Treatment for idiopathic inflammatory myopathies

First line:

Corticosteroid

PT/OT

Second line:

MTX

Azathioprine

IVIG

cyclophosphamide

cyclosporine

6-MP

IBM poorly responds to immunosuppressive agents

Treatment of SLE

First line treatment:

Hydroxychloroquine

Mild SLE: low dose steroid

Aggressive SLE: moderate dose steroid

Severe SLE: high dose steroid, combine with either cyclophosphamide, mycophenolate mofetil, or azathioprine

Hydroxychloroquine: continue indefinitely

Switch from cyclophosphamide to mycophenolate mofetil, or azathioprine in 3 to 6 mo

Impingement syndrome

Impingement syndrome is a special category of supraspinatus tendinitis caused by irritation of the subacromial bursa or rotator cuff tendon from mechanical impingement between the humeral head and the coracoacromial arch, which includes the acromion, coracoacromial ligament, and the coracoid process. Chronic overhead activity may contribute to narrowing of this space, which can lead to recurrent microtrauma and chronic local inflammation of rotator cuff tendons. Pain on the Hawkins test that resolves with injection of lidocaine into the subacromial space helps establish the diagnosis. Initial treatment is similar to rotator cuff tendinitis; however, persistence of symptoms after 3 months, which occurs in 10% to 25% of patients, may warrant an orthopedic referral.

PPT: Hyperkalemia Treatment

Hyperkalemia Treatment

Back Pain from Live Search

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Low back pain
Wikipedia
Back Pain, Spinal Manipulation
National Center for Complementary and Alternative Medicine
Spinal disc herniation
Wikipedia

