Case Files – Family Family Medicine
Cardiovascular Cardiovascular screening:
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Screen adults for HTN w/ BP measurement . – Level A Screening men aged 35 yrs or more & women aged 5 yrs or more for li!id disorders. – Level A Scr Screen een adu adult ltss > 20 yrs yrs who who are are at at ris risk k for for C dise diseas ases es.. – Lev Level ! "ltrasonogra!#y to assess for a$dominal aortic aneurysm is recommended for men "# – $% yrs o old who have ever smoked. N% AAA screening in en who '(() S*+(, o N% AAA screening in -*(' at all /Smoking or not o Total C#olesterol ' H() %* F+,T-N. F+,T-N. )i!id Panels includes )() o Screen1 Non&asting Total o
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Cancer screening: Adults > %0 yrs old should e screened for colorectal cancer. o 3*!4 is recommended annually5 sigmoidosco6y & arium enema every 7 – % yrs5 & o o colonosco6y every 80 yrs. %t#er #ealt# condition screening: o *esity screening via !9 & 6roviding 6roviding counseling & ehavioral ehavioral interventions to 6romote weight loss are recommended recommended for all adults.
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Screen for , 99 in adults w: ;4' or hy6erli6idemia. hy6erli6idemia. ,e6ression screening is recommended. Screening & counseling to 9, & 6romote cessation of toacco use is strongly recommended. o Scr Screeni eening ng & cou couns nsel elin ing g to to 9, 9, & 6rev 6reven entt mis misus use e of of alc alcoh ohol ol..
Case 3 – Hy!ertension: 4he risk of cardiovascular disease doules w: each increase in lood 6ressure of 20:80 mm ;g aove 88%:$% mm ;g. A66ro %0 million Americans have ;4' & a66ro. 70? are unaware of their 6rolem. 4he risk of com6lications is directly related to the elevation of the lood 6ressure – the higher the lood 6ressure5 the higher the risk. (levated systolic systolic lood 6ressure is a greater risk for cardiovascular disease com6lications than elevated diastolic 6ressure. 4he goal of treatment is to get the lood 6ressure to less than 8#0:@0 mm ;g. 3or 6ersons w: diaetes or kidney disease5 the goal is to achieve a lood 6ressure of less than 870:0 mm ;g. 4he lood 6ressure cuff should encircle encircle at least 0? of the 6atientBs arm a cuff that is too small can result in a falsely elevated reading. 4he diagnosis of ;4' is made ased on the average of 2 6ro6erly taken lood 6ressure measurements at 2 or more of=ice visits. o -hen ;4' is diagnosed5 an evaluation consisting of a history5 6hysical eamination5 & focused diagnostic studies should e 6erformed5 w: the goals of assessing overall cardiovascular cardiovascular risks5 identi=ication of 6ossily secondary causes of ;4'5 & determination of the 6resence of any endDorgan damage. A highD6o highD6otassi tassium um & highDcalc highDcalcium ium diet5 the ,ietary ,ietary A66roach A66roaches es to Sto6 Sto6 ;y6erten ;y6ertension sion /,AS; /,AS; diet 6lan5 reduces lood 6ressure in an amount com6arale to singleDagent drug thera6y. Case 78 –
ost often descried as a Ghungry ayH w: 6roEectile vomiting. omiting is nonilious & occurs immediately after meals. o *liveDsha6ed mass felt in the right u66er Iuadrant5 & 6eristaltic waves may e seen across the u66er adomen moments efore emesis occurs. Among the diagnoses that have to e entertained are hy6ertro6hic 6yloric stenosis5 malrotation w: volvulus:ostruction5 foreignDody ingestion5 & 6oisoning. o
alrotation occurs a66ro. in "0? of 6atients will e younger than 8 month of age. !:c it is 6rimarily a defect that occurs during emryogenesis5 the mesentery tat is formed will have an anormally narrow ase5 which allows the small owel to move more freely than normal. 4his creates a 6rolem when the intestinal attachment to the mesentery twists around itself5 creating a volvulus. *nce ostruction occurs5 the child will 6resent w: ilious vomiting & adominal 6ain. o o 9f the 6atient is hemodynamically stale & malrotation is sus6ected5 an u66er F9 series is the test of choice. ,iagnostic =indings on an u66er F9 are an oviously mis6laced duodenum5 or a duodenal ostruction w: the classic GeaklikeH a66earance of the contrast medium caused y a volvulus. o Surgery is the only treatment.
*nly 80? of 6atients that ingest a foreign ody will need an intervention either to relieve an ostruction or to 6revent F9 com6lications. Among oEects that reIuire immediate intervention are =lat disk5 or Gutton5H atteries in the eso6hagus. 4hese atteries will conduct electricity when oth 6oles are in contact w: the eso6hageal wall5 which will lead to 6erforation.
Case 0 – C#est Pain: 9nitial studies in the ()1 C!C5 electroylytes5 !K'5 creatinine5 <45 <445 99')5 glucose5 82Dlead (CF5 & chest Dray markers of myocardial damage including creatine kinase /C+ & ! isoenJyme /C+D!5 tro6onin 4 & tro6onin 9 to e done state & every "D80 hrs for 7 cycles. Studies that can e done later1 fasting li6ids5 liver fn tests5 g5 homocysteine level5 urine drug screen5 urinalysis5 & myogloin. 'et ste6 is *'A thera6y1 or6hine5 *ygen5 'itroglycerin5 As6irin or6hine can achieve adeIuate analgesia which decreases levels of circulating catecholamines5 thus reducing myocardial oygen consum6tion. *ygen 2 – # L:min. o o 'itroglycerin must e given sulingually initially every % min for a total of 7 doses. o As6irin 72% mg should e chewed & swallowed. o !etaDadrenergic antagonist reduces myocardial damage & may limit infarct siJe. o Flyco6rotein /F< 99:999a inhiitors reduce end 6oint of death or recurrent ischemia. st 4he 8 6riority is to otain (CF & CM)5 while giving medications to decrease the damage caused to his myocardium & simultaneously reducing his lood 6ressure. 'ew Nork ;eart Association 3unctional Classi=ication of Angina1 o Class 9 – angina only w: unusually strenuous activity. Class 99 – Angina w: slightly more 6rolonged or slightly more vigorous activity than usual. o Class 999 – Angina w: usual daily activity. o Class 9 – Angina at rest. Knstale angina1 angina of new onset5 angina at rest or with minimal eertion5 or a crescendo 6attern of angina w: e6isodes of increasing freIuency5 severity5 or duration. Atherosclerosis leading to 6laIue ru6ture & then cascading to coronary artery thromosis is the cause of an acute 9 a66ro. O@0? of the time5 ut many different conditions can e the cul6rit for angina. 9f the 6atient is e6eriencing myocardial ischemia or infarction5 time is myocardium. o
All 6atients who rule in for myocardial infarction should receive as6irin & an antithromotic treatment. Current American College of Cardiology:American ;eart Association recommendations advise withholding clo6idogrel for %D$ days efore 6lanned y6ass surgery.
