#PCN allergy

[mcatmemoranda]

Have a pt who gets a severe rash in response to amoxicillin. She probably has strep throat. Sending azithromycin instead.

[renee-mariposa]

Nothing in my day-to-day job shows me the limits of modern medicine like vancomycin does. And it makes me insane.

(extremely long, somewhat incoherent nerd rant below the cut)

See, vanc is really good at, like, three things: treating MRSA (when given IV), treating ampicillin-resistant enterococcus (when given IV), and treating c diff (when administered orally ONLY). Most every use outside of that, like when it’s used to treat methicillin-susceptible staph aureus for “penicillin allergic patients” (don’t get me started on PCN allergies), actually has data that it increases risk of morbidity and mortality (i.e. harm and DEATH).

Unfortunately, due to the prevalence of multi-drug resistant organisms, vancomycin is empiric therapy for a lot of presumed infections. And it's a lot more difficult to actually tell if someone has an infection than you'd think. A lot of medical conditions imitate each other and when time is of the essence to identify what's going on, the most ethical thing is to start an antibiotic and rule out infection as the hospitalization continues. Lab techniques have gotten a lot quicker: I can remember 8 years ago, it would take 3 days just to identify what microbe the patient had in their presumed infection. These days, anno domini 2023, PCR comes back in a matter of hours, identifying gram positive/gram negative staph/strep/bacilli/etc, and it's the sensitivities that take 2-3 days. (Don't get me started on contaminated cultures.) But even with improvements in lab technique, we might not culture any microbe at all or the provider might keep vancomycin on "just in case" because we don't know IF the patient is infected, WHAT they're infected with, or if the infection will get better with a different drug.

And vancomycin is terrible on kidneys. Extremely nephrotoxic. It isn’t as bad as the 80s when the drug first came out and was called Mississippi Mud colloquially, but it will fuck the patient up if not monitored closely.

But finding the correct dose for each patient in a timely manner is nigh impossible. This is because vancomycin is renally eliminated. We have to mathematically estimate how well the kidneys are working. Unfortunately, our mathematic equation is next to useless if you are:

-Less than 50 kg

-Shorter than 5 foot tall

-Have a BMI of more than 40

-Are an adult younger than 45 (twenty-year-olds get astronomical doses that would be destructive in an older patient)

-Are older than 65 (the official definition of 'geriatric', i'm relatively sure)

-Are female (this is really only applicable if the patient is less than 50 kg or older than 65 - think: little old frail lady - we have absolutely no fucking idea how their kidneys are doing until we order the serum drug level. It is next to impossible to accurately dose vancomycin in little old ladies on the first try.)

-Are missing limbs (lots of leg amputations in the older and impoverished diabetic population!!)

-Have a lot of muscle mass (think bodybuilder or really tall guys)

Fun fact: we estimate renal function by looking at height, weight, age, birth gender (few, if any, studies on trans patients taking HRT), and a lab value called serum creatinine. Creatinine is a byproduct of muscle metabolism, I don't know the fine details, but we can generally estimate how well kidneys are working by seeing how much creatinine is in the blood: low creatinine usually means kidneys are excreting it as they 'should' be. High creatinine means there's something wrong, the kidneys aren't able to excrete it as efficiently as they 'should' be. But the effect of low muscle mass and high muscle mass haven't been studied enough to be able to adjust our mathematical equation to compensate for them. And with high BMI: we often overestimate their renal function because we don't know how to estimate their muscle mass vs their body fat.

(I work out in the boonies. ~70% of our patients have diabetes. ~80% of our patients have a BMI of greater than 35. So what I'm trying to say here is: we are shooting in the fucking dark when we're estimating the renal function of the vast majority of our patients.)

Complicating this: vancomycin is useless until it reaches steady-state concentration in therapeutic range. On one side of this problem: a lot, if not most, medical providers assume that vancomycin starts working its magic from the first dose. So we sometimes get orders for "vancomycin 1 gram now and see how the patient is doing in the morning". That isn't going to solve jack shit! That's just going to increase the incidence of microbial resistance!!

