Clinical Pearls

The following are a list of teaching pearls compiled by the faculty. They are loosely organized into organ systems. As with any uncited, undated expert opinion, you are encouraged to think critically about what you find here. Do your own research when you have questions.

If you find a "pearl" that is in error, please e-mail the webmaster, Chris Knight , cknight@u.washington.edu.

Preventive medicine

Adults should receive Tetanus booster (TdAP if < 65) every 10 years or at least a booster at age 50 or after. Pneumococcal vaccine recommended for adults age 65 or greater. Annual influenza vaccine recommended for those > 65 years old, health care workers.
You can stop obtaining pap smears in women > 65 who have had repeatedly normal paps previously, and in any woman who has had a hysterectomy for benign disease.
Asplenic individuals should receive pneumococcal, H. influenza B Meningococcal vaccines.
Current recommendations for colon cancer screening are in adults > 50 annual fecal occult blood test, flex sig. every 3-5 years or both or colonoscopy every 10 years.

Geriatrics

The three most common causes of weight loss in the elderly are: depression, malignancy and GI disorders. In about 25% of patients no diagnosis is made.
Remember the pneumonic DRIIPS for incontinence: Drugs, Restricted mobility, Infection, Impaction, Polyuric States (hyperglycemia, CHF).

Dermatology

Livedo reticularis is associated with SLE, and when it is present there is frequently anticardiolipin antibodies and an increased risk of CNS events.
Psoriasis may be exacerbated by streptococcal infection, skin injury (sunburn or drug reaction) or HIV disease.
Think of the 5 P’s for the diagnosis of lichen planus pruritic, purple, polygonal, planar papules.
Porphyria cutanea tarda is associated with heavy alcohol consumption, hepatitis C, and iron overload. Clinical features include facial hirsutism, milia, erosions, scars and tense bullae (frequently on hands).
Pemphigus vulgaris often involves the mouth (50%). Diagnosed by immunofluorescent studies of perilesional skin. High fatality rate if not treated.
Important causes of erythema nodosum include: streptococcal, fungal and 1o TB infections, sarcoid, inflammatory bowel disease, and oral contraceptive pills.
Acanthosis nigricans is most often seen in association with obesity and diabetes with insulin resistance. It is occasionally seen associated with malignancy (60% gastric).
Cellulitis with bullae in a patient with liver disease think Vibrio vulnificus.
Pseudoxanthoma elasticum causes “chicken skin” around neck, axilla. Angioid streaks on funduscopic exam. Clinical features include recurrent GI bleeding.

Allergy

When a patient has intraoperative anaphylaxis suspect latex allergy, preoperative antibiotics, induction agents (especially thiopental), opiates.
Patients with hereditary angioedema present with recurrent episodes of swelling usually beginning in childhood and frequently after trauma. Episodes of abdominal pain due to edema are common. These patients do not have urticaria. A good screening test for this is C4 levels which are always low.
Acquired C1 esterase deficiency is seen in patients with B-cell proliferative disorders, connective tissue disorders and monoclonal gammopathies.
ACE inhibitors have two important hypersensitivity reactions, a) cough (20-30%) which may occur up to a year after starting med. It is associated with bronchial hyperactivity to methacholine; b) angioedema – (.1 .2%) involves face especially the lips, and tongue which can lead to fatal airway obstructions.
Aztreonam does not have cross reactivity in regards to allergic reactions with beta-lactams with the possible exception of Ceftazidime which shares an identical side chain.
Aspirin sensitivity occurs in 8-19% of adult asthma patients. The classic triad (Samter's triad) of aspirin allergy is a) asthma; b) nasal polyps; c) sinusitis.
Pearls about secondary rhinitis – conditions which cause nasal congestion – hypothyroidism, pregnancy, Wegener’s granulomatosis, medication induced (topical nasal decongestant over use, ACE inhibitors, alpha blockers).
Patients with moderate persistent asthma (daily symptoms) should be on inhaled steroids (moderate to high dose).

