IM mix UWQ - june 1st 2021 Flashcards
Exudative effusions
light criteria?
why glc decrease moa?
-> Glucose concentration decreased due to the high metabolic activity of leukocytes of bacteria in the fluid
Normal pleural fluid PH = 7.60
-> TRANSDUTE : Ph 7.40 - 7.55
- > EXUCATE: ph more acidic 7.30-7.45
- –> infection/ inflammatory/TB
- —> inc CAPILLARY PERMEABILITY!!! translocation cell and fluid from vasculature into peri-capillary space
- > Pleural fluid protein/serum protein ratio >0.5
- > Pleural fluid lactate dehydrogenase (LDH)/serum LDH ratio >0.6
- > Pleural fluid LDH >2/3 of the upper limit of normal for serum LDH
Hyperosmolar hyperglycemic state (HHS)
lab?
rx?
Glucose >600 mg/dL (frequently >1,000 mg/dL)
—-> total body K deficit!! excessive urinary loss
rx:
-> Aggressive hydration with NORMAL saline*
- > Intravenous insulin
- > Potassium replacement if level is <5.3 mEq/L
common variable immunodeficiency (CVID)
Abnormal differentiation of B cells into plasma cells → decreased immunoglobulin production
sym?
dx?
- > recurrent SINUSITIS / PN/ OTITIS infections and chronic lung disease @ diff regions of the lung
- > recurrent GI infection
- > Symptom onset in young adulthood (age 20-40)
dx: serum IG level
- > dec IgG, IgA, IgM
- > no response to vaccine
Acute spinal cord compression
sym?
dx?
MC loc @ thoracic spine
- > back pain and weakness,
- > LMN: Bilateral deficits at all levels below the area of injury, rather than deficits confined to a portion of one leg.
- > UMN + would also be present.
dx:
MRI
myelography
caud equina syndrome:
Compression of the lower sacral nerve roots
sym?
dx?
compression >2 Spinal nerve roots in lumber cistern
motor: affected dermatomes
- > reflexes absent
sensory deficits:
- > saddle anesthesia
- -> perineum and dysfunction of the urinary
- > rectal sphincters, bladder, sexual dysfunction
dx: MRI
L5 nerve root compression
sym?
etio?
dx?
common fibular neruopathy!!
etio:
-> injury, prolonged leg crossing, squatting
motor: FOOTDROP!!!
- > Foot PID (tibialis anterior)
- > Foot eversion (peroneus)
- > Toe extension (extensor hallucis and digitorum)
sensory:
- > Lateral shin
- > Dorsum of the foot
reflex: None
dx:
- > EMG
- > nerve conduction studies
chronic bronchitis, asthma
vs
acute bronchitis
lab?
CHRONIC bronchitis, asthma :
Normal DLCO
-> gas transfer btwn alveoli and pul capillary blood
dx:
PFT:
–> FEV1/FVC >70%
–> FVC < 80% predicted
ACUTE bronchitis: VIRAL
- -> recent URI: cough >5 days, yellow sputum
- > epithelial damage, slougthing , NO FEVER!!!
- > clx dx
- > Rx: symptomatic : NSAIDS, bronchodilators
- > NO Ab
Emphysema
lab?
Low DLCO
Plaque psoriasis
inc asso with HIV !!!
sym?
rx?
- > Nail pitting!!!!! ONCHOLYSIS
- > Conjunctivitis,
- > uveitis
- > Psoriatic arthritis (DIP) !!!! SAUSAGE FINGERS!!!
- > scaly, erythematous plaques (hand, scalp…)
-> Köbner phenomenon : dorsal surface caused by frequent minor trauma
rx:
1. topical :
- > high-potency glucocorticoids,
- > vitamin D analogs,
- > tar, retinoids,
- > calcineurin inhibitors, tazarotene
-> Ultraviolet light/phototherapy
Systemic: severe >5% BSA
- > methotrexate ( folate antimetabolites) ,
- > calcineurin inhibitors, retinoids, apremilast,
- > biologic agents (etanercept)
SLE
lab?
rx?
lab:
- > lowering C3, C4 levels
- > ANA ( SENSITIVE)
- >
- dsDNA Ab (specific)
- > IC deposit in subepithelial space -> nephrotic syndrome
sym:
-> multisystem, inflammatory dx with arthritis and arthralgias.
