Transcript Gen Med Board Review Part Deux Obesity, Hyperlipdemia, Hypertension, Women’s health, Men’s health, ENT Disorders and Geriatric Disorders.

Gen Med Board Review
Part Deux
Obesity, Hyperlipdemia, Hypertension,
Women’s health, Men’s health, ENT
Disorders and Geriatric Disorders
A 35-year-old man comes for a new patient evaluation. He takes
no medications. His parents both have diabetes mellitus.
On physical examination, blood pressure is 160/100 mm Hg. BMI
is 31. The remainder of the examination is unremarkable.
Laboratory studies, including serum electrolyte, blood urea
nitrogen, and creatinine levels and urinalysis, are normal.
In addition to lifestyle modification, which of the following is the
most appropriate next step in this patient’s management?
1.
2.
3.
4.
Lisinopril and hydrochlorothiazide
Metoprolol and hydrochlorothiazide
Terazisub
Lisinopril
0%
0%
0%
1
2
3
0%
4
HYPERTENSION
**Hypertension should be diagnosed after an average of 2 or more blood pressure readings
obtained more than a minute apart at two or more visits
Category
BP
Normal
<120/80
Prehypertension
120-139/80-89
Lifestyle modifications
Stage 1 HTN
140-159/90-99
1. Lifestyle
modifications: for 6-12
months
2. Medication
Stage 2 HTN
>160/>100
Lifestyle modifications:
1. Weight loss
2. Decrease sodium intake
3. Exercise 30 min/day for 3 days/week
4. Decrease alcohol consumption
Treatment
Two Medications
Goals:
> 80 years old: sbp
<150
DM and CKD:
<130/80
USPSTF Screening:
•
Every 2 years for normal BP
•
Annual for pre-HTN
Hypertension Treatment
Comorbidities and treatment
Uncomplicated
Hypertension
Thiazide
Gout
Primary Aldosteronism
or Resistant
Hypertension
Aldosterone
antagonists
Decreased
GFR and
HyperK
Heart failure,
Diabetes, post- MI
ACEi/ARB
Pregnant
and HyperK
CAD, angina
Beta blocker
Prostatic
Hyperplasia
Alpha Blockers
Calcium channel
blocker
Heart
block
Single agent ineffective at 1-3 months then add another agent or switch agents.
A 25-year-old woman is evaluated in the urgent care department because of the
recent onset of heel pain that is especially severe when jogging. She has been taking
ibuprofen for the past 7 days. Her only additional medications are a low-dose oral
contraceptive that she has been taking for the past 5 years and a multivitamin. She
does not smoke cigarettes. She is otherwise healthy and has no history of
hypertension.
On physical examination, blood pressure is 162/102 mm Hg and pulse rate is 90/min.
BMI is 24. The remainder of the examination, including cardiopulmonary, funduscopic,
and neurologic examinations, is normal.
Laboratory studies, including blood urea nitrogen, serum creatinine, and urinalysis, are
normal.
Which of the following is the most appropriate management of this patient’s
hypertension?
1.
2.
3.
4.
Begin captopril and hydrochlorothiazide
Begin hydrochlorothiazide
0%
0%
Begin labetalol
Discontinue ibuprofen
1
2
0%
3
0%
4
Secondary Causes of
Hypertension
Medications
Evaluate in:
1. Young patients with no RF
2. Rapid onset of significant HTN
3. Abrupt change in BP in a patient with well
controlled HTN
**OCPs, NSAIDs, calcineurin inhibitors, epo,
sympathomimetic agents
Chronic Kidney
Disease
Primary
Aldosteronism
Renovascular
Disease
Pheochromocytoma
**Hypokalemic metabolic
alkalosis with low renin
Fibromuscular
Dysplasia
White coat hypertension: diagnose with
ambulatory bp monitoring
Renal Artery
Stenosis
**High renin
A 63-year-old man is evaluated during a follow-up appointment. One month ago, he
had a transient ischemic attack. Carotid ultrasound revealed a 60% left internal carotid
artery stenosis, and transthoracic echocardiogram revealed left ventricular
hypertrophy. He is currently asymptomatic. He has hypertension and quit smoking 10
years ago. He has no history of coronary artery disease and no family history of
premature coronary artery disease. Current medications are hydrochlorothiazide and
aspirin. An LDL cholesterol level 6 months ago was 138 mg/dL (3.57 mmol/L), and he
has been compliant with recommended lifestyle modifications, including diet and
exercise.