Back pain
Back pain — Comprehensive overview covers causes, treatment, relief for this potentially disabling condition.
Definition
Back pain is a common complaint. Four out of five people in the United States will experience low back pain at least once during their lives. It's one of the most common reasons people go to the doctor or miss work.
On the bright side, you can prevent most back pain. If prevention fails, simple home treatment and proper body mechanics will often heal your back within a few weeks and keep it functional for the long haul. Surgery is rarely needed to treat back pain.
Causes
Your back is an intricate structure composed of bones, muscles, ligaments, tendons and disks — the cartilage-like pads that act as cushions between the segments of your spine. Back pain can arise from problems with any of these component parts. In some people, no specific cause for their back pain can be found.
StrainsBack pain most often occurs from strained muscles and ligaments, from improper or heavy lifting, or after a sudden awkward movement. Sometimes a muscle spasm can cause back pain.
Structural problemsIn some cases, back pain may be caused by structural problems, such as:
Bulging or ruptured disks. Disks act as cushions between the vertebrae in your spine. Sometimes, the soft material inside a disk may bulge out of place or rupture and press on a nerve. But many people who have bulging or herniated disks experience no pain from the condition.
Sciatica. If a bulging or herniated disk presses on the main nerve that travels down your leg, it can cause sciatica — sharp, shooting pain through the buttock and back of the leg.
Arthritis. The joints most commonly affected by osteoarthritis are the hips, hands, knees and lower back. In some cases arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
Skeletal irregularities. Back pain can occur if your spine curves in an abnormal way. If the natural curves in your spine become exaggerated, your upper back may look abnormally rounded or your lower back may arch excessively. Scoliosis, a condition in which your spine curves to the side, also may lead to back pain.
Osteoporosis. Compression fractures of your spine's vertebrae can occur if your bones become porous and brittle.
Rare but serious conditionsIn rare cases, back pain may be related to:
Cauda equina syndrome. This is a serious neurological problem affecting a bundle of nerve roots that serve your lower back and legs. It can cause weakness in the legs, numbness in the "saddle" or groin area, and loss of bowel or bladder control.
Cancer in the spine. A tumor on the spine can press on a nerve, causing back pain.
Infection of the spine. If a fever and a tender, warm area accompany back pain, the cause could be an infection.
Risk factors
Factors that increase your risk of developing low back pain include:
Smoking
Obesity
Older age
Female gender
Physically strenuous work
Sedentary work
Stressful job
Anxiety
Depression
When to seek medical advice
Most back pain gradually improves with home treatment and self-care. Although the pain may take several weeks to disappear completely, you should notice some improvement within the first 72 hours of self-care. If not, see your doctor.
In rare cases, back pain can signal a serious medical problem. See a doctor immediately if your back pain:
Is constant or intense, especially at night or when you lie down
Spreads down one or both legs, especially if the pain extends below the knee
Causes weakness, numbness or tingling in one or both legs
Causes new bowel or bladder problems
Is associated with pain or pulsation (throbbing) in the abdomen, or fever
Follows a fall, blow to your back or other injury
Is accompanied by unexplained weight loss
Also, see your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or drug or alcohol abuse.
Tests and diagnosis
Diagnostic tests aren't usually necessary to confirm the cause of your back pain. However, if you do see your doctor for back pain, he or she will examine your back and assess your ability to sit, stand, walk and lift your legs. He or she may also test your reflexes with a rubber reflex hammer. These assessments help determine where the pain comes from, how much you can move before pain forces you to stop and whether you have muscle spasms. They will also help rule out more serious causes of back pain.
If there is reason to suspect that you have a tumor, fracture, infection or other specific condition that may be causing your back pain, your doctor may order one or more tests:
X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. X-ray images won't directly show problems with your spinal cord, muscles, nerves or disks.
Magnetic resonance imaging (MRI) or computerized tomography (CT) scans. These scans can generate images that may reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels.
Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis. In this procedure, you'll receive an injection of a small amount of a radioactive substance (tracer) into one of your veins. The substance collects in your bones and allows your doctor to detect bone problems using a special camera.
Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. Studies of your nerve-conduction pathways can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).
Treatments and drugs
Most back pain gets better with a few weeks of home treatment and careful attention. A regular schedule of over-the-counter pain relievers may be all that you need to improve your pain. A short period of bed rest is okay, but more than a couple of days actually does more harm than good. If home treatments aren't working, your doctor may suggest stronger medications or other therapy.
MedicationsYour doctor may prescribe nonsteroidal anti-inflammatory drugs or in some cases, a muscle relaxant, to relieve mild to moderate back pain that doesn't get better with over-the-counter pain relievers. Narcotics, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.
Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve chronic back pain, independent of their effect on depression.
Physical therapy and exerciseA physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques will help prevent pain from coming back.
InjectionsIf other measures don't relieve your pain and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than six weeks.
In some cases, your doctor may inject numbing medication into or near the structures believed to be causing your back pain. Early studies indicate that botulism toxin (Botox) also may help relieve back pain, perhaps by paralyzing strained muscles in spasm. Botox injections typically wear off within three to four months.
SurgeryFew people ever need surgery for back pain. There are no effective surgical techniques for muscle- and soft-tissue-related back pain. Surgery is usually reserved for pain caused by a herniated disk. If you have unrelenting pain or progressive muscle weakness caused by nerve compression, you may benefit from surgery. Types of back surgery include:
Fusion. This surgery involves joining two vertebrae to eliminate painful movement. A bone graft is inserted between the two vertebrae, which may then be splinted together with metal plates, screws or cages. A drawback to the procedure is that it increases the chances of arthritis developing in adjoining vertebrae.
Disk replacement. An alternative to fusion, this surgery inserts an artificial disk as a replacement cushion between two vertebrae.
Partial removal of disk. If disk material is pressing or squeezing a nerve, your doctor may be able to remove just the portion of the disk that's causing the problem.
Partial removal of a vertebra. If your spine has developed bony growths that are pinching your spinal cord or nerves, surgeons can remove a small section of the offending vertebra, to open up the passage.
Prevention
You may be able to avoid back pain by improving your physical condition and learning and practicing proper body mechanics.
To keep your back healthy and strong:
Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.
Build muscle strength and flexibility. Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels.
Quit smoking. Smokers have diminished oxygen levels in their spinal tissues, which can hinder the healing process.
Maintain a healthy weight. Being overweight puts strain on your back muscles. If you're overweight, trimming down can prevent back pain.
Use proper body mechanics:
Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.
Sit smart. Choose a seat with good lower back support, arm rests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.
Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.
Alternative medicine
Many people choose hands-on therapies to ease their back pain:
Chiropractic care. Back pain is one of the most common reasons that people see a chiropractor. If you're considering chiropractic care, talk to your doctor about the most appropriate specialist for your type of problem. In addition to chiropractors, many osteopathic doctors and some physical therapists have training in spinal manipulation.
Acupuncture. Some people with low back pain report that acupuncture helps relieve their symptoms. The National Institutes of Health has found that acupuncture can be an effective treatment for some types of chronic pain. In acupuncture, the practitioner inserts sterilized stainless steel needles into the skin at specific points on the body.
Massage. If your back pain is caused by tense or overworked muscles, massage therapy may help loosen knotted muscles and promote relaxation.

