I Gotta Go!
Urine dipstick in clinic shows 3+ protein. What is your next step?
Quantitative testing with urine albumin/creatinine
Basics: What is the definition of diarrhea?
Three or more loose or watery stools in 24 hours
True or False:
Consumption of eggs leads to increased cardiovascular events.
False!
"This systematic review included 23 observational studies with nearly 1.4 million patients. Eating more eggs was not shown to increase the risk of cardiovascular events. In fact, compared with eating one or no eggs per day, those eating more than one egg per day had a decreased risk of coronary disease (hazard ratio = 0.89; 95% CI, 0.86 to 0.93)."
Females that engage in this type of athletic activity have 3 times the likelihood of concussion.
Contact sports (football, soccer, basketball, hockey)
Due to having decreased head and neck strength and increased peak angular head acceleration, females are at increased risk compared to males
The best initial lab evaluation option for suspected pancreatitis.
Serum lipase
Amylase normalizes more quickly than lipase
The optimal treatment and surveillance measure for a patient diagnosed with Celiac disease
Gluten free diet w/symptom based monitoring (Grade B)
Repeat serologic testing at 3-6 mo
Decrease in baseline serologic values = adherence to gluten free diet
Repeat EGD/biopsy if symptoms still persist
Which component of urinalysis has the highest specificity for detecting UTI?
Nitrites
Notes:
1. A few bacteria such as Enterococcus do not produce nitrites, leading to false-negative results.
2. Bacteria need four hours in the bladder to produce nitrites; therefore, false-negative results are common with frequent urination, including in infants
What are two pieces of history that would prompt you to test for C. diff?
1. Recently hospitalized for more than three days
2. Used antibiotics within the last 12 weeks
What is the first-line therapy for chronic constipation (there are two)?
Senna and miralax
There is moderate evidence for the effectiveness of the other meds!
a 17 year old soccer player reports she has not yet had her menses. She would screen positive on a screening questionnaire for this syndrome associated with decrease bone strength, increased injury, and delayed among other problems.
Relative energy deficiency in sport (RED-S)
The RED-S Assessment model groups common findings into three risk categories that guide management. RED-S is a diagnosis of exclusion
[ Daily Double ]
These 3 criteria, named after the home of the Falcons, are used to diagnose acute pancreatitis
1) upper abdominal pain
2) serum amylase or lipase > 3x ULN
3) characteristic imaging
This evaluation should be used to confirm the diagnosis of celiac in most patients
EGD (Grade C recommendation)
What is the best way to confirm dipstick testing that is positive for blood?
Microscopic analysis
You're taking care of a patient with watery diarrhea and would like to prescribe some medications to help relieve their symptoms. What would you pick?
Loperamide and simethicone
Notes: A loperamide and simethicone combination has demonstrated faster and more complete relief of acute watery diarrhea and gas-related abdominal discomfort compared with either medication alone
Additonally:
Your OB continuity patient has iron deficiency anemia, so you prescribe her an iron supplement. Would you also recommend having her take Vitamin C?
Maybe not!
"Clinicians have long recommended that people taking iron supplements also take vitamin C because it theoretically improves absorption. A study tested the theory by randomizing 440 adults with iron deficiency anemia to ferrous succinate, 100 mg, plus vitamin C, 200 mg, or to ferrous succinate alone, each given every eight hours. There was no difference in hemoglobin or serum ferritin levels at three months."
A female runner has anterior knee pain worsened by squatting and prolonged sitting. What two muscle group exercises are most likely to provide long term symptom relief?
Posterior hip and Quadriceps
This pt has patellofemoral syndrome. PT focused on both of these groups is more effective than quadriceps ex. alone. Patellar taping, bracing, and foot orthotics offer short term improvement only.
This imaging study is recommended when there is concern for acute biliary pancreatitis and the CBD appears normal or is not visualized on US.
