> can test for transitional cell carcinoma
● Work up and plan:
○ Infection: Rule out infection with urine culture. If do have a UTI, then treat
and repeat urinalysis in 6 weeks. If no more RBCs, then no more work up is
needed.
○ Cancer: Evaluate for malignancy (renal cell carcinoma, transitional cell
carcinoma) by imaging the urinary tract, cystoscopy, and voided cytology.
Rarely presents as asymptomatic hematuria, but it can.
○ Serum creatinine to assess renal function
● If work up is negative, do follow up BP, urinalysis, and voided cytology at 6
months, 1 year, 2 years, and 3 years. If still negative at 36 months, don’t need to follow
anymore (ie in asymptomatic hematuria, follow for up to three years)

Urine sediment analysis

● Eosinophils → interstitial nephritis from analgesics or other drugs
● If RBC casts and elevated creatinine → renal parenchymal disease (HTN, diabetes,
autoimmune). Consider renal biopsy
● Dysmorphic transitional cells are seen with high grade malignancy

CASE 15: THYROID DISORDERS

Hyperthyroidism
● Nervousness, palpitations, weight loss, resting tremor, dyspnea on exertion, difficulty
concentrating. Rapid pulse, high BP (especially systolic → widened pulse pressure).
● A fib in 10%
● Graves disease is the most common cause
○ Symptom management with antithyroid drugs like propylthiuracil (inhibits
organification and peripheral conversion, 2nd line except during pregnancy
because of hepatotoxicity) and methimazole inhibits organification and is 1st
line. Risk of agranulocytosis. Also beta blockers.
■ Drugs are especially good for adolescents, often go into remission.
○ Definitive therapy is radioiodine ablation (surgery if pregnant) - 40% become
hypothyroid after and need life long supplementation
● Evaluation:
○ First, get thyroxine and TSH levels
○ Then imaging with radionucleotide uptake. Graves shows diffuse uptake,
thyroiditis shows patchy uptake with reduce activity (release of existing thyroid
hormone, rather than overproduction)
○ Antibody tests for graves (thyroid receptor-TSH receptor)

Thyroid storm:

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 ● Autonomic instability - fever, tachycardia, elevated BP, dysrrhythmias. CNS dysfunction
w/ altered mental status, coma, or seizures. Can have confusion, psychotic behavior.
Maybe dyspnea on exertion, peripheral vasoconstriction.
● Most often in Graves
● Treat with PTU, methimazole, and beta blockers. Give hydrocortisone to prevent
adrenal crisis.

Hypothyroid
● Lethargy, weight gain, hair loss, dry skin, slowed mentation or forgetfulness,
constipation, intolerance to cold, depressed affect. Low BP, bradycardia, nonpitting
edema, hair thinning/loss, dry skin, decreased relaxation phase of reflexes
● Risk of confusing with other conditions
○ Elderly - risk of confusing with Alzheimer’s and other diseases that cause
dementia
○ Women - depression
● Hashimoto’s thyroiditis is most common noniatrogenic cause
● Evaluation
○ Measure TSH - will be high in primary hypothyroid and low in secondary
hypothyroid.
○ If primary hypothyroid and normal physical exam, don’t need further work up.
○ If secondary hypothyroid, need to test to see if problem is hypothalamic or
pituitary → give TRH to see if TSH level increases.
■ If it does. problem is hypothalamus. If it doesn’t, problem is pituitary →
need to procede with imaging and testing other pituitary hormones.
● Treatment: give thyroxine. In elderly, start on low dose and titrate up to avoid
cardiovascular problems from rapid increase in HR and BP (thyroid binding decreases in
elderly due to decreased albumin, so they need a lower dose and annual monitoring of
TSH to make sure not overdosing)

Thyroid nodules
● Red flags: younger than 30 or older than 60, hoarseness, prior neck radiation, other
obvious stuff
● Start with evaluation of thyroid function - E.g, thyroid scan if symptoms of hyperthyroid.
Hyperfunctioning nodules are rarely malignant.
● If not functioning and > 1cm by exam or ultrasound, do FNA.
○ Can’t distinguish follicular cell cancer cytologically from benign conditions based
on FNA! Must refer to surgery for definitive evaluation
● If pregnant - avoid radioactive iodine scan, but can evaluate with ultrasound and FNA. If
cancer, can generally follow during pregnancy and do surgery after delivery. Surgery is
also an option during 2nd and 3rd trimester.

CASE 16: LABOR AND DELIVERY

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Estimated date of confinement = 280 days after 1st day of LMP. Usually go into labor w/in 2
weeks of EDC. Labor > 3 weeks before is preterm. Admit to the birthing unit if membranes have
ruptured or in active labor.

Signs to confirm rupture of membranes: See amniotic fluid, pH > 6.5 with nitrazine paper
(contrast normal secretions < 5.5), and ferning on air dried microscope slide. Blood, semen, or
vaginosis, can falsely elevate pH.
● Rupture > 24 hours can predispose to infection.

3 stages of labor:
1. Stage 1 = onset to full dilation of cervix.
a. Latent Phase of Stage 1 - contractions become stronger, longer, and more
coordinated.
b. Active Phase of Stage 1 - > 3-4 cm of dilation, rate of dilating is maximal.
Contractions are strong and regular. Admit to the hospital for labor management
and monitoring.
i. If no epidural, at least 1.2 cm/hr in first birth and 1.5 cm/hr in subsequent.
No change for 2 hours → arrest of active phase.
2. Stage 2 = complete cervical dilation (10 cm) through delivery of the fetus. Usually <
2 hours in 1st birth and < 1 hr in subsequent. Epidural can add an hour.
a. Delivery = 4 cardinal movements: Flex chin to chest, internally rotate the fetal
occiput anteriorly, extend the head as it approaches vulva, then externally
rotate the head to face mom’s left or right so that one shoulder can be delivered
first. Mnemonic: F-I-E-ER.
b. If anterior shoulder gets stuck → shoulder dystocia, an emergency. Can treat
by hyperflexing the hips (McRoberts maneuver), suprapubic pressure,
episiotomy, or rotating the fetal body in the vaginal canal.
3. Stage 3 = after birth through delivery of placenta. Usually < 30 mins.

Progression of labor depends on Power (contractions, pushing), Passenger (fetal size, lie,
presentation, position), and Pelvis (shape and size).

Monitor fetal well-being w/ continuous or intermittent heart rate monitoring.

● Continuous - external doppler monitoring or internal electrode (requires membrane
rupture)
● Intermittent auscultation - in low risk, stage 1 = every 30 mins after a contraction,
stage 2 = every 15 mins after contraction. In high risk, increase frequency to 15 mins/5
mins.

Normal heart rate data:

● Baseline (= average) btw 110 and 160 bpm. Bradycardia → maternal hypothermia,
meds, congenital heart block, fetal distress, or normal variant. Tachycardia → most often
maternal fever, also can be meds or fetal arrhythmias.