ID

Major risk factors for tuberculosis include HIV infection, injection drug use, homelessness, residency in correctional facility, or prior residence in endemic country (Asia, Africa, Central America).
Diagnosis of tuberculosis pleuritis usually requires pleural biopsy. Two or more biopsies have a 95% diagnostic yield.
Close contacts of TB patients, HIV infected patients and individuals with chest x-ray suggesting old TB should receive INH if PPD ≥ 5 mm.
Mycoplasma pneumonia is associated with cold agglutinins developing during the second week of illness (~50%). Occasionally hemolytic anemia may develop.
Legionella clinical features abrupt onset of high fever, myalgias, headache initially non productive cough with purulent/sometimes bloody sputum developing later. Hyponatremia, leukocytosis common. Diagnosis urinary antigen or DFA of sputum/throat swab.
Patients with hepatitis B who are e antigen positive are the most infectious.
Hepatocellular carcinoma is an important life threatening sequelae of chronic hepatitis B infection.
Parvovirus B19 infection in adults can cause a rheumatoid arthritis like syndrome with polyarthritis. transient aplastic crisis occurs in patients with chronic hemolytic anemias (especially sickle cell disease). Patients with immunosuppression (especially HIV) can develop chronic anemia.
Treatment with immunoglobulin is used for chronic anemia due to parvovirus in immunocompromised patients.
The major reservoirs for rabies in the United States are bats, skunks, raccoons, foxes and coyotes.
Think of hantavirus infection in patients with fevers, myalgias, noncardiac pulmonary edema, increased hematocrit, and leukocytes.
Babesiosis is most commonly seen in the Northeastern U.S. (for board purposes think Martha’s Vineyard) but has been described elsewhere. Disease is more severe in splenectomized patients.
Ehrlichiosis is a rickettsial infection most common in South Central and South Atlantic states. Clinical features include fevers, headache, myalgias but rarely (<20%) rash. “Rocky mountain spotless fever.” As with all rickettsial infections expect to see thrombocytopenia, lymphopenia and increased LFT’s.
The classic finding of Lyme disease is erythema migrans, a rash which occurs 7-10 days after the tick bite (occurs in 60-80% of patients). It is an erythematous, annular lesion, usually with central clearing and is large over 5 cm (average 15 cm).
Think Lyme disease when you see bilateral 7th nerve palsies (sarcoid is another disease that can do this).
Psittacosis is spread from parrots, parakeets, lorries, pigeons and turkeys.
Third generation cephalosporins are particularly effective and indicated for treatment of meningitis (except cefoperazone), gonorrhea (ceftriaxone/cefixime) and nosocomial infections.
“Red man” syndrome is a side effect of infusion of vancomycin at too fast a rate. It consists of itching and rash on face, neck and trunk. It is due to histamine release
Patients with recurrent erythema multiforme should be evaluated for HSV infection. Consider a trial of acyclovir.
Risk factors for disseminated candidal infection include hyperalimentation, central venous catheters, diabetes, broad spectrum antibiotics and steroid therapy.
Clinical features of disseminated candidiasis fever, endophthalmitis, pulmonary infiltrates. Hepatosplenic candidiasis most common in transplant of leukemic patients fever, abdominal pain, hepatosplenomegaly, increase alkaline phosphate.
Risk factors for invasive aspergillosis prolonged granulocytopenia, corticosteroid therapy, cytotoxic chemotherapy. Interestingly not common in AIDS patients.
Rhinocerebral mucormycosis usually seen in patients with diabetic ketoacidosis or leukemics. High mortality rate due to complication of cavernous sinus thrombosis and cerebral infarction.
Coccidiomycosis Two presentations to know 1) symptomatic pulmonary infection “valley fever” flu like illness, hilar adenopathy or effusion on x-ray, mild eosinophilia. May have rash and erythema nodosum; 2) disseminated disease more common in Filipino’s/Asians/Blacks and patients with AIDS. Lesions can occur in bone, skin, meninges, joints.
Leishmaniasis epidemiology especially Latin America, Mediterranean littoral, middle east. Cutaneous and visceral disease. Key features of visceral disease hepatosplenomegaly, generalized lymphadenopathy, pancytopenia, fever, cachexia (resembles lymphoma).
In patients with virulent E. histolytica infections almost all have a positive serology. In a patient with a liver abscess and suspected E. histolytica serology usually needed to confirm diagnosis.
Trichinosis Clinical features severe muscle pain, periorbital and facial edema, subconjunctival and splinter hemorrhages, eosinophilia.
Young women with uncomplicated cystitis should not have a urine culture done.
Key features of disseminated gonococcal infection include tenosynovitis, asymmetric arthritis and a few skin lesions on hands, feet , wrist ankles.
Increased susceptibility to gonococcal and meningococcal bacteremia may be due to homozygous deficiency to complement components C5, C6, C7 or C8. Screen patients for these defects with a total hemolytic complement (CH50).

