General internal medicine (memo from NEJM knowledge plus and MKSAP)

＜general medicine＞

・management of patient with general weakness, slow gait, recent fall

prescribe vitamin D without obtaining level

・dumping syndrome

avoid refined carbohydrate

・zoster vaccine

live vaccine

・linezolid toxicity

type B lactic acidosis

・bisphosphonate to patient with CKD

contraindication to patient with GFR<30

・diagnosis of patient with one week history of sore throat, fever, neck pain, sign of pharyngitis, no cervical lymphadenopathy, CXR show multiple densities

septic thrombosis of the jugular vein (Lemierre syndrome)

・medical Tx for urinary incontinence  

anti-cholinergic (tolterodine)

・isolated elevation of ALP with normal γGTP in asymptomatic elderly person

bone scintigraphy for suspected Paget disease

・management of patient with opioid-induced delirium

switch to different opioid

・interval of blood pressure screening for healthy person

every 2 years for person older than 18 yo, with blood pressure < 120/80

 ・preoperative test for young healthy female

only pregnancy test

・sleep-maintenance insomnia

temazepam

・management of patient with cancer-related pain which is persistent throughout the day

sustained-release morphine

・thrombophilia work-up for patient with recent DVT on enoxaparin and warfarin

factor V Leiden and prothrombin gene-mutation

(acute thrombosis reduce protein S, protein C, antitrhombin III, heparin reduce antithrombin III, warfarin reduce protein S, protein C)

・management of patient with functional incontinence due to limited mobility or significant cognitive impairment

prompt voiding (periodically ask and remind patient to go to toilet)

・phenoxybenzamine 

alfa blocker

・management of patient with GERD-related cough whose cough and heart burn don't change 2 weeks after patient started omeprazole

continue omeprazole for 8 to 12 weeks

・antiemetic Tx for patient receiving chemotherapy 

ondansetron, dexamathasone, fosaprepitant (neurokinin-1 inhibitor)

・medication causing low testosterone level (erectile dysfunction, decreased energy)

opioid, high-dose corticosteroid, hormonal therapy 

・management of 28 yo female with breast mass, 1.5cm, mobile, tender, without nipple discharge or overlying skin change

ultrasonography (aspirate if cyst, biopsy if solid)

・most successful long-term and safe weight loss strategy

consistent reduction of caloric intake by 500-1000kcal/day

・cirrhotic patient with Child-Pugh C who undergo preoperative evaluation for elective total hip replacement

avoid elective surgery (mortality 80% with Child-Pugh C)

・next diagnostic step for patient with 6 months chronic non-productive cough, without apparent sign or cause, negative CXR, PFT, methachollin challenge test

sputum testing for eosinophil (for nonasthmatic eosinophilic bronchitis)

・first-line treatment of stress urinary incontinence

pelvic floor muscle training

・management of temporomandibular joint disorder

jaw relaxation, heat and therapeutic exercise

・DDx of patient with chronic pelvic pain with unexplained urinary symptoms

interstitial cystitis (no pyuria)

・management of patient with neuropathic pain secondary to DM who doesn't respond to NSAIDs, gabapentin, oxycodone-acetaminophen

sustained-release morphine

・management of perioperative warfarin for patient with atrial fibrillation with CHADS2 score of 5 and TIA 2 months ago

discontinue warfarin 5 days prior to surgery with enoxaparin bridge until the morning of surgery 

・first-line medication for elderly patient with chronic non-cancer pain

acetaminophen (325mg)

・indication of rapid antigen detecting test for patient suspected with streptococcal pharyngitis

all patients (Centor criteria 1-4)

