Osce Treatments

Pyelonephritis  Fever, chills, malaise, flank pain, N/V, dysuria, frequency/urgency, tachycardia, hypotension  Urinalysis (bacteriuria and pyuria)  leukocyte esterase, urine culture, blood culture  CT abdomen  Urine cx/antibiotic sensitivity to guide tx  Abx based on sensitivity; commonly Ciprofloxacin (fluoroquinolones) UTI

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Dysuria, frequency/urgency, hematuria, suprapubic pain Urinalysis  leukocyte esterase, nitrates, culture Abx: TMP/SMX (Bactrim), Nitrofurantoin, fluoroquinolones (Cipro)

Nephrolithiasis (kidney stones)  Abdominal pain, flank pain, N/V, hematuria, fever  Renal US, urinalysis and culture, chem labs, BUN, creatinine  Analgesics for severe pain: IV NSAIDs or opioids; less severe pain: oral NSAIDs  Lithotripsy, surgery if complicated Cholecystitis  Starts with dull pain; then sharp RUQ, fever, chills, tachycardia  CBC, LFTs, urinalysis, culture  X-ray, US  IV fluid, abx (cefazolin), typically laparoscopic cholecystectomy within 1 week of symptoms PID

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Abdominal pain, vaginal discharge, fever, chills, dyspareunia, dysuria Cervical, uterus, adnexal tenderness CBC, ESR, endometrial biopsy, CT/MRI Remove IUD if needed Ceftriaxone 250mg 1 dose and Doxycycline 100mg BID x 14 days

Gonorrhea  Urinary frequency/urgency, dysuria, gross discharge, conjunctivitis, pharyngitis, cervicitis, Bartholin’s inflammation, epididymitis, papule/pustule rash, arthritis  DNA probe, gram stain, Culture (chocolate, yum.)  Doxy = uncomplicated / drug resistant: tetracycline Chlamydia  Usually asymptomatic, urethritis, cervicitis, vaginitis, pelvic pain,  DNA probe, STD testing, culture, gram stain  Azithromycin or doxycycline Syphilis  Chancre, gumma, mild lymphadenopathy of inguinal nodes  lead to neuro signs  Primary/secondary/latent tx: PCN  Incubation tx: Ceftriaxone, Doxy Strep pharyngitis  Sore throat, dysphagia, odynophagia, fever, malaise, HA, exudate, petechial rash on soft palate, cervical lymphadenopathy, strawberry tongue  Leukocytosis, CBC, culture, strep test  Analgesic: NSAIDs  Abx: PCN V, amoxicillin Pneumonia  Bacterial: cough, purulent sputum, fever, fatigue, pleuritic chest pain, dyspnea, tachycardia/tachypnea, egophony, dullness to percuss, rales, tactile fremitus  Viral: non-productive cough, wheezing  CXR, sputum culture, blood culture,  Bacterial: abx – azithromycin, erythromycin  Viral: antivirals – rimantadine, amantadine, oseltamivir Bronchitis  Cough (productive or not), dyspnea, chest pain, wheeze, dyspnea, hoarse, constitutional  No signs of consolidation  Usually viral etiology, so abx not indicated  Supportive therapy Sinusitis  Sinus pain/pressure, HA, teeth pain, pain increases when leaning forward, nasal discharge/PND, snoring, mouth breathing fatigue, fever, sore throat  Most people improve in 2 weeks without abx  Do C&S, give abx empirically until C&S comes back  Amoxicillin = DOC COPD

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Croup    

Chronic Bronchitis: productive cough, dyspnea, obese, edema, o Tests: ABG, spirometry, pulm function test (FEV1), CXR Emphysema: thin, dyspnea, tachypnea, diminished breath sounds o Tests: same as bronchitis, CXR shows hyperinflation Smoking cessation, Pulmonary rehab Bronchodilator: ipratropium (short-acting); tiotropium (long-acting) 1st SABA (albuterol puffer) prn, start LABA (salmeterol, formoterol) if using SABA >3-4x/week LABA + ICS: Fluticasone + salmeterol = Advair

Bronchospasm, obstruction, inflammation, bronchial wall hyper-responsive Associated with allergic rhinitis, food allergy, atopic dermatitis, nasal polyps, ASA S/S: wheezing, dyspnea, chest tightness, accessory muscle use Tests: spirometry, ABG, CBC, Short term o SABA (Albuterol) Long term o ICS (Fluticasone Propionate (Flovent)) o LABA (Salmeterol) o ICS + LABA (Fluticasone + salmeterol = Advair)

Low fever, barking cough, stridor, wheezing, rhinorrhea, congestion, respiratory distress Avoid labs – maybe CBC Lateral neck x-ray: steeple sign Racemic epinephrine, cool-mist humidifier, corticosteroids

