Foils Flashcards
Rocky Mountain spotted fever
Tick bourne
Ricekettsia rickettsia
April September (Spring)
Children < 15
Southeast US
Fever, HA, myalgia
Small pink macule –> petechiae, purpura wrists/ankles –> trunk (spares face)
Normal WBC, left, shift, mild anemia, moderate thrombocytopenia, hyponatremia
Tx: doxycycline
Complications (due to vasculitis) - DIC, loss of limbs, CNS, lungs, kidneys
Guillain-Barre
Auto-immune demyelination
30-40 y/o
Weakness (progressive ascending), areflexia, paresthesia
Often preceded by viral illness
Associated with campylobacter and flu vaccine
Loss of DTRs
Respiratory failure can develop
Autonomic instability (vs tick paralysis)
CSF: increased protein
Tx: admit, airway support, plasmapheresis, IVIG
Strychnine
Rodenticide - white, odorless, bitter crystalline powder
Muscle spasms
Seizures, mydriasis, exophthalmos, nystagmus
Tachycardia, HTN, tachypnea, SOB, cyanosis, trismus, risus sardonicus, opisthitonus
Tx: supportive
Henoch-Schonlein Purpura (HSP)
Immune mediated vasculitis (most common acute vasculitis affecting children)
Age 2-11, whites, winter, male
Preceding strep or GI infection (salmonella, shigella)
Abdominal pain (colicky, ileoilial intussusception), GI bleed, hematuria, palpable purpura (dependent areas, extensor surfaces), migratory large joint arthritis
4-6 week illness
Tx: supportive, steroids if renal manifestations (40%)
Normal platelets and coags
Ransons criteria
GLOWS - glucose > 200, LDH > 350, older age > 55, WBC > 16, SGPT (AST) >250
BOB CHF - base defecit > 4, pO2 < 60, calcium < 8, BUN increase > 5, Hct drop > 10%, fluid deficit > 6L
Jones criteria
GABS
3-4 weeks after infection
Major: migratory polyarthritis, carditis, subQ nodules (back of wrist, elbow, front of knees), erythema marginatum, sydenham chorea
Minor: fever, arthralgia, history of RF, prolonged PT, elevate ESR/CRP, GABS infection
Diptheria
Club shaped gram + bacillus
Respiratory droplets
** pseudomembrane** exotoxin-induced necrosis
“Bull neck”
Heart (myocarditis), CNS (neuropathy), kidneys, liver
Tx: equine serum diphtheria antitoxin + erythromycin/PCN
Give antibiotics to carriers
Pertussis
Bortadella pertussis - toxin mediated
URI, 2 wks (catarrhal phase) –> 2-4 weeks paroxysmal coughing spasms (inspiratory whoop only 1/3rd), post-tussive emesis followed by milder cough for months
Adults = primary reservoir, children = greatest risk
Vaccine
Mucous plugs, secondary bacterial infections, increased intrathoracic pressure (rectal prolapse, ruptured diaphragm, hernias)
Tx: erythromycin, TMP/SMX, isolation
Chemophrophylaxis for household contacts
Babesiosis
Tick bourne
Hemolytic anemia
Tx: atorvaquone + azithromycin
CO poisoning
Leading cause of toxic death
Shifts oxyhemoglobin dissociation curve to the left (inhibits release of O2 from Hgb)
Colorless, odorless
Incomplete combustion of fuel
Scenarios: cooking with grill without ventilation, car engine in enclosed space, furnace
HA, nausea, confusion, coma, sz, no cyanosis
Looks like “flu” but no fever and dog is sick too
Crosses placenta
Pulse Ox normal, PaO2 normal, measure carboxyhemoglobin (levels don’t predict toxicity)
1/2 life: 5 hours (RA), 1.5 hours (100% O2), 20 min (HBO) - may prevent delayed neuropsychiatric syndrome
Hydrogen sulfide poisoning
Scenarios: oil refinery, hot asphalt, sewage, mines
Rotten egg odor