・management of patient with prolonged interval since the previous dose of multiple-dose vaccine

series should be resumed rather than restarted from the beginning

・DDx from pityriasis rosea (pink, scaly, christmas-tree pattern)

syphilis

<orthopedic surgery>

・initial management of carpal tunnerl syndrome

wrist splinting

・difficulty with arm abduction and positive drop-arm test

rorator cuff tear

・most common cause of knee pain in younger than 45 yo, worse with prolonged sitting and with walking up and down stairs

patellofemoral pain syndrome

・maneuver eliciting lateral epicondylitis

resisted wrist extension with elbow fully extended 

・indication of x-ray for ankle injury 

unable to bear weight or bony tenderness to palpation 

・pain along anteromedial aspect of proximal tibia distal to the joint line of knee, in the setting of overuse

pes anserine bursitis

・burning pain on the plantar surface in the space between third and fourth toes, in the setting of wearing high heels

morton neuroma

・management of acute back pain with positive straight leg raise test, diminished ankle refelx without motor or sensory deficit

analgesics and mobilization as tolerated (no imaging study)

・Dx of patient with burning sensation on the lateral aspect of thigh with sensory deficit

melargia paresthetica (entrapment of lateral femoral cutaneous nerve beneath inguinal ligament)

・management of patient with plantar fasciitis refractory to initial Tx with NSAIDs

arch support

・management of osteoarthritis of trapeziometacarpal joint (pain at base of thumb)

wrist splint with thumb post

・hip pain in young athlete with femoroacetabular dysplasia

labrum tear

・management of symptomatic popliteal cyst

glucocorticoid injection 

・diagnosis of knee osteoarthritis

weight-bearing x-ray

<dermatology>

・Tx for psoriasis and psoriatic arthritis 

TNF-alfa blocking agents

・V-shaped rash on upper chest 

dermatomyositis

・molluscum contagiosum in adults

possible sign of HIV progression

・ecthyma gangrenosum (purpuric patch with ulceration)

pseudomonas aeruginosa bacteremia

・actinic keratoses

5-fluorouracil cream

・most common identifiable cause of erythema nodosum

streptococcal infection 

・dyshidrotic eczema (pruritic vesicular eruption, due to repeated water exposure or sweating)

potent topical glucocorticoid (triamcinolone ointment)

・symmetric target-shaped lesions on palms

erythema multiforme, associated with herpes simplex infection 

・bedbug bite

steroid cream (triamcinolone acetonide cream) 

・venous stasis ulcer

unna boot compression 

・allergic contact dermatitis on face

hydrocortisone valerate (lower potency)

・treatment for impetigo

topical mupirocin

・ulcerative skin disease associatd with inflammatory bowel disease

pyoderma gangrenosum

・management of atypical urticaria, lasting for more than 24 hours, not pruritic

skin biopsy (to evaluate urticarial vasculitis)

・acne medication which is contraindicated during pregnancy

tazarotene

・pigmentation extending onto the proximal nail fold

subungual melanoma

・management of suspected toxic epidermal necrolysis

skin biopsy to confirm diagnosis and supportive care (systemic corticosteroid is controversial)

・DDx of red plaque on lip that is covered with scale, crust

squamous cell carcinoma

・crateriform pitted lesion on the sole of feet

pitted keratolysis

・flesh-colored smooth bump on face that occur by shaving

verruca plane (HPV)

・management of miliaria

cooling

(small papulovesicle associated with itching, caused by blockage and rupture of eccrine sweat duct, occur when skin is hot and occluded)

・slow-growing type of melanoma commonly seen on face of older fair-skinned patient

lentigo maligna

・pruritic blister on chest, abdomen, lower extremities, draining clear yellow fluid and crusting over before healing

bullous pemphigoid

・pruritic eruption that topical corticosteroid temporarily reduce inflammation, but recur after discontinuation

tinea corporis

・red papules on the chest, topped by vesicle or scale, waxing and waning, exacerbated by heat and sweating

Grover disease (achantholytic dermatosis)

・ulcer on the feet under metatarsal heads in DM patient

neuropathic ulcer

・management of intensly itchy small papulovesicle on scalp, elbow, knee, skin biopsy shows deposition of granular IgA

gluten-free diet for dermatitis herpetiformis associated with celiac disease

・Tx for seborrheic dermatitis (itchy, scaly rash in eyebrow, nose, ear)

ketoconazole cream

・acne that is widespread or that is inflammatory and refractory to topical medication 

doxycycline

<ophthalmology>

・corneal abrasion from fingernail

fluoroquinolone eyedrop (covering pseudomonas)