AngiotensinDconverting enJyme /AC( inhiitors reduce shortDterm mortality when started w:in 2# hrs of acute myocardial infarction.
4he goal level of L,L cholesterol in anyone w: a history of CA, & high risk for future cardiac events is P $0 mg:dL. any 6eo6le do not descrie angina as chest 6ain. Some descrie it as 6ressure5 sIueeJing5 crushing5 or smothering. Some may use a GLevine sign5H a =ist held =irmly against the chest. o Angina usually res6onds 6rom6tly to measures that reduce myocardial oygen demand. All lood vessels must e auscultated for ruits5 a direct sign of atherosclerotic disease. ,iminished 6eri6heral 6ulses are also a sign of atherosclerotic disease. KneIual carotid 6ulses or u66er etremity 6ulses can indicate aortic dissection5 ut most 6atients w: dissection will not have a 6ulse de=icit. usculoskeletal causes of chest 6ain are the most common etiology in an out6atient setting. 3or treatment of new onset of angina5 ra6id release5 shortDacting dihydro6yridines are contraindicated :c they increased mortality in multi6le trials. 4he changes of L!!! make the determination of an acute 9 y an (CF etremely dif=icult. 9n these 6atients5 it is 6articularly im6ortant to otain serum markers of myocardial damage.
Case 01 – Congestive Heart Failure: Congestive heart failure1 imalance in 6um6 fn where the heart fails to maintain the circulation of lood adeIuately.
3ramingham heart study1 large5 6ros6ective cohort study of the e6idemiologic factors associated w: cardiovascular disease. Systolic dysfn eists when there is a dilated left ventricle w: im6aired contractility. ,iastolic dysfn occurs in a normal or intact left ventricle that has an im6aired aility to rela5 =ill5 & eEect lood.
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,ys6nea on eertion is the most sensitive sym6tom for the diagnosis of C;35 ut its s6eci=icity is much lower.
Sym6toms of rightDsided heart failure include venous congestion5 nausea:vomiting5 distension:loating5 consti6ation5 adominal 6ain5 & decreased a66etite. o Common signs of rightDsided heart failure are =luid retention5 weight gain5 6eri6heral edema5 Q,5 he6atoEugular re=lu5 he6atic ascites5 & s6lenomegaly. LeftDsided heart failure manifests w: 6ulmonary congestion5 resulting in the sym6toms of dys6nea on eertion5 6aroysmal nocturnal dys6nea5 ortho6nea5 wheeJing5 tachy6nea5 & cough. o 4he signs of 6ulmonary congestion are ilateral 6ulmonary rales5 S7 gallo6 rhythm5 CheyneDStokes res6iration5 6leural effusion5 & 6ulmonary edema. 2 maEor criteria or 8 maEor criteria & 2 minor criteria can lead to a 6resum6tive diagnosis of C;3. o aEor signs1 6aroysmal nocturnal dys6nea5 Q,5 rales5 cardiomegaly5 6ulmonary edema5 S7 gallo65 central venous 6ressure grater than 8" cm ;205 circulation time of 2% seconds5 he6atoEugular re=lu5 & weight loss of
#.% kg over % days of treatment. o inor criteria1 ilateral ankle edema5 nocturnal cough5 dys6nea on eertion5 he6atomegaly5 6leural effusions5 decreased vital ca6acity y 8:7 of maimum5 & tachycardia. C;3 is the leading diagnosisDrelated grou6 /,)F among hos6italiJed 6atients older than "% yrs. o 4he median survival is 7.2 yrs for men & %.# yrs for women. o 4he most common cause of death is 6rogressive heart failure5 ut sudden death may account for u6 to #%? of all deaths. 9n a dys6neic 6atient5 a level of !'< less than 800 6g:mL suggests that the sym6toms are unlikely to e caused y C;3 a !'< level less than %00 6g:mL is consistent w: the diagnosis of C;3. *ne of the earliest CM) =indings in C;3 is ce6haliJation of the 6ulmonary vasculature. As the failure 6rogresses5 interstitial 6ulmonary edema can e seen as 6erihilar in=iltrates5 often in a utter=ly 6attern. (chocardiogra6hy is the goldDstandard diagnostic modality in the 6resence of C;3. -hen acute 6ulmonary edema caused y C;3 is diagnosed5 the net ste6 in management is the administration of a loo6 diuretic.
'itroglycerin also can ra6idly reduce !< & is the treatment of choice in a 6atient who has C;3 & whose lood 6ressure is elevated. All 6atients should e advised aout the im6ortance of dietary sodium & =luid restriction. A normal American diet contains " – 80 sodium chloride a day initial restriction in 6atients w: C;3 should e 2 – # g:d. AC( inhiitors should e considered =irstDline thera6y in 6atients w: C;3 & reduced left ventricular function. AC(9 reduce 6reload5 afterload5 im6rove cardiac out6ut5 & inhiit tissue reninDangiotensin systems. 4he result of this is an im6rovement in sym6toms & a reduction in mortality. o AC(9 are contraindicated in 6regnancy5 hy6otension5 hy6erkalemia5 & ilateral renal artery stenosis5 & should e used w: caution in 6atients w: renal insuf=iciency. 4he administration of etaDlockers5 es6ecially in high doses5 in the setting of acute C;35 can worsen sym6toms conseIuently5 initial doses should e low & titrated over several weeks. o !etaDlockers can reduce the sym6athetic tone & the cardiac muscle remodeling associated w: chronic heart failure. o !etaDlockers reduce mortality in 6ts w: an eEection fraction of less than 7%? & in 6ts w: CA,. ,iuretics should e used to reduce =luid overload in oth the acute & chronic setting. Loo6 diuretics can e used in all stages of C;3 & are useful in 6ulmonary edema & refractory heart failure. 4hiaJides can e sued in mild heart failure & may e used in comination w: other diuretics in more severe C;3.