Tx: remove from source, 100% oxygen, methylene blue in cyanide antidote kit –> binds to methemoglobin
Brown-Sequard
Unilateral cord injury Penetrating trauma Crossed below level of injury Ipsilateral weakness and loss of position/vibration Contralateral loss of pain/temp
Erythema nodosum
Painful, non-ulcerative on anterior tibias, arms, trunks
Drug reaction, systemic infection (TB/fungal), sarcoid, IBD, malignancy
Common in women 30-50 y/o
Resolves in 3-6 weeks
Crohns disease
Full thickness wall involvement (mouth to anus)
“skip lesions”
Gross blood < 50%
Granulomatous
Fistula formation
Increase oxalate absorption leads to calcium oxalate –> kidney stones
Ulcerative colitis
Colon involvement (not small bowel), continuous
Blood diarrhea
Toxic megacolon
Mucosal and submucosal layers only (not full thickness)
Risk of colon cancer increases 30 fold
Behcets disease
Vasculitis - diffuse involvement Eyes - uveitis Mouth - aphthous ulcers Skin - pustules/folliculitis Lung aneurysms --> lung hemorrhage Joints - arthritis CNS - headaches, confusion, strokes, personality changes, aseptic meningitis Genitals - painful ulcers GI - ulcers from mouth to anus (similar to Crohns)
Juvenile Rheumatoid arthritis (JRA)
Pain, swelling, morning stiffness > 6 weeks
Fever, LAD, trunkal rash
Uveitis, growth problems
Carcinoid syndrome
GI tumors: small bowel, appendix, stomach, colon, liver (or lung)
Secretes serotonin, prostaglandins
Skin flushing, diarrhea, hypotension, vasodilation, edema, ascites, bronchoconstriction
Tx: octreotide
Hypokelemia periodic paralysis
Hereditary: autosomal dominant
Avoid high-carbohydrate/sodium diet
Thyrotoxicosis: young Asian males, onset after exercise
EKG changes: decreased Twaves, U wave, ventricular dysrhythmias
Replete both K (orally) and Mg + beta-blocker
SLE
Female, African-american, multi-organ autoimmune
Fever, joint pain, rash
Butterfly facial rash (malar)
Discoid lupus: scaly, raised plaques on face, head, neck
Renal: nephritis, proteinuria, nephrotic syndrome, CRF
Cardiac: pericarditis, myocarditis, effusions, tamponade
Pulm: pleural effusions, pleurisy, pneumonitis, infarcts:
GI: oral and nasal lesions, GI vasculitis
Heme: anemia, thrombocytopenia, auto-splenectomy thrombosis
Neuro: sz, CVA, psychosis, migraines, neuropathy, transverse myelitis
Dx: ANA (most sensitive), anti-dsDNA (most specific)
Tx: severe with steroids
Sarcoidosis
Non-infectious, non-caseating multi-system granulomatous disease
African-american adult females
Bilateral *hilar adenopathy, pulmonary infiltrates, ocular and skin lesions (waxy violacious papules)
*Hypercalcemia, anemia, eosinophilia, elevated ACE
Tx: steroids
Dressler’s syndrome
Pericarditis 2-8 wks post-MI
Fever, leukocytosis, friction rub, pericardial and pleural effusions
Tx: NSAIDs, +/- steroids
Kawasaki Disease
Mucocutaneous LN syndrome
Age 2-5, males, Asian
Major criteria (fever > 5 days + 4): bilateral conjunctiva, strawberry tongue/fissured lips, desquamation of swelling of fingers/toes, erythematous rash (starts on palms/soles), enlarged cervical LNs
Minor criteria: elevated WBC, elevated ESR, elevated platelets
coronary artery aneurysms
Tx: aspirin, IVIG
Rubeola
3 C’s - cough, coryza, conjunctivitis
Koplick spots: buccal mucous (before rash), non-tender, tiny white spots (“grains of salt”
Maculopapular, moribilliform rash, head –> feet
Complications: encephalitis, PNA, OM, conjunctivitis
Not a TORCH infection
Roseola
