Residents on the HEROES Outpatient block shared pearls from their Hopkins/PEAC Module study session. A Random Sample of High Yield Points Below!
Cardiotoxicity related to chemotherapy:
– 2 broad categories of cardiac toxicity from chemotx: type 1 (dose-depending, irreversible ultrastructural necrosis) and type II (not dose dependent, often reversible)
– Type 1 injury is associated with doxorubicin, daunorubicin, and epirubicin (anthracyclines). Usually presents with dilated cardiomyopathy
– Type 2 injury more common with targeted therapy, such as trastuzumab (results in HFrEF), multi targeted TKI (sunitinib HTN and HFrEF), and anti endothelial growth factor antibodies (bevacizumab associated with reversible HTN).
– If receiving chemotx known to have cardiotox, EKG/TTE at baseline. Repeat TTE after total cumulative antrhacycle dose of 300 mg/m2, and q3 months if on trastuzumab.
GERD Learning Points: Indications for PPI
a. Uncomplicated GERD – short term use ideally (8 weeks)
b. GERD related complications (cough, dysphonia, esophageal stricture, etc) – for short term use or long term magement of symptomsa. Uncomplicated GERD – short term use ideally (8 weeks)
c. Symptomatic GERD + Barretts – long term
d. Asymptomatic GERD + Barretts – “consider” long term PPI
e. High risk for ulcer related bleeding from NSAIDS – long term IF continuing to take NSAIDS
f. **NOTE: Patients with uncomplicated GERD, should attempt to discontinue or transition to H2 blocker after 8 weeks
g. **NOTE: Should periodically attempt to identify lowest effective dose for patients on long term PPI
h. **NOTE: Should consider esophageal pH monitoring for patients unable to wean PPI dose, to ensure true presence of GERD before committing to long term therapy
Gender Medicine: STI and screening for immunocompromised
1. Trichomonas infection is considered an STD and partners should be treated. Treatment is 2g of PO metronidazole or tinidazole one time.
2. The CDC recommends re-testing of trichomoniasis 3 months after treatment.
3. For cervical cancer screening in immunocompromised, it is recommend for HIV 2 pap smears in year of diagnosis, then annually, for immunosuppressed (such as transplant) to do annual pap, and there is no clear guideline for intermittently immunosuppressed (i.e., rheum patients).
Dizziness:
1. Don’t forget that those who have had gastric bypass are at risk for B12 deficiency which can cause peripheral neuropathy and dizziness
2. Medications can be the cause of peripheral vertigo ie. antidepressants
3. Eye closure increases the amplitude of nystagmus in peripheral vertigo and has no effect on the nystagmus of central vertigo (ask them to open their eyes)
4. HINTS: In 2009, Kattah et al. examined the diagnostic accuracy of combining 3 previously established bedside diagnostic tests:
1: Horizontal head impulse testing (Head Impulse)
2: Direction-changing nystagmus in eccentric gaze (Nystagmus)
3: Vertical skew (Test of Skew)
https://www.emra.org/emresident/article/hints-exam/
“These tests were combined and have since been used as a tool to identify posterior circulation stroke: the Head Impulse, Nystagmus, Test of Skew (HINTS).2 A single central finding on any of the 3 components “rules-in” a posterior circulation stroke, and further testing/treatment is indicated. The Kattah study demonstrated the HINTS exam was more sensitive than an MRI in the first 24 hours. “