・Sx of uveitis

photophobia, eye pain, decreased vision

・bacterial VS viral conjunctivitis

viral conjunctivitis lacks morning gluing

・bothered by glare from oncoming headlights when driving

cataracts

・pseudodendrite

herpse zoster

・uveitis and lacrimal gland enlargement

sarcoidosis

・management of viral conjunctivitis

cool compression 

・central retinal artery occlusion vs central retinal vein occlusion 

CRAO: cherry red spot

CRVO: flame-shaped retinal hemorrhage, cotton-whool spots

・foreign body sensation and vascular growth over conjunctiva

pterygium

<OBGYN>

・reversible, highly effective contraception

levonorgestrel intrauterine device, etonogestrel implant

・medroxyprogesterone acetate IM injection every 3 months

not for long-term use, risk for osteoporosis

・prophylaxis Tx after sexual assault

azithromycin, ceftriaxone, HIV prophylaxis, HBV vaccine, metronidazole, levonorgestrel 

・inhaled glucocorticoid Tx for pregnant female with mild persistent asthma

budesonide

・uncomplicated mastitis

continue breast feeding and dicloxacillin (staphylococcal coverage)

・Tx for postpartum endometritis

clindamycin and gentamicin

・management of Graves disease during pregnancy

propylthiouracil in 1st tremester and methimazole in 2nd and 3rd tremester

・opioid addiction during pregnancy 

methadone / buprenorphine

・persistent lack of desire for sexual activity

hypoactive sexual desire disorder

・management of female who is planning to attempt conception, found to have HbA1c 7.5

metformin (class B, switch to insulin during pregnancy)

・next step for patient with heavy menstrual bleeding secondary to fibroid which is scheduled for surgery in 2 weeks

oral medroxyprogesterone acetate

・management of hot flush in patient with h/o cardiovascular disease or VTE

venlafaxine (serotonin norepinephrine reuptake inhibitor)

・first-line treatment of dysmenorrhea

NSAIDs

・recommended contraception for 38 yo female without PMH, smoking a pack daily 

progesterone contraceptive

(women older than 35 yo smoking more than 15 cigarettes daily shoud not be prescribed estrogen-containing preparations)

<otolaryngology>

・central cause of vertigo

direction-changing nystagmus, severe trunchal instability, negative head-thrust test

・Dix-Hallpike maneuver to BPPV

vertical-torsional nystagmus toward affected side

・Tx for acute otitis extema

almost always due to bacterial infection -> topical ABX covering pseudomonas and staphylococcus

・Tx for vestibular neuritis

meclizine and hydration 

・Tx for nasal polyposis

intranasal glucocorticoid

・idiopathic sudden sensorineural  hearing loss

high-dose prednisone

・cerumen impaction 

cerumenolytics (hydrogen peroxide, carbamino peroxide, mineral oil)

・whistling or swishing sound in ear, faster and louder when exercise

pulsatile tinnitus -> evaluate for bruit for possible vascular anomaly

・Tx for rhinosinusitis

anti-histamine (chlorpheniramine)

・Dx of patient with h/o allergic rhinitis who has intractable nasal congestion and rhinorrhea on oxymetazoline

rhinitis medicamentosa

(continued use of vasoconstictor (oxymetazoline) cause withdrawal congestion)

・erythematous patches with white hyperkeratotic rim on the tongue

georgraphic tongue (benign migratory glossitis)

・unilateral ulcerative tonsillar lesion with cervical lymphadenopathy

squamous cell carcinoma until proven otherwise

<psychiatry>

・medication for prevention of alcohol dependence relapse in patient with cirrhosis

acamprosate

・initial treatment for alcohol-use disorder

naltrexone

・dementia with visual hallucination 

dementia with Lewy bodies

・bulimia nervosa

Na in urine elevated when diuretic abuse, and decreased when self-induced vomiting

・first choice for panic disorder

SSRI

・major depressive disorder with sexual dysfunction

bupropion

・monotherapy for bipolar depression

quetiapine

・psychosis, purpuric skin lesion, neutropenia

intravenous cocaine use 

・indication for depression screening

all adults