HIV

Patients with acute HIV infection share many symptoms with mononucleosis. Differences between the illnesses: rash common with acute HIV (70%), oral ulcers occur with acute HIV (30%), diarrhea with acute HIV (30%).
Bacillary angiomatosis is due to Bartonella sp usually acquired from cats. Treat with erythromycin.
An HIV-infected patient with oral candidiasis complaining of dysphagia should be treated empirically for esophageal candidiasis (fluconazole). the positive predictive value of these symptoms is ~ 100%.
Patients with HIV who have oral candidiasis should receive PCP prophylaxis regardless of their CD4 count.
Patients with HIV who develop a spontaneous pneumothorax probably have an infection with pneumocystis (95% chance).
Clinical features of tuberculosis in patients with HIV differ by CD4 count. In patients with CD4 counts >300 typical symptoms occur (cough, sputum, fever, upper lobe infiltrates, cavities). When the CD4 count is <200 atypical TB presentations predominate (hilar adenopathy, no sputum, lower lobe infiltrates, extrapulmonary disease).
Antiretroviral therapy should be started in patients with CD4 counts < 350 or patients with viral loads > 55,000 and committed to taking the regimens. Patient compliance is the single most important issue in starting therapy.
Indinavir can cause renal stones and sludging.
Pseudomonas aeruginosa is an important cause of community acquired pneumonia in patients with HIV with CD4 counts <100.

Pulmonary and DVT/PE

Nonsmoking patients with chronic cough and a normal chest x-ray are most likely (> 90%) to have a) post nasal drip; b) asthma or c) GERD. Some patients may have a combination. Start with an empiric trial of antihistamine/decongestant combination, about 50% improve at the end of one week.
Reflux esophagitis should be considered in patients with refractory asthma.
A normal PO2 does not rule out pulmonary embolism. A normal PCO2 and a normal A-a gradient make PE unlikely.
A normal perfusion scan (V/Q scan with normal perfusion) makes PE extremely unlikely (~1%)
Indications for inferior vena cava barrier (Greenfield filter) : 1) patient with PE or DVT and anticoagulation is contraindicated or 2) patient has suffered recurrent DVT/PE despite appropriate anticoagulation or 3) massive life threatening PE.
Most common hereditary cause of unexplained venous thrombosis (20-60%) is APC (activated protein C) resistance (factor V Leiden mutation). This is especially common in women who develop clotting on OCP’s.
Antiphospholipid antibody syndrome acquired with SLE, some drugs, HIV disease or idiopathic. Venous or arterial clotting can occur as well as recurrent fetal loss. Pearl PTT may be elevated and does not correct with a 1:1 mix.
Causes of Vitamin K deficiency malabsorption, malnutrition, anticoagulants, cephalosporins (cefoperazone, cefotetan).

Cardiology

In aortic stenosis severe obstruction = valve area < 1 cm2. Mortality is > 50% if symptomatic and untreated.
Treatment options for severe mitral stenosis (symptomatic with valve area ≤ 1.0 cm2) a) surgical commissurotomy; b) catheter balloon mitral commissurotomy or c) mitral valve replacement.
Mitral valve prolapse endocarditis prophylaxis only if significant regurg. on echo or h/o prior endocarditis.
Appropriate treatment of PSVT in patient with WPW vagal maneuvers, adenosine or verapamil.
Appropriate treatment of atrial fibrillation in patient with WPW: unstable cardioversion, stable procainamide.
Rate control in patients with atrial fibrillation is best achieved with calcium channel blockers (diltiazem or verapamil) or beta blockers. Digoxin does not control rate well in patients who are exercising or sick.
*Must anticoagulate for three weeks prior to cardioversion in prolonged atrial fibrillation (> 48 hours) or AF of uncertain duration.
Torsade de Pointe arrhythmia due to QT prolongation often due to type I antiarrhythmic drugs also seen with Terfenadine, Astemizole, Cisapride. Other causes hypokalemia, hypomagnesemia.
Critical aortic stenosis and critical mitral stenosis are contraindications to elective surgery. Valve replacement should occur prior to any elective surgery.
The following are extreme risks for complications during non cardiac surgery: MI within 3 months, uncontrolled CHF, critical mitral or aortic stenosis.
Results of ETT that suggest high probability of severe 3 vessel disease or left main disease: a) duration of exercise < 6 min.; b) exercise induced hypotension or failure to increase SBP to > 120 mm Hg; c) ST depression > 2 mm at less than 6 METS and present in > 5 leads; d) exercise induced ST elevation; e) symptomatic exercise induced ventricular arrhythmia.
Add an imaging modality to the ETT if any of the following are present:
- widespread ST depression ≥ 1 mm on resting ECG
- ST changes due to digoxin, LBBB, LVH or WPW
CABG improves prognosis compared to medical therapy in patients with chronic stable angina with any of the following:
- left main coronary artery stenosis ≥ 50%
- three vessel CAD
- LV dysfunction
Patients with tamponade have equalization of diastolic pressures.