OR, like in the multiple situations I dealt with this afternoon, you make an educated guess on what regimen is going to work for the patient. You get a level 48 hours after the dose starts. And you find out that you fucking guessed wrong and the patient is subtherapeutic. It has been two fucking days and the patient hasn't started being treated for their (presumed) infection yet!! And we've increased the possibility of microbial resistance! *muffled screaming in frustration*

So what I'm trying to say here is: on almost every presumed infection that comes into the hospital (which we're guessing like 30%? 50%? of the time), we're starting an extremely toxic drug, oftentimes 100% guessing what regimen will be therapeutic, only finding out in 2 days that it is not therapeutic, and it can sometimes take days and days to titrate the dose sufficiently to find a therapeutic regimen. And sometimes we're really fucking unlucky and we destroy the patient's kidneys temporarily (or permanently! but kidneys can be very resilient so that's thankfully rare) because we guessed a regimen that's too high!! This is a fucking nightmare!!!!!!!!

And if all of this wasn't bad enough, we don't really have any drugs that do what vancomycin does therapeutically. We have things that can be used to cover some of what vancomycin does, but nothing that's equivalent AND less toxic.

Like, to fix this situation, we need:

-Better education to providers on what drugs are appropriate empiric therapy for different presumed infections (we're working on it, we are working on it)

-Better ways to estimate kidney function (there needs to be more research on kidney function in patients with BMI greater than 35!! And little old ladies!! And patients with low body weight and high body weight and amputations and...)

-Better prognostic tools to tell 1. when the patient is infected (looking at you, sepsis!!!) 2. what they're infected with

-Less-toxic antibiotics AND/OR better ways to treat infection (this would be the evolution of medicine as we know it)

And I want to be clear: vancomycin isn't bad. It's an extremely effective tool when used correctly but we often either don't have enough data to use it correctly or the provider doesn't understand that this tool is fucking useless for the job they're trying to perform.

[nursingscience]

Medical Abbreviations on Pharmacy Prescriptions

Here are some common medical abbreviations you may see on pharmacy prescriptions:

qd - once a day

bid - twice a day

tid - three times a day

qid - four times a day

qh - every hour

prn - as needed

pc - after meals

ac - before meals

hs - at bedtime

po - by mouth

IV - intravenous

IM - intramuscular

subQ - subcutaneous

mL - milliliter

mg - milligram

g - gram

mcg - microgram

stat - immediately, right away

NPO - nothing by mouth

cap - capsule

tab - tablet

susp - suspension

sol - solution

amp - ampule

inj - injection

Rx - prescription

C - Celsius

F - Fahrenheit

BP - blood pressure

HR - heart rate

RR - respiratory rate

WBC - white blood cell

RBC - red blood cell

Hgb - hemoglobin

Hct - hematocrit

PT - prothrombin time

INR - international normalized ratio

BUN - blood urea nitrogen

Cr - creatinine

Ca - calcium

K - potassium

Na - sodium

Cl - chloride

Mg - magnesium

PO2 - partial pressure of oxygen

PCO2 - partial pressure of carbon dioxide

ABG - arterial blood gas

CBC - complete blood count

BMP - basic metabolic panel

CMP - comprehensive metabolic panel.

ECG - electrocardiogram

EEG - electroencephalogram

MRI - magnetic resonance imaging

CT - computed tomography

PET - positron emission tomography

CXR - chest x-ray

CTX - chemotherapy

NSAID - nonsteroidal anti-inflammatory drug

DMARD - disease-modifying antirheumatic drug

ACE - angiotensin-converting enzyme

ARB - angiotensin receptor blocker

SSRI - selective serotonin reuptake inhibitor

TCA - tricyclic antidepressant

ADHD - attention deficit hyperactivity disorder

COPD - chronic obstructive pulmonary disease

CAD - coronary artery disease

CHF - congestive heart failure

DVT - deep vein thrombosis

GI - gastrointestinal

UTI - urinary tract infection

OTC - over-the-counter

Rx - prescription

OD - right eye

OS - left eye

OU - both eyes.