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 ● Variability - affected by any autonomic nervous system factor - sleep cycle, CNS
depressant meds, congental neuro problems, prematurity. Fetal hypoxia → acidemia →
impaired variability. Normal variability makes acidemia unlikely.
○ Short term variability (requires scalp electrode) = variation in rate from one beat
to the next. Normal = 6 - 25 bpm.
○ Long term variability = variability over 1 min, with normal oscillations at 3-5
cycles/min.
● Periodic heart rate changes from baseline
○ Accelerations = + 15 bpm for > 15 sec - a good sign, whether spontaneous or
after contractions, exam, etc. Rules out fetal pH > 7.2.
○ Decelerations from baseline.
■ Early decelerations coincide w/ contraction - result of compression of
fetal head, not a problem.
■ Late deceleration starts at or after the peak of contraction - indicate
uteroplacental insufficiency! Can happen w/ epidurals, oxytocin →
uterine hyperstimulation. Conditions that impair placental circulation will
exacerbate - maternal HTN, DM, long pregnancy, abruption.
■ Variable deceleration - abrupt drop and return to baseline, occurs
variably w/ respect to contractions. Most common type. Probably due to
umbilical cord compression during contractions. Usually not assoc’ed w/
fetal hypoximia.

Can assess frequency of contractions w/ external tocodynamometer. Can assess contraction

strength by palpating uterus or using an intrauterine pressure catheter. IUPC is useful when 1st
stage not progressing, requires membrane rupture.

If contractions not enough → IV oxytocin. Can cause uterine hyperstimulation = 6+

contractions/10 mins w/ non-reassuring fetal heart rate abnormalities (e.g. late decelerations).
Reduce/discontinue oxytocin, give oxygen via face mask.

20% of deliveries are C-sections. Can also use forceps or vacuum assistance if cervix is fully
dilated, membranes are ruptured, scalp is presented, and no problem with head/pelvis sizes.

CASE 17: CALCIUM DISORDERS

Measuring serum calcium: 98% of calcium is in the skeleton, 2% is in circulation. Of this, 50% is
bound to albumin and 50% is free and ionized
● Correct serum calcium for albumin abnormality: 0.8 x albumin deficiency + serum
calcium
○ Example: If albumin is 3 and serum calcium is 7, then 0.8 (4-3) + 3 = 3.8. Still
hypocalcemic, but less so.
● Normal is 8-10. Mild elevation up to 12.

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Hypercalcemia: caused by increased reabsorption from bone, increased absorption from GI
tract, or decreased renal excretion. Primary hyperthyroid and cancer = 90% of cases
● Symptoms:
○ Stones
○ Bones - pain, arthritis and osteoporosis
○ Psychic groans - poor concentration, weakness, fatigue, stupor, coma
○ Abdominal moans - pain, constipation, nausea, vomiting, pancreatitis, anorexia
○ Can also have shortened QT and arrhythmias
● Work up - measure PTH and urine calcium. Have to assess PTH level in the context of
what it SHOULD be based on high calcium status.
○ Low PTH -> worry about cancer and do that work up first. Also consider
vitamin D intoxication, vitamin A intoxication, granulomatous disease, milk alkali
syndrome, immobilization, rhabdomyolysis, adrenal insufficiency, hyperthyroid,
acromegaly
■ Follow up with TSH, cortisol, and pituitary imaging.
○ Higher than expected PTH - primary hyperparathyroidism, familial hypocalciuric
hypercalcemia, medications like thiazide diuretics and lithium
● Treatment:
○ Treat underlying disorder
○ Stay hydrated to reduce nephrolithiasis
○ Surgery for primary hyperparathyroid - if symptomatic, or asymptomatic if have
osteoporosis or renal insufficiency, markedly elevated calcium, younger than 50

Increased bone resorption

● Primary hyperparathyroidism: most common cause of hypercalcemia
○ Can be sporadic or familial with MEN 1 and 2A. Most often a benign adenoma of
the parathyroid gland.
● Cancer is the second most common cause.
○ Secretion of PTH-rp: Lung cancer, squamous cancer of head and neck, renal
carcinoma
○ Osteolysis: Breast cancer, multiple myeloma, prostate cancer
● Vitamin A intoxication (acne treatment) → increased bone resorption (think of this as
a side effect of accutane)
● Immobilization

Increased GI absorption
● Vitamin D intoxication
● Granulomatous disease - includes TB, sarcoidosis, hodgkin disease
● Milk alkali syndrome - excessive intake of calcium containing antacids

Misc causes of hypercalcemia

● Medications - thiazide diuretics, lithium can reduce urinary excretion and increase
PTH secretion
● Rhabdomyolysis

22
 ● Adrenal insufficiency - increased bone resorption and increased protein binding of
calcium
● Thyrotoxicosis - usually mild hypercalcemia from increased bone resorption
● Familial hypocalciuric hypercalcemia - defect in calcium sensing receptor → make
too much PTH. Can distinguish from primary hyperPTH because will have
hypercalcemia but LOW calcium in urine.

Other types of hyperPTH that are NOT associated with hypercalcemia

● Secondary hyperparathyroid: in response to low serum calcium - maybe deficient
intake or low Vit D
● Tertiary hyperparathyroid: in renal failure - usually present with hypocalcemia,
hyperphosphatemia, and low Vit D. If untreated, get hyperplasia of PTH glands, then can
end up with hypercalcemia

Cases:
1. 60 year old with symptomatic hypercalcemia taking HTN meds → first explore meds to
see if thiazide could be the cause.
2. 48 year old with symptomatic hypercalcemia and PTH in normal range → PTH is higher
than expected. Measure urine calcium excretion to distinguish primary hyperPTH from
Familial Hypocalciuric Hypercalcemia.
3. Long time smoker with hypercalcemia, low PTH, and normal chest xray → continue
malignancy work up! Could be cancer other than lung cancer.

CASE 18: GERIATRIC HEALTH MAINTENANCE

3 Parts: Assess impairments, preventative measures, end of life planning (advance directives,
durable power of attorney)
1. Assess impairments:
a. Functional: 25% of patients over 64 have impairments in IADLs or ADLs
i. Instrumental Activities of Daily Living = shopping, transportation,
cooking, using the phone, managing money, taking meds, house
cleaning, laundry
ii. Activities of Daily Living: Bathing, dressing, eating, transferring from
bed to chair, continence, toileting, grooming
b. Vision - independent risk for falls
i. Age related macular degeneration is the leading cause of severe vision
loss in the elderly - diabetic retinopathy is the most common cause in
working age adults
ii. Cataracts are the most common cause of blindness worldwide
c. Hearing
i. Whispered voice test - 70% sensitivity and 100% sensitivity
ii. Presbycusis is most common = age related sensineural hearing loss
associated with selected high frequency loss and difficulty w/ speech