On physical examination, blood pressure is 132/84 mm Hg. There are no focal
neurologic abnormalities.
Fasting lipid levels are as follows: total cholesterol 206, HDL 50, LDL 132, triglycerides
144
In addition to continuing therapeutic lifestyle changes, which of the following is the
most appropriate management option for this patient?
1.
2.
3.
4.
Add atorvastatin
Add nicotinic acid
Change hydrochlorothiazide to amlodipine
0%
0%
Change hydrochlorothiazide to carvedilol
1
2
0%
3
0%
4
Hyperlipidemia
Risk Category
LDL goal
Initiate TLC
Consider Drug
Therapy
HIGH Risk: CAD or CAD equivalents
(DM or atherosclerotic disease)
<100 (optional
goal <70)
> 100
> 130
Moderate risk: > 2 RF
< 130
>130
>160
Lower risk: 0-1 RF
<160
>160
> 190
LDL goals based on major risk factors: CHOLE
Cigarette smoking
Screen: lipid panel after 12 hour
Hypertension (> 140/80 or taking anti-hypertensives)
fast in men > 35 yo or women >
Older age (men > 45, women > 55)
45 yo
Low HDL (<40)
Elder  family history of premature coronary artery disease (male first degree relative <55,
women <65)
HDL > 60 removes one RF
ATP III treatment priority:
LDL
Non-HDL Cholesterol
(hypertrigylceridemia)
No specific HDL goal,
but raise HDL in those
with CAD
Treatment
Agent
Effectiveness
Statins
Lowers LDL, Raise DOC for elevated
HDL, Lowers trig LDL
Bile Acid
Lowers LDL
Binderscholestyramine
, colestipol)
Notes
DOC for children
and women with
child-bearing
potential and Liver
disease
Adverse Effects
Elevated LFTs, myalgias.
Avoid if trig > 300 or GI motility
disorder.
Ezetimibe
Lowers LDL and
trig
AVOID with acute liver disease or
elevated LFTs
Nicotinic Acid
Lowers trig,
raises HDL and
lowers LDL
DOC to raise HDL
Flushing, liver tox, nausea, gout, and
elevated uric acid levels
Fibrates
Lower trig, raise
HDL
DOC for elevated
trig
Caution in renal disease or
gallbladder disease
If myalgia present and statin must be used, add coenzyme Q10 to help resolve symptoms.
A 51-year-old woman is evaluated during a routine physical examination. She
has no history of hypertension and has never used tobacco. There is no family
history of heart disease. Her only medication is daily oral conjugated
estrogens combined with medroxyprogesterone acetate for intolerable hot
flushes.
Physical examination is normal. BMI is 31.
Fasting lipid panel: total cholesterol 218, HDL 42, LDL 128; triglycerides 240
Which of the following is the most appropriate next step in the management
of this patient?
1.
2.
3.
4.
Calculate Framingham risk score
Calculate non-HDL cholesterol level
Prescribe atorvastatin
Prescribe gemfibrozil 0%
0%
1
2
0%
3
0%
4
Hypertriglyceridemia Treatment
Triglycerides
>500
No
Yes
Non-HDL Cholesterol= Total Cholesterol- HDL
Non HDL Cholesterol is really just the LDL + VLDL. If
LDL at goal, then VLDL or triglycerides are above
goal.
Yes
Triglycerides
> 200
Treat
hypertriglyceridemia
No
Check Non-HDL Cholesterol
Above goal
Treat hypertriglyceridemia
Don’t treat
Below goal
Don’t treat
Risk Category
LDL goal
Non-HDL Cholesterol Goal
HIGH Risk: CAD or CAD
equivalents
<100 (optional goal
<70)
> 130
Moderate risk: > 2 RF
< 130
>160
Lower risk: 0-1 RF
<160
> 190
A 30-year-old woman is evaluated during a routine appointment. She has no
symptoms other than fatigue, which she attributes to long work hours. She
denies daytime somnolence and a history of snoring.
She is a lawyer and, owing to stress at work, she finds it difficult to eat
healthy foods and get exercise. She gained 9.1 kg (20 lb) with the birth of her
first child last year and has been unable to lose the weight. The patient had
gestational diabetes. She states that her menstrual periods are normal. She is
taking no medications.
Vital signs are normal. She is 177.8 cm (70 in) tall. BMI is 32. Her thyroid
examination is normal. She has normal hair distribution and normal skin color
with no evidence of striae.
In addition to a fasting plasma glucose, lipid panel, and thyroid-stimulating
hormone assay, which of the following should be done next?