Human herpes virus (HHV) 6
Ages 6 -18 months
High fever (3-4 days), then rash with defervescence
Febrile seizures common
Paint macules/papules on truck –> neck, face, extremities
Temporal arteritis
Headache (85%), impaired vision (50%), jaw claudication
Age >50
ESR > 50
Afferent pupillary defect
Pale/erythematous optic disc
Tx: ophthalmology consult, high-dose steroids, IV methylprednisolone if ocular symptoms < 48 hours
Central Retinal Artery Occlusion (CRAO)
Sudden, painless, monocular visual loss Afferent pupillary defect Pale retina, fixed, dilated pupil "Cherry red spot" in the macular "Box car" retinal artery Mostly embolic Ophtho consult + CVA work-up Tx: lower IOP, gentle massage, increase PaCO2 (rebreathe in bag), acetazolamide (carbonic anhyrase inhibitor), timoptic
Pheochromocytoma
Tumor of adrenal medulla (secretes norepinephrine)
Dx: 24 hour urine catecholamine and metabolites (VMA)
20-44 y/o
5 Ps: Pressure, pain, perspiration, palpitations, pallor
Tx: alpha- plus beta-blocker (ie labetalol + phentolamine)
Osler-Weber-Rendu syndrome
Autosomal dominant
Herediatary hemorrhagic telangiectasia
Nosebleeds
CREST syndrome
Calcinosis Raynaud's phenomenon Esophageal dysmotility Scelerodactyly Telangiectasia Chronic systemic autoimmune diorder
Raynaud’s phenomenon (disease = underlying cause)
3 criteria: precipitated by cold/emotion, bilateral, < 2 years, minimal to no gangrene
Triphasic attacks
Benign course - tx; reassurance
ITP
Immune or idiopathic
Low platelets
Pediatric version: peak age 5, sudden onset petechiae/purpura several weeks after infectious illness, resolve within 6 months, no tx
Adult: insidious onset/chronic/mostly women, transfuse at 20-30K or 30-50K with active bleeding, tx: steroids –> replace to 50K, high-dose Rho-GAM (anti-D immune globulin
TTP
Severe decrease in platelets
Severe microangiopathic hemolytic anemia with red cell fragmentation (shistocytes, helmet cells, fragmented RBCs)
Transient neuro deficits
Renal failure
Fever
Like DIC - damage to endothelial cells release von Willebrand factor and consumption thrombocytopenia –> small emboli –> end-organ ischemia
Causes: idiopathic, drug-induced, pregnancy, infection
Tx: steroids, plasmapheresis, FFP
** AVOID TRANSFUSING PLATELETS**
HELLP syndrome
Variant of preeclampsia Multigravida Hemolysis, Elevated LFTs, Low Platelets Epigastric/RUQ pain Hemolysis: schistocytes Tx: bedrest, delivery, Mg, control BP, no diuretics or ACE inhibitors
Horner’s syndrome
Ptosis, miosis (constricted pupil), and anhydrous
From unopposed parasympathetics
Causes: carotid disease (dissection, aneurysm, trauma) or tumor (neck, lung)
Rhabdomyolysis
Skeletal muscle injury Trauma, crush, burns, electrical injury, taser, heat stroke, ETOH, drugs)
Causes acute tubular necrosis (myoglobin clogs tubules)
Positive heme dip but no RBCs on micro
CK > 5 times normal
Elevated Cr
Tx: IV hydration, treat hyperkalemia and hypocalcemia, alkalinize urine with bicarb
Neuroleptic Malignant Syndrome
Antipsychotics
Onset within 2 weeks of starting - slow onset (vs serotonin syndrome)
FEVER: fever, encephalopathy, VS instability, elevated CPK, **rigidity (“lead pipe”) vs serotonin syndrome (myoclonus)
Tx: dantrolene or bromocriptine
Trichinosis
Raw/undercooked pork
N/D/V - first 1-8 days
*periorbital edema, edema, muscle pain, fever, weakness
CNS
Not contagious
Tx: antihelmentics - mebendazole/albendazole
Dengue fever