Otitis Media  Pain, rhinitis, cough, low fever, drainage, unilateral hearing loss, URI  Cloudy tympanic membrane, loss of landmarks, TM immobile  Abx: amoxicillin (if resistant, amoxicillin/clavulanic acid (Augmentin))  If allergic to PCN  cephalosporin Otitis Externa (Swimmer’s ear)  Pain, pruritis, edema, otorrhea, conductive hearing loss  TM is mobile, erythematous canal  Abx: Ciprofloxacin Ruptured TM  Otorrhea, weber lateralization  Refer, Cipro, surgery Appendicitis  Anorexia, N/V, pain starting periumbilical then to RLQ, low fever, tenderness, rebound tenderness, guarding, rigidity  CBC, C-reactive, CT abdomen with contrast  Typically surgery  Sometimes abx (Gentamycin) if uncomplicated, but 20% have recurrence within 1 year GERD       DVT

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Heartburn, acid regurgitation, dysphagia, abdominal pain, cough, hoarse, belching pH probe, upper endoscopy Avoid caffeine, chocolate, spicy & fatty foods; smoking cessation, don’t eat before bed, elevate head PPI: omeprazole H2 receptor blockers: ranitidine Antacids: Alka-Seltzer, Maalox, Tums, etc.

Clinical signs are unreliable, so is Homan’s D-Dimer, Doppler US Parenteral anticoagulant: Lovenox x 5 days (at least) Oral anticoagulant: Dabigatran, Rivaroxaban, etc. QD x 3 months (at least) Target INR: 2.5

Pulmonary Edema  Coughing, dyspnea, anxiety, leg swelling, sweating, cyanosis  ABG, pulse ox, CXR, EKG, Echo  Oxygen, Diuretics Pulmonary Embolism  Chest pain (pleuritic), cough, hemoptysis, dyspnea, syncope, sweating, tachy, fever  D-dimer, ABG, troponin, EKG, Echo, CT, BNP

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Anticoagulant: LMWH started as bridge while Warfarin kicks in Target INR: 2.5 Warfarin therapy usually continued for 3-6 months; lifelong tx necessary if hx of previous DVT or PE

CHF

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CXR, enzymes, BNP, EKG, echo ACEI: benazepril, lisinopril, enalapril, quinapril Beta blockers: bisoprolol, carvedilol, metoprolol Diuretics: furosemide (Lasix), spironolactone (Aldactone) Dyspnea, dizzy, palpitations, fatigue Associated with: CAD, CHF, COPD, HTN, alcohol, drugs, caffeine Labs: Troponin, CBC, BNP, thyroid, EKG Low stroke risk (CHADS/HASBLED): ASA High stroke risk (CHADS/HASBLED): warfarin Tx: Beta Blockers, diltiazem

Pericarditis  Exercise intolerance, fatigue, constitutional signs, sharp pleuritic chest pain, radiation to neck/jaw, friction rub, JVD, kussmaul breathing  Electrolytes, troponin, CBC, ESR, C-reactive protein, EKG, CXR, Echo  Anticoag, ASA, NSAIDS, pericardiocentesis MI

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Chest pain, radiation to neck/jaw/shoulder, angina not relieved with rest or nitro, nausea, sweating, pallor, tachycardia, S4, JVD, ST elevation Troponin (serum cardiac enzymes), EKG, Echo, CBC IV, O2, monitor, nitro, ASA, morphine, consult

Cor Pulmonale  Retrosternal chest pain, cough, dyspnea, fatigue, sputum, tachycardia, cyanosis, clubbing, S4, kussmaul, pulsus paradoxus, JVD  CBC, EKG, ABG, pulm function tests, CXR, echo  Bronchodilator, O2  Right Vent failure: low sodium diet, diuretics, digoxin  Arrhythmias: digoxin Cardiac Tamponade  Dyspnea, fatigue, chest pain, hypotension, JVD, pulsus paradoxus, friction rub, kussmauls, tachycardia  CXR, echo, EKG, cardiac cath  Pericardiocentesis, IV fluids Endocarditis  Fever, chills, sweating, weight loss, anorexia, malaise, pallor, CHF, murmur  Clubbing, splinter hemorrhage, Osler nodes, Janeway lesions  CBC, blood culture, urinalysis, EKG, transthoracic echo  Initial empirical: Gentamycin  Strep/staph/enterococcus: PCN Thrush  

Oral burning, white curd-like patches or plaques  can be scrapped off Nystatin, Miconazole gel

Migraine  Episodic HA, 1-2 times per month, prodrome/aura, N/V, photophobia/phonophobia  Treatment o Analgesics: NSAIDs, APAP, etc. o Triptans: Sumatriptan (Imitrex), Eletriptan (Relpax) o Ergotamines  Prophylaxis o Propranolol o Valproic Acid o Topiramate Cluster HA  Deep pain, burning, stabbing, lacrimation, Horner (ptosis, miosis)  Oxygen, Triptan Benign Prostatic Hyperplasia (BPH)  Weak urine stream, urinary retention, dysuria, nocturia, DRE, tenderness, fever  Urinalysis, PSA, renal function test  Alpha blockers: Flomax (tamsulosin)  Surgery indicated if drug therapy fails