Calcium channel lockers are contraindicated in systolic heart failure5 :c they increase mortality. 4he ece6tion to this is amlodi6ine which did not increase or decrease mortality. o 'ondihydro6yridine calcium channel lockers are useful in heart failure caused y diastolic dysfn5 as they 6romote increased cardiac out6ut y lowering heart rate5 which allows for more ventricular =illing time. Cardiac resynchroniJation thera6y5 synchronous contraction of oth left & right ventricles using a iventricular 6acemaker5 has een shown to reduce mortality & hos6italiJation in 6atients w: sym6tomatic C;3 in s6ite of maimal
medical thera6y.
Case 35 – Hy!erli!idemia: -
4he main cholesterol com6onent that im6acts on cardiovascular disease is the L,L level.
;igh cholesterol is a risk factor for coronary heart disease. As such5 an individualBs cholesterol levels must e inter6reted in the contet of their overall risks for C;,.
4he following % factors are considered to determine the L,L goal of a given individual1 o Cigarette smoking o ;4' /!< greater or eIual to 8#0:@0 or on antiD;4' med o Low ;,L o Age />#% yrs for men >%% ys for women o 3amily h of 6remature C;, Secondary causes of dysli6idemia include diaetes5 hy6othyroidism5 ostructive liver disease5 & chronic renal
failure. 4hera6eutic lifestyle changes are the cornerstone of all treatments for hy6erli6idemia. o S6eci=ic dietary recommendations should include a reduction of saturated fats to less than $? of total calories & an intake of less than 200 mg:d of cholesterol. o 4he addition of dietary solule =ier & 6lant stanols:sterols can e ene=icial.
Case 0 – Pal!itations: itral valve 6rola6se /< syndrome 6resents w: midsystolic click associated w: or w:out a late systolic murmur. Ksually asym6tomatic5 it is the most common valvular heart defect in the K.S. o A 2Ddimensional echocardiogram is recommended at least once when < is identi=ied.
usually not dangerous. 4hey usually are the result of a change in the heartBs electrical system.
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4he largest grou6 has s ome ty6e of 6rimary rhythm disorder5 including sinus radycardia5 sinus tachycardia5 -olfD
Atrial =irillation is the most common of all arrhythmias & ecomes increasingly more common w: older age & cardiomyo6athy. -<- syndrome is caused y an accessory track :w the atria & ventricles that conducts electrical im6ulses in addition to the A node. 4he classic (CF =inding is a slurring on the u6stroke of the R)S com6le known as a delta wave. Sick sinus syndrome usually involves a dysfn of the SA node that leads to radycardia & can cause fatigue & synco6e.
P")M%N+*2 Case 0 – C#ronic %$structive Pulmonary (isease: Asthma often 6resents earlier in life5 may or may not e associated w: cigarette smoking5 & is characteriJed y e6isodic eacerations w: return to relatively normal aseline lung functioning. C*<, tends to 6resent in midlife or later5 is usually the result of a longDterm history of smoking5 & is a slowly 6rogressive disorder in which measured 6ulmonary functioning never returns to normal. Assessment of the 6atient 6resenting w: dys6nea should always start w: the A!Cs – Airway5 !reathing5 & Circulation. o ;y6oemia should e treated w: su66lemental oygen. Chronic ronchitis1 cough & s6utum 6roduction on most days for at least 7 months during at least 2 consecutive years. (m6hysema1 shortness of reath caused y the enlargement of res6iratory ronchioles & alveoli caused y destruction of lung tissue. C*<, is a disease of in=lammation of the airways5 lung tissue5 & vasculature.
eacerations are usually caused y viral or acterial infections. o ,ys6nea is the 6rimary 6resenting sym6tom of C*<,. !y the time dys6nea develo6s5 lung fn /as st measured y force e6iratory volume in the 8 second of e6iration 3(8T has een reduced y aout U & the C*<, has een 6resent for years. 4he 6rimary diagnostic test of lung fn is s6irometry. o 9n normalDfning lungs5 the ratio of the 3(8 to 3C is greater than 0.$. o 9n C*<,5 oth the 3C & 3(8 are reduced & the ratio of 3(8 to 3C is less than 0.$5 indicating an airway ostruction. o )eversiility is de=ined as an increase in 3(8 greater than 82? or 200 mL. C*<, Severity staging1 o Stage 01 at risk. Cough5 s6utum 6roduction5 normal s6irometry. 4 w: vaccines & smoke cessation. o Stage 81 mild C*<,. 3(8:3C P 0.$ 3(8>0? 6redicted w: or w:out sym6toms. 4 w: SA!A. o Stage 21 moderate C*<,. 3(8:3C P0.$ 3(8 %0D0? 6redicted w: or w:out sym6toms. 4 w: LA!A. o Stage 71 severe C*<,. 3(8:3C P 0.$ 3(8 70D%0? 6redicted w: or w:out sym6toms. 4 w: inhaled steroids. o Stage #1 very severe C*<,. 3(8:3C P 0.$. 3(8 P70? 6redicted or 3(8 P%0? w: chronic hy6oemia. 4 w: oygen thera6y & inhaled steroids. *ygen only needed if
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6olycythemia5 6ulmonary ;4' or 6eri6heral edema.
Although smoking cessation does not result in signi=icant im6rovement in 6ulmonary fn5 smoking cessation does reduce the rate of further deterioration to that of a nonsmoker. *ygen thera6y is the only intervention that has een shown to decrease mortality & must e worn for at least 8% h:d.
Acute eacerations of C*<, are common & ty6ically 6resent w: change in s6utum color or amount5 cough5 wheeJing5 & o
increased dys6nea. iral & acterial infections are common 6reci6itants. o All acute eacerations should e treated w: SA!As until sym6toms im6rove. Systemic steroids shorten the course of the eaceration & may reduce the risk of rela6se. o (acerations associated w: increased amts of s6utum or w: 6urulent s6utum should e treated w: antiiotics. Pneumococcus, Haemophilus influenzae & Moraxella catarrhalis are the most common acteria im6licated.
Case 4 – "!!er *es!iratory -n&ections -
Acute ronchitis1 in=lammation of the tracheoronchial tree.
4he color of s6utum is not diagnostic of the 6resence of a acterial infection.
!ronchitis is nearly always selfDlimited in an otherwise healthy individual. Although most acute ronchitis lasts for less than 2 weeks5 in some cases the cough can last 2 months or more. )hinosinusitis is the in=lammation:infection of the nasal mucosa & of one or more 6aranasal sinuses.