Mosquito vector (Aedes aegypti) Flu-like - fever, HA, muscle/joint pain (bone breaking fever), moribilliform rash 80% asymptomatic 3-14 day incubation (usually 4-7 days) Hemorrhagic fevers Tx: supportive
Tick paralysis
Rapidly ascending paralysis (like Guillain-Barre) but no paresthesias
Tx: remove tick
Ehrlichiosis
1-2 weeks after tick bite - flu-like symptoms
Bacterial infection
Tx: doxycycline
Botulism
Food-borne, wound, infant (floppy baby, constipation, feeble cry)
Neurotoxin blocks acetylcholine release –> impairs motor and autonomic function
N/V/D
*Bulbar symptoms - diplopia, ptosis, dysphagia, dysphonia, dysarthria –> D’s diplopia, droopy eyelids, dilated pupils, dysarthria, dysphonia
*Descending flaccid paralysis
*Anticholinergic symptoms - dry mouth, urinary retention, dilated pupils ileum, decreased tears
Tx: antitoxin, wound –> debridement, PCN
Tetanus
Clostridium tetani (anaerobi gram + bacillus)
Neurotoxin
Risk: > 24 hours old, crush injury, devitalized tissue, burns, IVDA, early postpartum, soil
Muscle spasm, rigidity, rises sardonic, opisthotonus, fever
< 3 prior immunizations Tdap + TIG
Minor > 10 years give Tdap
Other wounds > 5 years give Tdap
Wernicke/Korsakoff
Thiamine (vit B1) deficiency
Encephalopathy, nystagmus, ophthalmoplegia (esp lateral rectus), ataxia, short-term memory problems
Korsakoff –> amnesia, confabulation
Tx: admission, thiamine (give before dextrose), magnesium
Normal pressure hydrocephalus
"Wet, wacky, wobbly" Urinary incontinence, progressive dementia, ataxia CT: enlarged ventricles, no atrophy LP: opening pressure not elevated Tx: shunt
Acoustic neuroma
Schwannoma - benign tumor fo the myelin forming cells of CN VIII
Sudden hearing loss
Marfan’s syndrome
Collagen vascular disorder
Risk of spontaneous PTX and aortic dissection
Osteogenesis imperfecta
Children: blue sclera, flaccid joints
Frequent fractures, growth retardation
Misdiagnosed as child abuse
Fractures usually stop after adolescence
Paget’s disease
Disorder of bone recycling
Causes hypercalcemia
Multiple sclerosis
Demyelination of multifocal areas
30s, F > M
Optic neuritis: unilateral, central vision loss, pain with eye movement of papilliitis, loss of color
*bilateral internuclear ophthalmoplegia = can’t look at nose
MRI (plaques), LP (increased protein, increased IgG, oligoclonal bands)
Tx: steroids, plasma exchanges, disease modifying agents
Eaton-Lambert
Similar to myasthenia gravis
Auto-immune, effects calcium channels, failure to release acetylcholine
Weakness/fatigue of proximal muscles (improves with use)
Decreased DTRs
Tx: remove tumor (50%, esp lung CA), plasmapheresis
Avoid: neuromuscular blocking agents, ahminoglycosides, IV contrast, CCBs
Optisthotonus
Severe hyperextension and spasticity
Tetanus
Strychnine toxicity
Prussic acid (hydrogen cyanide) toxicity
Phentolamine
Non-selective alpha-blocker (caused more reflex tachycardia)
MAOI (phenelzine)
Blocks degradation of catecholamines
6-12 hours post ingestion: HA, HTN, tachycardia
Hypertensive crisis: amphetamines, cheese, wine, lava beans (tyramine)
Contraindicated: meperidine and dextromethorphan –> severe hyperthermia
Tx: phentolamine + labetalol
Serotonin syndrome
SSRIs: fluoxetine (Prozac, Sarafem), sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil)
Rapid onset (vs NMS): AMS, coma, sz, hyperthermia tachycardia, HTN, *myoclonus (vs NMS - “lead pipe”), hyperkinesia