1.
2.
3.
4.
24 hour urine cortisol
Pelvic ultrasound
Serum insulin like growth factor concentration
Waist circumference measurement
0%
1
0%
2
0%
3
0%
4
Obesity
BMI
Category
20-24.9
25-29.9
Overweight
30-34.9
Class I Obese
35-39.9
Class II Obese
>40
Class III Obese, Morbid Obesity
Treatment:
•
Screen for secondary causes:
• Medications: thiazolidinediones, oral hypoglycemics, insulin; TCA’s, SSRIs, lithium
and antipsychotics, valproic acid and carbamazepine
• Endocrine disorders: hypothyroidism, cushings, growth hormone deficiency, PCOS,
hypothalamic damage
• Diet and exercise; behavioral therapy
• Pharmacologic:
• Orlistat
• Sibutramine- avoid in poorly controlled hypertension
• Surgical: BMI > 40 or > 35 with comorbidities
Metabolic Syndrome
Risk Factor
Defining Level
Abdominal Obesity
>40 in in men, >35 in in women
Triglycerides
> 150
HDL
< 40 in men, < 50 in women
Blood Pressure
> 130/85
Fasting glucose
> 110
*Presence of 3= Metabolic Syndrome
• Metabolic Syndrome identifies pt at high risk for
developing diabetes and cardiovascular disease
• ANY person with metabolic syndrome is a candidate
for aggressive therapeutic lifestyle changes
A 56-year-old woman is evaluated for hot flushes that
have been interfering with her sleep and causing
discomfort while at work. She wants some relief from
her symptoms, which have been persistent since she
experienced menopause 3 years ago. She is a
nonsmoker and has no history of thromboembolic
disease and no personal or family history of cancer.
Which of the following is the most appropriate
treatment?
1.
2.
3.
4.
Black Cohosh
Bupropion
Estrogen Replacement therapy
0%
Raloxifene
1
0%
2
0%
3
0%
4
Menopause
• Dx: Clinical.
– Only check FSH if occurring in younger patients or
unsure of diagnosis
• Vasomotor symptoms:
– Tx: low dose estrogen (add progesterone if still has
uterus); SSRI, clonidine, venlafaxine, gabapentin
• Vaginal dryness
– Tx: estrogen cream
Hormone Replacement Therapy
Estrogen
Estrogen +
Progesterone
Breast Cancer
Endometrial Cancer
Ovarian Cancer
Colorectal Cancer
Fracture Risk
VTE, Heart Disease, Stroke
**Estrogen alone causes endometrial hyperplasia and increase risk of endometrial
cancer- must use combination estrogen progesterone in women with a uterus
HRT is NOT recommended for prevention of chronic disease after menopause.
AVOID HRT in smokers, CAD, history of breast cancer, high risk of thromboembolic
disease, undiagnosed vaginal bleeding or who are well past menopause.
A 40-year-old woman presents with a history of heavy painless menstrual bleeding for
the past 4 days. Her last period was 20 days ago, but before that, her periods had
become more irregular over the previous 2 years, with lighter than usual bleeding. She
has been sexually active with her husband, but had a tubal ligation after the birth of
her fourth child 6 years ago.
On physical examination, the vital signs are normal. There is no evidence of
hypovolemia or conjunctival pallor. The skin examination is negative for ecchymoses
and petechiae. The bimanual pelvic examination reveals a nontender, normal-sized,
and regular uterus. Speculum examination reveals a normal-appearing cervix with
dark blood in the cervical os but no other abnormalities. A Pap smear is performed. A
urine pregnancy test is negative.
Which of the following is the most appropriate next step in the management of this
patient?
1. Endometrial Biopsy
2. Measurement of luteinizing hormone and follicle stimulating
hormone
0%
0%
0%
0%
3. Oral Contraceptive
4. Pelvic Ultrasound
1
2
3
4
Abnormal Uterine Bleeding
• Physical exam with pelvic and pap
– If pelvic abnormal or difficult 2/2 body habitus  pelvic US
• Labs:
–
–
–
–
Pregnancy test
Thyroid function test
Prolactin: galactorrhea or cycle length varies in length
Platelets/aPTT/bleeding time: excessive bleeding since menarche, FHx
of bleeding disorder or easy bruising
• ENDOMETRIAL BIOPSY in women > 35 years old
• Treatment in young women:
– High dose estrogens to reset the cycle then:
•
•
•
•
Cyclical progesterone
OCP
Levonorgesterel IUD
NSAIDs
A 24-year-old woman is evaluated for a 2-week history of vaginal itch and a
discharge. She has tried douching and an over-the-counter vaginal cream
without success. She and her partner have been together for 2 years, and
they have been considering getting pregnant. Current medications are a
vaginal benzocaine cream and an oral contraceptive.