23
 discrimination. Physical exam of the ears is normal. Can use hearing
aids.
iii. Noise induced hearing loss = tinnitus, difficulty with speech
discrimination, and problems hearing background noise
iv. Cerumen impaction affects 25-35% of institutionalized or hospitalized
elderly
v. Otosclerosis = autosomal dominant - progressive conducting hearing
loss with onset most common in late 20’s to early 40’s - speech
discrimination typically okay
vi. Central auditory processing disorder - can hear sounds but difficulty
with spoken language
d. Falls and Gait - leading cause of nonfatal injuries
e. Cognitive impairment - prevalence of dementia doubles every 5 yrs after 60 - by
85 yrs, 30-50% have some degree of impairment
i. Rapid and fairly reliable office test = clock draw and three item recall
When fail either one, follow up with Folstein Mini Mental Status
questionaire
f. Incontinence
g. Depression: slightly lower prevalence than in younger populations. Usually
treatable.
i. Simple screen: Have you felt down/depressed/hopeless in last 2 weeks?
Have you felt little interest or pleasure in doing things? Follow up with
Geriatric Depression Scale
2. Preventative Measures
a. Nutrition - 15% of older adult outpatients and 50% of hospitalized are
malnourished. Assess with serial weight measures and inquiry about changing
appetite
i. Protein undernutrition - increased risk of infections, anemia, orthostatic
hypotension, and decubitus ulcers
b. Hypertension - thiazides are the drug of choice
c. Stroke prevention
i. Biggest risk factor = hypertension, followed by a-fib. Use warfarin to
reduce risk of a-fib stroke. But avoid anticoagulation if patient has multiple
falls, high risk falls, or a very low risk of stroke.
d. Cancer: Can stop colonoscopy and mammogram when life expectancy < 5
to 10 years. Stop PAP smears at 65-70 when have had 3 normal PAPs within
the past 10 years and no new partners.
e. Osteoporosis - screen for risk factors, use DEXA scans
f. Immunizations - influenza after 6 months, pneumococcal after 65 and single
booster of TDAP. Shingles after age 60.
3. End of Life Issues
a. Advance directives
i. Durable Power of Attorney for Healthcare

24
 ii. DNAR - only 15% of patients who survive CPR survive to hospital
discharge

CASE 19: ACUTE BRONCHITIS

Pneumonia: Inflammation or infection of the lower respiratory tract, involving distal bronchioles
and alveoli.
● Suspect pneumonia with prolonged fever and signs of pulmonary consolidation on exam.
● Also evaluate for pneumonia if abnormal vital signs. Can present atypically in elderly and
in patients with chronic lung disease

Acute bronchitis: Inflammation of the tracheobronchial tree in response to infection, allergy,

irritant → increased mucous production and airway hyperresponsiveness
● Often occurs with URI - viruses and atypical bacteria (chlamydia pneumonia and
mycoplasma) are the most common causes.
● Can have wheezes, rales, rhonchi
● Usually self limited and lasts < 2 weeks, but cough can last > 2 months
● Treatment: Abx usually not useful, except with pertussis. Can do bronchodilators for
airway hyperreactivity. Cough meds might be useful.

Rhinosinusitis = inflammation of nasal mucosa and 1+ paranasal sinuses - occurs w/

obstruction of drainage.
● Acute < 4 weeks, chronic >12 weeks, subacute in between. Can also have acute
exacerbation of chronic.
● Basically like an URI, but doesn’t resolve after 7 days in adults or 10 days in kids. May
also have tooth or facial pain, unilateral maxillary sinus tenderness, or worsening of
symptoms after initial improvement
● Acute bugs: Strep pneumo + H flu. Kids also get moraxella.
○ Treat w/ amoxicillin and bactrim. Then try the pneumonia meds
● Chronic bugs: anaerobes are more common

Pharyngitis
● Usually benign and self-limited. Most important to r/o more serious conditions like
epiglottitis (H flu), peritonsillar abscess, and to diagnose group A strep infection.
● Most often viral, especially with cough and runny nose
● Petechiae on tonsils or palate → Group A strep or EBV
● Group A strep is a common cause - 15% of adult cases and 30% of kids.
○ Abrupt onset, petechiae on tonsils and/or palate, cervical adenopathy, no cough.
Might also see sand paper rash. Can have peritonsillar abscess (also with other
bugs - must drain surgically)
○ Rapid strep test. If negative, culture for a day or two. If either positive, penicillin.
○ Complications: RF, glomerulonephritis (regardless of treatment!), toxic shock,
meningitis, bacteremia, abscess

25
 ● EBV can look like GAS, with petechiae, etc. Also see hepatosplenomegaly, generalized
lymphadenopathy. See atypical lymphocytes.
● In kids and YA’s, consider atypical pneumonia bugs (chlamydia and mycoplasma), along
with arcano bacterium haemolyticus

Otitis externa
● Infection of external auditory canal, can have severe pain.
● Often staph, strep, skin flora. Swimmer’s ear = psuedomonas
● Patients w/ diabetes are at risk for invasive otitis media caused by psuedomonas -
must debried and give 4-6 weeks of abx

Otitis media
● Obstruction of Eustacean tubes, often from URI → infection. Typically S pneumo, H flu,
Moraxella catarrhalis. Viral infection with serous otitis can set the stage for acute
bacterial infection.
● Seen in preschool kids most often
● Symptoms: fever, ear pain, decreased hearing, vertigo, tinnitus
● Diagnosis: decreased membrane mobility or fluid behind ear - red tympanic membrane
isn’t enough!
● Treatment: Usually resolves on its own! Treat w/ abx (amoxicillin) if prolonged, recurrent,
or severe symptoms.
● Complications - mastoiditis, bacterial meningitis, brain abscess, subdural empyema

CASE 20: CHEST PAIN

Consider: angina, MI, aortic dissection, pneumothorax, myocardial or pulmonary contusion,

chest wall injury
● Risk factors for aortic dissection: HTN, tobacco
● Risk factors for CAD: male > 40, postmenopausal woman, tobacco, HTN, diabetes
● Risk factors for MI: cocaine, hyperlipidemia, left ventricular hypertrophy, family history of
premature CAD
● MSK causes are the most common in an outpatient setting - e.g. chostochondritis,
will have tenderness to palpation
● GI problems are the second most common etiology
● Pericarditis - sharp pain that increases with inspiration, worse when leaning forward,
can have global ST elevation, not relieved by nitro

Step 1: Morphine, oxygen, nitroglycerin, aspirin (can use clopidogrel if allergic or GI

intolerant to aspirin) and beta adrenergic antagonists. (“Mona and blockers”)
● Also give platelet glycoprotein IIb/IIa receptor inhibitors because reduces risk of
death, MI, and recurrent ischemia
● ACE inhibitors may decrease short term mortality
● Mag sulfate if mag levels are low - reduces risk of torsades ventricular
tachycardia

26
 ● Rapid, short acting dihydropyridine calcium channel blockers like nifedipine are
CI'ed - increase mortality
Step 2: Chest X Ray and ECG (ST changes, t wave inversion).
● Not all MI's will have ECG changes!
● If see LBBB - must do serum cardiac enzymes because this can signal organic heart
disease. LBBB makes the determination of MI by ECG very difficult
Step 3: Labs
● initially get CBC, electrolytes, BUN, creatinine, coagulation studies (PT, PTT, INR),
markers of heart damage (creatinine kinase, CK-MB, troponins - do T's stat and every 6-
10 hours for 3 cycles)

Angina
● Class 1 - only with strenous activity
● Class 2 - slightly vigorous or prolonged activity
● Class 3 - daily activity
● Class 4 - at rest
● Unstable - new onset, at rest or with minimal exertion, crescendo pattern with episodes
of increasing severity, duration, or frequency

Angina vs MI: same symptoms but MI will last > 30 mins

Long term follow up

● Aspirin, nitrates, beta adrenergic antagonists
● LDL goal < 70
● BP control and exercise

CASE 21: CHRONIC KIDNEY DISEASE

Most common causes are diabetes, HTN, and glomerulonephritis.

Normal GFR = 90-120. ESRD = GFR < 15.