Links for Lower Back Pain

http://emedicine.medscape.com/article/310353-overview

http://www.emedicinehealth.com/back_pain/article_em.htm

Antibiotics

1. Semisynthetic penicillinase-resistant penicillins: Oxacillin, cloxacillin, dicloxacillin, nafcillin
when sensitive, better than vancomycin, also treat strep: s. pneumonia, Viridans, group A, B, C, G
MRSA: use vancomycin, or Linezolid, quinupristin/dalfopristin as alternatives

2. Penicillin G, penicillin VK, ampicillin, amoxcillin
strep + E. Coli + listeria + Neisseria

3. Piperacillin, ticarcillin, mezlocillin
Enterobacteriacceae + pseudomonas

4. Ceph for pseudomonas: Only ceftazidime and cefepime

5. Penicillin insensitive pheumococci: cefatriaxone & cefataxime

6. Quinolones for pseudomonas: only ciprofloxacin

7. Exclusive Gram (-): gentamicin, tobramycin, amikacin, aztreonam

8. all: imipenem, meropenem, ertapenem(no pseudomonas)

9. Anaerobes: Metronidazole, clindamycin, carbapenem

Endocarditis

Roth's spot



Splinter Hemorrhage


Osler's node with Janeway Lesion

Rocky Mountain Spotted Fever

Lyme disease

Anemia Algorithm from First Aid

Inflammatory Myopathies

Involve proximal muscles first, fine-motor tasks are involved later.
Ocular muscles are never involved, diff from myasthenia gravis and Eaton-Lambert syndrome

Lab: CPK, aldolase, anti-Jo-1
Electromyograph: short-duration, low-amplitude

steroids for polymyositis and dermatomyotitis


Heliotrope Rash


Gottron's sign





Inclusion body myositis

Vasculitis syndrome

txt for PAN & WG: steroids + cytotoxic agent
Churg-Strauss=PAN+asthma




Do an ESR, if high, give prednisone 60mg/day





treat Kawasaki's with aspirin and intravenous immunoglobulin, glucocorticoids are contraindicated

COGAN'S DISEASE: abrupt onset of nerve deafness, interstitial keratitis, and/or a systemic vasculitis often with aortic aneurysm formation.

TAKAYASU'S PULSELESS DISEASE

RA

T-cell caused disease, mediated by TNF-a, IL-1, IL-6
very rare in HIV

Never involved: 1. DIP, 2. lower back

felty syndrome: RA+splenomegaly+neutropenia

COX-2 inhibitors rofecoxib, valdecoxib increase myocardial infarct and stroke risk, celecoxib does not

Infliximab: sepsis, TB, and other opportunistic infection
Adalimumab: longer half-life
Etanercept: TB

Atlantoaxial subluxation: paraplegia, quadriplegia, neck pain, c2 radicular pain, myelopathy
X-ray for cervical spine