On speculum examination, she has a cloudy, thin discharge coating the
vaginal walls with a fishy odor to the discharge when potassium hydroxide is
applied. The cervix appears normal. A bimanual examination is normal. The
vaginal discharge has a pH level of 5.0. Clue cells are seen on wet mount.
Which of the following is the most appropriate management option for this
patient?
1.
2.
3.
4.
5.
Clotrimazole for patient and partner
Clotrimazole for patient only
Lactobacillus intravaginal suppositories
Metronidazole orally for patient and partner
Metronidazole orally for patient0%
only 0%
0%
1
2
3
0%
0%
4
5
Vaginitis
Cause
Diagnosis
Treatment
Bacterial
Vaginosis
imbalance of
normal
(Lactobacillus and
Gardnerella) flora.
Fishy odor,
po metronidazole 500mg BID
smooth white
x1week & don’t treat
discharge, ph >4.5 partners
whiff test positive,
clue cells
Vulvovaginal
candidiasis
Common in dm or Cottage cheese
after abx
discharge, ph
<4.5, KOH with
hyphae
Trichomoniasis
Trichomonas
vaginalis
fluconazole po 150mg x1;
miconazole or clotrimazole
cream
Strawberry cervix, po metronidazole 2 g x1;
mobile
consider treating partner
trichomads on
wet mount
Contraception
• OCP:
–
–
–
–
–
–
–
Increased risk of MI, but reduced estrogen has improved this
May increase risk of hypertension
Increased risk of stroke (small)
Increased risk of venous thromboembolic disease **especially for smokers
Reduced risk of ovarian and endometrial cancer (opposite of HRT)
Increased risk of cervical cancer
Conflicting data with breast cancer
• IUDs: increase risk of PID
• Male and Female condoms: help with prevention of STDs (not HIV)
• Sterilization: in women who become pregnant with tubal ligations, rate of
ectopic pregnancies is high
• Emergency contraception:
– Oral levonorgestel- take 2 doses within 5 days of intercourse
– Oral mifepristone- only approved for termination of pregnancy
– Copper IUD- most effective; insert within 5 days of intercourse and can be kept
in place for up to 10 years
A 49-year-old woman is evaluated after noticing a small lump in her right
breast 3 weeks ago. It is painless and has not changed in size. She has no
other pertinent medical history and did not use oral contraceptives. She had
menarche at age 12 years and is still menstruating. Her last menstrual period
was 2 weeks ago. She has two children, the first at age 25 years and the
second at age 30 years. Her mother had breast cancer at age 55 years; there
is no other family history of cancer.
On physical examination, vital signs are normal. There is a 1.0 cm × 1.5 cm
firm, discrete, mobile mass in the upper outer quadrant of the right breast.
There is no lymphadenopathy or other abnormalities on examination.
A mammogram done 18 months ago was normal. A bilateral mammogram
does not reveal any suspicious lesion in either breast.
Which of the following is the most appropriate management option for this
patient?
1.
2.
3.
4.
Aspiration or biopsy
Clinical reevaluation in 1 month
0%
MRI of both breast
1
Repeat mammogram in 6 months
0%
2
0%
3
0%
4
Evaluation of a Breast Mass
< 30 years old > 30 years old
Bilateral mammo
Ultrasound:
1. Cystic:
A. Asymptomatic: observe
B. Symptomatic: aspirate +
bx
2. Solid: mammogram with
tissue dx*
3. Not seen: mammogram with
tissue dx*
Thickening
or
asymmetry
Unilateral
mammo
Skin
Changes
Tx for mastitis Bilateral mammo
if no change, with biopsy
Bilateral
mammo with
biopsy
Nipple
Discharge
• Bilateral, milky: pregnancy test
*Tissue diagnosis: FNA, core bx or surgical excision
and endocrine eval
• Unilateral, serous/bloody:
mammo and surgical biopsy
Lump or
mass
Ultrasound or Bilateral mammo
observe for 1- + ultrasound with
2 months
surgical biopsy
A 64-year-old man is evaluated for a 1-year history of slow urinary stream, urinary
hesitancy, and postvoid dribbling. Previously, he got up once a night to urinate, but in the
past 2 months, his nocturia has increased to three times per night. His American Urological
Association prostate symptom score is 9 (score >7 indicates moderately severe symptoms).