TID - thrombosis in dementia

TDS - ter die sumendum (three times a day)

BOM - bilaterally otitis media (infection in both ears)

BT - body temperature

C&S - culture and sensitivity

D/C - discontinue or discharge

D/W - dextrose in water

ETOH - ethyl alcohol

FUO - fever of unknown origin

H&P - history and physical examination

I&D - incision and drainage

I&O - intake and output

KVO - keep vein open

N&V - nausea and vomiting

PERRLA - pupils equal, round, reactive to light and accommodation

PR - per rectum

QAM - every morning

QHS - every bedtime

QOD - every other day

S/P - status post (after)

TPN - total parenteral nutrition

UA - urinalysis

URI - upper respiratory infection

UTI - urinary tract infection

VO - verbal order.

XRT - radiation therapy

YOB - year of birth

BRBPR - bright red blood per rectum

CX - cervix

DVT - deep vein thrombosis

GB - gallbladder

GU - genitourinary

HCV - hepatitis C virus

HPI - history of present illness

ICP - intracranial pressure

IVP - intravenous pyelogram

LMP - last menstrual period

MRSA - methicillin-resistant Staphylococcus aureus

MVA - motor vehicle accident

NKA - no known allergies

PEG - percutaneous endoscopic gastrostomy

PRN - pro re nata (as needed)

ROS - review of systems

SOB - shortness of breath

TAH - total abdominal hysterectomy.

TIA - transient ischemic attack

Tx - treatment

UC - ulcerative colitis

URI - upper respiratory infection

VSD - ventricular septal defect

VTE - venous thromboembolism

XR - x-ray

w/c - wheelchair

XRT - radiation therapy

ASD - atrial septal defect

Bx - biopsy

CAD - coronary artery disease

CKD - chronic kidney disease

CPAP - continuous positive airway pressure

DKA - diabetic ketoacidosis

DNR - do not resuscitate

ED - emergency department

ESRD - end-stage renal disease

FFP - fresh frozen plasma

FSH - follicle-stimulating hormone.

GCS - Glasgow Coma Scale

Hct - hematocrit

Hgb - hemoglobin

ICU - intensive care unit

IV - intravenous

JVD - jugular venous distension

K - potassium

L - liter

MCH - mean corpuscular hemoglobin

MI - myocardial infarction

Na - sodium

NGT - nasogastric tube

NPO - nothing by mouth

OR - operating room

PCN - penicillin

PRBC - packed red blood cells

PTT - partial thromboplastin time

RBC - red blood cells

RT - respiratory therapy

SOA - short of air.

SCD - sequential compression device

SIRS - systemic inflammatory response syndrome

STAT - immediately

T - temperature

TPN - total parenteral nutrition

WBC - white blood cells

ABG - arterial blood gas

A fib - atrial fibrillation

BPH - benign prostatic hypertrophy

CBC - complete blood count

CO2 - carbon dioxide

COPD - chronic obstructive pulmonary disease

CPR - cardiopulmonary resuscitation

CT - computed tomography

CXR - chest x-ray

D5W - dextrose 5% in water

Dx - diagnosis

ECG or EKG - electrocardiogram

EEG - electroencephalogram

ETO - early termination of pregnancy.

FHR - fetal heart rate

GSW - gunshot wound

H&P - history and physical exam

HCG - human chorionic gonadotropin

I&D - incision and drainage

IBS - irritable bowel syndrome

ICP - intracranial pressure

IM - intramuscular

INR - international normalized ratio

IOP - intraocular pressure

LFT - liver function test

LOC - level of consciousness

LP - lumbar puncture

NG - nasogastric

OA - osteoarthritis

OCD - obsessive-compulsive disorder

OTC - over-the-counter

P - pulse

PCA - patient-controlled analgesia

PERRLA - pupils equal, round, reactive to light and accommodation.

PFT - pulmonary function test

PICC - peripherally inserted central catheter

PO - by mouth

PRN - as needed

PT - physical therapy

PT - prothrombin time

PTSD - post-traumatic stress disorder

PVC - premature ventricular contraction

QD - once a day

QID - four times a day

RA - rheumatoid arthritis

RICE - rest, ice, compression, elevation

RSI - rapid sequence intubation

RSV - respiratory syncytial virus

SBP - systolic blood pressure

SLE - systemic lupus erythematosus

SSRI - selective serotonin reuptake inhibitor

STAT - immediately

TB - tuberculosis

TIA - transient ischemic attack.