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Sinusitis occurs w: ostruction of the normal drainage mechanism. Acute /sym6toms P # wks5 suactue /#D82 wks5 chronic /> 82 wks. o o Consider acterial sinusitis after $ dys of sym6toms in adults & 80 dys in children. 4he diagnosis is suggested y the 6resence of 6urulent nasal discharge5 maillary tooth or facial 6ain5 unilateral maillary sinus tenderness5 & worsening of sym6toms after initial im6rovement.
clinically from FAS infection. (udative 6haryngitis is 6rominent. 3eatures suggestive of mononucleosis include retrocervical or generaliJed adeno6athy & he6atos6lenomegaly. Aty6ical lym6hocytes can e seen on 6eri6heral lood smear. o 4he associated s6lenomegaly can e signi=icant5 as it 6redis6oses to s6lenic ru6ture in res6onse to trauma. 4he 6atency of the airway must e addressed =irst. 4he 6resence of stridor5 drooling5 & a toic a66earance suggest e6iglottitis. Sweling of the 6eritonsillar region5 w: the associated tonsil 6ushed toward the midline & with contralateral deviation of the uvula5 is consistent w: a 6eritonsillar ascess. Sus6icious of 6eritonsillar ascess should 6rom6t immediate referral for surgical drainage of the ascess. 4he diagnosis of FAS infection can e made y ra6id antigen testing5 which are highly s6eci=ic ut have a lower sensitivity than throat culture. A 6ositive ra6id antigen test would 6rom6t antiiotic treatment5 a negative test should e followed y a throat culture. 4hroat cultures are considered the gold standard for diagnosis of FAS infections. o Com6lications from untreated FAS infections are rare. o
ost cases of acute * will resolve s6ontaneously. Amoicillin remains the recommended initial thera6y.
Case 0 Pneumonia: ;el6ful clues to the 6atientBs overall condition include a toic a66earance5 using accessory muscles to reathe5 & low oygen saturation. 4achycardia5 hy6otension5 & altered mentation are signs of more critical illness. Airway5 reathing5 & circulation must always e addressed.
o ;igh risk comoridities include neo6lastic disease5 liver disease5 renal disease5 congestive heart failure5 & diaetes. o La =indings include a low 6;5 low serum 'a5 low hematocrit5 low oygen sat5 high glucose5 high !K'5 & 6leural effusion on CM). 9n health 6ersons5 a macrolide or doycycline is recommended em6iric thera6y. 4reatment w: a newer =luoroIuinolone or the comination of a etaDlactam 6lus a macrolide would e recommended. 3or hos6italiJed 6atients w: communityDacIuired 6neumonia who do not reIuire 9CK treatment5 an intravenous etaDlactam & an intravenous macrolide are recommended. 4he duration of the treatment is in=luenced y the severity of illness5 the etiologic agent5 res6onse to thera6y5 the 6resence of other medical 6rolems5 & com6lications. o 4hera6y until the 6atient is aferile for at least $2 hrs is usually suf=icient for S. 6neumoniae. o A minimum of 2 wks for other 6neumonia. 4he 6resence of em6yema usually reIuires drainage w: a chest tue or surgical 6rocedure.
Case 34 – #ee6ing: Sym6toms such as weak cough5 inaility to s6eak or cry5 highD6itched sounds or no sounds during inhalation5 cyanosis5 choking5 vomiting5 drooling5 wheeJing5 loodDstreaked saliva5 & res6iratory distress are clues to the diagnosis of foreignDody airway ostruction. Stridor1 wheeJing coming from ostruction of the large airway that has a constant 6itch & intensity throughout the entire ins6iratory effort. -heeJing1 a musical sound heard on 6ulmonary auscultation 6roduced y the oscillating walls of airways that has een narrowed y mucus5 in=lammation & etc. 4he etiology of acute wheeJing in children could e infectious or mechanical ostruction. )ecurrent wheeJing on the other hand5 encom6asses anomalies of the tracheoronchial tree5 cardiovascular disease5 F(),5 & immunologic disorders. !ronchiolitis is the most common acute cause of wheeJing in children younger than 2 yrs of age5 es6ecially in infants who are 8 – 7 months old. 9nfants younger than " mos are most severely affected5 owing to smaller5 more easily ostructed airways & a decreased aility to clear secretions. o )es6iratory syncytial virus /)S accts for $0? of causes5 the rest are caused y 6arain=luenJa5 adenovirus5 yco6lasma5 & meta6neumovirus. 4hese viruses elicit in=lammatory & immune res6onses that 6roduce mucus5 edema5 & cellular deris that lock the small airways. o
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(6iglottitis is a acterial infection of the su6raglottic tissue & surrounding area that causes ra6idly
6rogressive airway ostruction. -:in 2# hrs the e6iglottis would a66ear GtoicH & develo6 fever5 severe sore throat5 muf=led s6eech /Ghot 6otato voiceH5 drooling5 & dys6hagia. 4he child is usually noticealy anious & assumes the sitting 6osition5 leaning forward on outstretched arms w: chin thrust forward & neck hy6eretended /tri6od 6osition so as to increase the airway diameter. o (6iglottitis is a medical emergency & visualiJation to con=irm the 6resence of severely erythematous e6iglottis is 6referaly done in the o6erative room. o )adiogra6hic =inding is the Gthum signH or 6rotrusion of the enlarged e6iglottis from the anterior wall of the hy6o6haryn seen on a lateral neck Dray. o 4reatment consists of a66ro6riate antiiotics & airway management. ,ee6 ascesses of the neck are less common causes of acute airway. )etro6haryngeal ascess affects children 2 – # yrs. 4he ascess is usually caused y etension of 6haryngeal infection5 6enetrating trauma5 iatrogenic instrumentation5 or foreign ody. Children 6resent w: fever5 drooling5 dys6hagia5 odyno6hagia5 stridor & res6iratory distress. o , made y lateral neck =ilms that show ulging in 6osterior 6haryn.
M,78,7-N Case 3 – Non8traumatic 9oint Pain ' ,welling: st
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9n a case w: sudden onset of monoarticular Eoint 6ain5 the 8 diagnosis that needs to e ecluded is an infected st Eoint. (clusion of an infectious etiology is 6aramount as cartilage can e destroyed w:in the 8 2# hrs of infection.
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Qoint as6irate crystals1 Calcium 6yro6hos6hate dehydrate1 rodDsha6ed5 rhomoid5 weakly 6ositive irefringence. o Calcium hydroya6atite1 seen y electron microsco6y5 cyto6lasmic inclusions that are nonirefringent. o Calcium oalate1 i6yramidal a66earance5 strongly 6ositive irefringence seen mostly in endD stage renal disease 6atients. Fouty arthritis1 condition of ecess uric acid leading to de6osition in Eoints5 es6ecially the great toe.