On physical examination, temperature is normal, blood pressure is 146/80 mm Hg, and
pulse rate is 74/min. Abdominal examination is normal without tenderness or masses or
evidence of a distended bladder. Digital rectal examination reveals a slightly enlarged
prostate without discrete nodules or tenderness. Routine laboratory studies and urinalysis
are normal. Prostate-specific antigen level is 1.0 ng/mL (1.0 µg/L). A urine culture shows no
growth.
In addition to decreasing total fluid intake and voiding just before bedtime, which of the
following is the most appropriate treatment for this patient?
1.
2.
3.
4.
Doxazosin
Finasteride
Saw Palmetto
0%
Transurethral microwave0%therapy
1
2
0%
3
0%
4
BPH
**Does not increase chance of prostate cancer.
Evaluation:
1. Rectal exam and abdominal exam
2. Check a UA and if pyuria or hematuria  urine culture
3. PSA in those with > 10 year life expectancy or in those who it would change
management (BPH raises it mildly)
Watchful Waiting
*act within
Alpha antagonists:
tamsulosin, doxazosin, 48hrs
terazosin, alfuzosin
Treatment Options
Medications
5 alpha reductase
inhibitors : finasteride,
dutasteride
TURP
**urinary retention, UTI, bladder stones, hydronephrosis, no
reponse to medications
A 19-year-old man is evaluated for increasing pain in the left testicular region for 2
days. It is tender when he palpates the scrotum or moves. He has had some mild
dysuria but has not noted any urethral discharge. He is taking no medications, has not
had any procedures or trauma to the region, and has no history of similar symptoms.
He feels generally ill today with some mild nausea and a poor appetite but no
vomiting.
On physical examination, temperature is 38.4 °C (101.2 °F) and other vital signs are
normal. There is mild erythema overlying the left side of the scrotum. There is no
edema of the scrotum. An area superior and posterior to the left testicle is moderately
tender to palpation, with mild fullness and bogginess. The left testicle is nontender,
similar in size to the right testicle, and sits lower in the scrotum than the right testicle.
The cremasteric reflex is intact bilaterally. The penis and right testicle are normal.
Which of the following is the most likely diagnosis?
1.
2.
3.
4.
Epididymitis
Hernia
Orchitis
Testicular Torsion
0%
1
0%
2
0%
3
0%
4
A 65-year-old man with chronic stable angina is evaluated for a 1-year history of erectile
dysfunction. His libido is intact and he would like to resume sexual activity. He experiences
occasional exertional chest pain after quickly walking six to eight blocks or three flights of
stairs, but has no chest pain at rest or with usual activities and no dyspnea. This symptom
has been stable for the past few years, and he has not used any nitroglycerin for it. He has
hypertension. He has no history of myocardial infarction or diabetes mellitus. He does not
smoke or drink alcohol. Current medications are aspirin, metoprolol, atorvastatin, and
enalapril.
Results of physical examination and laboratory studies are unremarkable. An
electrocardiogram reveals normal sinus rhythm and left ventricular hypertrophy with no
ischemic changes.
Which of the following is the most appropriate management option for this patient?
1.
2.
3.
4.
5.
Cardiac stress test
Serum testosterone level
Start a phosphodiesterase-5 inhibitor
Start yohimbine
0% dysfunction
0%
0%
Advise against treatment of0%erectile
1
2
3
4
0%
5
Erectile Dysfunction
•
•
Causes:
1. Organic causes: vascular disease,
dm, thyroid disease, smoking,
alcohol
2. Medications: SSRIs, Beta blockers,
thiazides, clonidine, aldactone
3. Psychogenic causes: depression,
usually younger patients
Evaluation:
– Obtain glucose, BUN/Cr, lipids, TSH and EKG
to identify systemic causes
– Total or free testosterone and PSA
controversial- obtain if signs of
hypogonadism
– Nocturnal penile tumescence not routinely
recommended
•
Treatment:
1.
2.
Lifestyle modifications
PDE-5 inhibitors (sildenafil)
•
3.