!!! -> Joint inv are symmetric, migratory, and nonerosive with brief morning stiffness
-> butterfly, malar rash, DISCOID rash ( dermal atrophy + scarring)
- > pleurisy, pericarditis : MR : nonbact thromboitc endocarditis
- > peritonitis
!!! -> thromboembolic event : hypercoagulable state!!!! EMBOLISM, SCD —> Splenic infarction!!!
- > seizure, psychosis
- -> scarring alopecia !!!
dx:
echocardio
rx:
hyroxychloroquine: se/ RETINOPATHY!!!!
conus medullaris compression
sym?
- > Perianal anesthesia and bowel/bladder dysfunction
- > upper (not lower) motor neuron signs in the lower extremities.
diffuse esophageal spasm
sym?
dx?
rx?
sym:
- > spontaneous pain, odynophagia for cold and hot food
- –> NON cardiac chest pain + DYSPHAGIA
—> UNCOORDINATED, simultaneous contraction esophageal body
rx:
-> Nitrates + CCB
dx:
- > Resolution of her chest pain after taking NG
- > Esophageal manometry
GERD
sym? dx? moa? rx? hx? risk?
sym
-> burning discomfort (heartburn) rather than radiating pain
asso with esophagitis on endoscopy
-> sore throat , morning hoarseness, worsening cough only at night
-> need inhaler following meals
dx: endoscopy w/in 24 hrs !!
hx:
- -> symmetric , circumferential narrowing Barium swallow
rx: PPI
comp:
- > Barrett’s esophagus + esophageal strictures !!!
risk: chronic gastric acid exposure
- > radiation , sys sclerosis, caustic ingestion
Hazard ratio?
–> median survival asso for time-to-event outcomes
> Hazard ratio > 1 signifies an event is more likely to occur in the treatment group.
- > ratio = 1 implies little difference between the 2 groups.
- > CI contains the null value of 1, indicating that there is no significant difference
1- HR = benefits
brain death
sign?
dx?
absence all CN reflexes, coma
-> absence pupillary light rxn
-> + DTR : movement from SC –> monosynaptic patellar reflex still observed
dx:
1. + apnea test: confirms absent resp response
- EEG: silence
- absent IC blood flow
somatostatin analogs eg. octreotide
rx?
- variceal ACTIVE bleeding (DILATED esophageal vessel) - > Etho induced cirrhosis
- RISK of hemorrhage:
rx: nonselective beta blocker!!
- -> dec progressive to large varices : dec adrenergic tone mesenteric arterioles : vasoconstriction + dec portal venous flow !!!
dx:
endoscopy within 12 hrs
—> endoscopic variceal ligation
COPD
–> Supplemental O2 improves hypoxia causes?
moa?
brain?
- Loss of compensatory vasoconstriction in areas of ineffective gas exchange
- -> worsens V/Q mismatch - INC in oxyhemoglobin reduces the uptake of CO2 from the tix
- -> Haldane effect - DEC resp drive + slowing of the RR
- -> reduced min vent - brain: inc CO2 -> inc brain GABA and glutamine –> change in consciousness
- hypercapnia -> reflex cerebral vasodilation –> seizure
inc risk:
- > hypertrophic pul osteoarthropathy
- -> CLUBBING + arthropathy + LUNG Ca!!!!!
** met alkalosis (kidney inc HCO3 retention) + resp acidosis ( co2 retention)
right-sided infective endocarditis
etio?
sym?
rx?
IV Drug user
risk:
- –> ischemic cerebral septic emboli stroke!!!
- -> IC mediated glomerulonephritis : RBC cast, pnuria
sym:
tricuspid regurgitation
–> holosystolic murmur inc with inspiration
rx:
VNC (emp rx)
- –> PNC G : naive valve viridans streptococci
- -> aminoglycoside: native valve IE
clindamycin
rx for?
cellulitis MRSA
- -> slowly spreading rash, warm, tender, erythematous with flat, indistinct broader
- > fever, lymphangitis
** dental procedure prophylaxis
Recent cardiac catheterization
causes?
sym?
rx?
atheroembolism (cholesterol embolism)
- > ATS plaque disrupted and cholesterol crystals and debris in circulation
- -> AKI
- -> ischemia and necrosis limbs
- -> blue toe syndrome
- > levedo reticularis
- > acute pancreatitis attacks
- -> self improve 4-7 days
rx: supp care, IV fluid, statin
Management of salicylate toxicity?