TID - three times a day

TKO - to keep open

TNTC - too numerous to count

TPN - total parenteral nutrition

URI - upper respiratory infection

UTI - urinary tract infection

V-fib - ventricular fibrillation

V-tach - ventricular tachycardia

VA - visual acuity

WNL - within normal limits

AED - automated external defibrillator

ARDS - acute respiratory distress syndrome

BID - twice a day

BP - blood pressure

BUN - blood urea nitrogen

CAD - coronary artery disease

CHF - congestive heart failure

CVA - cerebrovascular accident

D/C - discontinue

DKA - diabetic ketoacidosis.

DM - diabetes mellitus

DVT - deep vein thrombosis

EGD - esophagogastroduodenoscopy

ER - emergency room

F - Fahrenheit

Fx - fracture

GI - gastrointestinal

GTT - glucose tolerance test

HCT - hematocrit

Hgb - hemoglobin

HRT - hormone replacement therapy

ICP - intracranial pressure

IDDM - insulin-dependent diabetes mellitus

IBS - irritable bowel syndrome

IM - intramuscular

IV - intravenous

K - potassium

KVO - keep vein open

L&D - labor and delivery

LASIK - laser-assisted in situ keratomileusis.

ROM - range of motion

RT - radiation therapy

Rx - prescription

SCD - sequential compression device

SOB - shortness of breath

STD - sexually transmitted disease

TENS - transcutaneous electrical nerve stimulation

TIA - transient ischemic attack

TSH - thyroid-stimulating hormone

UA - urinalysis

US - ultrasound

UTI - urinary tract infection

VD - venereal disease

VF - ventricular fibrillation

VT - ventricular tachycardia

WBC - white blood cell

XRT - radiation therapy

XR - x-ray

Zn - zinc

Z-pak - azithromycin (antibiotic).

AAA - abdominal aortic aneurysm

ABG - arterial blood gas

ACS - acute coronary syndrome

ADL - activities of daily living

AED - automated external defibrillator

AIDS - acquired immunodeficiency syndrome

ALS - amyotrophic lateral sclerosis

AMA - against medical advice

AML - acute myeloid leukemia

APAP - acetaminophen

ARDS - acute respiratory distress syndrome

ASCVD - atherosclerotic cardiovascular disease

BPH - benign prostatic hyperplasia

BUN - blood urea nitrogen

CABG - coronary artery bypass graft

CBC - complete blood count

CHF - congestive heart failure

COPD - chronic obstructive pulmonary disease

CPAP - continuous positive airway pressure

CRF - chronic renal failure.

CT - computed tomography

CVA - cerebrovascular accident

D&C - dilation and curettage

DVT - deep vein thrombosis

ECG/EKG - electrocardiogram

EEG - electroencephalogram

ESRD - end-stage renal disease

FSH - follicle-stimulating hormone

GERD - gastroesophageal reflux disease

GFR - glomerular filtration rate

HbA1c - glycated hemoglobin

Hct - hematocrit

HIV - human immunodeficiency virus

HPV - human papillomavirus

HTN - hypertension

IBD - inflammatory bowel disease

IBS - irritable bowel syndrome

ICU - intensive care unit

IDDM - insulin-dependent diabetes mellitus

IM - intramuscular.

IV - intravenous

LFT - liver function test

MI - myocardial infarction

MRI - magnetic resonance imaging

MS - multiple sclerosis

NPO - nothing by mouth

NS - normal saline

OCD - obsessive-compulsive disorder

OSA - obstructive sleep apnea

PCOS - polycystic ovary syndrome

PMS - premenstrual syndrome

PPD - purified protein derivative

PSA - prostate-specific antigen

PT - prothrombin time

PTT - partial thromboplastin time

RA - rheumatoid arthritis

RBC - red blood cell

RSV - respiratory syncytial virus

SLE - systemic lupus erythematosus

TB - tuberculosis.

It is important to remember that medical abbreviations can vary based on location and specialty. 

Healthcare professionals should use medical abbreviations with caution and only when they are familiar with their meanings. 