GI

Barium x-ray in patients with achalasia shows bird beak distal esophagus with dilated esophageal body.
Key clues of Zenker’s diverticulum are cervical dysphagia, halitosis and aspiration pneumonia.
Intermittent non-progressive solid dysphagia is suggestive of a Schotzke's ring.
Pill induced esophagitis is most commonly caused by: Tetracycline/doxycycline followed by KCL, NSAIDS, or bisphosphonates.
Patients with alcoholic hepatitis usually have AST levels less than 300 with trivial elevations of ALT with an AST/ALT ratio usually >3.
Hemochromatosis and alcoholic liver disease share several overlapping features hepatomegaly, glucose intolerance, testicular atrophy and cardiomyopathy.
Nonalcoholic steatohepatitis can mimic alcoholic hepatitis. It usually occurs in middle aged women with obesity, diabetes and hypertension. Clinical features are hepatomegaly and elevated transaminases (usually AST > ALT).
Autoimmune hepatitis usually occurs in women and serologically these patients frequently have antinuclear and anti-smooth muscle antibodies as well as hyperglobulinemia.
Wilson’s disease is a rare autosomal recessive disorder of copper metabolism. Clinical features include hepatitis (both fulminant and chronic), neurologic symptoms, hemolytic anemia and Kayser Fleischer rings around the iris.
Several drugs can cause prominent drug induced cholestasis oral contraceptive pills, erythromycin, amoxicillin/clavulanate, chlorpromazine, gold, and chlorpropamide.
Sclerotherapy is effective in controlling acute variceal bleeding (75-90%). Serious complications limit it’s usefulness. Variceal band ligation is as effective but with less complications. B-blockers are effective for prophylaxis of variceal bleeding. Octreotide drip can reduce bleeding in the acute setting.
Spontaneous bacterial peritonitis is usually caused by gram negative rods and should be treated with a five day course of a 3rd generation cephalosporin or a fluoroquinolone.
Remember prophylaxis for spontaneous bacterial peritonitis in patients with a serum/ascities albumin gradient (SAAG) < 1.
Crohns disease most commonly involves the terminal ileum and cecal region (45%)
Ulcerative colitis does not involve the small bowel. Colitis from campylobacter and occasionally amebiasis can mimic the symptoms and appearance of ulcerative colitis.
Extra intestinal manifestations of inflammatory bowel disease include uveitis, spondyloarthropathy, erythema nodosum and pyoderma gangrenosum.
Acute pancreatitis is caused by alcohol consumption or gallstones 60% of the time.
Pseudocysts develop in 20% of patients with severe acute pancreatitis. Pseudocyst larger than 6 cm are at risk for perforation, infection and hemorrhage. Surgical drainage should be performed if they do not resolve.
In evaluating suspected chronic pancreatitis, the initial diagnostic test should be plain abdominal x-ray. Presence of diffuse calcifications in the pancreas is diagnostic (~40%). The most sensitive imaging test is ERCP.

