00:04all right what's up guys
00:06so today we're gonna do a cram session
00:09for your family medicine shelf or for
00:13the family medicine component of your
00:15step 2 CK or for anyone who's just
00:19interested in listening to family
00:22medicine knowledge so first we're gonna
00:24talk about Triple A abdominal aortic
00:27aneurysm when do you start doing
00:30screening for that so it's in people
00:33aged 65 and if they've ever smoked
00:36you're gonna do an abdominal ultrasound
00:38for a triple-a what about for lung
00:42cancer screaming so anyone who is 55
00:45years or older with a 30-pack year
00:48history of smoking who currently smokes
00:52or who or if they have quit within 15
00:56years if they make for any of those
00:59criteria then you're gonna do a low-dose
01:02CT scan of the chest for a lung cancer
01:05so meanwhile I'm gonna take this
01:08opportunity to give you guys a little
01:11bit of advice for the family medicine
01:13shelf make sure you review the USPSTF
01:16guidelines the a and B rated ones these
01:20ones if you know them really well and
01:22review them you can search it online
01:24it'll help you live a lot of these
01:26questions are based off your knowledge
01:28of the guidelines alright so next is
01:34colonoscopy you do a colonoscopy for
01:38colon cancer screening starting at 50
01:42years old and you do it every 10 years
01:44if they have someone in the family who
01:47was diagnosed with colon cancer before
01:49age 60 then you're gonna scream at 40
01:53years old or 10 years before the family
01:58member got diagnosed with colon cancer
02:00whatever comes first so say someone in
02:06your family had colon cancer at 45 then
02:09you want to start a colon cancer
02:13five but say someone in your family got
02:16diagnosed at sixty ten before that is 50
02:19so you will pick 40 years old because
02:23that one came first pap smears start at
02:26age 21 years old and happened every
02:29three years you can stop at age 65
02:33mammograms USPSTF and ACOG which is the
02:38ob/gyn Society used to argue about this
02:41but lately I've been noticing that
02:43there's more of a consensus now and it's
02:4640 years old starting at 40 years old
02:49and every year or two when do you start
02:53screening for osteoporosis
02:5565 years old and you're gonna use a DEXA
02:58scan of the lumbar spine you want to
03:01give this zoster vaccine at 60 years old
03:04you want to give the HPV vaccine between
03:079 to 26 years old chlamydia and
03:09gonorrhea screening occurs in females
03:12who are sexually active in less than 24
03:16years old HIV screening is done for
03:18anyone between ages 15 and 65 and so
03:22those are your major screenings and you
03:25should definitely try and commit this to
03:27memory so next is COPD
03:30there's mild moderate severe and very
03:33severe and how you categorize it depends
03:38and the fev1 is also the main metric for
03:43prognosis if you have a very low fev1
03:45then your prognosis is poor so it starts
03:49with above 80% 50 to 80 30 to 50 and
03:54less than 30 so if it's your fev1 is
03:58you're gonna give someone with COPD
04:00albuterol which is a short-acting beta-2
04:03mist between 50 to 80 which is moderate
04:05you're gonna add a long-acting beta
04:07agonist such as cell materal between 30
04:10to 50 you want to add it inhaled steroid
04:13below 30 which is very severe this is
04:16when you start adding oxygen therapy
04:18there's also two other metrics that you
04:22can use for when patients will start
04:25oxygen therapy at home and that's if
04:28you're owed to saturation is less than
04:34is less than 55 so forego doubt is
04:39basically a plastic presentation is a
04:43cute abrupt onset of severe pain of the
04:47metatarsal phalangeal joint of the foot
04:50which is the at the base of your big toe
04:54that part will become swollen and really
04:57red and extremely painful
04:59so painful that it might even wake the
05:01patient up in the middle of the night
05:02inside this joint is going to be filled
05:06with uric acid crystals which are
05:08negatively birefringence and the first
05:11thing you always want to do with the hot
05:13swollen joint is aspiration so when you
05:16do the joint aspiration that's where
05:19you'll find the uric acid crystals
05:21remember the positively birefringence
05:23crystals are also known as pseudo gout
05:26and those are the ones that have the
05:28calcium pyrophosphate crystals and they
05:31will be rhomboid shaped so forget you
05:34have a couple treatments for acute gout
05:37you want your first line is you want to
05:39treat it with the NSAIDs such as
05:40indomethacin or colchicine if you had to
05:44pick one of the other pick indomethacin
05:46first but here's a trick if the patient
05:50has any sort of kidney disease where
05:52their GFR is really low or their
05:55creatinine is high if they have CKD then
05:58these drugs are contraindicated and you
06:00want to proceed instead with the
06:02intra-articular steroid injection like I
06:05said any hot swollen joint needs to be
06:08aspirated because we fear of septic
06:12arthritis and if that's untreated it can
06:15be deadly but it can also destroy the
06:18someone with septic arthritis commonly
06:21happens in the knee or the hip and its
06:23secondary to systemic infections such as
06:26bacteremia and this person will have an
06:29extremely tender swollen joint that's
06:32really red and they won't be able to
06:34bear weight either on the hip or be able
06:37all very severe pain and they'll also
06:41have fever and leukocytosis so the first
06:44thing what you want to do is
06:45arthrocentesis take it out and when you
06:48analyze the joint fluid you'll see that
06:51usually a septic joint will have over 50
06:55thousand white blood cells inflammatory
06:58joints are usually between ten to fifty
07:00thousand and that's more kind of like
07:02Dell or like rheumatoid arthritis and
07:05then septic joint will have 90% plus
07:08neutrophils and then with that you want
07:11to treat with IV antibiotics
07:13so for gout meds that you want to use
07:16for chronic treatment of gout and
07:19preventing future flares you can either
07:22treat with probenecid or allopurinol so
07:25in order to know how which one to use
07:28you can check the uric acid in the urine
07:32so basically if the urine uric acid is
07:36low then that means that there's a
07:38problem with excreting uric acid so you
07:41want to use probenecid which helps
07:43improve excretion and then allopurinol
07:46which is a xanthine oxidase inhibitor
07:49which prevents the formation of uric
07:53acid is used if the urine uric acid is
07:57really high that means that the body is
07:59making so much uric acid and it's
08:01spilling out into the urine so this is
08:04an excess production problem not a under
08:07excretion problem so then you can use
08:09allopurinol but for acute flares you
08:13always start off first line with the end
08:15said don't use pick the more long-term
08:19types of treatments such as allopurinol
08:21because that makes it worse in the
08:23short-term so initial prenatal care the
08:27first you should know about what type of
08:29things you want to work up for the first
08:32initial visit the visit at week around
08:35week 28 and the visit at around week 35
08:40so the first visit you want to always do
08:42a CBC a urinalysis STD HIV hepatitis B a
08:49pap smear blood typing
08:51and rubella at weeks 28 you check for
08:55three things the CBC to check for anemia
08:58and then diabetes screaming and then the
09:02rhogam shot if they're Rh negative so
09:05diabetes screening remember you start
09:09off with the 50 gram oral glucose and
09:12after one hour if that's greater than
09:15140 then you're advanced to the next
09:18stage which is the hundred gram glucose
09:21load and then that you measure hours one
09:24two and three if it's high and two out
09:27of the three hours then you diagnose
09:29gestational diabetes so at hours one it
09:34should be greater than 180 and then
09:38hours two is greater than 160 and hour 3
09:41is greater than 140 180 160 140 and that
09:45can be plus or minus at some different
09:48sources give other numbers but usually
09:50in the question if they want to make it
09:52clearer it'll be way above those values
09:55like so hours one two and three if two
09:57out of the three are high in the 100
10:01gram then that's just a tional diabetes
10:03so you want to check that at week 28 and
10:06then the rhogam shaw if the mom is Rh
10:09negative and remember the reason why you
10:12give the rhogam shot is it's an antibody