Patients should always communicate any questions or concerns they have about their medications or medical care to their healthcare provider or pharmacist to ensure they receive safe and accurate medical care.

[doctorfoxtor]

how does one even leave their consciousness at someone's front door step? well who am I to question our queen Willow anyway tbh

100 days of productivity

day 40 + 41

CVS/RS

20-25% of presenting PEs do NOT have an associated DVT

no impact of steroids on silicotic lungs

isocyanates → NSCLC

ILO categories of profusion of small opacities in pneumoconioses (esp CWP/silicosis): cat 0 = no small opacities, cat 1 = few opacities, cat 2 = many opacities but normal lung markings visible, cat 3 = normal lung markings virtually absent (can choose two adjacent categories to assign if it's felt to be borderline, can choose the same category twice)

CNS/Ophthal/Psych

Bowlby-Parkes stages of grief: numbness, pining, disorganisation & disrepair, reorganisation & recovery

progressive brainstem symptoms not explained by a single localisation → vertebral artery disease (?dissection, especially if h/o chiropractor or unsupervised yoga)

chronic small subdural haematoma from 2 weeks ago with no focal deficits or AMS - no need to evacuate

on the same track, if neurological decline is slow, then you can pretty much rule out epidural bleed

meningitis w/ PCN + cephalosporin allergy: USA vanc + moxifloxacin ± cotrimoxazole (OR) UK chloramphenicol ± cotrimoxazole (OR) meropenem monotherapy (mero covers Listeria!); all these regimens are acceptable here

Parkinson-like symptoms but LL rigidity > UL rigidity ± falls: this is ischaemic, NOT neurodegenerative! falls occur *late* in parkinsonian illness, not early

severe dementia (MMSE <10) is a contraindication for anticholinesterases; only memantine is approved for MMSE <10

Endocrine/Repro

insulin resistance → excess insulin production → defective/dystrophic lipogenesis → ectopic fat pockets → release of inflammatory mediators from fat pockets → upregulation of plasminogen activator inhibitor 1 (PAI-1) → inhibition of tPA → procoagulant state

X-linked vs AR adrenoleukodystrophy: AR (Zellweger's) presents in infancy, is rapidly progressive and kills in adolescence; X-linked presents in adolescence and is far more indolent and survivable

rapid improvement in blood glucose is actually assoc w/ acute worsening of microvasculopathy (esp retinopathy); long term improvement in blood glucose is ofc assoc w/ bettering of microvascular dz

Rheum/Derm/Immuno

anti-ribosomal P Abs are specific for lupus encephalitis

hyaline cartilage (carTWOlage = type 2 collagen) is avascular and gets nutrition from synovial fluid diffusion

response to osteoporosis therapy → procollagen-1 propeptides (PICP, PINP, osteocalcin) (bone formation markers)

colloid plasma expanders, like opioids, directly act on mast cells to secrete histamine

GIT

generally, anti-TNFs are only used in IBD that is active despite use of 5-ASA + thiopurine + MTX; the exception is fistulous Crohn's, when anti-TNFs are started ASAP

King's College criteria for APAP-induced ALF for txp referrak: I ACHE (INR >6.5, Acidosis w/ pH <7.3, Creat >3.5 mg/dl, Hepatic Encephalopathy grade 3)

CT is scan of choice for acute pancreatitis; CT is usable in chronic panc but MRI (MRCP) is ideal

80-90% of pancreatic cancers are assoc w/ KRAS2+; only 50% are assoc w/ p53-

by the way! faecal elastase/trypsin is the best measure of chronic pancreatitis, w/ elastase <200 mcg/g being diagnostic

in hepatorenal syndrome, terlipressin causes splanchnic vasoconstriction and reduces splanchnic volume, as well as reducing afferent arteriole pressure and thence renin secretion

SIBO vs short bowel syndrome: SIBO causes not just diarrhoea but also bloating and abdominal discomfort but not marked fat malabsorption and definitely not oxaluria/oxalate stones; both cause folate/B12 deficiency, dehydration, electrolyte disturbances