- Hemodialysis
- > severe ingestion causing shock, CNS dys, cerebral edema, seizure, pul edema, ARF/CRF - IV NaHco3
- > large voln needed - Activated charcoal: give within 2 hrs acute ingestion
acetazolamide
rx for?
moa:
- > carbonic anhydrase inhibitor with diuretic effects, alkalinizes urine,
- > contraindicated in patients with salicylate toxicity.
- > increasing urinary HCO3 loss
- > lowering arterial pH, allow salicylate diffusion into the CNS, increasing its neurotoxicity.
Furosemide
mannitol
rx for?
furosemide: used in congestive heart failure)
** mannitol: used in cerebral edema
beta blockers
se?
unopposed: Alpha + –> inc glc uptake , weight gain, risk T2DM
Rx:
first line rx for anginal sym: reducing myocardial oxygen demand thru -> dec in HR + contractility
lobar Pn
breath sound?
dullness to percussion
- > inc Breath sound!!
- -> sound conducts rapidly thru solid
–> inc tactile fremitus , egophony + , crackles
** pleural effusion (fluid) : dullness + dec/absent breath sound !!!
warfarin-associated IC Hemorrhage
- > left thalamus with intraventricular extension
- > BG putaminal (MCA)
rx?
CT:
White lesions @ internal capsule
etio:
-> HTN vasculopathy: small penetrating branches: Charcot- bouchard aneurysms
12-24 hr to be effective
-> intravenous vitamin K
rapid (minutes) and short-term (hours) reversal of warfarin
- > Prothrombin complex concentrate (PCC)
- -> vitamin K-dependent clotting factors (eg, II, VII, IX, X)
Tissue plasminogen activator
rx?
ischemia stroke by blood clots
CT: Black lesions
orthostatic hypotension
sym?
etio?
presyncope
POSTURAL decrease by > 20 SBP / 10 DBP
normally:
arterial BARORECEPTOR inc SNS -> vasoconstriction, inc HR
etio:
- > autonomic dysfunction: PD, DM
- -> degenerative changes to autonomic ganglia / cns nuclei -> impair release NE / vasoconstriction
BPPV
sym?
rx?
–> BRIEF (<1 min), episodic peripheral vertigo triggered by head position changes (eg, looking up, bending down)
*** NOT cause HA!!!!
rx:
dix-hallpike maneuver
Arthropathy of hereditary hemochromatosis
etio:
- > onset age <40 with OA
- > 2/3rd MCP joints
moa?
sym?
XR?
rx?
asso with:
- > DM
- > inc liver enz
moa:
inc intestinal IRON absorption , iron deposition
sym:
- > elev liver enz
- > elev ferritin, transferrin saturation
- > HFE genetic mutation
XR:
-> Joint space narrowing
!!!! -> Chondrocalcinosis
-> Hook-shaped osteophytes at metacarpal heads
rx:
- > NSAIDS, APAP
- > prevent other complication: Phlebotomy
primary hyperaldosteronism (Conn syn)
lab?
rx?
- > dec renin
- > inc aldosterone
—-> MORE common: UNILATERAL adrenal adenoma !!!!
dx:
early morning plasma ALDO concentration ( PAC) : plasma renin activity ( PRA) ratio
!!! ratio > 20 & plasma aldo > 15 –> primary hyperaldo!!!!
- > inc Na ( inc Na excretion aldo escape)
- > dec K
- > inc Hydrogen into urine ( dec H+)
- > inc Hco3 ( METABOLIC ALKALOSIS)
rx: unilat: surgery
- > aldo antagonist ( spironolactone, eplerenone)
arsenic toxicity
sym?
rx?
- > polyneuropathy
- -> stocking-glove distribution with burning, painful hypersensitivity, distal weakness, and hyporeflexia.