10:15that prevents the fetal red blood cells
10:19from being detected by moms immune
10:22system because if she sees those babies
10:25red blood cells that are possibly Rh
10:28positive then her antibodies might
10:31switch from IgM to IgG and that's bad
10:34news for the second baby and then in
10:38finally in week 35 to 37 that's when you
10:41do the group B strep test of and do a
10:45swab of the vagina and rectal area in
10:48the perianal area because if they show
10:51up for having a positive Group B Strep
10:54then that's when you give penicillin
10:56prophylaxis for hours before delivery
11:00for pap smears starting at age 21 you're
11:04three years and then there's three types
11:07of outcomes with the pap smear it can be
11:09askus low a grade or high grade and
11:12ascus means a typical squamous cells of
11:15undetermined significance if you have
11:18ascus then the next thing you want to do
11:21is an HPV test if that's positive then
11:26you proceed to colposcopy what if the
11:31mom is pregnant during the pap smear and
11:33she has askus then you basically take
11:38your chances and do the pap after birth
11:40because it's not likely she'll have
11:41cancer if it's low grade or high grade
11:44as an LS il RHS il then you're gonna
11:49proceed with the Koska P once you do the
11:52colposcopy that's when you do use the
11:55speculum and view the cervix under
11:58microscopy and then biopsy the lesions
12:02this can come back as cin 1 2 & 3 if
12:07it's cancerous then that's when you
12:10proceed with doing a hysterectomy for
12:13pap smears remember every three years
12:17and that 65 years old the Tdap vaccine
12:21is something that's given during
12:22pregnancy and that happens between weeks
12:2527 to 30 six any live vaccines we'll
12:29have to wait until after the baby is
12:31born term is considered anything
12:35starting at 37 weeks and post term is
12:37starting at 42 weeks
12:39alright so pediatric milestones it's
12:43hard to remember anything like all of it
12:45but here are some of the key ones you
12:47should try to remember so at two months
12:50the baby can lift their head off the
12:52ground and Composition and then at four
12:55months the baby can roll over at six
12:58months the baby can sit up on their own
13:00at nine months the baby can crawl or
13:04cruise cruising meaning they can kind of
13:07get up and walk but they need to use the
13:09couch as like a crutch and they're gonna
13:11be using the couch to like keep
13:15themselves propped up
13:17and then at 12 months the baby can use
13:20one two three words other than mama dada
13:23two years old can has hundreds of words
13:27that they know to zeros and two-word
13:29phrases at three years old thousands of
13:32words three zeros and three word phases
13:36at five years old you can dress yourself
13:39and write your own name at six years old
13:41you can tie your shoes and identify left
13:44and right and also remember that in
13:49terms of like vision and hearing testing
13:52audiometry should start at four years
13:55old and same with vision testing it
13:57should start around that age as well if
13:58a kid is really young and they're
14:01cross-eyed you want to make sure that
14:03they go to the eye doctor because any
14:06early onset of strabismus can cause a
14:09kid to be an increased risk for
14:11amblyopia which basically means that
14:14there whatever eye is not focused is not
14:18getting enough stimulation to the visual
14:20cortex and this can lead to a blindness
14:23so you want to make sure that any kid
14:25who has true business or a congenital
14:28cataract needs to have vision testing
14:32and see an ophthalmologist at six months
14:35old the babies can start using
14:37toothpaste they can also start visiting
14:41the dentist by 1 year old breastfeeding
14:44happens exclusively until six months and
14:46then you can start introducing solids
14:48the first flu shot happens at six months
14:52the first live vaccine happens at one
14:55years old and that's the MMR vaccine if
14:58someone has constantly a runny nose due
15:01to allergies the first-line treatment is
15:04intra nasal steroids the main side
15:07effect of intra nasal steroids you
15:09should be aware of as epistaxis because
15:11the steroids can cause atrophy of the
15:13mucosa which predisposes to bleeding
15:16anything of a hemoglobin less than seven
15:19needs to be needs transfusion remember
15:22this what's the most common cause of
15:23folate deficiency alcohol abuse so if
15:26someone has acute gastroenteritis with
15:31aka bloody diarrhea what's the next step
15:34stool analysis to check for white blood
15:38cells if there are white blood cells
15:40present this confirms that it's an
15:42inflammatory diarrhoea meanwhile any
15:45type of gastroenteritis make sure to
15:48rehydrate yeah make sure just to keep
15:50them hydrated with oral or IV fluids if
15:54they're hypotensive then IV fluids if
15:56they're normotensive then you can give
15:59oral rehydration therapy which is just
16:02glucose and the salt together be aware
16:05of the main common culprits of
16:08inflammatory diarrhoea and that's
16:10Campylobacter yak Salmonella Shigella
16:14and Yersinia most of the time these are
16:18treated with supportive care and you
16:20only give antibiotics if the patient is
16:23really young or immunosuppressed or very
16:27elderly other than that if you're an
16:29immuno competent person you don't want
16:32to treat with antibiotics and definitely
16:34you don't want to treat the diarrhea
16:37with anti diarrheal such as loperamide
16:40because that traps in the bacteria and
16:43you can make things worse by promoting
16:46diarrhea or letting it pass then the
16:48patient can excrete out all the bacteria
16:52remember one of the main complications
16:54is with a hack and Tarot hemorrhagic
16:57ecoli if you give someone antibiotics
17:01such as the fluoroquinolone this can
17:03preusse can progress to hemolytic uremic
17:06syndrome which leads to anemia
17:08thrombocytopenia and renal failure and
17:11you don't want that to happen if it does
17:14happen then you would treat it with
17:16dialysis if someone has chronic diarrhea
17:19means diarrhea lasting for greater than
17:21a month then you want to do a stool over
17:24and parasite analysis see death is
17:27Clostridium difficile it's a type of
17:29diarrhea that can happen most likely
17:33after taking broad-spectrum antibiotics
17:35it's also classically associated with
17:38clindamycin use and this to diagnose
17:41this um first the clinic
17:43science will be diarrhea and abdominal
17:46pain after taking antibiotics they might
17:50even have fever and leukocytosis what
17:53you want to do a toxin a and B analysis
17:57of the stool and then if it's confirmed
18:00that they have seeded you want to treat
18:02with oral vancomycin because if you give
18:06it IV it won't have good enough and
18:08iteration to the colon so if you give it
18:11orally it's more active in the colon so
18:14remember the two most common causes of
18:16viral watery diarrhea are norovirus and
18:21rotavirus these two in the vignette will
18:24usually be associated with cruise ships
18:27or classrooms so make sure if you see
18:31someone who has like a viral watery
18:33diarrhea with vomiting and diarrhea with
18:36acute onset and they were on a cruise or
18:39in areas close to other people such as
18:41classrooms this is Nora or rotavirus and
18:44the kids should stay home until that
18:46illness is resolved also rotavirus is
18:49common in the winter for osteoporosis
18:54when you do the DEXA scan at 65 years
18:56old that result will have a t-score if
18:59it's less than negative two point five
19:02if it's below that that's diagnosed as
19:05osteoporosis between negative one and
19:07two point five is considered osteopenia
19:10what's the first-line treatment of
19:14it's bisphosphonates such as a legend
19:17eight all right next is msk injuries so
19:21so you're gonna need to know the
19:23indications for an x-ray of an ankle
19:25when someone rolls it and this follows
19:27the Ottawa ankle rules so you want to do
19:30an x-ray if there's posterior malleolus
19:32tenderness or inability to bear weight
19:36immediately after injury any of those
19:39two and it's an indication for an x-ray
19:42of the ankle so hematuria is remember
19:46sometimes it can you can have
19:48microscopic hematuria which means it's
19:50invisible to the naked eye or
19:54if this is the first time it's
19:57been detected on a urine dipstick then
20:00the next step is to repeat the
20:02urinalysis but with the repeat this time