CASE 22: VAGINITIS

Diagnosis: Examine discharge w/ the following:

● Wet mount = mixed with normal saline to see normal epithelial cells, look for WBCs,
RBCs, clue cells, and motile trichomonads
● KOH prep to see candida and for whiff test (bacterial vaginosis)
● Cultures for gonorrhea and chlamydia

Trichomonas: Foul smelling, green frothy discharge, strawberry cervix, some soreness. Maybe
worse during menstruation. No itching or systemic symptoms.
● Risk factors: sexually transmitted 3 days to 3 weeks after exposure. Increased risk w/
multiple partners, pregnancy, menopause.

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 ● Diagnosis: Motile, flagellated trichomonads and lots of WBCs
● Treat patient and partner w/ metronidazole. Also screen for other STDs

Candida: Thick discharge, itchy. pH is acidic (4-5).

● Risk factors = recent antibiotic use, diabetes
● Diagnosis: KOH prep. Do not need to culture, but can if the infection recurs or doesn’t
respond to treatment.
● Uncomplicated - vaginal suppositories or oral fluconazole (inhibits P450 production of
ergosterol). Complicated cases require 10-14 days of treatment followed by 6 months of
maintenance. Treat partner only if symptomatic.

Bacterial vaginosis: overgrowth of anaerobes + gardnerella vaginalis → alkaline discharge,

usually thin consistency.
● Risk factors: not an STD, but assoc’ed with multiple sexual partners.
● Diagnosis w/ 3 of 4:
○ Thin homogenous discharge
○ pH is basic > 4.5
○ Positive KOH whiff test (fishy odor)
○ Clue cells - epithelial cell is diffusely speckled
● Treatment: Oral or topical clindamycin or metronidazol. Treat asymptomatic pregnant
women to reduce risk of preterm delivery.

Mucopurulent cervicitis
● Test for chlamydia trachomatis and gonorrhea - but these infections are asymptomatic
50-70% of the time!
● Diagnosis: culture for the bugs.
● Treatment: Empiric treatment if area has high prevalence or follow up is unlikely. Treat
both G&C, also treat partner.
○ Gonorrhea: ceftriaxone - not flouroquinolones like ciprofloxacin because of
increased resistance.
○ Chlamydia: Doxycycline or 1 dose azithromycin
○ Remember GC/CD

Pelvic Inflammatory Disease = inflammation of upper genital tract from gonorrhea, chlamydia,
or vaginal and bowel flora
● Diagnosis: Lower abdominal tenderness w/ both adnexal and cervical motion tenderness
w/out other explanation.
○ Don’t need specific testing, but get more specificity w/ fever > 101 F, abnormal
discharge, elevated ESR or CRP, confirmed G or C infection
○ Definitive dx - not necessary, but can be based on laproscopy, endometrial
biopsy, ultrasound
● Can present like ectopic pregnancy - must do pregnancy test!
● Outpatient treatment for gonorrhea, chlamydia, and bacterial vaginosis. Inpatient
treatment w/ IV abx if pregnant, severe, or HIV.

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 CASE 24: PNEUMONIA
Pneumonia = infection of the lungs.
Pneumonitis = inflammation of the lungs from non-infectious source (chemicals, radiation,
autoimmune, blood)

Pneumonia symptoms: productive cough, fever, pleuritic chest pain, dyspnea. Rapid breathing
in young, altered mental status in old people.

Diagnosis: CXR, sputum gram stain and culture, blood cultures

● CXR is gold standard, but normal xray does not rule it out. Can be normal early in
disease or if dehydrated.
● Cultures have low sensitivity (many false negatives), but positive result can guide
treatment
● Exam: look for ronchi or rales, egophony → focal lung consolidation, dullness to
percussion → pulmonary effusion

Potential complications: bacteremia, sepsis, parapneumonic pleural effusions, pneumonia

CA pneumonia
● Typical: Most common in very young and older patients
○ Most often strep pneumo - acute onset, rusty sputum, fever and chills, lobar
infiltrate. Give penicillin.
○ H flu: underlying COPD. Give cefuroxime.
○ Moraxella catarrhalis
○ Staph aureus - often follows viral infections (influenza). Give erythromycin.
● Atypical: More often in adolescent and YA’s. Tend to cause bilateral, diffuse infiltrates
○ Mycoplasma pneumoniae - Can ID with direct fluorescent antibody testing on
sputum.
○ Chlamydia pneumoniae,
○ Legionella pneumophila - often have diarrhea, too. Can ID with direct
fluorescent antibody testing on sputum or with urinary antigen testing. Give
erythromycin.

Health-care associated pneumonia

● Risk factors: intubation (oropharyngeal is less risky than nasopharyngeal), NG tube
feeding, preexisting lung disease, multisystem failure.
○ Reduce risk by keeping the head of the bed elevated during tube feedings,
infection control techniques (purel, etc).
● Pathogens: CA pathogens plus aerobic gram negatives (psuedomonas, klebsiella,
acinetobacter), and gram + cocci like staph aureus. Incidence of drug resistant bugs
(MRSA) is increasing.

Others:

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 ● Pneumocystis jiroveci in AIDS patients - see ground glass on CXR
● Apical consolidation in TB
● Aspiration pneumonia → right lower lobe

Treatment:
● Determine if the patient needs inpatient or outpatient treatment - toxic appearance,
accessory muscle use, low O2 sat, tachycardia, hypotension, altered mentation?
○ If respiratory distress → ABGs
○ If low O2 sat → oxygen via nasal canula
○ Pneumonia Severity Index - assigns patients a risk category based on age,
comorbid illnesses, specific exam and lab findings.
■ High risk: cancer, liver dz, renal dz, CHF, diabetes
■ Physical exam: tachypnea, fever, hypotension, tachycardia, altered
mental status
■ Labs: low pH, low serum sodium, low HCt, low O2 sat, high glucose, high
BUN, pleural effusion on CXR
■ Treat low risk: Classes 1 and 2 as outpatient, higher risk (3,4,5) in
hospital
● Start abx.
○ Healthy patients w/ CA pneumonia:
■ Macrolide (azithromycin, clarithromycin)
■ Doxycycline
■ If in an area w/ high macrolide resistance:
● Flouroquinolone (levofloxacin, moxifloxacin)
● Beta lactam + macrolide
○ Hospitalized patients w/ CAP who don’t need ICU - give IV abx
■ Flouroquinolone (levofloxacin, moxifloxacin)
■ Beta lactam + macrolide
○ HA pneumonia requires broader abx - don’t use macrolide or
flouroquinolone alone!
■ Beta lactam + fluoroquinolone
■ Beta lactam + aminoglycoside
■ MRSA → vancomycin
● Duration of therapy
○ Strep pneumo: 72 hours afebrile
○ 2 weeks for S aureus, psuedomonas, klebsiella, anaerobes, M pneumo, C
pneumo, legionella

Complications
● Strep pneumo
○ Up to 30% get bacteremia! If so, ⅓ die - or 60% in elderly!
○ Pleural effusion in 40% - do thorcentesis w/ gram stain + culture. 5% will get
empyema → drain with chest tube or surgery.

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Vaccinations
● Pneumovax for 65 yrs and older, and for any adult with cardiopulmonary disease,
smokers, and immune compromised patients. Revaccinate in 5 yrs if known to have
rapid decrease in antibodies - nephritic syndrome, renal failure.
● Influenza for 6 months and older

CASE 26: POSTPARTUM CARE

Post partum = 6 to 12 weeks after.