Contraindications: nitrates, hypotension,
unstable angina, HOCM, AS, CHF
Intracavernous injection and
transurethral alprostadil in pts who
cannot use PDE5 or fail to respond to
them
Men’s Health
Andropause
• Symptoms:
– Decreased sexual function
– Decreased bone mineral density
– Decreased muscle mass
– Decreased muscle strength
– Decreased mentation
• Treat if testosterone <200
• Do NOT screen elderly men and don’t
treat asymptomatic men
A 51-year-old woman has a 2-year history of involuntary leakage of small amounts of
urine. Episodes are more frequent after coughing or exercising. There is no urinary
frequency, dysuria, or nocturia. The patient is gravida 3, para 3. All three pregnancies
were uncomplicated and resulted in normal vaginal deliveries. She has not had a
menstrual period for the past 3 years.
On physical examination, vital signs are normal. BMI is 32. Abdominal examination is
unremarkable except for moderate obesity, and pelvic examination is normal except
for some vaginal atrophy and mild uterine prolapse.
Results of complete blood count, blood chemistry studies, and urinalysis are normal.
Which of the following is the best treatment at this time?
1.
2.
3.
4.
5.
Bladder training
Oral estrogen therapy
Oxybutynin
Pelvic floor muscle exercises
Retrograde suspension surgery
0%
1
0%
0%
2
3
0%
0%
4
5
INCONTINENCE
Type
Symptoms
Mechanism
Treatment
Urge
sense of urgency
Uncontrolled bladder contractions
Bladder training
Oxybutinin
NO SURGERY
Stress
inc intraabdominal
pressure causes
leakage of urine
Urethra can’t maintain pressure gradient;
associated with multiple deliveries, pelvic
surgery
Kegel exercises
Duloxetine
Surgery- suspension or slings
Overflow
Incomplete bladder
emptying; leakage
after void
Underactive bladder with trouble contracting
Alpha blockers for men; intermittent caths
D- drugs
I- infection
A- atrophic vaginitis
P- psychiatric/CNS
E- endocrine/metabolic
R- restricted mobility
S- stool impaction
**Urodynamic testing unnecessary in uncomplicated UI
**If you suspect overflow incontinence, obtain postvoid residual
volume:
Normal 50-100
Abnormal > 200-300
Screening in the Elderly
Assessment Screening/Prevention Normal Aging
Notes
Hearing
Whisper Test or
Audioscope
Presbycusis- bilateral
sensorineural high
frequency loss
Weber and Rinne are NOT
used
Vision
Snellen Eye Chart
Presbyopia- diminished
ability of lens to
accommodate
Falls
Periodically ask about
fall history
Dementia
MMSE or MiniCog
Pressure
Ulcer
Specialized foam
mattress or overlays,
specialized sheepskin
overlays
If fall reported:
1. Get up and Go test
2. Check 25-(OH)2-vitamin D
if weak
Benign senescent
forgetfulness- decline in
memory, acquire and
retain new info
No consensus about
neuropsych testing and
neuroimaging
Air filled boots, water gloves,
regular sheepskin, and
doughnut devices should NOT
be used
ENT
Diagnosis
Notes
Treatment
Otitis Media
PO Amoxicillin; Macrolides for PCN
Allergic. Augmentin for failure
Otitis Externa
TOPICAL antimicrobials
Sinusitis
Tx if 2 of the following are present:
1. sx> 7days
2. facial pain
3. purulent nasal discharge
PO Amoxicillin
Allergic Rhinitis
Skin prick test to confirm; Test for
asthma
Intranasal Steroids (fluticasone,
mometasone)
Pharyngitis
Centor criteria:
1. Fever
2. No cough
3. Tender anterior cervical LAD
4. Tonsillar exudates
Rapid strep for +2, treat for 3+ or
4+
PO Penicillin V; Erythromycin for PCN
allergic
Oral Lesions
• Candidiasis: white plaques on erythematous base which can be scrapped away
– Denture candidiasis: erythema in denture areas with angular cheilitis.
– Tx: topical nystatin or clotrimazole. Po fluconazole if unresponsive or pt with HIV
• Herpes Labialis: vesicles along vermilion border of lip. Vesicles rupture and crust
within 48-72hrs
– Tx: don’t use topical antivirals, use po antivirals
– Prophylaxis: po antivirals
• Aphthous ulcer: painful, well-defined circular ulcerations on buccal and labial
mucosa
– Tx: chlorhexidine mouth rinse and topical corticosteroids in dental paste
– Risk of recurrence reduced with smoking cessation
• Lichen planus: white, lace-like striae on buccal mucosa or hyperkeratosis or painful
erosive changes. May be associated with increased risk of oral cancer.
– Tx: topical steroids for symptomatic mouth lesions
• Leukoplakia and erythroplakia: white or red patches/plaques; common in
smokeless tobacco users. Usually precancerous.