20:05it should have a microscopic analysis
20:08because with the microscopic analysis
20:11this can be more specific red blood cell
20:14casts or if there are dysmorphic red
20:18blood cells so the microscopic analysis
20:20can give more information and then one
20:23of the key mysteries of your analysis is
20:27sometimes you'll have your analysis that
20:30has a lot of blood on dipstick but no
20:34red blood cells so what is that
20:37something that has a lot of blood but no
20:39red blood cells is usually a thorough
20:42mnemonic for rhabdomyolysis because
20:45rhabdomyolysis will have myoglobin which
20:47gets released and the myoglobin is
20:50detected as blood so for thyroid
20:54disorders remember the first line drugs
20:57you can use for hyperthyroidism or
20:59methimazole and Pokhara Cyril uracil and
21:03the main side effect on want you to
21:06remember is it can cause a granulocytes
21:08as' which means deficiency of
21:12granulocytes and remember granulocytes
21:14or your base fulfils use in the phils
21:17and neutrophils and these will be down
21:20and so if the patient a hyper thyroid
21:23patient who's being treated with this
21:24comes in with a sore throat or signs of
21:27infection then the most likely culprit
21:30is due to these medications causing a
21:32granulocyte OSIS so remember if a
21:36patient is pregnant that the thyroid
21:38hormone she's taking if she's
21:40hypothyroid and she's taking
21:42levothyroxine then with pregnancy the
21:45levothyroxine dose should be increased
21:48because when your estrogen levels are
21:51very high the thyroid binding globulin
21:54levels increase a lot and this kind of
21:57you can think of it as it kind of like
21:59sucks up all the ex sucks up all the
22:03medication and then binds to it and then
22:06basically you're gonna need more
22:09I read hormone to replace it and also
22:13it's always better for the mom to be a
22:15little bit hyperthyroid rather than you
22:18theory or hypothyroid because
22:21hypothyroidism and pregnancy can cause
22:23cretinism which is congenital
22:26hypothyroidism and this can be
22:28devastating for the kids development so
22:31next is a thyroid nodule the next step
22:34that you should do is a TSH level and an
22:38ultrasound so basically you want to do
22:40an ultrasound to assess for the nodule
22:43to see how many nodules there are get
22:45some information look at it to see if
22:47it's cystic or if it looks cancerous and
22:50also to measure the size the TSH will
22:53help you determine if they're hyper
22:55thyroid or youth thyroid if the TSH is
22:58low it means they're hyper thyroid most
23:00of the times thyroid nodules that are
23:03hyper thyroid it came a hot nodule
23:06usually they are not malignant but the
23:09cold nodules aka the ones that are you
23:12--they roid are the ones that are most
23:15likely to Fulop malignant so if someone
23:17is hyper thyroid with a fire-rate nodule
23:20the next step after that is you want to
23:23do a radio active iodine uptake and then
23:27from there if it's a diffuse uptake this
23:30is Graves disease if it is taken up in
23:33one area then that's called a toxic
23:36adenoma and if it's taken up in multiple
23:39patchy areas that's called a
23:40multinodular goiter which is multiple
23:43toxic adenoma if they have Graves
23:46disease then you can treat with pto and
23:48methimazole and see if it goes away and
23:52if they have a toxic adenomas or
23:55multinodular goiter then you can do
23:58radioactive iodine therapy which
24:00basically ablates the toxic thyroid
24:03nodules if there's a cold nodule aka
24:06it's not hyper thyroid and the nodule is
24:09greater than one centimeter then you
24:12wanna do a biopsy of that lesion a fine
24:15needle aspiration and to assess to see
24:18if it's cancerous or not
24:20if it's less than a centimeter then you
24:22can follow-up in six months after the
24:25biopsy and it's cancerous then the next
24:28step is surgical removal for fetal heart
24:31rate tracings remember for the fetal
24:33heart rate normal as between 110 and 160
24:37if the fetal heart rate is above 160 for
24:41fetal tachycardia that means that the
24:43mom has an infection if the fetal heart
24:46rate is sinusoidal this means that the
24:49baby has anemia if the baby has a
24:53complete heart block then most likely
24:55mom has lupus and then in terms of
24:58accelerations you want to know that a
25:02good acceleration is a sign that the
25:05baby is healthy and to define
25:07acceleration as the 15 and 15 to + 20
25:11rule which means if the heart rate
25:13raises by 15 and lasts for at least 15
25:16seconds and you see two of those in 20
25:19minutes that means the baby is healthy
25:21and it rules out hypoxia a non-stress
25:24test which is done when mom feels like
25:28there's reduced movement in the baby
25:30then you do a non-stress test and that's
25:33where you check for accelerations if you
25:35don't see any accelerations the 15 for
25:40in 15 2 and 20 then you proceed to a
25:43biophysical profile which incorporates
25:46more elements such as breathing tone
25:48movement and like amniotic fluid volume
25:52and if the score for that is less than 4
25:54then you want to deliver but for now
25:57just remember what an acceleration is if
26:00you see 2 and 20 it means that the baby
26:03next is hypercalcemia calcium levels are
26:07usually between 8 to 10 anything higher
26:09than that is hypercalcemia and this is
26:12dangerous because it can lead to
26:14arrhythmias or coma it's very important
26:16to know what is the first-line treatment
26:19IV fluids if someone has hyponatremia
26:23this is a bit difficult but I'm gonna
26:26try and give you a spark note version of
26:28hyponatremia what in theory first you
26:33tenacity so normal tenacity is 275 to
26:38295 so you can be hypertonic if you're
26:41above that isotonic or hypotonic and
26:44then the hypertonic ones are usually due
26:47to elevated glucose levels and then the
26:51isotonic hyponatremia is are usually due
26:54to elevated proteins or fat but the
26:56hypotonic which is less than 275 is
26:59where it gets tricky because it
27:02subdivides further into fluid status so
27:06you can be hypervolemic euvolemic or
27:09hypovolemic hyponatremia you know common
27:13differentials for hypervolemic
27:15hyponatremia would be like CHF CKD but
27:20then for isotonic the two main ones
27:23would be primary polydipsia or SIADH and
27:26then for hypo bulimic would be like
27:30diuretics or vomiting what what I want
27:34you to know if someone has hyponatremia
27:36and they're hypovolemic without symptoms
27:39first-line treatment is normal saline if
27:43they have a severe hyponatremia with
27:48symptoms and the symptoms of
27:50hyponatremia would be like lethargy
27:52possibly coma and if sodium level is
27:55really low like 120 you want to treat
27:58with hypertonic saline 3% if they have
28:02euvolemic or hypervolemic hyponatremia
28:05the most common one is that you'll see
28:08in a question as someone with SIADH then
28:11the treatment will be water restriction
28:14so that's kind of like a quick
28:18of what kind of fluid resuscitation you
28:20would use hypokalemia and hyperkalemia
28:23they both manifest with weakness as
28:26their main symptoms and then if the typo
28:29Klimek then you want to treat with oral
28:31potassium replacement and then for
28:34hyperkalemia check the EKG because
28:36hyperkalemia can present with EKG
28:40changes such as peaked t-waves and a
28:42wide QRS if you see that this page
28:45can have an arrhythmia at any moment so
28:48the first thing you want to give is
28:49calcium gluconate which stabilizes the
28:52cardiac membranes and then you can also
28:54give insulin which pushes potassium into
28:57the cell the correct answer with someone
28:59with hyperkalemia potassium over five
29:02with EKG changes the first thing is
29:06calcium gluconate acute bronchitis this
29:09is more of a diagnosis by exclusion it's
29:12mostly caused by a virus but it's
29:14different than other lung pathologies
29:16because it usually starts with a runny
29:19nose and no fever where's the other
29:21dangerous ones like pneumonia and stuff
29:23won't really have a runny nose and it's
29:25more just like a productive cough and
29:27fever so for acute bronchitis if you
29:31rule everything else out the treatment
29:33is just supportive care then you should
29:36know acute otitis media versus otitis
29:38externa versus otitis media with
29:41so a qø tightness media is an infection
29:44of the middle ear and then this on
29:47otoscopy will show very puffed out red