Onc/Haem

slight increase in PT/aPTT or slight drop in platelets will NOT explain large scale ecchymotic bleeds; in such a patient who is also taking aspirin, blame aspirin

generally, B-cell lymphomas are more common than T-cell lymphomas

that said: Sézary is a form of advanced, more virulent mycosis fungoides (MF: patches of erythema, SS: widespread erythroderma ± keratoderma as well as leukaemic infiltration of marrow)

ID

MTB doubles in 1 day; T. pallidum doubles in 2 days; M. leprae doubles in 2 *weeks*

Pharm/Toxo

cranberry juice is not as bad a culprit as grapefruit is, but it also has some pretty significant interactions (especially 2C9 which metabolises eswarfarin, the active enantiomer of warfarin; expect INR to skyrocket)

100 mg desferoxamine chelates 8 mg iron

[mysaallergist022]

Most advanced pcn testing available at Advanced Allergy, Asthma, & Immunology Center

[virtualpharmacist]

The Role Of Heath Care Practitioners In Various Medical Fields

A medical services professional is one having the power or permit to give corrective or preventive medical care administrations to people or networks in a coordinated and purposeful GP practice pharmacist in the field of medication, obstetrics, drug store, nursing, pediatrics, clinical brain science or other related areas. The nature of administration given by medical services specialists is completely observed by the state experts based on pre-fixed standards and guidelines. The state has the privilege to pass judgment on the activities of the medical care suppliers, and hold onto their permit on the off chance that they are found to disregard any of the standards. In such conditions, it is the obligation of the state to give the Board of Medical Examiners the name and the activity subtleties of the concerned medical services supplier for the execution of vital activities.

Allow us to see the different sorts of medical care suppliers accessible:

Essential Care Providers (PCP): The individual you make your first visit to for an overall wellbeing examination is characterized as your essential consideration supplier. You can settle on the best PCP for you based on your medical issues and the medical care plan you have. Allow us to talk about a portion of the potential choices:

By and large, an overall doctor can be the best PCP, who can investigate your medical conditions and allude you to the most suitable trained professional. An overall doctor alludes to a specialist of medication or osteopathy with a specialization in inside medication and family practice.

You can likewise pick an Obstetrician and Gynecologist has a specialization in ladies' wellbeing and pre-birth care as your PCP.

For routine exams and general medical problems, you can designate attendant professionals with advanced educations as your PCP. They are approved to give essential consideration in the field of pediatrics, family medication, ladies' wellbeing, grown-up care and so on

Nursing Care: The nursing area can be partitioned in different classes.

Authorized Practical Nurse (LPN): LPNs allude to prepared medical caretakers having the permit to give wellbeing insurance administrations to people, families or networks.

Enlisted Nurse (RN): RNs are needed to get past a state board assessment and achieve an advanced education from a nursing program to get the permit for giving wellbeing security administrations.

Progressed Practice Registered Nurse (APRN): APRNs are better than general medical caretakers attributable to their high level preparation phases and extraordinary degrees. APRNs incorporate guaranteed enrolled nurture anesthetists, nurture professionals, clinical medical caretaker subject matter experts and authorized attendant birthing specialists.

Psychological well-being Practitioners: An emotional well-being professional alludes to a wellbeing security supplier who is known to offer preventive or corrective administrations to treat psychological circumstances in people. Emotional well-being experts incorporate clinical clinicians, specialists, clinical social laborers, marriage and family advisors and so forth

 Drug specialists: Having an advanced education from drug schools, authorized drug specialists offer types of assistance in the field of wellbeing insurance by getting ready medications that are recommended by essential or specialty care suppliers.

Specialty Care Providers: Specialty care suppliers are medical care experts, who give wellbeing assurance administrations in different specific fields like Cardiology, Dermatology, Gastroenterology, Orthopedics, Nephrology, Allergy and Asthma and some more.

 For More Info, Visit Us:

clinical pharmacist

Primary Care pharmacist

PCN Pharmacist

[guidedpapers]

Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.

Provide a rationale for each question you ask by explaining why it is appropriate and how it aligns to the chief complaint.