- > pancytopenia
- > hepatitis: mild transaminase elevation
- > SKIN lesions:
- -> Hypo- and hyperpigmentation
- -> hyperkeratosis and scaling of the soles and palms
- -> Mees lines (horizontal striation of fingernails)
rx:
- > dimercaprol
- > dimercaptosuccinic acid
Acute intermittent porphyria
AD
sym?
lab?
sym:
partial deficiency of porphobilinogen deaminase
sym: 5P’s
- > port-wine urine
- >severe abdominal pain
- > psy: acute , intermittent neurovisceral attack
- > polyneruopathy
- > precipitate by drugs
lab:
elev porphyrin, ALA, PBG
hypoNa ( SIADH)
** lead poisoning: fatigue, joint pain, anemia, NOT hypoNa
Chronic lead poisoning
sym?
lab?
rx?
sensorimotor neuropathy in a stocking-glove distribution along with microcytic anemia
- -> motor wkness ( wrist/ ankle drop)
- > GI pain
- > anemia
- > psychosis
lab:
microcytic anemia
basophilic stippling: impair purine met –> hyperuricemia
—-> disrupt HEME SYNTHESIS
-> skin changes NOT usually seen.
rx:
chelation: Ca Disodium EDTA
Pul HTN due to LVSD
rx?
LVSD -> reduce EF -> pul edema
rx: loop diuretics ACEi beta blockers aldo antagonist
Pul HTN -> idiopathic symptomatic
rx?
- > Endothelin receptor antagonists (eg, bosentan)
- > phosphodiesterase-5 inhibitors (eg, sildenafil),
- > prostanoids (eg, epoprostenol)
Blastomyces dermatitidis and Histoplasma capsulatum
sym?
loc?
loc:
- > central and midwestern states
- –> bat cave dropping
sym:
- > Blastomyces acute or chronic pneumonia!!!!
- > often with skin lesions, LAD
- >longer incubation time (3-6 weeks)
** histoplasma urine Ag testing: -> NON-CASEATING GRANULOMA !!!!! narrow -based budding yeasts
!!! —-> Mississippi
!!! —-> bilateral hilar adenopathy
- > rx: Amp B ( severe)
- > itaconazole ( mild/ maintenance)
Coccidioides
loc?
sym?
loc:
-> desert southwest ( california, arizona)
sym: lasting >1 wk
- > community-acquired pneumonia (CAP) (fever, chest pain, productive cough, lobar infiltrate)
- > arthralgias, erythema nodosum, or erythema multiforme
rx:
CAP: cefariaxone + azithromycin / doxycycline
idiopathic Intracranial HTN
/ pseudotumor cerebri
sym?
dx?
rx?
sym:
- > elev CSF pressure
- > papilledema
- > N6 palsy
- —> impaire absorption CSF arachnoid villi : risk BLINDNESS!!!!
dx: LP : elev opening pressure
rx:
- > WL
- > acetazolamide
- > inhibits choroid plexus carbonic anhydrase -> dec CSF production and ICH
Myasthenic crisis
sym?
rx?
risk?
- > intubation!!
- -> deteriorating respiratory status
- -> diaphragmatic impairment + RESP FAILURE ( resp acidosis)
- -> bulbar wkness , dysphagia !!!!
-> Plasmapheresis or IVIG + corticosteroids
risk:
- > quinolones, macrolides, beta blockers
- > infection (UTI)
- > surgery, pregnancy
Infective endocarditis
etio?
comp?
dx?
etio:
- prosthetic valves/ Implant device: MC: s. aureus + staph epidermidis !!!!!
rx: PNG - DENTAL procedure: Viridans strep (S. sanguinis, S. mitis, S. orilis, S. mutans, S. sobrinus, S. milleri)
- Nasocominal UTI: Enterococci !!!!
comp:
- > perivalvular abscess : heart block !!!
- -> AR : early diastolic murmur @ left sternal border
B/C from 3 diff venipuncture sites
prior Rx
-> TEE
** *LYME dx: less affect valve : AR less likely
hypothermia
rx?
- mild 32-35 -> active external rewarming tech
- moderate 28-32
- severe <28
- -> active internal rewarming (pleural / peritoneal irrigation)
- —> comp: hypotension, areflexia, coma, malign vent arrhythmia ( vent fib) , acidosis ( hypoventilation)
eg. warm blankets, warm baths, warmed IV fluid: target 1-2 c/hr
aspirin-exacerbated respiratory disease (AERD)
sym?