29:51erythema das angry-looking
29:53eardrum and then this is caused by the
29:56main three bugs strep pneumo h flu and
30:00Moraxella those three are also the main
30:02culprits for pneumonia as well and also
30:06for bacterial sinusitis as well and for
30:10meningitis jab pneumo H flu are also the
30:14main culprits for meningitis and then
30:17the third one would be Neisseria
30:19meningitidis four and then that also has
30:21a rash which helps diagnose meningitis
30:25but anyways back to the ear pathologies
30:28otitis externa is usually associated
30:32with swimmers or diabetics and the main
30:34bug is Pseudomonas for acute otitis
30:37media you want to treat with amoxicillin
30:39otitis media with effusion is basically
30:42in the middle ear there is fluid bubbles
30:45behind the wall and then this is you
30:48treat it supportively so then MI there
30:52are three drugs you need to remember
30:54that decrease mortality and that's ace
30:56inhibitors beta blockers and aspirin you
31:00want to use ace inhibitors indefinitely
31:02because it prevents future ischemic
31:05events and left ventricular hypertrophy
31:07from remodeling after an mi so the main
31:10thing I want to talk about for MI is
31:13that if someone has stable angina which
31:18means that there's substernal chest pain
31:22that's worsened with exertion and
31:24relieved with rest and not getting any
31:27worse and it's kind of just every time
31:29they exercise they feel chest pain and
31:32this is stable angina what you want to
31:34do next is exercise stress test which is
31:37the exercise EKG if they have
31:40contraindications to exercise as a like
31:43maybe they've had a hip replacement or
31:45they're wheelchair-bound and they can't
31:46exercise then you can do a pharmacologic
31:50stress test but what is more important
31:52is when someone presents with an acute
31:55onset of chest pain that's happening
31:58right now or that has been getting worse
32:00so the first thing you want to do it
32:02someone who comes in with chest pain is
32:04you want to rule out acute coronary
32:06syndrome so the first thing you do is
32:09the EKG with troponin and acute coronary
32:13syndrome is defined as three different
32:15pathologies one is unstable angina
32:19the second is n STEMI and the third is
32:22STEMI so a STEMI is if you have C St
32:26elevations and two continuous leads so
32:29the ST segment is raised higher than one
32:32millimeter if you see that that's
32:34automatically a STEMI you don't even
32:37need to wait for the troponin this
32:39person goes straight to cath lab or if
32:42they have a new left bundle branch block
32:44with symptoms of MI they also go
32:46straight to cath lab and n STEMI an
32:49unstable angina are virtually
32:52indistinguishable upon presentation so
32:55you need serial troponin to
32:57differentiate and you're gonna do the
32:59troponin every few hours and what you do
33:03is you treat matically first with mona
33:05see - so morphine oxygen nitrates
33:09aspirin clopidogrel beta blockers ACE
33:12inhibitors statin and heparin
33:14if the serial troponin is come back
33:16elevated then this is an N STEMI if it
33:19doesn't then this is most likely
33:21unstable angina with these two you will
33:24not apply something called a Timmy score
33:26if the Timmy score is between zero to
33:27two you do a stress test
33:30it fits three or more then you want to
33:32go to the cath lab how do you apply the
33:35Timmy score coronary stenosis greater
33:38than 50% age 65 plus two episodes of
33:42angina in the last 24 hours three risk
33:46factors for cardiovascular disease such
33:49as obesity smoking hypertension
33:51hyperlipidemia diabetes etc greater than
33:54three of those aspirin usage troponin
33:57elevation or ast changes between 0 to 2
34:01you're gonna do a stress test three or
34:02more they go to the cath lab also the
34:05definition of unstable angina you should
34:08know that it's considered chest pain
34:11that's been evolving worsening or occurs
34:16at rest coz stable angina when they're
34:19at rest they don't have chest pain but
34:21someone with unstable angina
34:23even at rest it'll hurt or the symptoms
34:26seem to be worsening unstable angina or
34:30apply the Timmy score STEMI doesn't need
34:33a Timmy score straight to cath lab so I
34:36hope that helps CKD what is the most
34:39likely cause of death from CKD
34:42cardiovascular causes what about for
34:45rheumatoid arthritis it's also
34:47cardiovascular causes because rheumatoid
34:49arthritis accelerates atherosclerosis
34:52CKD blood pressure goals is less than
34:55140 over 90 women with diabetes mellitus
34:58are associated with getting candidiasis
35:01or vaginal yeast infections and you
35:05treat those with easels remember anyone
35:07who has asymptomatic vaginosis and a
35:10woman so vaginosis is gardnerella then
35:14you want to treat that with
35:15metronidazole because if it's left
35:18untreated it can lead to preterm
35:19delivery anyone who uses antibiotics and
35:23then has vaginal discharge afterwards
35:25think of Candida I kind of think of it
35:28as like the sea death of the vaginal
35:30infections for GI bleeding hematochezia
35:34if they're stable the first step is
35:37colonoscopy if they're unstable you want
35:40to give IV fluids and you wanna do an
35:44EGD because majority of those are from
35:47the upper GI for diverticulitis you
35:50treat it with fluoroquinolones and
35:52metronidazole diverticulitis will
35:55present that with left lower quadrant
35:57pain a history of constipation with
36:00fever and leukocytosis it's diagnosed by
36:04CT of the abdomen ulcerative colitis
36:06remember there's some key associations
36:08it's associated with colon cancer it
36:11also can cause toxic megacolon and it's
36:15also associated with primary sclerosing
36:19cholangitis this is very high yield an
36:22older person who presents with the
36:24microcytic anemia which means the MCV is
36:27less than 80 and they're anemic which
36:30means the human globin is less than 14
36:32and males are less than 12 and females
36:34the next debt is colonoscopy this is
36:37huge make sure you remember this why do
36:39you do the colonoscopy because you want
36:41to rule out cancer rust-colored sputum
36:44is associated with strep pneumo
36:46Legionella is pneumonia plus diarrhea
36:50plus hyponatremia and it's associated
36:53with elderly smokers who hang out in
36:56areas with dirty air conditioning
36:59machines or areas with contaminated
37:02sources of water inpatient pneumonia is
37:05treated with a fluoroquinolone a healthy
37:08person who is treated with pneumonia
37:10outpatient for typical pneumonia is
37:13treated with amoxicillin for outpatient
37:17atypical pneumonia the first line is a
37:20macrolide like a zero Meissen the
37:23typical and atypical pneumonia is based
37:26on chest x-ray findings a typical
37:28pneumonia will have low bar
37:30consolidation whereas a typical who have
37:33interstitial infiltrates the most common
37:36typical pneumonias are strep pneumo h
37:39flu and maxilla and the most common
37:41atypical pneumonia are mycoplasma
37:44chlamydia and Legionella how do you
37:46decide whether to admit someone to the
37:49inpatient hospital for pneumonia is
37:52supplied the curb 65 criteria confusion
37:55uremia respiratory rate that's tachypnic
37:59blood pressure that's hypotensive and
38:01age greater than 65 if they have true or
38:04greater of this then you want to admit
38:07them to the hospital to diagnose
38:09depression MC deep caps mood sleep
38:12insomnia guilt energy concentration
38:15appetite changes psychomotor changes and
38:18suicidality if they have 5 of the 9
38:22symptoms greater than 2 weeks then you
38:24want to start them first-line on an SSRI
38:26and remember that it takes four to six
38:29weeks for SSRIs to start working so if
38:33they come in early and they haven't
38:35noticed changes yet tell them to hang in
38:37there be patient before it starts
38:40working and then if they start feeling
38:42better to continue it for at least nine
38:45months because you don't want to risk
38:48them going back into depression so you
38:50keep treating for at least nine months
38:52and then reassess later to see if you
38:55can wean off the antidepressants
38:57remember that people who have MI or
39:01strokes and have depression after that
39:04are three times more likely to die after
39:06giving birth the endometrium will keep
39:09shedding and this is called lochia and
39:12it's normal to see vaginal bleeding with
39:16lochia for at least a month