Tx: cooling, cyproheptadine
Tensilon (edrophonium)
Increases acetylcholine by blocking breakdown of acetylcholine by cholinesterase –> increase muscle strength
Can cause bradycardia and syncope –> tx: atropine
Physotigmine
Treatment for refractory anti-cholinergic toxicity (except TCA)
(“Hot as hell, blind as a bat, dry as a bone, red as a beet, mad as a hatter”) - dry, flushed, dilated pupils (mydriasis), decreased bowel sounds, urinary retention
Antihistamines, atropine, TCA, phenothiazines, antiparkinsonian drugs, Jimsonweed
Myasthenia gravis
Auto-antibody to acetylcholine receptors
Women (20-30 y/o) > men (50-60 y/o)
25% thymoma
Bulbar symptoms - muscle weakness and fatiguability with diplopia and ptosis
Limb weakness proximal > distal
Worsens with use
Precipitants: infection, fever, stress, AE medication
Dx: anti-acetylcholine receptor Abs, tensilon test, ice pack test
Tx: pyridostigmine or neostigmine
Respiratory distress: exacerbation vs cholinergic crisis
Amyotrophic Lateral Sclerosis (AML)
Degeneration of upper and lower motor neurons
Muscle wasting, *fasciculations, *spasticy
Weakness, difficulty eating and swallowing
Dx: EMG
Lower motor disease (anterior horn): atrophy, fasciculations
Slowly progressive
Death 2/2 respiratory failure
Hemophilia A, B
A (factor VIII deficiency): most common (85%)
B (factor IX): 15%
Both are x-linked recessive
Bleeding sites: joints, soft tissue (neck, airway, retroperitoneal), extremities (compartment syndrome), mucocutaneous (mouth, GI, nose), CNS (ICH most common cause of death), GU (hematuria), bone cysts from resolved hematoma
Normal PT, increased PTT, decreased factor VIII or IX
Tx: desmopressin (causes release of VWB factor –> allows extra factor VIII to be carried into plasma) - increases levels 3x within an hour, factor VIII replacement
Von Willebrand disease
Most common inherited coagulation disorder
VWB factor facilitated platelet activation and adhesion and carries factor VIII in the plasma
PT normal, prolonged bleeding time, PTT increased
Tx: desmopressin, factor VIII concentrate
PT
Measures extrinsic pathway
Prolonged due to: warfarin, liver disease, Vit K deficiency, DIC
PTT
Measures intrinsic pathway
Prolonged due to: heparin, hemophilia A/B (factor VIII, IX), VWB disease, lupus anticoagulant
Direct thrombin and Factor Xa inhibitors
Indication: non-valvular atrial fibrillation
Dabigatran (Pradaxa) - 80% renal excretion, tx: idarucizumab
Rivaroxaban (Xarelto) - 35% renal excretion
Apixaban (Eliquis) - 37% renal excretion
G6PD deficiency
Genetic disorder common in males, African-American
Causes hemolytic anemia
Jaundice, pallor, splenomegaly
Precipitated by: certain foods (fava beans)/medications (quinine, ASA, NSAIDs, sulfa, quinolones, nitrofurantoin), infections, stress
Coombs test
Tests for globulin antibodies on the surface of RBCs
Dx for acute hemolytic transfusion reaction
Sickle cell vasocclusive crisis (sludging causes obstruction)
Ischemic musculoskeletal pain (most common)
Abdominal pain (2nd most common)
Acute chest (leading cause of sickler death and 2nd most common cause of hospitalization, most common < 21 y/o) *Mycoplasma and Chlamydia pneumoniae
CNS crisis
Renal: infarct, hematuria, plank pain, papillary necrosis
Hand-foot syndrome
Priaprism: tx exchange transfusion, corpus cavernous epic and aspiration
Splenic sequestration (2nd most common cause of death): tx RBCs and exchange transfusion