● Stay in hospital 1-2 days after vaginal delivery, 3-4 days after c-section.
● May have urinary difficulties - infection, incontinence, retention
● Postpartum fever → suspect endometritis (polymicrobial infection of uterus, usually
ascended from vagina), but can also be UTI or wound infection, thromboembolic
disease, or mastitis

Normal sequences:
● Immediately after - uterine contractions to compress blood vessels, can give IV oxytocin
during or after 3rd stage to aid. Early breast feeding also helps. Usually returns to
normal size by 6 weeks.
● Vaginal discharge: Bleeding for hours after delivery, then decreases → brown or blood
tinged lochia (RBCs, decidual cells, fibrinous products) for a week → yellow or white
lochia for 3-6 weeks.
● Breast feeding - colostrum = yellow/clear w/ lots of antibodies, milk comes 2nd to 4th
day after delivery.
○ CI’s to breast feeding: HIV, active Hep B (chronic Hep B and C are okay), breast
reduction w/ nipple translation.
○ Sore nipples: manage w/ position changes, alternating sides, lanolin

Uterine hemorrhage - early is w/in 24 hours, late is 24 hrs to 6 weeks. Most often caused by
the 4 T’s.
1. Tone (atony) - most common cause. Risks = prolonged labor, prolonged use of oxytocin,
large baby, grand multipara (5+ previous babies)
2. Trauma,
3. Tissue (retained placenta or membranes)
4. Thrombin (coagulopathy)

Managagement of uterine hemorrhage:

1. ABC’s first! Manage hypovolemia by placing large bore IV(s) and giving a bolus of NS.
Then address source.
2. Start IV oxytocin and bimanual uterine massage.
3. Move to methylergonovine - but contraindicated in patients with hypertension! Can
increase BP.
4. Third, try to increase uterine tone with prostaglandin F2 (hemabate) injection
(contraindicated in asthma) or misoprostol rectally or orally.

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Return to sex & fertility. Most women start having sex again by 3 months. Can place IUD at 6
weeks. Refit diaphragms and cervical caps at 6 weeks.
● Not breastfeeding: Wait 3 weeks to start OCP. Resume menstruation by 3rd month.
● Breastfeeding - anovulation can last much longer, 98% contraception protection for 6
months if exclusively breast feeding. Wait 6 weeks to start depo shots or OCP - use
progestin-only pills to avoid interfering w/ lactation.

Mood issues:
● 30-70% have Baby Blues - tearful, emotional, sad. Starts in week 1 and resolves in
week 2.
● 10-20% have post partum depression - onset of depression w/in one year of birth.
Symptoms and treatment are the same as in major depression. High recurrence rate in
subsequent pregnancies. Higher risk if previous history of depression.
○ SSRIs are safe w/ breastfeeding
● 1 in 1000 have post partum psychosis - manic or delusional behaviors present within
a few days to a few weeks, should be hospitalized. High risk of suicide and infanticide.

CASE 27: CONGESTIVE HEART FAILURE

Most cases of CHF are caused by either CAD or HTN. Two main classes - systolic and diastolic.
● Systolic = dilated left ventricle with impaired contractility. Think of myocarditis, dilated
cardiomyopathy, malnutrition, ischemia.
● Diastolic = normal or intact left ventricle that has an impaired ability to relax, fill, and eject
blood. Think of hypertrophic or restrictive cardiomyopathy.

Right sided heart failure

● Symptoms: venous congestion, n/v, distention & bloating, constipation, abdominal pain,
decreased appetite.
● Signs: fluid overload, JVD, splenomegaly, hepatomegaly, etc

Left sided heart failure

● Symptoms: pulmonary congestion --> dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, wheezing, tachypnea, cough
● Signs: bilateral pulmonary rales, S3 gallop, cheyne stokes respiration (pattern of
breathing with progressively deeper and faster breathing, then apnea episode), pleural
effusion and edema, etc

Diagnosis of CHF
● Echocardiogram is the gold standard - can see wall motion problems,
cardiomyopathy, areas of hyptertrophy, and cardiac ejection fraction, along with
tamponade, constriction, and pulmonary embolus.
● Elevated levels of Brain Natriuretic Peptide are sensitive and specific.
● ECG to look for arrhythmias, ischemia, ventricular enlargement

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 ● CXR - cardiothoracic ratio > 50%, cephalization of pulmonary vasculature.`

Treatment: Note that catecholamines make CHF worse by causing tachycardia and increasing
peripheral vascular resistance
● Morphine sulfate: anxiolytic and vasodilation
● Furosemide and other diuretics: Diuresis → reduction of fluid overload. Also
vasodilation of pulmonary vessels. Best for acute exacerbations.
● Spironolactone reduces mortality in advanced CHF. Must monitor for hyperkalemia.
● ACE inhibitors decrease preload and afterload and improve cardiac output. First line in
patients with CHF and reduced LV function. Reduce mortality and delay symptom onset.
Can also use ARBs.
● Beta blockers reduce sympathetic tone and cardiac remodeling. Mortality benefit!! Start
with low doses
● Calcium channel blockers are generally CI’ed because they increase mortality,
except for the dydropyridine CCB called amlodipine. Watch out for peripheral
vasodilation, decreased HR, decreased cardiac contractility, and decreased cardiac
conduction. Nonhydropyridine CCBs are useful because they lower heart rate →
increased filling time → increased cardiac output.
● ⅓ of CHF patients have prolonged QRS → can use a pacemaker for cardiac
resychronization therapy.

CASE 28: CONTRACEPTIVES

80% of women who have unprotected sex will get pregnant w/in one year.

● Permanent → sterilization
● Not permanent
○ Hormonal options: combo pill, progestin pill, norplant, depo provera, transdermal,
ring
i. CI’ed in smokers > 35 y/o
○ Barrier: spermacide, condoms, sponge, diaphragm, cervical cap
○ IUD: progesterone or copper
○ Post coital contraception:
i. Can take high doses of combined OCPs for 72 hours after - decrease
pregnancy by 74%.
ii. Plan B (levonorgestrel) is more effective than combined OCPs and does
not cause nausea.
iii. After 72 hours, must use mifepristone.

OCPs generally: effects decreased w/ abx, antifungals, and some barbituates. May prolong
theophylline, benzodiazepine, caffeine.

1. COMBINED HORMONES

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OCP combined estrogen + progesterone: Suppresses ovulation, alters cervical mucus,
retards sperm entry, and discourages implantation. 1-2% failure.
● Additional benefits: Protects against
○ Ovarian cancer, endometrial cancer, colorectal cancer
○ Uterine leiomyomata, ovarian cysts
○ Iron-deficiency anemia,
○ PID - thickens cervical mucus
○ Fibrocystic breast disease
○ Acne
○ Good for bone mineral density
● Absolute contraindications:
○ Known thrombogenic mutations or previous events,
○ CAD or cerebrovascular disease,
○ Cigarette smoking and > 35 y/o
○ Uncontrolled HTN
○ Diabetes w/ complications,
○ Breast or endometrial cancer, or undiagnosed vaginal bleeding
○ Liver disease
○ Congenital hyperlipidemia
● Relative contraindications:
○ Diabetes in general
○ Obstructive jaundice in pregnancy
○ Epilepsy - drugs may decrease effectiveness
○ Migraines with aura - not just headaches alone.
○ Breastfeeding
○ Morbid obesity

Transdermal patch: combined norelgestromin and estradiol, similar to OCPs except increased
risk of blood clots - remember the Williams sisters.