MRCP
> 90% sensitivity for CBD stones >=6mm
(compared to 50-80% for RUQ US)
Though this test has a > 99% negative predictive value for celiac disease, it's routine use for evaluation is discouraged unless other findings are inconclusive or the patient can't participate in a gluten trial
Testing for HLA alleles DQ2 and DQ8 (Grade C)
If you're seeing glucosuria on a urine dipstick, at least how high can you estimate the plasma glucose concentration to be?
180 to 200 mg per dL
Notes:
1. Remember that SGLT-2 inhibitors cause this
2. If there's not elevated plasma glucose or SGLT-2i use, consider Fanconi syndrome (when was the last time anyone thought about this?! Disorder of the proximal tubule leading to electrolyte abnormalities)
Discuss the empiric antibiotics you could use to treat traveler's diarrhea.
Your next patient's chief complaint is low back pain (eek!). Your patient is interested in medications and also in non-pharmacological treatment. Name at least 3 things you could recommend.
1. Exercise
2. Duloxetine
3. Tylenol + ibuprofen together are safer and as effective as opioids for acute pain relief
4. Yoga, massage, mindfulness-based stress reduction
ACL tears
Female risk factors: smaller ACL, increased ligament laxity, hip and knee alignment, increase quad-hamstrings activation with landing
A 2018 systematic review and meta analysis found that patients who received this therapy had significantly lower odds of SIRS at 24 hours and lower odds of mortality (not statistically significant)
Lactated ringers (compared to NS)
Guidelines suggest goal directed resuscitation starting at 5-10 cc/kg/hr
OR for mortality 0.61 (CR 0.28-1.29)
Not recommend in patients with hypercalcemia
Goals: HR < 120, MAP 65-85, UOP 0.5-1cc/kg/hr, Hct 35-44%
*higher rates of fluid resuscitation is associated with higher rates of AKI and respiratory failure*
a 32 year old male presents with diarrhea and bloating after starting a low fat and whole grain diet. What is the recommended first diagnostic step?
IgA tTG serologic testing ( Grade C)
Suggested first line test in all ages
Your patient comes in with complaints of dysuria and urinary frequency. Urine dipstick shows 5 bacteria per HPF. What can you estimate from this?
Infection. It is likely that colony counts of 100,000 will be found on urine culture!
When should you obtain stool studies in a patient? The article listed 6, give me 4!
1. Acute bloody diarrhea
2. Fever
3. Severe abdominal pain
4. Signs of sepsis
5. Duration of seven days or greater
6. Patients with occupational or residential risk factors for an outbreak
SGLT-2s and GLP-1s are becoming popular medications to treat diabetes. Name three specific benefits of these medications. Think large-scale here.
Both classes of drugs reduced:
1. all-cause mortality
2. cardiovascular mortality
3. nonfatal myocardial infarction
4. kidney failure
5. reducing hospital admission (SGLT-2s)
"The absolute benefit of treatment increased with a patient’s cardiac risk. For example, over five years, there were 2 to 5 fewer deaths per 1,000 patients at low cardiac risk compared with 24 to 48 fewer deaths per 1,000 patients at the highest risk. A useful calculator that allows estimates of benefit at various risk levels is available at https://magicevidence.org/match-it/200820dist."
New research suggests that this method of recovery for concussion is safe and perhaps more effective than traditional management.
Active rest for 24-48 hr of symptom limited cognitive rest followed symptom limited increase in activity
All students should be integrated in school before returning to sports. Most symptoms resolve spontaneously, usually within 2 weeks.
For mild acute biliary pancreatitis, this intervention decreases length of hospitalization and readmission when completed on initial admission
Cholecystectomy
No difference in surgical complications vs delayed cholecystectomy
Children with these 2 lab findings may get to avoid a diagnostic EGD biopsy
1) High IgA tTG (> 10x ULN)
2) Positive IgA endomysial ab test in a second serum sample
Grade C recommendation