Summary
Highlights
Gluten intolerance with a specific rash suggests dermatitis herpetiformis, requiring a skin biopsy and dapzone treatment. A positive McMurray test indicates a meniscus tear, confirmed by MRI, which is also the best imaging for osteomyelitis.
For a patient with a family history of thyroid cancer, palpating the thyroid is the initial screening test, even over ultrasound. In asthma, a normal spirometry may require a methacholine challenge test. Improvement of FEV1 by 12% and 200ml after albuterol is diagnostic for asthma.
Vocal cord polyps are often linked to HPV, diagnosed via laryngoscopy and treated with surgical excision. Sudofovir, a treatment, requires monitoring for nephrotoxicity. Visual impairment with a CD4 count below 50 suggests CMV retinitis, treated with ganciclovir, foscarnet, or cidofovir.
For Alzheimer's patients with sinus bradycardia, avoid cholinesterase inhibitors and use memantine. In pseudo-dementia (depression mimicking dementia), treat the depression with antidepressants like vortioxetine.
Painful, restricted shoulder and hip motion with a low-grade fever indicates polymyalgia rheumatica (PMR), treated with prednisone. New vision loss in PMR suggests giant cell arteritis, requiring immediate steroids, then temporal artery biopsy. A quick review of various vasculitides including Takayasu arteritis, Kawasaki disease, Henoch-Schonlein purpura, Mixed Cryoglobulinemia, Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss), and Polyarteritis Nodosa (PAN) follows.
For carpal tunnel syndrome, start with wrist splints. Vesicles in atopic dermatitis indicate eczema herpeticum, treated with acyclovir. The atopic dermatitis algorithm proceeds from emollients to topical steroids, topical tacrolimus and then UV light therapy.
For IBS with constipation/diarrhea, try a fiber supplement like psyllium. Beta-blockers are a good treatment for hypertension, also helping with migraine prophylaxis. Even with a normal BMI and LDL, slightly elevated total cholesterol warrants an exercise program.
When a question stem lists many medications, consider side effects and polypharmacy. Drug-induced esophagitis, Stevens-Johnson syndrome, aplastic anemia, and drug-induced lupus are possibilities. Treatment for diabetic neuropathy is Gabapentin, then Nortriptyline. Examine feet thoroughly.
For polycystic kidney disease with hypertension, treat with lisinopril. Associations include mitral valve prolapse, diverticulosis, intracranial aneurysms, and liver cysts. Autosomal recessive polycystic kidney disease is associated with Caroli disease (dilated bile ducts).
Mycoplasma presents with crackles and no visible organism on Gram stain. Associations include cold agglutinins, hemolytic anemia, erythema multiforme, and acute interstitial nephritis. Legionella requires charcoal yeast agar, is diagnosed with a urine antigen test, and presents with hyponatremia and a triad of lung, GI, and CNS issues. Chlamydophila pneumoniae presents with reticulate bodies and is associated with erythema nodosum and Guillain-Barré.
Causes of erythema nodosum include fungal infections (coccidioidomycosis, histoplasmosis), leprosy, Behcet's syndrome (oral/genital ulcers, uveitis), tuberculosis, and streptococcus. Sweet syndrome is characterized by a neutrophilic dermal infiltrate, high fever, and association with hematologic malignancies, treated with steroids.
Pyoderma gangrenosum (often with IBD or rheumatologic issues) is marked by worsening wounds after minor trauma (pathergy), the same as in Behcet's syndrome. Lofgren syndrome presents with hilar lymphadenopathy, erythema nodosum, and migratory polyarthritis (a resolving subtype of sarcoidosis).
The most sensitive test for diabetes is a two-hour glucose tolerance test. Charcot joint associations include: diabetes, syphilis, steroid use, syringomyelia, spinal cord injury, spina bifida, scleroderma, leprosy and alcohol.
Recurrent stabbing chest pain with elevated CK and flu-like symptoms suggests Coxsackievirus pleurodynia (Bornholm disease), with NSAID treatment. Watch out for dilated cardiomyopathy and acute pericarditis.
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