Ring: etonogestrel (progesterone) and estradiol. Wear it for three weeks.

2. PROGESTERONE ONLY

Lower risk of blood clots than combined estrogen + progesterone.

Minipill w/ progesterone only: Decreases and thickens cervical mucus, prevents uterine lining
from thickening. 1-3% failure.
● Best for breast feeding!

Depo-Provera: Injectable progestin, given every 3 months and lasts for 14 weeks.
● Side effects: weight gain, irregular menses (50% have amenorrhea), hirsutism,
prolonged return to fertility

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Implanon: progesterone only, effective for 3 years. Failure rate is < 1% for women who weight
less than 150 lbs.

3. BARRIER METHODS

Female condom failure rate = 21 to 26%

Sponge failure = 18 to 28%. Rare risk of toxic shock.
Diaphragm - should leave in for 6 hours after intercourse. With spermacide, failure rate is 6-18%
Cervical cap - can leave for up to 48 hours. Rare risk of TSS. Failure = 18%
Spermacides alone: failure rate is 20-30%
Spermacide + condom= very effective, like OCPs

4. IUDs

● All IUDs alter uterine and tubal fluids, inhibiting sperm entry through cervix. Copper does
so via an inflammatory process. Progesterone will also thin uterine lining.
● Recommended for women in monogamous relationships because of risk of PID.
○ CI’ed if endometritis w/in 3 months or recurrent endometritis, PID, STD,
pregnancy, anatomic distortions, HIV.
○ Relative CI’s - many are obvious, also known or suspected malignancy, previous
problems with an IUD
● Copper: 4-5% failure rate; Mirena: failure rate < 1%

5. NATURAL FAMILY PLANNING

● Abstain during the 10 days of greatest fertility. Can monitor temp before out of bed in the
morning - will drop by several tenths of a degree before ovulation, then return to normal
after ovulation. Can also monitor cervical mucus.
● Failure is 14-47% per year.

6. STERILIZATION

Vasectomy is considered safer than tubal ligation - can be done as an outpatient.

CASE 29: ADOLESCENT HEALTH MAINTENANCE

Complete physical exams - do once in early adolescence, once in mid-adolescence, and once
in late adolescence

Vaccinations:
● Td booster - at 11-12, then every 10 years. Tdap is recommended in place of one
booster for adolescents and adults
● Varicella if haven’t had chicken pox or been vaccinated before
● MMR if the patient didn’t receive a booster at 4-6 years

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 ● Meningococcus
● Start HPV (strains 6 & 11 cause warts, 16 & 18 cause cervical dysplasia)
● Hep A if live in an area with high infection rates, travel to at risk areas, have chronic liver
disease, or inject IV drugs, or gay men

Sexual health
● Pap smears start at 21 unless extenuating circumstances - symptomatic,
immunocompromised, or pregnant
● Screened for gonorrhea and chlamydia by urine nucleic acid amplification in any
teen who is sexually active and symptomatic or high risk.

Cardiovascular screening:
● Screen everyone for BP, screen high risk for lipids
● Hypertrophic cardiomyopathy is the most common cause of sudden death. Suspect if
when ventricular filling is decreased (valsalva) → murmur gets louder because of more
obstruction. When ventricular filling is increased → murmur becomes quiet.
● Cardiology referral if: suspect Marfan syndrome (risk of aortic root dilation or
dissection), murmur suggesting hypertrophic cardiomyopathy, grade 3/6 or louder
systolic murmur, or diastolic murmur. Absolute contraindications to sports are rare.
○ Murmur grading:
■ Grade 1 = barely audible
■ Grade 2 = faint but immediately audible with stethoscope on chest
■ Grade 3 = readily audible but no palpable thrill
■ Grade 4 = readily audible with palpable thrill
■ Grade 5 = audible with just the corner of the stethoscope on the chest +
palpable thrill
■ Grade 6 = audible with stethoscope actually lifted above the chest +
palpable thrill

Misc: TB tests for high risk - exposures, live in high risk area, live in shelters, etc

CASE 30: HYPERTENSION

HTN → ⅓ of heart attacks, ½ of heart failure, ¼ ESRD, and ¼ of premature death. Higher BP →
higher risk.
● Normal = < 120/80
● PreHTN = 120/80 and below 140/90
● Stage 1 HTN = 140/90 and below 160/100. Give hydrochlorothiazide!
● Stage 2 HTN = 160/100 and higher. Give combo therapy!

HTN in kids: most common cause is renal parenchymal disease. Do urinalysis, urine culture,
and renal ultrasound.

Treatment

36
 ● High potassium, high calcium diet - DASH diet - is as good as single drug therapy.
● Try diet and exercise for 6 months, then move to meds
● Thiazide diuretics are the first line (hydrochlorothiazide). Start once patients are 20/10
above their goal (either 120/80 or 130/80 if diabetes or kidney disease)
● If stage 2 HTN (> 160/100) or still more than 20/10 over goal, then start on combo
therapy of 2+ meds

CASE 36: FAMILY VIOLENCE

USPSTF doesn’t recommend for or against screening for domestic violence (insufficient
evidence), but recommends that doctors be aware of the signs and symptoms and ask direct
questions about abuse - increasing levels, weapons in the home, safety plan. Discuss
resources.

Non-obvious signs:
● Chronic abdominal or pelvic pain
● In kids: 75% of fractures in kids < 1yr are from abuse!
○ Aggression, anxiety, bedwetting, depression
○ Corner or “bucket handle” fractures of metaphysis of long bones
○ Spiral fracture of femur or humerus
○ Posterior fractures - ribs, scapula, spinous processes
○ Sternal fracture, skull fracture

Reporting: Must report child abuse, but many states don’t mandate reporting if the victim is a
competent adult. Elder abuse in nursing homes - can contact the state nursing home
ombudsmen program for investigation.

Diagnosis in kids:
● Do full skeletal xray survey to look for fractures
● Vomiting and lethargy are signs of brain injury! Do CT scan to rule out hemorrhage.

CASE 41: SUBSTANCE ABUSE

Substance abuse: Pattern of using leading to significant impairment and ongoing use in spite
of poor consequences (legal, professional, relationships)

Substance dependence: Pattern of using leading to significant impairment or distress with

drug tolerance, withdrawal, inability to cut down, and continued use despite problems

Reward pathways are mediated by dopamine, GABA, and some peptides

● Stimulanant reward center: Ventral tegmentum, nucleus accumbens, frontal cortex
● Opiate reward center: Periaqueductal gray, arcuate nucleus, amygdala, locos coeruleus

Genetics = 40-60% of vulnerability to addiction

37
Screening
● USPSTF says insufficient evidence to assess whether adolescents, adults, and pregnant
women should be screened for drug use.