Case 0 – Musculoseletal -n;uries: ost ankle s6rains are the result of inversion of an ankle that is 6lantar =leed. 4he lateral ankle is inEured much more commonly than the medial ankle5 as the ony anatomy of the tiiotalar Eoint & the very strong deltoid ligament com6le 6rotect the medial ankle from inEury. o 4he lateral ligaments – anterior talo=iular ligament5 calcaneo=iular ligament & 6osterior talo=iular ligament – relatively weaker & more commonly inEured. 4he A43L is the most commonly inEured ligament5 followed y the C3L.
4he *ttawa Ankle )ules have a sensitivity a66roaching 800? in ruling out signi=icant malleolar & midfoot fractures. 4hese rules show that Drays of the ankle should e 6erformed if there is ony tenderness of the 6osterior edge or ti6 of the distal " cm of either the medial or lateral malleolus5 or if the 6atient is unale to ear weight immediately or when eamined. Age %% yrs or older o 9solated 6atella tenderness o o 4enderness of the head of the =iula o 9naility to =le the knee to @0 degrees 9naility to ear weight for # ste6s immediately & in the eamination room. o o *nly a66lies to adult 6atients who have a normal mental status5 who donBt have other 6ainful inEuries5 & who are seen w:in 80 days of their inEury. 4he management of ankle s6rains should follow the mnemonic G<)9C(H –
Anterior drawer1 eaminer 6ulls forward on 6atientBs heel while stailiJing lower leg w: other hand. 4ests anterior talo=iular ligament. 9nversion stress test1 eaminer inverts ankle w: one hand while stailiJing lower leg w: other hand. Calcaneo=iular ligament. SIueeJe test1 eaminer com6resses tiia:=iula at midcalf. 4ests for syndesmosis. Lachman test1 knee in 20 degree =leion5 eaminer 6ulls forward on u66er tiia while stailiJing u66er leg. 4ests anterior cruciate ligament. Anterior drawer1 knee in @0 degree =leion5 eaminer 6ulls forward on u66er tiia while stailiJing u66er leg. 4ests anterior cruciate ligament. algus stress1 in full etension & at 70 degree =leion5 medialDdirected force on knee5 lateralDdirected force on ankle. 4ests medial collateral ligament.
arus stress1 in full etension & at 70 degree =leion5 lateralDdirected force on knee & medialDdirected force on ankle. 4ests lateral collateral ligament.
Case 3 – ,in )esions: 4he role of the 6hysician is to determine the likelihood of malignancy or 6remalignancy & to de=ine a course of action that is a66ro6riate. 4he single most im6ortant risk factor for the develo6ment of skin cancer is e6osure to ultraviolet radiation. *ther factors include a 6rior history of skin cancer5 a family history of skin cancer5 fair skin5 red or londe hair5 a 6ro6ensity to urn easily5 chronic e6osure to toic com6ounds & a su66ressed immune system. A su6er=icial s6reading melanoma is the most common ty6e of melanoma in oth sees. Lentigo maligna is most often found in the elderly5 usually on chronic sunDdamaged skin. Although this is the least common of the # ty6es of melanoma5 it is the most common form of melanoma found in ;awaii. Acral lentiginous melanoma is the most common melanoma found in African Americans & Asians. 4his melanoma is usually found under the nails5 the soles of the feet5 & on the 6alms of the hands. 'odular melanoma is usually invasive at the time of diagnosis & is the most aggressive ty6e of melanoma. Com6lete ecision of malignant melanomas reIuires at least a %Dmm margin.
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4he single most im6ortant 6iece of information for 6rognosis in melanoma is the thickness of the tumor5 known as the !reslow measurement. elanomas les s than 8Dmm thick have a low rate of metastasis & a high cure rate w: ecision.
!asal cell carcinomas are the most common of all cancers. 4hey ty6ically a66ear as 6early 6laIues5 often w: a central ulceration or w: multi6le telangiectasias. SIuamous cell carcinomas have a higher rate of metastasis than asal cell carcinomas5 ut the risk is low. 4hey are freIuently scaly5 ulcerated & leed easily.
Case < – +llergic (isorders: -
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Allergic rhinitis1 in=lammation of the nasal 6assages caused y allergic rn to airorne sustances. o )hinitis is in=lammation of the nasal memranes & is characteriJed y any comination of the following1 sneeJing5 nasal congestion5 nasal itching5 & rhinorrhea. Ana6hylais1 ra6idly 6rogressing5 lifeDthreatening allergic rn5 mediated y 9g( immediate hy6ersensitivity rn.
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Common =indings on eamination include Gallergic shiners5H which are dark circles around the eyes related to vasodilation or nasal congestion. 4he Gnasal creaseH can e seen in some cases. 9t is a horiJontal crease across the lower half of the ridge of the nose caused y re6eated u6ward ruing of the ti6 of the nose y the 6alm of the hand
/Gallergic saluteH.
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(am of the nose may reveal mucosa of the nasal turinates to e swollen /oggy & have a 6ale5 luishDgray color.
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o 4hin & watery secretions are freIuently associated w: allergic rhinitis5 whereas thick & 6urulent secretions are usually associated w: sinusitis. ,ennieDorgan lines /6rominent creases elow the inferior eyelid are associated w: allergic rhinitis.
GColestoningH of the 6osterior 6haryn is often oserved. 4his is caused y the 6resence of streaks of lym6hoid tissue on the 6osterior 6haryn. 4onsillar hy6ertro6hy can also e seen. 4he management of allergic rhinitis consists of 7 maEor categories of treatment1 allergen avoidance5 6harmacologic management5 & immunothera6y.
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6roduction of in=lammatory mediators & the recruitment of in=lammatory cells. Side effects include noseleeds5 6haryngitis5 & u66er res6iratory tract infections. o Leukotriene inhiitors are indicated for oth allergic rhinitis & for maintenance thera6y for 6ersistent asthma. o *ral corticosteroids are 6otent inhiitors of cellDmediated immunity. 4he use of systemic steroids is limited y adverse effects5 including su66ression of the hy6othalamicD6ituitaryDadrenal ais & hy6erglycemia. o ,esensitiJation thera6y is freIuently attem6ted in 6atients who remain sym6tomatic des6ite maimal medical thera6y. Krticaria is characteriJed y large5 irregularly sha6ed5 6ruritic5 erythematous wheals. Angioedema is 6ainless5 dee65 sucutaneous swelling that often involves the 6eriorital5 circumoral5 & facial regions.