Nephrology

Patients with nephrotic syndrome are at increased risk for infections due to urinary loss of IgG and complement. They are also at risk for thrombosis due to urinary loss of anti-thrombin III and an increase in coagulation factors.
Features of renal vein thrombosis includes flank pain, hematuria and enlarged kidney by U/S.
Minimal change disease is more common in children but when seen in adults it is associated with atopy/allergy, NSAID use, or with Hodgkin’s disease.
IgA nephropathy is the most common cause of nephritis syndrome worldwide. This usually presents as micro/macroscopic hematuria often within 48 hours of a URI.
Goodpasture’s disease usually presents in patients with a typical epidemiology young male smokers with a history of hydrocarbon exposure.
Evaluation for renovascular hypertension is appropriate in young females with marked hypertension (risk for fibromuscular dysplasia) and in patients with new hypertension and evidence of advanced atherosclerosis.
Evaluate patients with spontaneous hypokalemia and hypertension for hyperaldosteronism.
Patients with renal disease have volume dependent hypertension (90%) and should be treated with loop diuretics (thiazides lose effectiveness when GFR < 50).
Atheroembolic renal disease occurs after angiography, aortic surgery and can occur after institution of anticoagulation. Clinical features include livedo reticularis, purple toes, and progressive renal dysfunction. Peripheral eosinophilia is far more common than eosinophiluria.
Drug induced acute interstitial nephritis is most commonly due to B-lactams (especially penicillins) and NSAIDS. Dilantin and allopurinol also important causes.
Clues to renal failure due to ethylene glycol include oxalate crystals in the urine and a marked anion gap acidosis with an osmolar gap.