Physical exam
● Dilated pupils → stimulants and hallucinogens, withdrawal from opioids
● Constricted pupils → opioids

Treatment:
● Detox has 3 goals: begin abstinence, reduce withdrawal symptoms and complications,
and keep the patient in treatment
● Pharmocotherapy
○ Opioids: withdrawal is basically the flu = cramping, aches, anxiety, vomiting,
malaise, goose bumps (cold turkey), runny nose, diarrhea, insomnia, elevated
BP and pulse
■ Methadone - long acting synthetic opioid. Can cause euphoria and
sedation
■ Buprenorphine - partial agonist, lowers risk of overdose, reduces/stops
withdrawal symptoms. No euphoria and sedation.
■ Naltrexone - long-acting synthetic opioid antagonist. Prevents feeling
positive feelings from drug, reduce withdrawal
■ Naloxone - for acute intoxication treatment. Give nalOxOne at the Onset
of Overdose
○ Tobacco
■ Varenicline - partial agonist/antagonist. Minimal stimulation of opioid
receptor but not enough for dopamine release → reduces cravings. Not
studied in combination with other smoking cessation agents.
■ Buproprion - blocks norepi and dopamine reuptake
■ Nicotine replacement
○ Alcohol - DTs in 48-72 hours. Naltrexone and acamprosate are most effective in
combo with behavioral therapy.
■ Naltrexone - reduces relapse by up to 36% in first 3 months but not very
good for long term.
■ Acamprosate - reduces withdrawal by acting on GABA and glutamate
pathway. Good at maintaining abstinence in severe drinkers for several
weeks to months
■ Topiramate - like acamprosate but not FDA approved for this use
■ Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) - reduce
severity of withdrawal, reduce risk of seizures and DT
■ Disulfiram - retention of acetaldehyde → flushing, nausea, vomiting
■ Beta blockers - as adjuncts to improve vital signs and reduce craving
■ Clonidine - alpha agonists, decrease withdrawal severity
○ Stimulants: paranoia, depression, sleepiness, anxiety, irritability, difficulty
concentrating, increased appetite, motor retardation

38
 ■ Propranolol - improves treatment retention, reduce cocaine use. Seems
similar to the principle of naltrexone.
■ Desipramine, buproprion - antidepressant
■ Methylphenidate, amantadine - indirect dopamine agonists, improve
treatment retention

CASE 43: ANIMAL AND INSECT BITES

Insect stings -
● Local reaction is toxin-mediated, causes a histamine like reaction. Treat with ice and
antihistamines for itching. Give tetanus if out of date
● Large local reactions are caused by IgE - can take 24-48 hours to fully manifest. Treat
with oral steroids.No increased risk for anaphylaxis. Give tetanus if out of date.
● Systemic reactions are caused by IgE. Treat anaphylaxis with epinephrine and admit
for observation for 12-24 hours. Also antihistamines, bronchodilators, and steroids. Can
reduce the risk of future reactions up to 50% with desensitization therapy. Give epi
injection to bring home.

Animal and human bites:

● Give augmentin as prophylaxis for 3-5 days. If cellulitis is developing, give for 7-14 days.
● Don’t close the wound if > 24 hours have past or if it is infected.
● Give tetanus if out of date.
● Eikenella is the most common bug in closed fist punching bite injuries.

CASE 50: IRREGULAR MENSTRUAL CYCLES

Normal: 3 to 5 week cycle.

Hormone regulation: GnRH → anterior pituitary releases FSH and LH. In first half of cycle, FSH
predominates → ovarian follicles mature and release estrogen to induce endometrial
proliferation. Mid-cycle LH surge → ovulation and formation of corpus luteum that secretes
progesterone → compacts and matures the endometrium. If no pregnancy, progesterone drops
off and menstruation occurs.

Consider: PCOS, thyroid problems, whether the source of bleeding is elsewhere (vagina,
rectum, cervix, etc), medications (anticoagulants, phenytoin, antipsychotics, TCAs, steroids),
pregnancy, examine for galactorrhea

First do a pregnancy test! Then check prolactin, LH, TSH, total testosterone

Heavy periods (menorrhagia) w/ regular intervals → suggests ovulation, endocrine

pathways are working.
● May have leiomyomata or polyps = increase endometrial surface area

39
 ● May have coagulopathy - most often VWF disease or anticoagulant meds, also liver
disease or thrombocytopenia

Light periods with regular intervals - suspect Asherman syndrome, scarred or obstructed
cervical os.

PCOS → irregular heavy periods

● Insulin resistance and androgen excess.
● Diagnosis: Must have 2 of 3: hyperandrogenism, chronic anovulation (causes menstrual
cycle abnormalities - no luteal production of progesterone), and polycystic ovaries by
ultrasound.
● Labs: measure serum total testosterone and sex hormone binding protein → calculate
Free T.
● Treatment:
○ Induce periods w/ periodic supplemental progesterone or with OCPs.
○ Insulin issues: use metformin and thiazolidinediones (glitazones; work by
activating PPAR-gamma)
○ Infertility: clomiphene citrate, aromatase inhibitors, gonadotropins

Unpredictable timing and flow = Dysfunctional Uterine Bleeding (DUB) → abnormal

hypothalamic-pituitary-ovarian axis.
● Most often after menarche/before menopause. Can signal anovulation.
● Management:
○ Watch for a few years after menarche.
○ < 35 y/o w/out risk factors for endometrial cancer → can treat without workup -
use OCPs with combined estrogen and progestin or progestin alone.
○ Work up if > 35 y/o. risk factors for endometrial cancer, no response to treatment,
or postmenopausal.
● Diagnosis
○ Initial work up: check prolactin, LH, TSH, total testosterone
○ Transvaginal pelvic ultrasound and endometrial biopsy. Then hysteroscopy to
visualize and direct any further biopsies - can do with D&C for diagnostic and
therapeutic reasons.

Endometritis
Common cause of vaginal spotting. Usually polymicrobial infection ascended from vagina. Can
involve gonorrhea, chlamydia, ureaplasma, peptostreptococcus, gardnerella vaginalis, and
group B strep. Do endometrial biopsy - see inflamed cells, especially plasma cells.

CASE 51: DIABETES

Suspect DM if:
● Recurrent/difficult to treat fungal infections (also HIV, immune compromise for other
reasons)

40
 ● Polydypsia, polyuria. Type 1 DM can also have polyphagia because can’t metabolize
food properly
● Overt signs of insulin resistance: acanthosis nigricans, elevated BP, obesity

Initial labs for suspected DM: finger stick blood glucose followed by electrolytes, BUN,
creatinine, fasting lipids, urine microalbumin: creatinine ratio, and hemoglobin A1c.

Risks:
● At risk for CV disease, PVD, leading cause of blindness in working age adults, leading
cause of ESRD and non-traumatic amputations.
● Also peripheral neuropathy, gastroparesis, immune compromise → fungal infections,
etc.

Goals for treatment: Try to prevent macrovascular disease (accelerated CAD, accelerated
cerebral and peripheral disease) and microvascular disease (retinopathy, neuropathy,
nephropathy).
● Glycemic control of HgA1c < 7%
● LDL 70-100
● BP < 130/80
● Lifestyle modifications of diet low in carbs and saturated fat and at least 150 mins/week
of exericise at 50-70% max heart rate and resistance activity 3x week.

Type 1: AI destruction of pancreatic beta cells → no insulin. Risk factors = viruses, genetics,
environmental factors.
● Lack of insulin → fat metabolism. Risk of diabetic ketoacidosis = hyperglycemia, high
levels of serum acetone, anion gap metabolic acidosis. Stressors (infection, MI) are risk
factors.

Type 2: Hyperinsulinemia with peripheral insulin resistance - 90% of cases in the US. Stronger
FH than type 1.
● Risk of nonketotic hyperosmolar syndrome - blood glucose can reach 1000. Serum
osmolarity > 320 and patient has a large fluid deficit - up to 9L.