Ana6hylais is a systemic reaction w: cutaneous sym6toms that is associated w: dys6nea5 visceral edema5 & hy6otension. st o At the 8 sus6icion of ana6hylais5 aIueous e6ine6hrine 8180005 in a dose of 0.2 to 0.% mL /0.2D0.% mg is inEected sucutaneously or intramuscularl. o All 6atients w: ana6hylais should e monitored for a 6eriod of time. Asthma is a chronic disease characteriJed y airway hy6erres6onsiveness. 4here are recurrent muscle s6asms of the ronchi & ronchioles. Status asthmaticus is an ostruction that lasts for days or weeks & is refractory to treatment. -
o o
4he ra6id acting !2Dadrenergic agonist aluterol is the mainstay treatment for acute sym6tomatic relief in asthma. 9t works to ra6idly rela ronchial smooth muscle. 9t also reduces the release of mast cell mediators & increases mucociliary clearance. LongDacting !2Dadrenergic agonists have the same mechanism of action5 ut are not used for acute ronchos6asm. 4hey are effective at reducing the freIuency of eaceration in 6ersistent asthma. 4he 6rimary treatment of 6ersistent asthma is the daily use of inhaled corticosteroids5 which reduce the 6roduction of in=lammatory mediators & reduce vascular 6ermeaility. 4hey do not have the effect on smooth muscle relaation & should not e used for an acute eaceration. Leukotriene inhiitors5 which either reduce the 6roduction of these in=lammatory mediators /Jileuton or com6etitively antagoniJe their rece6tors /Ja=irlukast5 montelukast5 are also effective in the 6revention of eaceration in 6ersistent asthma. Systemic corticosteroids are used in the treatment of acute eaceration & for 6ro6hylais in severe 6ersistent asthma. ConEunctivitis is an infection of the 6al6eral &:or ular conEunctiva. 94 is the most common eye disease seen in community medicine. o 4he organisms isolated most commonly in acterial conEunctivitis are Staphylococcus, Streptococcus, Haemophilus, Moraxella, & Pseudomonas. ,isease is usually selfDlimited5 lasting aout 80D8# dys if untreated. Sulfonamide instilled locally 7 times daily will usually clear the infection in 2D7 dys. (6idemic keratoconEunctivitis /6ink eye is highly contagious & will s6read y 6ersonDtoD6erson contact or fomites. 4he most common cause is adenovirus. Ksually associated w: 6haryngitis5 fever5 malaise5 & 6reauricular lym6hadeno6athy. Locally5 the 6al6eral conEunctiva is red w: a co6ious watery discharge & scanty eudates. ontelukast is indicated for oth the management of 6ersistent asthma & chronic allergies. 'asal steroids & oral antihistamines are only indicated for allergies.
.Case – +cute (iarr#ea: ost immediate 6rolem is volume de6letion5 the 6riority is to re6lace the lost intravascular volume5 usually w: intravenous normal saline. (lectrolytes & renal fn should evaluated & anormalities corrected. K6 to @0? of acute diarrhea is infectious in etiology. -
4he 6resence of lood in the stool would suggest an invasive acterial infection5 such as hemorrhagic or enteroinvasive E.coli s6ecies5 Yersinia s6ecies5 Shigella5 & Entamoeba histolytica . (amination of stool for leukocytes is a sim6le5 ine6ensive test that hel6s to differentiate :w the ty6es of infectious diarrhea. Acute diarrhea1 diarrhea 6resent for P 2 week duration. -
Chronic diarrhea1 diarrhea 6resent for > # weeks.
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,iarrhea1 6assage of anormally liIuid or 6oorly formed stool in increased freIuency.
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Suacute diarrhea1 diarrhea 6resent for 2D# week duration.
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Consum6tion of food is a common cul6rit1 Salmonella or Shigella can e found in undercooked chicken. o o (nterohemorrhagic E. coli from undercooked hamurger. Staphylococcus aureus or Salmonella from mayonnaise. o o )aw seafood may haror ibrio, Salmonella, or ;e6atitis A. 9llness w:in " hrs of eating a salad containing mayonnaise suggests S. aureus5 w:in D82 hrs suggests !lostridium per"ringens5 & within 82D8# hrs suggests E.coli.
ost 6atients w: acute diarrhea have selfDlimited 6rocesses & do not reIuire much worku6. (ce6tions to this rule include 6rofuse diarrhea5 dehydration5 fever eceeding 800.# /7.0 degrees5 loody diarrhea5 severe adominal 6ain5 duration of diarrhea for more than # hrs5 & children5 elderly & immunocom6romised 6atients. 4he 6atient who is oth vomiting & having diarrhea is more 6rone to dehydration & more likely to need hos6ital admission for 9 hydration. Although classically associated w: Clindamycin5 any antiiotic can cause 6seudomemranous colitis. -
;and washing is a sim6le & effective way to 6revent the s6read of viral diarrhea.
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4he est method for 6reventing travelerBs diarrhea is to avoid contaminated food & water. o -hen antiiotics are indicated5 thera6y w: a Iuinolone antiiotic should e started as soon as 6ossile after the diarrhea egins. ost commonly ci6ro=loacin /%00 mg twice daily is given for 8D2 days. o AJithromycin given in a single 8000 mg dose for adults of 80 mg:kg daily for 7 days in children is another effective treatment.
Case 03 – )ower .astrointestinal Bleeding: -
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;ematocheJia1 right red lood visile in the stool. o Ksually 6athognomonic of lower F9 leeding5 ut can also e found in 6atients w: heavy u66er F9 leeding. Lower F9 leeding1 leeding that comes from a source distal to the ligament of 4reitJ. 4he manifestations of F9 leeding de6end on the source5 rate of leeding5 & underlying or coeisting disease.
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4he test of choice for the determination of the source of lower F9 leeding is colonosco6y. AdeIuate owel 6re6 w: an oral sulfate 6urge to clear the owel of lood5 clots5 & stool increases the yield in diagnosing colonic leeding sites.