B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 • DOB: 01 January 2004 • Gender: Male • Age: 7 years 6 months CC: Well visit today with parental concern about short stature Ht: 48” Wt: 48 lb Resp.: 18 Temp. 98 F HR: 74 Allergies: PCN Here with parents. Parental concerns about B. being the shortest child in class. They are concerned about his height. Denies any PMH…

[thinklio]

[QUESTION SOLVED] B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 •

[QUESTION SOLVED] B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 •

B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 • DOB: 01 January 2004 • Gender: Male • Age: 7 years 6 months CC: Well visit today with parental concern about short stature Ht: 48” Wt: 48 lb Resp.: 18 Temp. 98 F HR: 74 Allergies: PCN Here with parents. Parental concerns about B. being the shortest child in class. They are concerned about his height. Denies any PMH…

[mcatmemoranda]

Penicillin allergy is over diagnosed. Most people don’t have a true penicillin allergy and even if they do, 80% of people grow out of it in 5 years. In pregnant women, as long as their reaction isn’t anaphylaxis, they can get penicillin for GBS tx.

[doctorfoxtor]

I got 25% of my questions correct today so who's the winner in all of this? The people I paid for their question bank, probably

100 days of productivity

Day 10

RS/CVS

endocarditis prognosis: viridans = good prognosis (overall strep mortality ~5%); staph/culture-negative = poor prognosis (overall staph mortality ~30%); prosthetic valves and low serum complement also assoc. w/ poor prognosis

prosthetic valves = gent + RIF + fluclox if known MSSA source + vanc if unknown MSSA or suspected MRSA or PCN allergy

native valves = fluclox if MSSA; benzylpenicillin if strep + low-dose gent if less PCN-sensitive; vanc + RIF if PCN-allergy or MRSA; amox/(vanc if PCN-allergic) + low-dose gent if neither

latent TB in HIV → INH x9 mos

AV block: MILD RASH: myotonic muscular dystrophy, IHD, Lyme, digitoxicity (often +atrial tachy), RHD, aortic abscess/aortic root dilation, sarcoid, hypo/hyperkalaemia

CNS

NCS: ↓compound muscle action potential amplitude → axonal neuropathy

NCS: reduced velocity/conduction blocks → myelin disorders; reduced amplitude → axonal disorders

dizziness + absent corneal reflex = acoustic schwannoma

mumps meningitis causes low CSF glucose! however, other CSF stigmata point to viral disease (normal to mildly elevated protein, lymphocytes, negative stains/cultures) (differentiate from TB by acuity of mumps vs subacuity/chronicity of TB + cobwebbing in TB + *markedly* elevated protein in TB; PCR is 75% sensitive for TB)

GIT

best single-marker indicator of severity in acute pancreatitis is CRP; good predictor of necrosis

mucoid diarrhoea + very mild anaemia + hypokalaemia → villous adenoma (IRL, anaemia → r/o ca colon; but a colonoscopy will catch the adenoma anyway)

inducing Crohn's remission: 1. glucocorticoids + salazines 2. add-on azathioprine/6-mercaptopurine or MTX if cannot use aza/6-MP 3. add-on infliximab (I am unsure why aza/6-MP are used for inducing remission as they take upwards of 2-3 months to take effect; they are generally excellent for *maintaining* remission, not inducing it, but them's the guidelines I guess)

Endo/Repro/Infections

9am cortisol between 100-500 → inconclusive; proceed to cosyntropin test (but as long as levels <500 you will proceed with cosyntropin stimulation test)

urethritis NAAT-neg for gono/chlam → doxy x1 wk or azithromycin (NAAT will only be positive 2 weeks after likely transmission event)

malaria: sensitivity of QBC is greater than than of thick smear for parasite burden estimation, but less than that of thin smear for species identification

Onc/Haem

AIHA: in warm, the haemolysis occurs *extravascularly* (hence haptoglobin and peripheral smear will NOT show stigmata of haemolysis); in cold, the haemolysis occurs *intravascularly* (so hapto/smear WILL reflect haemolysis)

myelofibrosis = V617F JAK2 mutation (asso. w/ teardrop poikilocytosis)