Aplastic crisis: precipitated by infection, low folate
Infections: pneumococcus , salmonella, H flu, staph, E coli, Mycoplasma - also influenza and parvovirus
*Vaccinate
Boutonnierre deformity
Central slip of extensor tendon
Cholinergic toxidrome
“SLUDGE and the killer Bs”
Salivation, Lacrimation, Urination, Diarrhea, GI upset, Emesis, Bradycardia, Bronchospasm, Bronchorrhea
Miosis
Nicotinic effects: muscle weakness, fasciculations, respiratory failure
or :DUMBBELS”: diarrhea, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, salivation/sweating
Causes: organophosphates, insecticides, mushrooms, chemical warfare
Tx: atropine and 2-PAM (treat until dry secretions)
Turner syndrome
2 in 1000 female US births
Short stature, subbed neck, lymphedema, low hairline, low-set ears, sterility, shield-shaped thorax, *coarctation of the aorta, *bicuspid aortic valve, horseshoe kidney, visual impairment, learning disabilities, micrognathia
Risk of aortic dissection 100-fold increase in females
Vit B 12 deficiency
Macrocytic anemia
Neurologic signs/symptoms
Medical/organic vs functional/psychiatric psychosis
“MADFOCS”
Memory - recent vs distant impairment
Activity - slow, tremor, ataxia vs repetitive
Distortion - VH vs AH
Feelings - labile vs flat
Orientation - disoriented vs oriented
Cognition - wax/wane vs inattentive, continuous
Symptoms - age > 40, sudden, abnormal VS, immodest, aphasic vs age < 40, gradual, normal VS, modesty intact, intelligible
Indications for CPAP
Mod-severe dyspnea + accessory muscle use
Respiratory rate > 25 bpm
Mod-severe acidosis pH < 7.35
Hypercapnia PaCO2 > 45
Acute fatty liver of pregnancy (AFLP)
Late pregnancy
Malaise, N/V, abdominal pain, *jaundice (vs HELLP)
Hypoglycemia, low bilirubin, hypofibrinogenemia, ascites, encephalopathy
Hanta virus
Rodent droppings
Prodromal fever, severe body aches, abdominal pain, N/V/D
Capillary leak –> ARDS/pulmonary edema –> cardiopulmonary phase
Dx triad: thrombocytopenia, left shift, immunoblasts > 10%
Lyme disease
Borrelia bergdorferi (First 1-2 months) erythema migrans, fatigue, HAs, arthralgia, abdominal pain (also CN palsies, ophthalmic conditions, carditis, meningitis) Late sequela (weeks to months later): joint, neurologic, cardiac (heart block) complications Dx: doxycycline (cefuroxime, amoxicillin) 2-3 weeks
Features of typical pneumonias
Strep: lobar, rusty sputum
H flu: COPD/smoker, lobar/patchy
Staph: HCAP (includes MRSA), post-viral, patchy/multilobar, abscess/cavities, fumigating/necrotizing
Klebsiella: diabetics, alcoholics, lobar, bulging right UL, current jelly sputum
Anaerobes: aspiration, neurologic compromise, patchy, dependent lobes, abscesses
Pseudomonas: HAP, cystic fibrosis, immunocompromised, patchy, multi lobar, sickly sweet odor, abscess, effusion
Features of atypical PNA (don’t show up on gram stain)
Mycoplasma: “walking”, young adults, patchy, interstitial, extrapulmonary symptoms (bullies myringitis, hemolytic anemia, Guillain Barre, erythema multiform, cold agglutinins, encephalitits, relative bradycardia)
Chlamydia: “walking”, young adults, 3-20 wk old infants, staccato cough, conjunctivitis, relative bradycardia
Legionella: old men with COPD, summer & winter, contaminated A/C, GI symptoms, not contagious, hyponatremia
Fungal: not contagious, subacute – coccidiomycosis (SW US), blastomycosis (SE US), Histoplasmosis (Mississippi valley) –> fluconazole