Gestational diabetes
● Increased insulin resistance caused by chorionic somatomammotropin, progesterone,
and estrogen - all are insulin antagonists.
● Maternal complications: increased risk of UTIs, preeclampsia, retinopathy,
hyperglycemia, DKA
● Fetal complications: congenital malformations, macrosomia, respiratory distress
syndrome, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia,
hydramnios
● Screen: All women at 24-28 weeks with 1 hour glucose challenge. If > 130, do 3 hour
test - hours 0, 1, 2, and 3. Abormal = 2+ outside of range. All screen high risk women at
the first visit.

41
Pregnancy
● Type 2 diabetes - higher risk of fetal malformations because of hyperglycemia during
early weeks before gestational diabetes has occurred
● Gestational diabetes → macrosomia and polyhydramnios
● Both gestational and type 2 → shoulder dystocia

Diagnosis:
● glucose > 200 with symptoms
● fasting glucose > 126
● 2 hour glucose of > 200 with 75 g
● HgA1C > 6.5. Can do fructosamine in patients with Hgb-opathies, recent blood loss,
recent change in diet - measures past 2-3 week

Meds:
● Biguanide = Metformin - decreases glucose output during gluconeogenesis
● Sulfonylureas = glyburide, glipizide, glimepiride - stimulate insulin secretion
● Thiazolidinediones = -glitazones - improve insulin sensitivity in muscle and adipose
tissue, decrease liver gluconeogenesis, increase peripheral glucose utilization. Decrease
TGs and increase HDL. Liver metabolism.
● Meglitinides - short acting stimulants of insulin secretion. Fast onset - 1 hr. Good if
patients have trouble with blood glucose after meals but not while fasting. Can cause
hypoglycemia.
● Alpha glucosidase inhibitors - inhibit this enzyme in the small intestine to decrease
after meal hyperglycemia
● Pramlintide - inhibits inappropriately high glucagon during hyperglycemia (e.g., after
meals)
● GLP-1 agonist = Exanatide: Incretin mimetic. Stimulates insulin release. Can add to
metformin, sulfonylurea, or TZDs.
● DPP-4 Inhibitors - block the inhibitor of incretin hormones, which stimulate insulin
release in glucose-dependent manner. Can be used as monotherapy or in combo with
other oral agents.

Goals:
HbA1c < 7%, fasting glucose 70-130, 1-2 hour post prandial of < 180.
BP < 140/90
LDL < 100.

Hypoglycemia
● Cognitive symptoms = confusion, difficulty concentrating, irritability, hallucinations, focal
impairments like hemiplegia
● Sympathetic symptoms → sweating, palpitations, tremulousness, anxiety, hunger
● Causes: fasting, insulin overdose, sulfonylurea abuse, hormonal deficiency -
hypoadrenalism, hypopituitary, glucagon

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 ● Treat: Outside of the hospital - IM glucagon, sugar containing products. At hospital, 50%
dextrose. Watch closely - can recur!
CASE 54: DEVELOPMENTAL DISORDERS

Verbal development: Should say mama/dada by nine months, and know 2 other words by age 1

Autism Spectrum Disorder: Includes autism disorder, Asperger’s disorder, and pervasive
developmental disorder NOS.
● 1 in 110, boys 4x > girls. Recurrence of 5-6% when an older sibling has it.
● Risk factors: no causal link identified, but implications for genes, exposure to teratogens
in utero, maternal illness during pregnancy
● Diagnosis: All ASDs have severe deficits in social skills and limited, repetitive, and
stereotyped behavior patterns. Only autism and PDD-NOS have language deficits.
○ Autistic disorder: must have abnormal behavior by age 3, must have deficits in
social interaction, language used for social communication, and
symbolic/imaginative play
○ Asperger’s: May go unnoticed until school. Mild or limited speech delay. Deficits
in social language like choosing a topic, tempo, facial expression, body
language. Speech is often pedantic and limited to only a few topics that hold an
all-consuming interest.
● Screening: screen FH, concerns, history, etc. at every visit. At 18 and 24 months, do the
Modified Checklist for Autism in Toddlers
○ Red flags: No babbling/pointing by 1 year, no single words by 16 months,
no 2 word phrases by 24 months, loss of social or language skills at any
age
○ If 2 or more red flags, must follow up immediately! Refer for full ASD evaluation,
early intervention services, and audiology screen
● 10% have a neurogenetic comorbid condition and 50% have mental retardation.
○ Rett syndrome - x linked disorder that is fatal in males. Microcephaly, seizures,
hand wringing
○ Childhood disintegrative disorder - normal development until 2-4 years, then
motor and social functioning fall apart
○ Fragile X - most common genetic cause of AD and retardation in males. Have
MR, macrocephaly, large pinnae, large testicles, hypotonia, and hyperextensible
joints
○ Neurocutaneous disorders: Both are AD, but 50% are new mutations
■ Tuberous sclerosis: hypopigmented macules, fibroangiomata, kidney
lesions, CNS hamartomas, seizures, MR, ADHD
■ Neurofibromatosis: cafe-au-lait spots, axillary freckling, neurofibromas,
ocular lisch nodules
○ Phenylketonuria - MR/AD preventable with dietary modification
○ Fetal Alcohol Syndrome: associated with AD and other developmental
disorders

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 ○ Angelman syndrome: loss of maternally expressed ubiquitin-protein ligase
gene. Global developmental disorder, hypotonia in early childhood, wide based
ataxic gait, seizures, progressive spasticity
○ Childhood schizophrenia - thought disorder, delusions, hallucinations

CASE 57: OBSTRUCTIVE SLEEP APNEA

Apnea: Breathing pause of at least 10 seconds w/ 90% drop in airflow

Hypopnea: 10 second period of 50% drop in airflow w/ 3% drop in O2 saturation or 30% drop in
saturation with 4% drop in saturation
AHI: apnea and hyopnea per hour
Respiratory disturbance index: apneas, hypopneas, and respiratory-effort related arousals
per hour of sleep

● Affects 2-9% of adults and 2-5% of kids.

● Associated w/ obesity, a-fib, resistant hypertension, acute coronary syndrome → MI,
CHF, type 2 diabetes, stroke, nocturnal dysrhythmias, pulmonary HTN

AHI or RDI > or = 5 and symptoms → OSA. Or > 15 if no symptoms.

● Severe: RDI > 30
● Moderate: RDI = 15-30
● Mild: RDI 5-15

Diagnosis: history and physical, polysomnogram or home study to confirm and assess severity
● Differential: narcolepsy, pulmonary dz, periodic limb movements of sleep, shift workers
syndrome, obesity hypoventilation syndrome - often overlaps, have PCO2 > 45 mm Hg
when awake.
Non-obvious symptoms: nocturia, decreased libido, morning headache, insomnia, history of
falling asleep while driving
Non-obvious physical signs: thick neck, macroglossia, acromegaly, thyroid enlargement, large
tonsils or uvula, large nasal turbinates or polyps, narrow or high arched palate. Obesity is the
biggest red flag!

Mallampati Score: for assessing the oropharynx. Score of 3-4 may suggest OSA.
1. Entire tonsil visible
2. Upper half of tonsil visible
3. Soft palate and hard palate visible
4. Only hard palate visible.

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