Renal/Biochem/Toxo

MDRD equation for eGFR: CAGE: Creat, Age, Gender, Ethnicity

ADPKD assoc. w/ AR (aortic root dilation), MVP/MR, TR

warfarin × azathioprine interaction → ↓warfarin effect → impaired thromboprophylaxis in immunosuppressed (mechanism unknown)

atorvastatin (only) × digoxin → digitoxicity (inhibition of digoxin transport by the p-glycoprotein efflux transporter)

all statins interact with fibrates, but fenofibrate has the least potential for precipitating the myotoxic interaction and should be preferred when both statins and fibrates must be prescribed

thiazides cause impotence in up to 33% of patients???

if VICKO STUMBLED, luckily for him those toxins are dialysable: Valproate, Isoniazid/Isopropyl alcohol, Carbamazepine, Kerosene/Ketones, Organophosphates, Salicylates, Topiramate, Urea, Methanol/Methylxanthines (caffeine, theophylline etc), Barbiturates/Benzos, Lithium, Ethylene glycol/Ethanol, Dabigatran

[thinklio]

[QUESTION SOLVED] B.P. ScenarioShort Stature, 7-year-old male• Name: B.P.• Date: 15 July 2011•

[QUESTION SOLVED] B.P. ScenarioShort Stature, 7-year-old male• Name: B.P.• Date: 15 July 2011•

B.P. Scenario Short Stature, 7-year-old male • Name: B.P. • Date: 15 July 2011 • DOB: 01 January 2004 • Gender: Male • Age: 7 years 6 months CC: Well visit today with parental concern about short stature Ht: 48” Wt: 48 lb Resp.: 18 Temp. 98 F HR: 74 Allergies: PCN Here with parents. Parental concerns about B. being the shortest child in class. They are concerned about his height. Denies any PMH…

[mcatmemoranda]

Notes from an internal medicine rotation that I never posted.

Lower UTI = cystitis, urethritis Upper UTI = pyelonephritis

Uncomplicated = healthy young women Complicated = structural abnormalities, instrumentation, pregnant women, men

Signs & sxs: F/U/D, suprapubic pain. Dysuria is especially important to make you think of UTI.

Bacteriuria: more than 10000 colony forming units per mL UA: nitrites (from E. coli), leukocyte esterase (from WBCs)

Complicated UTIs occur in immunocompromised pts (chemotherapy, chronic steroids, HIV, transplant pts), diabetics, ESRD, liver disease, pts w/ recent abx use.

For complicated UTI, you must do urine culture pre- and post-treatment. Recurrent UTI = 3+ uncomplicated UTI with 1+ urine culture.

Prophylaxis for recurrent UTI: 2L daily fluid, voiding frequency, hygiene, avoid spermicide & constipation. Estrogen cream reduces recurrence.

Screen for asymptomatic bacteriuria (ASB) especially in pregnant women. ASB: +UA & + UC w/o sxs.

Sterile pyuria: +UA & -UC, seem in pts with gonorrhea/chlamydia; no need to treat if no sxs.

Pregnant women need to be screened and treated. You can give amoxicillin, nitrofurantoin if PCN allergic. Never FQs or bactrim in pregnant women.

Nosocomial UTI occurs if Foley catheter left in.

In pts with indwelling catheter, get clean catch culture if symptomatic.

Acute bacterial prostatitis = acute suprapubic pain, prostate tenderness, dysuria. Often due to E. coli. Tx for 4 to 6 weeks.

Non-complicated UTI does not require culture. Treatment is 3 to 5 days w/ nitrofurantoin, bactrim, cefuroxime. Pyelonephritis can be treated with ceftriaxone. Ertapenem txs ESBL UTI.

For hospitalized pts, IV CTX or aztreonam if PCN allergy.

At NUMC, they don’t use FQs first-line for empiric tx. There is resistance and lots of side effects.

TMP-SMX can cause hemolytic anemia in people with G6PD deficiency.

Nitrofurantoin can cause pulmonary fibrosis.

FQs can cause QT prolongation, tendinopathy, aneurysms. Must do baseline EKG before using FQs. C/I in pediatrics.

For a nursing home pt with recurrent UTI, nothing will help in terms of prophylaxis. So if the immune system can protect you, you don’t need to do anything.

[mysaallergist022]

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