;emorrhoids are dilated veins in the hemorrhoidal 6leus of the anus. 4hey are de=ined as GinternalH if they arise aove the dentate line & GeternalH if they arise elow the dentate line oth can e the cause of hematocheJia. o Chronic consti6ation5 straining for owel movements5 6regnancy5 & 6rolonged sitting are risk factors. o Conservative treatment w: a highD=ier diet5 stool softeners5 & 6recautions against 6rolonged straining are usually successful. ,iverticula are out6ouchings of the colonic mucosa through weakened areas of the colon wall. 4hey occur most often where lood vessels 6enetrate through the muscles of the colon. 4hey are most often asym6tomatic & found on endosco6y or owel imaging studies. o Asym6tomatic diverticulosis is managed w: dietary modi=ication5 6rimarily a highD=ier diet. ,iverticulitis is a 6ainful in=lammation & infection of a diverticulum. ,iverticulitis freIuently causes left lower Iuadrant adominal 6ain along w: fever5 nausea5 diarrhea5 & consti6ation. o
o
o ;y6er6lastic 6oly6s tend to e small5 smooth growths found incidentally during endosco6y & are of no 6rognostic signi=icance. Adenomatous 6oly6s are enign growths that have a 6otential to ecome malignant. o illous adenomas > tuulovillous > adenomatous 6oly6s /most to least likely to ecome malignant. o Larger 6oly6s have a higher risk of causing leeding & ecoming malignant than smaller 6oly6s. Any 6atient older than age %0 yrs who has lower F9 leeding must e evaluated for the 6resence of colon
cancer. 4he ,ukes System stages colon cancer from A to ,5 de6ending on the 6enetration through the owel wall layer5 the 6resence of lym6h node s6read5 & distant metastases. o ,ukes A colon cancer has an ecellent 6rognosis w: surgical resection ,ukes , cancer is usually not curale & is treated w: cominations of surgery5 chemothera6y5 & radiation.
Case – -rrita$le Bowel ,yndrome: 9rritale owel syndrome /9!S1 this is a functional F9 disorder characteriJed y chronic adominal 6ain & altered owel haits. Lui6rostone /AmitiJa1 6harmacologic agent that selectively activates intestinal chloride channels & increases =luid secretion is 3,A a66roved for 9!S in women w: consti6ation5 ut has a side effect of nausea in a signi=icant 6ercentage of 6atients. nd rd 9!S affects women 2 – 7 times more often than men & 6ts ty6ically 6resent in the 2 or 7 decades of life5 although virtually any age grou6 can e affected.
Case < – 9aundice: -
ost cases of Eaundice can e characteriJed as having 6rehe6atic5 he6atic5 or 6osthe6atic causes. o
Ca6ut medusa1 dilated su6er=icial 6eriumilical veins that usually result from shunting associated w: severe 6ortal ;4'. S6ider veins1 ,ilated5 small5 su6er=icial veins that a66ear as red5 lue5 or 6ur6le weDlike formations5 most often seen on the legs & face. 9tching is a common sym6tom in Eaundice & may 6recede the onset of yellow color. -
Associated sym6toms5 such as unintended weight loss or the develo6ment of adeno6athy may lead to the consideration of certain diagnoses5 including malignancies. !ruising or leeding disorders may suggest severe he6atic dysfn that is interfering w: the 6roduction of clotting factors. 9ncreasing adominal girth may e caused y ascities 6eri6heral edema y ostruction of venous return from the lower etremities or hy6oaluminemia. & Qaundice may =irst e noticed as a yellowing of the sclera5 es6ecially in 6ersons w: darker skin ty6es. Nellow discoloration can also commonly e seen under the tongue. 4he re6orted direct iliruin is a measurement of the conEugated iliruin level. ConEugated iliruin is ecreted in urine5 whereas unconEugated iliruin is not. A mild unconEugated hy6eriliruinemia5 usually identi=ied as incidental =ining when liver enJymes are tested5 is often caused y Filert syndrome. ;emolysis can cause an unconEugated hy6eriliruinemia in 6ro6ortion to the amt of hemolysis that occurs. 9t is most often diagnosed y identi=ication of anemia along w: the 6resence of red cell fragments or anormalities. 4he management is to treat the cause of the hemolysis. ;e6atitis A is a viral infection of the liver 6rimarily transmitted via fecalDoral contamination & accts for 70? of acute viral he6atitis in the K.S. Contaminated food & water are the 6rimary sources of infection5 although risks also include drug use5 maleDmale seual contact5 & working in a daycare setting. o ;e6atitis A causes a selfDlimited illness characteriJed y Eaundice5 fever5 malaise5 & adominal discomfort. 4he incuation 6eriod is 2 – wks & transmission is 6ossile for 2 to 7 weeks after sym6toms egin. Su66ortive care & sym6tomatic treatments. o ;e6atitis ! has infected 2 illion 6eo6le worldwide & there are 7%0 million chronic carriers. 9t is a viral infection transmitted via contact w: contaminated lood or ody =luids. Seual contact & needle sharing are common mechanisms of infection. 4he incuation 6eriod is " weeks to " months. o o Chronic he6atitis ! is highly related to the age of the 6atient5 which can lead to cirrhosis & he6atocellular carcinoma. ;e6atitis ! causes u6 to 0? he6atocellular carcinoma. o o Acute he6atitis ! infection is treated su66ortively.
Case 1 – (ys!e!sia ' Pe!tic "lcer (isease: -
,ys6e6sia is de=ined as chronic or recurrent u66er adominal 6ain or discomfort.
-eight loss o
(arly diagnostic endosco6y should e considered for 6atients who have newDonset dys6e6sia who are older than age %% yrs or who have sym6toms that may e associated w: u66er F9 malignancy. ;2Dlocerk1 class of medications that are com6etitive antagonists of histamine inding to gastric 6arietal ;2 rece6tors5 which 6revents activation of the 6athway that mediates release of acid into the gastric lumen.
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;elicoacter 6ylori s a corkscrewDsha6ed gramDnegative acillus that is the causative agent of most nonD 'SA9,Drelated ulcers. ;. 6ylori is also associated w: the develo6ment of gastric cancer. 4he 6resence of the organism is associated w: a % to $ times increased risk of develo6ment of
H=M+T%)%.2 Case – Hematuria: 4he u66er tract can e imaged y either an intravenous 6yelogram /9< or com6uted tomogra6hy /C4 scan. 4he lower tract is most commonly evaluated y cystosco6y5 an endosco6ic 6rocedure. 9ncidence of cancer 6resenting as asym6tomatic microsco6ic hematuria is low. -
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;ematuria is divided into glomerular5 renal /nonglomerular & urologic etiologies. o
Flomerular hematuria is associated w: signi=icant 6roteinuria5 erythrocyte casts5 & dysmor6hic )!Cs. o )enal /nonglomerular hematuria is secondary to tuulointerstitial5 renovascular5 & metaolic disorders. Ksually associated w: signi=icant 6roteinuria no dysmor6hic )!Cs or erythrocyte casts. o Krologic causes of hematuria include tumors5 calculi5 infections5 trauma5 & !<;. Asence of 6roteinuria5 dysmor6hic )!Cs5 & erythrocyte casts.