- asthma (often severe and presenting in adulthood)
- bronchospasm or nasal congestion following the ingestion of aspirin or NSAIDs.
- chronic rhinosinusitis with nasal polyposis.
telogen effluvium (TE)
sym?
etio
- -> IDA
- -> stressful event
Hair follicles pass through 3 phases:
- Growth phase (ANAGEN; 90% of follicles): proliferative hair follicles target this phase!!
- —-> CMT - Transformative phase (catagen; <1%): regression + apoptosis
- Rest/shedding phase (TELOGEN; 10%) -> induced by stressful event/ pregnancy!!!
autosomal dominant polycystic kidney disease
sym?
- flank pain, with/ without hematuria, flank mass
- HTN
- polyuria, nocturia
- renal dysfunction -> CKD
- -> CKD inc risk with CVD
asso with:
- > liver cysts
- > cerebral aneurysms
drug ind myopathy
sym?
lab?
- > Progressive proximal muscle weakness & atrophy without pain or tenderness
- > Lower extremity muscles are more involved
ESR normal
CK normal
Polymyalgia rheumatica
sym?
lab?
dx?
rx?
- > Muscle pain & stiffness in the shoulder & pelvic girdle
- > Tenderness with decreased range of motion at shoulder, neck & hip
- ——> inc RISK : GIANT cell arthritis ( GCA) : inc ESR
- –> 10-20% AORTIC ANEURYSM + BLINDNESS!!
- –> > 50 YR
- –> Dx: temporal artery BIPOSY!!
Rx -> rx not delay!!
Responds rapidly to LOW dose glucocorticoid in days
lab: ESR inc
CK normal
dx: ISOLATED Polymyalgia rheumatica , no GCA: dx with ESR + CRP: NO additional studies needed !!!
thyrotoxicosis
toxic adenoma
multinodular goiter
lab?
moa?
hyperplastic cells in toxic adenoma and toxic multinodular goiter
– > overproduce thyroid hormone autonomously without TSH stimulation
–> older Pt
- > inc T3, T4
- > dec TSH
dx: ----> MEASURE THYROGLOBULIN level: ddx -> elev : endogenous TH release -> dec : factitious/ exogenous
sym:
- > systolic HTN + inc pulse pressure
- > inc contractility + CO: AF/flutter
- > premature atrial /vent complexes
- > dec SVR
- > inc myocardial O2 demand
- > high output failure
- > exacerbation of preexisting low output failure
- –> coronary vasospasm
Comp:
- –> OSTEOPOROSIS: TH inc osteoclastic bone resorption!!
- > hyperCa, hypercalciuria !!!!
** sensitive to catecholamine : inc expression beta-1 adrenergic receptor activity !!!
NOT stimulate production !!!
RAIU:
INCREASE NODULAR pattern
Graves dx
moa?
lab?
rx?
moa:
thyroid-stimulating autoantibody-induced T cell activation of TSH receptors on thyroid follicular cells + Thyrotropin receptor AB ( TRAB) on TSH receptor on retro - orbital fibroblasts + adipocytes
RAIU: DIFFUSE!!!!
rx:
- > Beta blocker ( dec T4- T3 conversion): rx CV arrhythmiam HTN
-> methimazole (agranulocytosis, teratogenic 1st trimester, cholestasis)
-> PTU
——-> se/ hepatic failure, ANCA vasculitis)
!!! -> radioactive iodine ( worsening opthalomopathy: inc TRAB titer
——> glucocorticoids used to prevent
-> thyroidectomy
subacute (de Quervain) thyroiditis
silent thyroiditis,
transient hyperthyroid phase
chronic lymphocytic (Hashimoto) thyroiditis
lab?
moa?
Release of excess PRE-FORMED thyroid hormone:
self limited hyperthyroid phase
dx: thyroid nodules
- -> serum TSH !!!
- -> thyroid u/s
- —> thyroid peroxidase autoAB ( anti-TPO)
RAIU: markedly REDUCED!!!
comp: INC risk MISCARRIAGE!!!
rx:
Beta blockers : control palpitation
-> sys glucocortioids
acute cholangitis
sym?
hx?
dx?
rx?