Lupus    

Fatigue, fever, malaise, weight loss Malar butterfly rash, photosensitivity, vasculitis, arthritis, lymphadenopathy, arthritis, cotton wool, retinal hemorrhage, oral ulcers ANA titer, CBC, ESR, EKG Immunosuppressants: hydroxychloroquine, corticosteroids

Melasma  Rash in pregnancy and lupus  Topical depigmentation agent: hydroquinone  Tretinoin – acid that increases keratinocyte turnover (cannot be used during pregnancy) Osteoarthritis  Stiffness, pain worsens with joint movement  ESR, C-reactive protein, RH factor  Analgesic: Acetaminophen, NSAIDs  Glucocorticoid injections: hydrocortisone  Joint replacement surgery if severe Rheumatoid Arthritis  Morning stiffness, symmetrical  DMARDs: methotrexate

Septic Arthritis  Fever, pain, decreased ROM, joint swelling and warmth, erythema  ESR, C-reactive, CBC, Synovial fluid culture, gram stain, culture  Abx  Septic Arthritis with gonorrhea o Treat gonorrhea, should help septic arthritis o Ceftriaxone with azithromycin or doxycycline Gout

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Chills, fever, swelling, painful! Aspirate for crystals, CBC NSAIDS, Allopurinol

Musculoskeletal pain  NSAIDs Poison Ivy  Pruritis, papulovesicular derm (linear)  Cold compress, oatmeal bath, Burow’s solution  Topical glucocorticoid, antihistamine Tick bite    

Bull’s eye rash (erythema migrans), prodromal, joint pain, fatigue Lyme disease: neuro s/s Titer and western blot Abx: doxycycline 100mg oral BID x 10-21days

Shingles  Rash develops after 48-72h, follows dermatomes, erythema, maculopapular rash, vesicles  Tzank Smear  Antiviral: acyclovir; analgesics for pain Psoriasis  Topical steroids: clobetasol propionate

Pancreatitis  Hospital admission  NPO, aggressive hydration, analgesics for pain, no abx  Treat underlying conditions (i.e., gallstones) Cirrhosis  Fatigue, weight loss, anorexia, N/V/D, scleral icterus, hepatomegaly, ascites, jaundice, purpura, spider nevi, telangiectasia, Terry’s nails, blubbing  CBC, LFT, electrolytes, HEP studies, US  Supportive HTN

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Beta blockers (metoprolol), diuretics, ACEI (Lisinopril), calcium channel blockers

Diabetes  Type 1: insulin  Type 2: metformin Hyperlipidemia  Statin Hypothyroidism  High TSH, Low T4  Hormone replacement: Levothyroxine Hyperthyroid  Low TSH, High T4  Anti-thyroid drugs: Lugol’s solution, radioactive iodine, thioamines (PTU)  Irradiation  Surgical removal Bacterial Conjunctivitis  Usually unilateral, discharge, matting lashes, irritation, puffy  Topical abx: TMP/polymyxin  Systemic abx: gentamycin or cipro Blepharitis  Pruritus, irritation, burning, inflammation  Clean lid margin (gentle scrubbing, soaking, warm compress)  Erythromycin if staph Macular Degeneration  Slow central vision loss, bilateral involvement, drusen  Laser photocoag, photodynamic therapy Retinal detachment  Flashes, floaters, visual field defects, unilateral, painless vision loss  Immediate referral, cryotherapy, laser photocoag Glaucoma  Increased intraocular pressure, peripheral vision loss, halos  Prostaglandin analogues, intraocular beta blockers Cataract  Reduced vision bilaterally, skewed colors  Referral for extraction  dilating drops Diverticular Bleeding  Painless rectal bleeding, anemic, tachycardic  Pre-existing diverticulitis  Higher risk of bleed with ASA use  Colonoscopy (not during acute diverticulitis flare-up), tagged RBC scan  CT is test of choice for diverticulitis  Flagyl & Cipro for diverticulitis  IV fluids, possible blood transfusions, high fiber diet Stroke     

Sx depend on area of stroke – facial drooping, right or left-sided body weakness, disturbed speech CT without contrast tPA if within 3-4.5 hours & no evidence of hemorrhage BP control with IV Labetalol Mannitol for cerebral edema

ACL tear     

Ask about mechanism of injury Popping noise, knee gives out while walking, loss of full ROM, discomfort MRI Anterior drawer test, Lachman test, McMurray test Non-surgical tx is bracing & PT; surgical tx requires ortho referral, ACL reconstruction, followed by PT

Meniscal tear  Ask about mechanism of injury  Knee locks while walking  Apley compression test, McMurray test  Ortho referral

Abuse   

Order x-rays Vaginal exam Check for STDs in children