4he initial =inding of hematuria y the di6stick method should e con=irmed y microsco6ic evaluation of urinary sediment. 4he limited s6eci=icity is due to the fact that urine di6stick lacks the aility to distinguish red lood cells from myogloin or hemogloin. (valuation of urinary sediment can allow for the diagnosis of renal 6arenchymal disease. 9t will allow for distinction :w glomerular disease & interstitial ne6hritis. Flomerular disease will often have red cell casts & dysmor6hic )!Cs interstitial ne6hritis will have eosino6hils. & 9f hematuria resolves w: treatment of the K495 no further worku6 is needed. 4he C4 scan should e initially 6erformed as a noncontrast study to detect calculi5 & then a contrast study should e otained.
=N(%C*-N= Case 5 – T#yroid (isorders: 4he most common cause of noniatrogenic hy6erthyroidism is Fraves disease5 an autoimmune thyroid disorder. Autoantiodies to the 4S; rece6tors on the thyroid gland result in hy6erfuncitoning of the gland5 w: the result that the thyroid gland functions outside the usual control of the hy6othalamicD6ituitary ais. o Sym6tomatic treatment include antithryoid drugs /6ro6ylthiouracil & methimaJole &:or etaDlockers to lock some of the 6eri6heral effects of the ecessive thyroine. 17
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4he de=initive treatment is radioactive iodine5 which destroys the thyroid gland. At least #0? of 6atients who receive radioactive iodine eventually ecome hy6othyroid. Surgical removal of the thyroid gland is another o6tion for the treatment of Fraves disease5 ut is often o reserved for 6regnant 6atients. Fraves disease1 an autoimmune thyroid disorder in which autoantiodies to the 4S; rece6tors on the thyroid gland result in hy6erfunctioning of the thyroid gland. A 6rominent =inding is also the GstareH due to the o6hthalmic involvement. A66roimately %0? of 6atients w: Fraves disease also have eo6hthalmos. o o
4hyroid storm1 an acute hy6ermetaolic state associated w: the sudden release of large amounts of thyroid hormone into circulation5 leading to autonomic instaility & central nervous system dysfunction such as altered mental status5 coma5 or seiJures. 4his condition has a signi=icant mortality risk. 4hyroid storm is a medical emergency that reIuires 6rom6t attention & reversal of the metaolic demands of the acute hy6erthyroidism. )adionucleotide imaging 6rovides a direct scan of the gland & an indication of its functioning. 9maging is 6erformed using either an isoto6e of technetiumD@@ m or iodineD827. 9n 6atients w: Fraves disease there will e diffuse hy6eractivity w: large amounts of u6take. o o 4hyroiditis demonstrates 6atchy u6take w: overall reduced activity5 re=lecting the release of eisting hormone rather than the over6roduction of new thyroine. Antithyroid drugs are es6ecially useful in treating adolescents5 in whom Fraves disease may go into s6ontaneous remission after "D8 months of thera6y. 9n older 6atients5 hy6othyroidism can e confused w: AlJheimer disease & other conditions that cause dementia.
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'onfunctioning nodules measuring greater than 8 cm y eamination or ultrasonogra6hy reIuire io6sy.
Kltrasound =indings suggestive of malignancy include irregular margins5 intranodular vascular s6ots5 & microcalci=ications. 3ollicular cell malignancy cannot e distinguished cytologically from its enign eIuivalent. o o
Case 1 – Calcium (isorders: ;y6er6arathyroidism1 condition of elevated 6arathyroid hormone usually due to ecessive 6roduction y the 6arathyroid glands5 leading to hy6ercalcemia. Secondary hy6er6arathyroidism1 condition as the 6arathyroid glands over6roduce <4; to res6ond to low serum calcium levels. 4his may occur as a res6onse to low dietary calcium intake or a de=iciency of vitamin ,. 4ertiary hy6er6arathyroidism1 elevated <4; in 6atients who have renal failure. GCorrectedH serum calcium V /'ormal alumin W /
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4he most common cause of hy6ercalcemia in the amulatory 6atient is hy6er6arathyroidism. Cancer ranks nd as the 2 leading cause5 as hy6ercalcemia is often an early manifestation of malignancy.
;y6ercalcemia can lead to Gstones5 ones5 6sychic groans5 & adominal moansH. *ther clinical manifestations include shortening R4 interval & arrhythmias. 4he vast maEority of 6rimary hy6er6arathyroidism is caused y an adenoma /enign tumor of one of the # 6arathryoid glands. 4he treatment of hy6ercalcemia is directed at the underlying disorder. -
RENAL
Case 0 – C#ronic 7idney (isease: A signi=icant reduction in urination reIuires immediate evaluation of creatinine fn & volume status. olume status is assessed y skin turgor5 mucous memranes5 s6eci=ic gravity in the urinalysis5 & orthostatic !<. A common offender for acute eaceration of chronic kidney disease is an uncontrolled diaetic with ;4' who is taking 'SA9,s. @0 mL:min o o o
Stage 2 C+, V "0 – @ mL:min Stage 7 C+, V 70 – %@ mL:min Stage # C+, V 8% – 2@ mL:min
Stage % C+, V P 8% mL:min or on dialysis. 4he eval in all 6ts w: C+, includes renal imaging & microsco6ic eval of urine. 4reatment is more successful in 6ts w: normalDsiJed kidneys. Small kidneys show irreversile disease & asymmetry suggest renovascular disease. A urine is considered 6ositive if there is more than 70 mg of microalumin 6er gram Cr. 9t is recommended in the case of less than 200 mg of 6rotein 6er gram Cr that the test e re6eated yearly. ,rugs such as 'SA9,s5 aminoglycosides at full strength & radiogra6hic contrast material can affect kidney fn. o
Foals of treatment include a lood 6ressure less than 870:0 mm ;g & a reduction of 6rotein ecretion to less than %00 to 8000 mg:d. o ,ietary 6rotein restrictions of 0. to 8.0 mg:kg:d may e ene=icial. ;y6erli6idemia should e treated w: a goal lowDdensity li6o6rotein /L,L of less than 800 mg:dL5 & some say the goal should e less than $0 mg:dL :c C)3 is a cardiovascular eIuivalent. -hen the F3) is elow 2% – 70 mL:min5 oral 6hos6hate inders are usually reIuired. Caution is used when treating hy6er6hos6hatemia in stages 7 – % C+,. 9t is recommended that 6ts w: a creatinine more than 8.2 mg:dL in women & more than 8.% mg:dL in men e referred to ne6hrology.
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