39:18contraindications to breastfeeding or
39:21HIV and chemotherapy mastitis is where
39:25you see erythema over the breast it can
39:29also look like cellulitis the first-line
39:32treatment is dicloxacillin this is due
39:36cracks in the nipple and when the baby
39:37feeds oral bacteria infiltrates the
39:41cracks in the skin and then an abscess
39:44can also look like mastitis but on
39:47palpation there's fluctuant which means
39:49that it feels like there's fluid
39:51underneath and that's treated with
39:53antibiotics and incision and drainage
39:56breastfeeding happens from birth till
39:59six months exclusively and it benefits
40:02the baby a lot and prevents it from
40:04having infections and allergies later on
40:08in life and also it's good for the mom
40:11and reduces the chances of mom getting
40:15CHF there's four types of heart failure
40:18based on the New York Heart Association
40:20class one two three and four so one is
40:24if there's no symptoms two is if their
40:27symptoms with activity three if there's
40:31no symptoms only when they're at rest
40:33and four is when there's symptoms at
40:35rest depending on each class you want to
40:38treat with different drugs and add
40:40different drugs so first class one it's
40:43an ACE inhibitor for class 2 you want to
40:45add a beta blocker for class three you
40:48add a diuretics such as spironolactone
40:50and class four is where you can add
40:53drugs that increase contractility and
40:56inotropy such as digoxin remember there
40:59are three heart failure drugs that can
41:02improve mortality and that's an ACE
41:04inhibitor a beta blocker and Sparano
41:07lactone which is a potassium sparing
41:09diuretic so CHF is diagnosed on
41:12echocardiogram if someone has a CHF
41:15exacerbation which means they're
41:18suddenly having a Q onset of shortness
41:20of breath with pulmonary edema the
41:23first-line treatment is furiosa mite
41:25which is a loop diuretic and that'll
41:28help alleviate a blood pressure and that
41:31will help drain out some of the fluid
41:35CHF usually presents with paroxysmal
41:38nocturnal dyspnea or orthopnea and that
41:43means when they lie down they feel like
41:45they have difficulty breathing OC peas
41:49in migraines with aura smokers or at 35
41:52years or older because estrogens can
41:55increase the risk of DVT MI PE and
41:59stroke and it's prothrombotic it's
42:03contraindicated in these patient
42:05populations because it increases the
42:08risk of complications
42:09remember that OCPs protect against
42:11ovarian cancer endometrial cancer but it
42:14has a slight increased risk of breast
42:17cancer and then the copper IUD is the
42:19most effective form of emergency
42:21contraception and can be used with them
42:23five days of intercourse however its
42:26main side effect as man or Asha so it's
42:28contraindicated in patients who have
42:30many rajah first-line for hypertension
42:33or a calcium channel blockers ACE
42:35inhibitors and thighs Ides in
42:38african-americans you want to avoid ACE
42:40inhibitors as first-line so you want to
42:43use thighs Ides or calcium channel
42:45blockers because african-americans are
42:47predisposed to angioedema because ACE
42:51inhibitors prevent the breakdown of
42:53bradykinin and Brady kinase are similar
42:56to histamine which can cause angioedema
42:58anyone who has proteinuria the first
43:02line is ace inhibitors because ACE
43:04inhibitors remember they cause
43:08vasodilation of the afferent arteriole
43:11and this reduces pressure on the
43:14glomerulus and decreases the GFR which
43:17is protective and it's not so hard on
43:19the clam areolar unit hypertension is
43:22considered anything greater than 140
43:25on three consecutive visits this is an
43:28indication for starting
43:30antihypertensives and if the blood
43:33pressure is not reached to the target
43:35goal which is under 140 over 90 after
43:39one month then you can increase the dose
43:41or add a second drug intussusception
43:44which is caused by telescoping of the
43:47ileum into the cecum and then this can
43:50cause irritation to the mucosa and
43:53possibly ischemia and this causes the
43:55mucosa to slough off and that produces
43:58currant jelly stools and colicky pain
44:02so and it'll most likely be in the right
44:04lower quadrant with intermittent
44:06abdominal pain the next up you want to
44:09do is an abdominal x-ray to rule out per
44:12for Asian intussusception is treated
44:15with an air enema versus a med got
44:18volvulus the mid got volvulus is an
44:21embryonic pathology where if you
44:24remember during embryology the
44:26intestines don't rotate
44:29270 degrees and it twists around the SMA
44:33improperly so basically the cecum is on
44:37the right upper quadrant and this
44:38predisposes to to twisting around the
44:41SMA and this causes a small bowel
44:44obstruction so the kid will present with
44:46bilious vomiting and constant abdominal
44:49pain versus intussusception which has
44:52colicky abdominal pain first thing you
44:54want to do is an abdominal x-ray to rule
44:56out / for a shin and then when you see
44:59that it's once you've ruled out
45:01perforation then the next thing you want
45:03to do is an upper GI series which is an
45:06x-ray with a barium swallow and it
45:09visualizes the esophagus stomach and
45:11duodenum what you'll see is a double
45:15bubble sign with some fluid after the
45:18double bubble or something called the
45:20corkscrew Simon jejunal atresia is
45:23caused by a vascular accident in utero
45:26mostly associated with maternal cocaine
45:29use and you'll see the triple bobl syÃn
45:31the double bubble sign is associated
45:34with Down's syndrome which is due to the
45:37duodenum failing to wreak analyze
45:40pneumomediastinum is something that you
45:43would see in esophageal perforation most
45:46commonly Boerhaave syndrome which is
45:49perforation of the Safa gas and it's
45:52most commonly caused by endoscopic
45:55procedures for Hubbs will present with
45:57pneumomediastinum on chest x-ray but
46:01also this patient will have fever and
46:03crepitus on palpation of the skin and
46:06you want to diagnose this with
46:09gastrografin swallow which will show the
46:12water soluble dye extravasated
46:15out of the esophagus and you don't want
46:18to do an endoscopy because this can make
46:21once poor Hobbs is diagnosed then you
46:23treat it surgically so just to summarize
46:26constant abdominal pain you should think
46:28of midgut volvulus and colicky pain
46:31think of intussusception
46:33remember intussusception also has a
46:36couple associations and one is
46:38henoch-schonlein purpura can predispose
46:40to it and the second one the rotavirus
46:43vaccine is contraindicated and kids who
46:47have had interception in the past so
46:49with dementia make sure before you
46:52diagnose dementia to always rule out
46:55hypothyroidism or b12 deficiency first
46:58make sure you rule out all the
47:00reversible causes before you make the
47:02diagnosis first-line treatment for
47:05weight loss is lifestyle modifications
47:07such as diet and exercise and if that
47:10doesn't work then you can progress to
47:14you can give metformin to help with
47:16weight loss bariatric surgery is
47:19indicated in patients who have a BMI of
47:22greater than 40 or a BMI of greater than
47:2435 with comorbidities remember that
47:28after bariatric surgery certain
47:30complications or stole most enosis or
47:33dumping syndrome which is basically the
47:36food is transiting through the stomach
47:38too quickly and not being absorbed fast
47:41enough and this can cause diarrhea to
47:44treat it you want to eat small meals
47:46with high-protein migraine headache
47:48remember the pound's criteria pulsatile
47:52one day duration unilateral nausea and
47:55vomiting and debilitating but red flags
47:58for headaches would be a headache that's
48:01getting worse a headache that increases
48:03with valsalva or exercise or a headache
48:06that was associated with recent head
48:09trauma or a headache that awakens you
48:12from sleep other than that then you can
48:15diagnose a migraine headache first-line
48:17treatment for migraine headache is more
48:19conservative like getting exercise
48:22getting good sleep less caffeine less
48:26erm but if it's a severe or refractory
48:30migraine then you want to give
48:31sumatriptan which is a serotonin agonist
48:34and then for migraine prophylaxis you
48:38can give beta blockers or TCAs so the
48:40next is very high yield is knowing what
48:43are the four types of patients that get