Endocrinology

Flushing is a common symptom usually due to menopause, blushing, or anxiety or medications (especially dihydrophyridines like nifedipine). When it is due to carcinoid it usually is associated with diarrhea.
Think of pheochromocytoma in patients with a) unsuspected hypotension or shock during surgery; b) episodic severe hypertension; c) hypertension and orthostatic hypotension; d) hypertension refractory to treatment.
When thinking of pheochromocytoma, think of the H’s: Hypertension, Headache, Hyperhidrosis, orthostatic Hypotension, increased Hematocrit, Hyperglycemia
Most chronic fatigue is due to depression or stress. Features which support this in the history are fatigue unaffected by sleep which may improve later in the day.
Clinical features of 1o adrenal insufficiency: weakness/fatigue, weight loss, anorexia, hyperpigmentation, hypotension and GI symptoms. Abnormal labs: hyponatremia (88%), hyperkalemia (64%), eosinophilia, hypoglycemia and hypercalcemia.
Differences in clinical presentation between secondary and primary adrenal insufficiency: hyperpigmentation absent, hyperkalemia not present, hypoglycemia is more prominent (due to coexistent growth hormone deficiency).
Diagnosis of adrenal insufficiency: acute insufficiency suspected: During stress cortisol should be > 20, if less adrenal insufficiency likely. Chronic: synthetic ACTH given (cosyntropin) with blood samples for cortisol at 0, 30, 60 minutes.
Hyporeninemic hypoaldosteronism most commonly seen with diabetes. Typical features are hyperkalemia and hyperchloremic metabolic acidosis (type IV RTA).
Cushing’s disease pituitary over secretion of ACTH. Clinical features facial plethora, striae, easy bruisability, weakness, osteopenia (80%), glucose intolerance, centralized obesity (85%), neuropsychiatric effects (85%).
Diagnosis of Cushing’s syndrome: 24 hour urinary free cortisol has lower false positive rate than overnight dexamethasone suppression test. If an equivocal 24 hour urinary free cortisol or overnight dexamethasone suppression test, then perform standard low dose dexamethasone suppression test.
Differentiating adrenal versus pituitary Cushing’s: standard high dose dexamethasone suppression test will suppress patients with pituitary Cushing’s to 50% of pre-test values. Adrenal tumors fail to suppress.
Clinical importance of hyperlipidemia Primary prevention In men without known CAD lipid lowering with HMG CoA reductase inhibitor caused a 30% decrease in coronary events over 5 years. Secondary prevention Scandinavian simvastatin survival study showed decrease in coronary events and mortality in hyperlipidemic patients with CAD. Lipid lowering with statins has shown decreased morbidity and mortality in patients with CAD and “normal” cholesterol.
Secondary causes of hyperlipidemia to be aware of include diabetes (increased triglycerides), hypothyroidism (increased triglycerides and LDL), drugs (Thiazides/B blockers), and nephrotic syndrome.
Recommendations for drug treatment are based on cardiac risk factors & LDL level. If the patient has no CAD and < 2 risk factors drug treatment initiated at LDL > 190, if no CAD but > 2 risk factors LDL level of > 160, if patient has CAD LDL > 130 with target for LDL < 100 in CAD patients.
A few key points about lipid lowering drugs -
- Niacin improves HDL and lowers LDL and triglycerides. Limited by side effects particularly flushing, gout and glucose intolerance (hard to use in patients with diabetes).
- HMG CoA reductase inhibitors lower LDL cholesterol with modest effect on triglycerides (except atorvastatin which has good triglyceride lowering properties).
- Bile acid bringing resins lower LDL cholesterol but can raise triglyceride levels. Had block absorption of drugs.
- Fibrates lower triglycerides with slight improvement in HDL but minimal effect on LDL.
Metformin improves insulin resistance improving glucose uptake by muscle and fat. Benefits of this drug include no weight gain and improvement of triglyceride levels as well as glucose control. Best used as monotherapy or in combination with other oral agents in obese Type II patients with normal renal function. Risk of lactic acidosis in patients with renal insufficiency.
Patients with diabetes should be evaluated for microalbuminuria, an early marker for diabetic nephropathy. If patients have microalbuminuria they should be treated with an ACE inhibitor.
The following states increase thyroid binding globulin and raise total T4 (patient remains euthyroid): pregnancy, estrogen administration, acute hepatitis, chronic active hepatitis, heroin, clofibrate and methadone.
In hyperthyroid patients radioactive iodine uptake is increased with Grave’s disease, toxic multinodular goiter, toxic adenoma and TSH producing pituitary adenoma. It is decreased in subacute thyroiditis, thyroid hormone therapy, metastatic functioning thyroid cancer and iodine induced hyperthyroidism.
Several drugs are important causes of hypothyroidism: Amiodarone, lithium and iodine.
Hypothyroidism is difficult to diagnose clinically as most of the symptoms are common to most patients: dry skin, cold intolerance, constipation, weight gain, and fatigue. Think of hypothyroidism in patients with: unexplained bradycardia, hyperlipidemia, carpal tunnel syndrome, hoarseness.
Laboratory tests associated with hypothyroidism include: increased cholesterol, hyponatremia, increased CPK, increased SGOT, macrocytic anemia.
Clinical features of hyperparathyroidism: bone pain, renal colic, fatigue, constipation, mental disturbances. Most patients are identified when they are asymptomatic due to elevated calcium drawn for other reasons.
Hyperparathyroidism lab abnormalities increased Ca, decreased PO4, increased PTH, increased urinary calcium.
Hyperparathyroidism is part of both MEN 1 (hyperparathyroidism, pituitary adenoma and pancreatic tumors) and MEN 2a (hyperparathyroidism, pheochromocytoma and medullary thyroid carcinoma).
Magnesium deficiency leads to hypocalcemia through impaired synthesis or release of PTH and end organ resistance to PTH in bone and kidney.
Causes of osteomalacia vitamin D deficiency, malabsorption, anticonvulsant therapy, renal tubular acidosis, chronic renal failure, hypophosphatemia. Typical labs decreased Ca, decreased P0 4, increased alk phos., increased PTH, decreased urine calcium.
Paget’s disease sites of occurrence: Lumbosacral spine, skull and pelvis. Lab increased alk phos. Pearl can cause deafness in patients with skull disease. Osteogenic sarcoma is a rare complication.
Gynecomastia is caused by an increase in estrogen relative to testosterone. Causes: puberty, estrogen therapy, hyperthyroidism, drugs (spironolactone, ketoconazole, high dose cimetidine, digoxin) liver disease, klinefelter’s syndrome, testicular tumors.
Women with Polycystic ovarian disease will report a lifelong history of erratic menses. Clinical features: hirsutism, acne, menstrual disturbances and obesity. Trt: spironolactone or OCP.