All RA needs X-ray for C1, C2 before intubation or anesthesia

swollen painful calf: ruptured baker cyst

Antiphospholipid syndrome

Increased PTT
false positive RPR, VDRL
spontaneous abortion
Thromboembolism

treat with lmwh + aspirin

ANA

FANA is preferred to diagnose rheumatic diseases

ANA pattern:
diffuse: SLE
centromere: crest
nucleolar: systemic sclerosis

anti-RNP: mixed connective tissue disease
anti-histone: drug-induced lupus

Synovial Fluid

WBC
<2000: OA or trauma
2000-50,000: RA, gout
>50,000: septic

Crystal
needle, negative birefringent: gout
rhomboid, positive birefringent: pseudogout

Common ECG

Mobitz II 2nd Degree AV Block With LBBB

RBBB plus Mobitz II 2nd Degree AV Block

Atrial Fibrillation in Patient with WPW Syndrome

Atrial Flutter With 2:1 AV Conduction-KH

all above ecgs are from: http://library.med.utah.edu/kw/ecg/index.html

AIDS Opportunitistic Infection

PCP (CD4<200): first occuring opportunitistic disease

Dx: bronchoscopy with lavage
lab: increased LDH
Txt: TMP-SMZ, steroid if severe
Prophylaxis: TMP/SMZ, Dapsone, Atovaquane, Pentamidine, if CD4<200

Cryptococcosis (CD4<100)
meningitis
Dx: CSF: india ink + antigen test, lower CSF cell count --> worse
Txt: amphotericin + fluconazole
Prophylaxis: not recommended

Cytomegalovirus (CD4<50)

retinitis + colitis + esophagitis + encephalitis
Dx: fundoscopy of retinitis + endoscopic biopsies
Txt: Valganciclovir P.O., IV ganciclovir if sever, foscarnet and cidofovir if resistant
A.E.: ganciclovir --> neutropenia foscarnet and cidofovir --> renal toxicity


MAC (CD4<50)
fever + night sweats + bacteria + wasting + anemia + diarrhea
Dx: culture of blood, BM, and other tissues
Txt: clarithromycin + ethambutol
Prophylaxis: azithromycin, clarithromycin if CD4<100

Toxoplasmosis (CD4<50)
Brain mass lesion
Dx: CT or MRI contrast shows ring enhancing lesion, shrink after trial therapy
serology, CSF PCR
Txt: Pyrimethamine + sulfadiazine
Prophylaxis: TMP/SMZ

Liver Cirrhosis

Ascites: spontaneous bacterial peritonitis (SBP) is determined by white cell count, treat with cefotaxime/ceftriaxone and albumin infusion (decrease hepatorenal syndrome)

Serum Ascites Albumin Gradient (SAAG)
SAAG>1.1 --> portal hypertension
SAAG<1.1> cancer or infection

General Txt
1. spironolactone to reduce ascites and edema
2. propranolol to prevent bleeding
3. neomycin and lactulose to prevent encephalopathy
4. vit K is in general useless

Primary Biliary Cirrhosis(PBC)
fatigue + pruritus + elevated alkaline phosphatase + osteoporosis
Lab: elevated alkaline phosphatase, GGTP, IgM, and antimitochondrial antibody(most specific)

Primary Sclerosis Cholangitis
PBC - antimitochondrial antibody
Dx: ERCP or transhepatic cholangiogram, No biopsy

Hemochromatosis
Cirrhosis + cancer + restrictive cardiopathy + vibrio/Yersinia infection
Dx: elevated iron, ferritin, diminished iron binding capacity, biopsy
Txt: phlebotomy, deferoxamine

Wilson Disease
choreoathetoid movement + psychosis + K-F rings + Fanconi syndrome + type II renal tubular acidosis + hemolytic anemia
Dx: low ceruloplasmin + high urinary copper level + biopsy
Txt: penicillamine + transplant

Alpha-1 antitrypsin deficiency
cirrhosis + COPD(emphysema in young non-smoker)

Txt for HBV and HCV
HBV: interferon or lamivudine or adefovir
HCV: interferon and ribavirin