–> ascending infection asso with biliary OB ( choledocholithiasis, biliary stricture)
charcots traid:
-> fever, RUQ pain, Jaundice
hx:
dilation of intrhepatic and CBD
lab:
inc direct hyperbilirubinemia , inc ALP, GGT
dx + rx:
- > Ab, drainage
- > ERCP with sphincterotomy
acute cholecystits
hx?
thickening GB WALL and pericholecystic fluid : cystic duct Ob
lab: NO elevate bilirubin / ALP
- -> AST, ALT <1000
dx: HIDA SCAN
Confidence interval with inc 90% -> 95% ?
wider CI
- tighter the CI = more precise the results
- > inc sample size INC precision
BPH, mc bladder outflow ob
dx?
rx?
sym:
urinary retention
dx:
u/a
urinary u/s
rx: first line:
1. terazosin, tamsulosin ( a-adrenergic antagonist): relax SM bladder neck, prostate
- —-> combine with PDE-5 inhibitor!!!
se/ orthostatic hypotension!!!!! , dizziness
- 5-a-reductase inhibitor ( finasteride, dutasteride): inhibit coversion testo -> DHEA
se/ dec libido, erectile dysfunction, SLOWER ONSET - AntiMus (tolterodine) : overactive bladder ( Urinary freq, urgency, incontinence)
se/ urinary retention, dry mouth
Detrusor sphincter dyssynergia
moa?
sym?
moa:
simultaneous activation of the detrusor muscle and the urethral sphincter, resulting in BOO.
-> neurologic disorders (eg, spinal cord injury, multiple sclerosis)
Poor urethral sphincter function
moa?
sym?
Result in stress incontinence with urinary leakage,
-> NOT urinary retention.
onychomycosis (tinea unguium)
vs
tinea cruris
vs
tinea manuum
vs
tinea capitis
sym?
dx?
rx?
tinea unguium:
-> extensive thickening and discoloration of the toenails
-> Trichophyton rubrum
tinea Cruris:
—> jock itch!!
tinea manum:
- -> puritic, scaly patches on palms / annular plaques with raised border on dorsum
- -> DOES NOT improve with emollients
tinea capitis:
-> sup dermatophyte inf , scaly, erythematous, patches hair loss, prominent itching + tender LAD
dx: KOH
need SKIN INSPECTION : autoinfection + reexposure
rx: antifungal - topical:
- > terbinafine
- > MICONAZOLE
- > griseofulvin
ovarian teratoma strongly suggest ?
dx?
anti-NMDA receptor (anti-NMDAR) encephalitis
dx:
presence of CSF Ab to the GluN1 subunit of the NMDAR.
sym:
1. psychiatric symptoms (eg, anxiety, psychosis, insomnia)
- autonomic instability (eg, hyperthermia, hypertension, tachycardia)
- cognitive impairment, rigidity, hyperreflexia, dystonia, and focal seizure
CMV
lab?
- > Autoimmune hemolytic anemia and thrombocytopenia,
- > IgM cold agglutinin Ab cause complement-mediated destruction of RBC
- > jaundice
- > elev bilirubin, and inc RETICULOCYTES count
Plasmodium vivax causes malaria
sym?
- > cyclic fever
- > jaundice,
- > hepatosplenomegaly, and anemia
dystonia
sym?
- > sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures
- > Torticollis can be congenital, idiopathic, secondary to trauma or local inflammation, or drug-induced.
Autoimmune hemolytic anemia (AIHA)
lab?
- > A negative family history
- > positive Coombs test suggest AIHA
- > warm agglutinin IgG autoAb mediated
hereditary spherocytosis
lab?
dx?
- > strong family history
- > negative Coombs test.
- > inc MCHC !!!!
rx: inc osm fragility : acidified glycerol lysis test
- > abnormal eosin-5 maleinide binding test
syphilis
sym?
rx?