Exotic: Q fever (sheep/cow, hepatitis, endocarditis), psittacosis (parrot, epistaxis, headache, tetracycline), hanta virus (rodents, SW US, hemorrhage)
Meniere’s (idiopathic endolyphatic hydros) vs labrynthitis
Hearing loss, tinnitus, vertigo vs hearing loss, tinnitus, vertigo ++ post-viral ++
SLE criteria
4 out of 11
1) malar rash
2) discoid rash
3) photosensitivity
4) oral ulcers
5) non erosive arthritis
6) pleurites or pericarditis
7) renal disorder (proteinuria or casts)
8) neurologic disorder (seizure or psychosis)
9) hematologic disorder
10) immunologic disorder (anti-dsDNA or anti-Sm)
11) positive ANA
Acute radiation sickness
lymphocyte count >1200 = less severe
3.5 Gy exposure = lethal
Background radiation = 3.6 mSV
N/V/D within a few hours
Addison’s disease
Chronic adrenal insufficiency (primary)
Fatigue, weightloss
Hyponatremia, hyperkalemia (hypoNa, hypoglycemia)
Skin pigmentation
ACTH stimulation test
ACTH level high/normal in primary adrenal insufficiency (adrenals not functioning) vs low in secondary (pituitary not functioning)
Lhermitte sign
Flexion of neck causes electric shocks down spine
Seen in MS, cervical myelopathy/radiculopathy, tumor, Fit B12 deficiency
Oculovestibular reflex
“COWS” - intact brainstem cold opposite, warm same
If brainstem function lost = tonic deviation towards irrigation
Hypocalcemia
Chvostek sign - tapping cheek
Blood pressure spasm
Tumor lysis syndrome
Hyperkalemia, hyperphosphatemia, **hyperuricemia, hypocalcemia –> tetany, hyper-reflexia
Acid-base disturbances
Metabolic acidosis (low HCO3) with compensatory hyperventilation (low pCO2) Metabolic alkalosis (high HCO3) with compensatory hypoventilation (high pCO2) (ie, volume contraction, vomiting, diuretics) Respiratory acidosis (high pCO2) with compensatory increased renal absorption (high HCO3) (ie hypoventilation) Respiratory alkalosis (low pCO2) with compensatory decreased renal absorption (low HCO3) (ie anxiety, mechanical ventilation, CNS disease)
Non-gap metabolic acidosis
HARDSUPS
Hyperventilation, Acetazolamide, renal tubular acidosis, diarrhea, ureteral diversion, pancreas, spironolactone
Most common = diarrhea, spironolactone
Adrenal insufficiency
Primary: Addison’s, congenital adrenal hyperplasia
Secondary: pituitary (decreased ACTH)
Tertiary: hypothalamic (decreased corticotropin releasing factor)
Primary symptoms: shock, abdominal pain, fever, hyperglycemia, hyperpigmentation, fatigue (chronic), weightloss (chronic)
Secondary symptoms: no hyperpigmentation, hypotension, hyponatremia, hypoglycemia, less GI
Amebiasis
Entamoeba histolytica
Fecal-oral transmission
Liver abscesses = non-surgical, bacterial superinfection uncommon
Alk phos and AST/ALT elevated
Tx: metronidazole 750 mg TID x 1 week –> paromomycin/iodoquinol/diloxanide furoate
Anterior cord syndrome
Loss of motor, pain/temperature and bladder control
Hyperflexion injuries
Mallet finger
Disruption of the extensor tendon at level of DIP
Hyperflexion of DIP
Tx: splint, refer for surgical repair
Jersey finger
Disruption of FDP at level of DIP
Extension at DIP (like grabbing a jersey)
Gamekeeper’s thumb
Avulsion of ulnar collateral ligament (UCL) at thumb-MCP joint
Forced abduction and extension
Tx: thumb spica, refer for surgical repair
Erythema multiform
Target lesions
Most common cause = HSV
Common bacterial cause = Mycoplasma penumoniae
Schistosomiasis