48:46statin therapy and so the first does any
48:49patient at all who has the LDL greater
48:51than 190 gets a statin any patient with
48:54a SC VD aka atherosclerosis Collor
48:59disease those who have peripheral artery
49:01disease or coronary artery disease will
49:03also get a statin any patients older
49:06than 40 with diabetes and LDL greater
49:09than 70 also gets a statin and any
49:13patients with the CVD risk greater than
49:167.5% with the LDL greater than 70 also
49:20gets a statin so those are the four
49:22patients that get us ten little things
49:24to also memorize are that niacin niacin
49:27is best at increasing HDL and fibrates
49:30are veste decreasing triglycerides but
49:33you don't really use any of those as
49:35first-line you might use a vibrate if
49:38the triglycerides are over a thousand
49:41and remember that super high
49:43triglycerides are associated with
49:45pancreatitis but the most common causes
49:48of pancreatitis are call stones and
49:50alcohol use so in terms of abuse any kid
49:54who has bruises on the thigh on the
49:57buttocks on the cheeks and varying ages
49:59you should suspect abuse posterior rib
50:02fractures or metaphyseal fractures are
50:05also suspicious for abuse and spiral
50:08fractures if you suspect child abuse try
50:11to talk to the child alone without the
50:14parents present and if you really
50:16suspect abuse then what you should do is
50:19separate the kid from their parents and
50:21admit them to the hospital for further
50:23workup and some of the further workup
50:25things you can do our fund escapee to
50:28look for retinol have ridges you can do
50:30a bones there survey to check for more
50:34and you can also call Child Protective
50:37Services so hip conditions you should
50:40know the difference between Skippy and
50:42Lake a vapor theis disease versus septic
50:46arthritis versus transient synovitis so
50:50skip via slips capital femoral epiphysis
50:53and this is usually in an obese
50:56eleven-year-old and this is where the
50:58epiphysis has slipped off though you
51:01usually show you an x-ray photo and if
51:03you see that it slipped off they'll
51:05usually ask you what to do next and
51:07that's treated with surgical pinning
51:09versus leg calve a Perthes disease which
51:13is idiopathic avascular necrosis of the
51:16hip and this is just treated
51:17conservatively it's usually in a younger
51:20like six year old who's more skinny and
51:23then septic arthritis is a very hot and
51:27swollen red joint where the patient
51:29can't even bare anyway on it won't move
51:32it at all and it hurts a lot and the
51:35first thing you want to do is aspirate
51:37that joint the most common bugs are
51:40staph aureus and strep pyogenes the
51:42favorite test is a way to assess for
51:45ankylosing spondylitis it irritates the
51:48sacroiliac joint Faber stands for
51:50flexion abduction and external rotation
51:53and this is a way to but if you suspect
51:56ankylosing spondylitis on the Faber test
51:59the next step would be to do a lumbar
52:02and sacral x-ray which will show the
52:05bamboo patterning malignant hyperthermia
52:07is caused by calcium accumulating in the
52:11muscles due to Halo theme or
52:13succinylcholine and the treatment is
52:16supportive or dantrolene this should be
52:19contrasted with neuroleptic malignant
52:22syndrome and serotonin syndrome which
52:25also present with fever and rigidity but
52:29serotonin syndrome would be seen in a
52:31patient who's been taking
52:33antidepressants and neuroleptic
52:35malignant syndrome would be seen in a
52:37patient who's taking antipsychotics
52:39whereas malignant hyperthermia
52:41would be seen in a patient who just went
52:44under anesthesia aspiration pneumonia
52:46people who are at risk for this are
52:48people who can't really control their
52:51swallow or gag reflex so it would be
52:53like people who have had seizures people
52:57with dementia people who have had
52:59strokes people who are alcoholics and
53:02lose consciousness a lot or people who
53:05are mechanically ventilated these people
53:09are more likely to get aspiration
53:11pneumonia and what you'll see is inflict
53:15rates on the right lower lobe that can
53:17progress to abscesses which will show
53:20air fluid levels and you want to cover
53:22for anaerobes so you treat this with the
53:25so sin which is piperacillin Tazo back
53:27TM or clindamycin clindamycin covers and
53:31robes there's a little trick is that
53:34clindamycin covers anaerobes above the
53:37diaphragm and metronidazole covers
53:40anaerobes below the diaphragm DVT is
53:43when you have a deep venous thrombosis
53:46it'll present with a very tender and
53:48swollen calf and then if you suspect DVT
53:52the first thing you should do is start
53:54heparin and then bridge to warfarin this
53:57can also be treated with factor 10a
54:00blockers like rivaroxaban if there's a
54:03surgical site infection the skin around
54:06the sutures will be very red and err
54:09feminist and the patient will have fever
54:11and signs of infection and what you want
54:14to do is open the wound clean it out and
54:17let it drain and give antibiotics
54:19respiratory syncytial virus is one of
54:23the most common pediatric respiratory
54:25diseases and it's usually in kids less
54:29than two years old and it starts with
54:31upper respiratory symptoms such as nasal
54:34congestion and it progresses to wheezing
54:37and Eickhoff and the treatment here is
54:40supportive for adults normal breathing
54:43is anywhere between 12 and 20 breaths
54:45per minute but for kids less than two
54:48years old anything greater than 40
54:52is to keep me up epiglottitis you should
54:54definitely know caused by H flu and it's
54:58vaccine preventible the kid will usually
55:00be drooling and having difficulty
55:02breathing and they'll assume the tripod
55:05form where they lean over with their
55:07palms on their knees to breathe better
55:09and stick they'll also stick their
55:12tongue out and the first thing you want
55:14to do is intubate that'll usually be the
55:16right answer and then croup is caused by
55:20para influenza virus this will present
55:23with the barking cough and Strider and
55:25you want to treat this with
55:27corticosteroids or nebulized epinephrine
55:31or what they call racemic epinephrine if
55:34the child has Strider at rest with
55:37respiratory distress
55:38so then sometimes croup can advance to
55:42something called bacterial tracheitis
55:44where their secretions start having more
55:47phlegm they start getting posi
55:49secretions at this point it's
55:51life-threatening and you want to
55:53intubate them and the bug is most likely
55:55staph aureus peritonsillar abscess is
55:58what you look for is the deviated uvula
56:02and difficulty swallowing also they will
56:05have a muffled voice fever and
56:08leukocytosis what you want to do is IMD
56:11and give antibiotics irritable bowel
56:14just thank alternating constipation with
56:17diarrhea and improvement after going to
56:21the bathroom if it's diarrhea
56:22predominant you can shoot with
56:24loperamide if it's constipation
56:26predominant then you can increase
56:27vibrant take this should be contrasted
56:29with celiac disease which happens in
56:33younger patients who will have diarrhea
56:36abdominal pain and weight loss but their
56:39diarrhea will be bulky greasy stools and
56:42this is due to malabsorption at the
56:45duodenum due to villous atrophy and this
56:48is a reaction to gluten so they'll have
56:51anti tissue transglutaminase anti and
56:54domicile or anti-gliadin antibodies and
56:57you want to treat this by avoiding
57:00gluten so remember that someone who
57:04with a cocaine overdose or cocaine
57:07toxicity with chest pain you don't want
57:10to give a beta-blocker because in theory
57:13this can cause unopposed alpha
57:15vasoconstriction which can cause an mi
57:18so the first thing you want to do with
57:20cocaine toxicity even with chest pain is
57:23IV benzodiazepines like lorazepam people
57:27who want to quit drinking alcohol the
57:29first-line drugs are a campers say and
57:32naltrexone first-line for quitting
57:34smoking would be a nicotine patch and
57:38nicotine gum and then the next line
57:40would be be appropriate or varenicline
57:43and tachycardia you can have a super
57:46ventricular tachycardia or ventricular
57:50tachycardia so super ventricular
57:52tachycardia happens above the AV node
57:54and ventricular happens below the AV
57:57node and on EKG the super ventricular
58:00tachycardias you'll just the QRS T qrst
58:04qrst and that QRS complexes are very