Rheumatology

Back films are usually not necessary in the evaluation of acute back pain. They should be ordered if the patient is: a) > 50 years old; b) recent serious trauma; c) unexplained weight loss or adenopathy; d) history of malignancy likely to metastasize to bone; e) fever or; f) long-term steroid use.
Lofgren’s syndrome (form of sarcoid) is the constellation of fever, erythema nodosum, hilar adenopathy and arthritis. It has a superb prognosis for remission.
Strongly consider sarcoid in patients with a) asymptomatic hilar adenopathy or b) unexplained iritis or c) restrictive lung disease.
The HLA B27 associated spondyloarthropathies are ankylosing spondylitis, Reiter’s syndrome.
Key clinical features of ankylosing spondylitis are back stiffness, sacroiliac pain and iritis (25%). Rarer manifestations include aortic insufficiency (10%), upper lobe pulmonary fibrosis.
Spinal complications on ankylosing spondylitis: fractures due to an immobile spine, cauda equina syndrome, and spinal stenosis.
Radiographic features of ankylosing spondylitis include sacroiliitis, “bamboo” spine and vertebral squaring.
Psoriatic arthritis can cause an asymmetric oligoarthritis, sometimes causing swelling of the whole digit, causing a sausage digit.
Arthritis mutilans can occur with psoriatic arthritis, usually in patients with severe psoriasis. Digits can be destroyed.
Radiographic features of psoriatic arthritis include marginal erosions causing a “pencil in cup” deformity at the interphalangeal joints.
Reiter’s syndrome may occur after dysentery or following chlamydial or other forms of NGU.
Think of Reiter’s syndrome in young adults with seronegative asymmetric arthritis (also think of disseminated gonococcal infection in this group).
Clinical features of Reiter’s syndrome include: peripheral arthritis affecting the lower extremities, swelling of the Achilles tendon, conjunctivitis/uveitis, urethritis, prostatitis, and two important skin lesions keratodermia blennorrhagica (rash on soles/palms) and circinate balanitis (rash on penis).
Risk factors for gout include medications (diuretics, niacin), alcohol use, exposure to lead, family history of gout. Gout is also very common in Filipino’s and Samoan’s.
Most initial attacks of gout are monoarticular (85-90%) with 50% involving the first MTP joint.
Urate gout attacks can be precipitated by trauma or surgery. Severe attacks of gout can be accompanied by fever.
Most cases of calcium pyrophosphate deposition disease are idiopathic. Occasionally it can be associated with systemic disease, hyperparathyroidism and hemochromatosis are the two most important of these.
The most common presenting symptoms of patients with SLE are joint complaints (56%) and skin problems (20%). Almost all patients (90%) will have joint involvement during the course of the disease.
The use of ANA for diagnosis of SLE is very dependent on the clinical pretest probability of disease. A positive ANA in a patient with several clinical features suggesting SLE, example: (photosensitivity, arthritis and pleuritic pain) is a powerful diagnostic tool making the diagnosis of SLE very likely. If the patient has only arthralgias as a symptom and has a positive ANA it is still very unlikely for the patient to have SLE even with the positive ANA.
A positive anti-DS DNA test is specific for SLE, but not too sensitive (only 50-60% of lupus patients have a positive anti-DS DNA).
Anti-Sm antibody is highly specific for lupus but very insensitive (20-30%).
*Subacute cutaneous lupus is associated with annular lesions with scale. Patients usually have anti-Ro antibody.
Patients with lupus with CNS involvement often have antineuronal antibodies and anti-ribosomal P.
Drug induced lupus antihistone antibody present in > 90% of patients. Most common drugs procainamide and hydralazine.
Patients with discoid lupus do not have involvement of other organs.
Rheumatoid factor are IgM antibodies reactive with IgG. It is neither sensitive nor specific for RA. High titers of RF in RA patients is associated with vasculitis and a worse prognosis.
Felty’s syndrome is the combination of neutropenia, splenomegaly, rheumatoid factor and longstanding RA.
Caplan’s syndrome is presence of multiple pulmonary nodules in a patient with RA. Pleural effusions in patients with RA are associated with low glucose levels in pleural fluid.
Henoch-Schonlein purpura usually occurs in the Spring, often after an URI. Clinical features: palpable purpura, arthritis and abdominal pain.
Cryoglobulinemia (especially type II mixed) is strongly associated with hepatitis C. Clinical features glomerulonephritis, vascular infarcts, palpable purpura (especially on legs).
Polyarteritis nodosa is associated with hepatitis B (antigen positive) in about 20% of patients. Common clinical features: renal failure, livedo reticularis, mononeuritis multiplex, palpable purpura. This is a systemic disease and may involve CNS, GI tract and heart.
Wegener’s granulomatosis consider in patients with sinus disease, pulmonary infiltrates (especially if nodular), and renal involvement. This can cause saddle nose deformity as well. c-ANCA (anti-PR3) is sensitive and specific (99%) for this disease.
Giant cell arteritis occurs in older individuals usually with northern European background. Many patients also have PMR. Typical features are headache, weight loss and jaw claudication.
Anti-SSA (anti-Ro) is associated with neonatal lupus, Sjogren’s syndrome and subacute cutaneous lupus.
Anticentromere antibody is seen in 80-90% of patients with CREST syndrome.