Flu-like illness: fever, cough, HAs myalgias
*eosinophilia
Late complications: cirrhosis, renal failure, pulmonary complications
Tx: Praziquantel
Wallenberg syndrome
Lateral medullary infarct
Sx: disequilibrium, vertigo
Ipsilateral Horner syndrome (anhydrosis, mitosis, ptosis)
Ipsilateral limb ataxia
Loss of pain/temperature contralateral limb
Hearing intact vs acoustic neuroma (hearing loss)
Causes: vertebral artery dissection or atherosclerosis
Cyanide poisoning mechanism
Inhibition of oxidative phosphorylation causes lactic acidosis
Tx: sodium nitrite, sodium thiosulfate, hydroxycobalamin
Avoid nitrites in concomitant CO poisoning
CN III palsy clinical findings
Down and out
If pupillary sparing –> CVA
Ciguatera vs scromboid
Ciguatera: GI symptoms (N/V/D, crampy abdominal pain) and neuro symptoms (perineal paresthesia, cold allodynia, numbness) –> tx = supportive
Scromboid: histamine-like toxin –> flushing –> tx = anti=histamines
Prinzmetal angina
Vasospasm
Can be relieved with exercise
Tranexamic acid
Use in hemorrhagic shock due to trauma
Best to give within 3 hours
Decrease in mortality without increase in thrombotic events
Middle cerebral artery stroke
contralateral arm/face > leg weakness, ipsilateral homonymous hemianopsia, dysarthria, aphasia
CN III -oculomotor
Levator palpebrae Superior and inferior rectus Medial rectus Inferior oblique Pupillary constrictor Palsy --> ptosis, "down and out" Pupil sparing = infarct Mydriasis = mass, aneurysm
Myxedema coma
Hypothermia
Non-pitting periorbital edema
“hung-up reflexes” - delayed relaxation phase
Parethesias
Median nerve palsy
Hyponatremia, hypoglycemia, hypoventilation
Goodpasture syndrome
Glomerulonephritis and diffuse alveolar hemorrhage
Digoxin toxicity rhythm disturbances
PVCs = most common
pathognomonic = bidirectional tachycardia and atrial tachycardia with AV block
Tx: digibind
Missed abortion
Intrauterine demise with retained products Vs incomplete (some tissue expelled)
Magnesium toxicity
Decreased DTRs, decreased respiration, decreased CNS
Reactive arthritis (Reiter syndrome)
Arthritis, urethritis, uveitis/conjunctivitis
Common after chlamydia or shigella, campylobacter or yersinia infection (GI or GU infections)
Seronegative spondyloarthropathies - ankylosing spondylitis, psoriatic arthritis, reactive arthritis and arthropathy of IBS –> commonly affect SI joint, *RA negative, *HLA-B27 positive
How long does it take for a G-tube to mature?
2-3 weeks
Septic arthritis pathogens
Staph aureus, Gp A strep, strep pneumo, neisseria gonorrheae (young adults)
Body fluid analysis – low viscosity, low glucose, WBC > 30K
Bacterial tracheitis (aka laryngotracheobronchitis or pseudomembranous croup or bacterial croup)
5-8 years old
Staph aureus, strep pneumo, strep progenies, H flu, mortadella catarrhalis
Abx and consult ENT
Mechanism of diabetes medications
Sulfonlyreas - stimulate pancreas to release insulin –> hypoglycemia
Insulin -stimulates tissue uptake of glucose, suppresses hepatic gluconeogenesis, suppresses peripheral lipolysis
Metformin - cause lactic acidosis
Jarisch-Herxheimer reaction
Treating syphillis with PCN –> endotoxin release –> fever, rigors, hypotension, tachycardia
Neurosyphillis
Meningitis, dementia, neuropathy
Argyll-Robertson pupils (accommodate but don’t react)
Tabes dorsalis (decreased sensation and DTRs lower extremities – affect dorsal column)
Tx: PCN