58:08narrow if they're stable first line is
58:10adenosine and if they're unstable then
58:13this cardioversion for a few tak what
58:15you'll see is just repeated QRS
58:17complexes but they look a little bit
58:20abnormal they look kind of like
58:22upside-down used and the QRS is will be
58:25really wide so the stable patient will
58:28get amiodarone if they're unstable then
58:31you want to also cardiovert high-yield
58:33whites you must know between cat bite a
58:35dog bite and human bite so a cat bite a
58:40it'll most likely be Pasteurella same
58:42with the dog bite and you treat these
58:44with augmentin whereas a human bite is
58:47usually multi bacterial and it's usually
58:51the Hasek organisms like eikenella and
58:54you also treat this with augmentin and
58:57also people who have human bites should
58:59get Hep B and HIV prophylaxis the
59:02difference between T ia and ischemic
59:05stroke is T ia has symptoms that are
59:08resolved within 24 hours whereas stroke
59:10the symptoms do not resolve after 24
59:13hours and still remain and stroke can be
59:16into ischemic or hemorrhagic the
59:19majority of strokes are ischemic whereas
59:21the minority are hemorrhagic it's like
59:2485% to 15% the greatest risk factor for
59:28stroke is hypertension so make sure you
59:30remember that you always give TPA within
59:33four and a half hours of the stroke so
59:35the first thing you want to do with
59:37suspected stroke is a head CT without
59:40contrast this is to rule out hemorrhage
59:43if they don't have hemorrhage then you
59:45proceed with TPA if they do have
59:49then this changes your management and
59:51you treat hemorrhagic stroke by
59:54maintaining blood pressure and keeping
59:57it lower so that they don't bleed out
59:58more and the first type of hypertensive
01:00:01drug you want to use is a calcium
01:00:03channel blocker like nifedipine after
01:00:06you treat the stroke then the next thing
01:00:09you want to do is look for the source so
01:00:11the three things you want to order or
01:00:13EKG and echo and carotid Doppler the
01:00:18carotid Doppler will look for
01:00:20atherosclerosis of the carotid arteries
01:00:22or any narrowing and this can shoot
01:00:25emboli up into the brain on the echo is
01:00:28test assessed for possible heart failure
01:00:31and it'll also look for thrombi and EKG
01:00:34is to assess for any or as Mia's or it
01:00:37possible mi which caused the stroke if
01:00:40you if you see that there is to no
01:00:43SACEUR the carotid artery greater than
01:00:4670 percent the correct answer the next
01:00:49thing you want to do is a carotid
01:00:51endarterectomy HIV is a cd4 deficiency
01:00:55due to the HIV virus what once it
01:00:58becomes below 200 this is called AIDS
01:01:01and at 200 this is when you start with
01:01:04prophylaxis and you want to prevent p0
01:01:08Veggie pneumonia and you treat this with
01:01:10TMP SMX if you don't then they could get
01:01:13p0 of matchin pneumonia which prevents
01:01:16with fever dry cough and interstitial
01:01:18infiltrates HIV the prodrome when you
01:01:22first get HIV it can present a lot like
01:01:25mono with the fever sore throat and
01:01:30on top of that this patient will also
01:01:32have a rash and then at CD 450 you want
01:01:35to give Mac prophylaxis which is
01:01:37prophylaxis against Mycobacterium avium
01:01:40complex and you prophylaxis as a
01:01:43thorough Mason if they talk about ring
01:01:46enhancing lesions on the brain imaging
01:01:50think of primary CNS lymphoma which is
01:01:53seen in AIDS or Toxoplasma or a brain
01:01:57abscess but a brain abscess can happen
01:02:00in healthy individuals who have
01:02:02infections on the face like bacterial
01:02:05sinusitis or any type of sinus infection
01:02:08that can invade the brain what's the
01:02:11pathophysiology for palmar erythema /
01:02:15spider angiomas and people with liver
01:02:18disease such as cirrhosis well once you
01:02:21have cirrhosis your liver can't break
01:02:23down estrogen and these increased
01:02:25estrogen levels dilate the blood vessels
01:02:28and that leads to spider angiomas
01:02:31remember that if you have bilirubin urea
01:02:35bilirubin in the urine can only be found
01:02:39in its conjugated form you cannot
01:02:41urinate unconjugated bilirubin
01:02:44hyperbilirubinemia is anything greater
01:02:47than one if the direct portion is
01:02:49greater than 20% and this is called
01:02:51direct hyperbilirubinemia or conjugated
01:02:55hyperbilirubinemia below that is
01:02:57unconjugated or indirect
01:02:59hyperbilirubinemia they're both they
01:03:01both mean the same things anyone with
01:03:03painless jaundice that's a sign of
01:03:06pancreatic cancer the most common causes
01:03:09of ulcers are h pylori or NSAIDs if
01:03:13someone comes in with symptoms of GERD
01:03:16or gastritis or heartburn you can start
01:03:20them with empiric proton pump inhibitors
01:03:23but if they're from a foreign country
01:03:26where H pylori is endemic then you can
01:03:30start with the h pylori test but if
01:03:32they're from the United States then you
01:03:36start with a proton pump inhibitor and
01:03:38see if it gets better if it doesn't get
01:03:41then you can test for h pylori or do an
01:03:44endoscopy patients with symptoms of GERD
01:03:47gastritis heartburn if they have alarm
01:03:50symptoms which means they've had
01:03:52dysphasia or a microcytic anemia which
01:03:56suggests chronic bleeding or weight loss
01:03:59these are called alarm symptoms and in
01:04:02that case you proceed with endoscopy to
01:04:04look for a possible cancer people often
01:04:09mix up spicy foods pausing ulcers but
01:04:12that's not true why C foods can make
01:04:14heartburn and indigestion worse and
01:04:17symptoms of GERD worse because the
01:04:20spiciness can irritate the lower
01:04:22esophageal sphincter and people might
01:04:25think that that is causing all sirs
01:04:28because the symptoms are similar but it
01:04:30doesn't cause ulcers it just exacerbates
01:04:33heartburn or indigestion but any sets
01:04:37and h pylori can definitely cause ulcers
01:04:40and remember in an old diabetic woman if
01:04:43she complains of upper abdominal pain
01:04:46this can be an atypical sign of a heart
01:04:50attack so you need an EKG chronic proton
01:04:53pump inhibitor use is also linked with
01:04:56CF and osteoporosis in the kid who is
01:04:59less than 30 days old with a fever you
01:05:02should suspect either meningitis or
01:05:04pneumonia and in this case you'll treat
01:05:07empirically with ampicillin and
01:05:09gentamicin and you should know what are
01:05:11the most common bugs for neonates and
01:05:13that's Group B Strep
01:05:15u coli and Listeria in adults the most
01:05:18common causes of meningitis or strata
01:05:21pneumo h flu and Neisseria meningitidis
01:05:24and you would treat them empirically
01:05:27with ceftriaxone and vancomycin so you
01:05:30need to know that small pox vs. chicken
01:05:34pox they can both have papules that show
01:05:37up but smallpox has the same stage of
01:05:40development all across the skin whereas
01:05:42chickenpox has successive crops of
01:05:46vesicles and papules that are of
01:05:48different ages and some will be new and
01:05:50some will be oscar ated and
01:05:52you need to know the difference between
01:05:54measles and rubella measles is also
01:05:59known as Ruby Ola and rubella is also
01:06:03known as German measles they present
01:06:06very similarly they both start with the
01:06:08rash that starts on the head and
01:06:10progresses down to the lower extremities
01:06:12but the differences are that measles has
01:06:15the four C's Kafka Raisa complex pots
01:06:19and conjunctivitis
01:06:21whereas rubella does not have the four
01:06:23C's and it has arthralgias both are
01:06:26vaccine preventable through MMR measles
01:06:30can progress to pneumonia or sspe
01:06:33subacute sclerosing pan encephalitis
01:06:36which is a brain infection that happens
01:06:3910 years later and you treat it with
01:06:42vitamin b6 you need to know the
01:06:44difference between roseola
01:06:45and parvovirus roseola is fever that
01:06:51breaks what ends and men are rash
01:06:53follows whereas parvo virus is a slap
01:06:56cheek with the lacy reticular rash
01:06:59remember that if a pregnant mom gets
01:07:01parvo virus that the kid the fetus is
01:07:05predisposed to hydrops fetalis so for
01:07:08breast masses if the female is under 30
01:07:12the next best step is ultrasound if it's
01:07:15over 30 years old then the next best