Toxicology and Adverse Drug Effects

In a patient with an anion gap acidosis and an osmolal gap the two possibilities are methanol and ethylene glycol ingestions.
In patients who arrive late to the ER following an overdose, charcoal is a better option than lavage for most poisonings. Charcoal is contraindicated in caustic ingestions.
Alkalinization therapy is used to counteract cardiac arrhythmias and hypotension seen with tricyclic antidepressant overdoses.
Thyroid hormone can be bound by iron, cholestyramine, antacids and sucralfate.
TMP/Sulfa decreases Warfarin’s binding leading to overanticoagulation.
Remember drugs that can cause hyperkalemia ACE inhibitors, TMP/Sulfa, Ksparing diuretics and NSAIDS.

Oncology

Recommendations for treatment of breast cancer premenopausal women tumors > 1 cm with or without lymph node positive receive chemotherapy +/Tamoxifen if (ER +)
Postmenopausal women tumors ≥ 1 cm with or without lymph nodes and ER receive Tamoxifen, if ER receive chemotherapy.
Risk for developing lung cancer: smoking, asbestos (asbestos smoking increase risk > 50 times), “scar.”
Small cell lung cancer treatment
limited stage disease = chemo radiation
advanced disease = chemo
Colorectal cancer treatment:
Stage A stage B surgical resection
Stage C (lymph nodes positive) : resection 5 FU leucovorin x 6 months.
Staging of testicular cancers should include: alpha fetoprotein, beta HCG, Chest x-ray, CT of abdomen and pelvis.
Treatment of testicular cancer
Localized to testis → orchiectomy and retroperitoneal LND
Bulky lymph node involvement or mets → chemo
Risk factors for ovarian cancer: genetic, asbestos, talc, fertility agents. History of OCP use reduce risk of ovarian cancer.
Symptoms of ovarian cancer (usually advanced disease): abdominal pain (57%), abdominal distention (51%), vaginal bleeding (25%).
Carcinoma unknown primary workup: review of path specimen and evaluate for treatable/curable malignancies (breast, germ cell tumors, prostate cancer).
Paraneoplastic erythrocytosis seen with hypernephroma, hepatoma, cerebellar hemangioblastoma.
Glomerulonephritis seen with carcinomas (colon/lung), minimal change disease Hodgkin’s disease.
Sweets syndrome (acute febrile neutrophilic dermatosis) can be associated with acute nonlymphocytic leukemia (most common).
Necrolytic migratory thrombophlebitis is seen with glucagonoma.
Cancers that cause fever: hepatoma, hypernephroma and lymphoma.
Acute myeloid leukemia may have Auer rods on the smear (diagnostic if present).
Philadelphia chromosome is positive in 90% of patients with CML. Low leukocyte alkaline phosphatase, high vitamin B12 level, and high acid phosphatase.
Patients with CLL should be treated for symptoms (anemia/repeated infections). No cure with treatment and may not prolong survival. Autoimmune hemolytic anemia occurs in ~ 10%.
Myeloma symptoms: bone pain (68%), infection (12%), fatigue, bleeding. Hypercalcemia, renal failure, neuropathy and anemia are all features of this disease. Occasionally patients can present with diffuse osteopenia and fractures. More commonly patients have lytic bone lesions. Pearl the lytic bone lesions do not show up on bone scan.

Medical Issues in Pregnancy

The following drugs should absolutely be avoided during pregnancy: Isotretinoin (Accutane), ACE inhibitors, Benzodiazepines, Quinolones, Estrogens, Tetracycline and Coumadin.
Asymptomatic bacteriuria of pregnancy should be treated. Increase risk of pyelonephritis 20-30 times compared to non pregnant patients. Amoxicillin and cephalosporins are preferred agents.
Treat hypertension during pregnancy at DBP > 100 or if patient has diabetes or renal disease DBP > 90. Safe drugs methyldopa, hydralazine, labetalol.