01:07:17step is mammogram and then any breast
01:07:20mass always has to be biopsied
01:07:22regardless of the imaging results on a
01:07:25unilateral nipple bleeding is suggestive
01:07:27of intraductal papillary and you should
01:07:30do a mammogram for that and remember
01:07:33mammogram screenings happen age 40 every
01:07:35year if there's a breast cysts you want
01:07:39to aspirate it and drain the fluid if
01:07:41it's yellow and completely drains then
01:07:43you follow-up in a month if not then
01:07:46you're gonna biopsy if the fluid is
01:07:49bloody make sure to send to a cytology
01:07:52PCOS the first lab test is a pregnancy
01:07:56remember PCOS is characterized by an
01:07:58ovulation hirsutism and obesity and on
01:08:04ultrasound there'll be
01:08:05multiple cystic follicles of the ovary
01:08:09and if they are having problems with
01:08:12getting pregnant the first thing you
01:08:14want to suggest is weight loss and then
01:08:16hopefully weight loss will get their
01:08:18periods to normalize so diabetes is
01:08:22diagnosed by a fasting glucose of over
01:08:24126 a random glucose of 200 plus with
01:08:28symptoms such as polyuria polydipsia
01:08:31polyphagia dehydration weight loss or a
01:08:35hemoglobin a1c of 6.5 what is considered
01:08:40controlled diabetes that's if the blood
01:08:42pressure is under 140 over 90
01:08:45if the a1c is less than seven and if the
01:08:48cholesterol is less than 100
01:08:50particularly the LDL remember that
01:08:53metformin is contraindicated in kidneys
01:08:56disease and CHF because it can cause
01:08:59lactic acidosis so in terms of low back
01:09:03pain majority of causes of low back pain
01:09:06or muscle strain but some red flags of
01:09:09low back pain would be night pain that's
01:09:11unrelenting which is suggestive of
01:09:13cancer pain at rest or six plus weeks
01:09:16know what the difference between disc
01:09:18herniation versus spinal stenosis they
01:09:21kind of have opposite presentations or
01:09:24desk herniation is worsened with any
01:09:27valsalva types of maneuvers like
01:09:30sneezing or coughing and it's improved
01:09:33with extension of the back like lying
01:09:35down but worsened with a bending forward
01:09:38and it will cause pain that radiates
01:09:41down the leg whereas spinal stenosis is
01:09:44actually better with flexion and
01:09:47worsened with extension and sometimes in
01:09:50vignettes they won't really say it so
01:09:52directly they'll say it and directly
01:09:54like a patient might feel better when
01:09:58they walk uphill but feel worse when
01:10:00they walk downhill and that is an
01:10:03indirect way of saying that the pain is
01:10:05worse with extension and then there's
01:10:07cauda equina syndrome which is when you
01:10:10have damage to the cauda equina and this
01:10:13presents with bowel incontinence
01:10:16urinary incontinence paresthesias around
01:10:19the perianal area and the legs and
01:10:22possibly paralysis and the next best
01:10:25step is to do an MRI and get ready for
01:10:28surgery and also a herniated disc is
01:10:31diagnosed clinically and you treat it
01:10:34conservatively with NSAIDs and Tylenol
01:10:37for one month and then if there's no
01:10:39improvement then you proceed with
01:10:41imaging such as an MRI and remember
01:10:44anyone who presents with lumbar muscle
01:10:47strain it's never the right answer to
01:10:49suggest bed rest it's always better to
01:10:52increase exercise and movement to keep
01:10:55yourself loose essential tremor is a
01:10:58tremor that increases with movement and
01:11:01is better at rest and it's treated with
01:11:03propanolol and it usually runs in the
01:11:06also it improves with drinking alcohol
01:11:10Tourette's is treated with clonidine or
01:11:14guanfacine which are alpha-2 agonist or
01:11:17atypical antipsychotic remember this
01:11:21person needs to have a motor and vocal
01:11:23tic for greater than a year Huntington
01:11:26disease is the autosomal dominant
01:11:29disease on chromosome 4 it runs in the
01:11:32and that causes early onset dementia
01:11:34with movement disorders and it's treated
01:11:37with Tetra benzene asthma comes in four
01:11:40flavors intermittent mild moderate and
01:11:43severe the intermittent is less than two
01:11:46days a week mild is three to seven days
01:11:49a week moderate is everyday and severe
01:11:52is multiple times a day and the
01:11:55intermittent you just treat with
01:11:57albuterol PRN but mild then you add a
01:12:00low dose steroid moderate you add a
01:12:02medium dose steroid and severe you add a
01:12:05high dose steroid to diagnosed asthma
01:12:08you will do a medically intest which is
01:12:11a muscarinic agonist and it narrows the
01:12:13bronchioles which exacerbates the asthma
01:12:16symptoms which helps with diagnosis
01:12:18remember Accu exacerbation of asthma and
01:12:22COPD have similar treatments with some
01:12:26differences so they both get
01:12:28oxygen and they both get IV or oral
01:12:32steroids like systemic steroids and
01:12:34bronchodilators but exacerbation of COPD
01:12:37you want to give antibiotics and you
01:12:41want to cover for COPD for Pseudomonas
01:12:44and you want to give them
01:12:46fluoroquinolone a patient with
01:12:48obstructive sleep apnea definitely in
01:12:51the vignette look at the PMI it'll be
01:12:53over 30 plus this person snores a lot at
01:12:57night with multiple episodes where they
01:12:59wake up in the middle of the night with
01:13:01problems breathing and throughout the
01:13:03day they feel very tired and when they
01:13:06wake up they don't feel like at rest and
01:13:08they might have headaches and lethargy
01:13:11and low-energy and possibly some signs
01:13:15of mood changes and then so if you
01:13:18suspect obstructive sleep apnea the next
01:13:21best step is a sleep study and you treat
01:13:24it with the CPAP remember that
01:13:26obstructive sleep apnea untreated can
01:13:29cause right-sided heart failure due to
01:13:31hypoxemic vasoconstriction of the
01:13:34pulmonary arteries osteoporosis the
01:13:38first-line treatment as bisphosphonates
01:13:40the greatest risk factor for
01:13:42osteoporosis is age also the greatest
01:13:45risk factor for breast cancer is also
01:13:48age so make sure you know what are the
01:13:50greatest risk factors like on the back
01:13:53cuz they like to ask these things like
01:13:55what's the greatest risk factor for
01:13:57stroke hypertension what is the
01:14:00first-line analgesic for cancer patients
01:14:03opioids what is the first language
01:14:06analgesic for people who have sickle
01:14:08cell crisis it is also opioids studies
01:14:11have shown that people underestimate the
01:14:15pain of sickle cell crisis chronic
01:14:17venous insufficiency look for the medial
01:14:20malleolus ulcer and then versus CHF can
01:14:25also have pitting edema of the lower
01:14:28bilateral lower extremities but in CHF
01:14:31it'll also include ascites and jvd and
01:14:36signs of heart failure such as pulmonary
01:14:39deema and possibly some heart murmurs no
01:14:43the different ear diseases like benign
01:14:46paroxysmal positional vertigo versus
01:14:49Meniere's disease versus vestibular
01:14:51neuritis which is also known as acute
01:14:54labyrinthitis so BPPV this is worse with
01:14:59random movements of the head like
01:15:01getting up from the bed it's exacerbated
01:15:03by random movements and you want to do
01:15:06the Dix Hall Pike maneuver to treat it
01:15:08which helps get the little stones in the
01:15:11semicircular canals out Meniere's
01:15:14disease has the triad of tinnitus
01:15:16hearing loss and vertigo and this is due
01:15:19to increased pressure in the endolymph
01:15:21and you treat it with diuretics and then
01:15:24vestibular neuritis is this is hearing
01:15:27loss and vertigo but it follows a viral
01:15:30upper respiratory tract infection an
01:15:32umbilical hernia self resolves the
01:15:35answer is usually reassure the parent
01:15:38unless it's over five years old then you
01:15:40do surgery but most of the time the
01:15:43correct answer is reassured remember on
01:15:45colon cancer screening if you find a
01:15:48polyp and you remove it the next time to
01:15:50follow-up is three years remember the
01:15:52most dangerous type of polyp is the
01:15:55villus polyp because it sounds like a
01:15:57villain and that's basically it for a
01:16:00family medicine so I hope that was
01:16:02helpful and yeah enjoy your studies and
01:16:07we'll see you in the next one
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