-> dorsal columns (tabes dorsalis) and causes sensory ataxia
2ndary :
- -> episodes of severe pain that may affect the limbs, trunk/face, and cause pupillary abnormalities
- -> maculopapular diffuse rash ( palm and soles)
- -> oral lesion
- -> condyloma latum: PAINLESS lesion with nonpurulent base, bilateral , painless LAD ( CHANCRE)
–> inc risk Aortic aneurysm !!!
rx: 10-14 days IV aqueous crystalline Penicillin G
-> alternate:
oral doxycycline 14 days
+ cefariaxone IV 14 days ( neisseria)
HIV-associated neurocognitive disorders
sym?
MRI?
Rf?
MRI:
diffuse brain atrophy, ventricular enlargement, and increased white matter intensity
Rf:
age >50, and CD4 count <200/mm3.
- Early impaired memory & attention/concentration
- Personality & behavior changes
- Motor symptoms (eg, ataxia, slowed movement)
Frontotemporal dementia
MRI?
sym?
MRI:
atrophy in the frontal and anterior temporal cortices
sym: 50-60 onset, EARLY personality change, compulsive beh
- > rather than increased white matter intensity.
*** vascualr dementia: cognitive impairment, focal neruo finding!!!
Progressive multifocal leukoencephalopathy
-> reactivation of the JC virus
MRI?
MRI:
well-delineated, asymmetric (rather than diffuse) PATCHY white matter lesion
anterior uveitis
sym?
sym: painful, red eye associated with photophobia, tearing, and diminished visual acuity
- -> iritis, HYPOPYON (aqueous humor), pupillary constrict
asso with:
IBD, sarcoidosis
- > uvea: tissue layer between cornea/sclera and the retina;
- > anterior uvea: consist iris and ciliary body
- > posterior uvea consists choroid
Episcleritis
sym?
acute redness and tearing with injection of conjunctival and episcleral vessels.
Lateral epicondylitis
rx?
- > Initial treatment: activity modification, counterforce bracing/strap
- > Refractory symptoms: short-term NSAIDs, corticosteroid injection, surgery
disseminated gonococcal
sym?
dx?
rx?
!!! -> tenosynovitis
- > asymmetric polyarthralgia
- > skin rash few pustules
dx:
- > det Neisseria in urine ,cervial , urethral, anal
- > proctitis: anal intercourse, prutitus, rectal pain
- > Joint fluid: WBC >50,000, PMN ( GN diplococci), opaque
rx: 3rd gen cephalosporin IV + VNC ( cover strep pn) + DOXYCYCLINE ( chylamydia)
rickettsia rickettsii
RMSF
sym?
lab?
- > 3-4 days of constitutional symptoms (eg, fever, myalgia, nausea, vomiting, headache)
- > MACULOPAPULAR RASH develops on the wrists and ankles, inv palms/soles, and progresses centrally.
- > noncardiogenic pulmonary edema (eg, bilateral rales) and shock
lab:
-> thrombocytopenia
!!!! -> hyponatremia
-> inc AST, ALT
rx: DOXYCYCLINE !!!
herpes encephalitis
sym?
lab?
MRI?
dx?
herpes rash vesicular
focal ACUTE neuro deficits
seizure, fever, beh change
** herpetic whitlow: gp vesicles on erythematous base
LP: lymphocytic pleocytosis,
!!!! inc RBC in CSF
MRI:
UNILATERAL temporal lobe lesions!!!
dx: PCR
Diabetes insipidus (DI)
etio?
lab?
nephrogenic DI @ renal CT –> blocks response to ADH!!!
etio:
lithium ( nephrogenic)
lab:
-> euvolemic hypernatremia
!!!
—> Urine Osm LOW ( diluted )
!!!! —-> Serum osm HIGH ( losing water -> concentrated)
——> low urine specific gravity <1.006 !!!!!
sym: severe polyuria, mild hypernatremia
** dehydration:
hyopvolemia + hyperNa
–> inc Urine Osm
epidural hematoma
rx?
etio:
-> MENINGEAL ARTERY tears due to trauma head injury
sym:
with neuro deficits
–> immediate surgery!!!
-> inc ICP
MRI: EYE shape biconvex
hypokalemia
etio?
ecg?
broad flat T wave, U wave, ST depression, premature ventricular beats
etio:
- > Diuretics K wasting ::
- > beta-2 agonist
- -> asthma exacerbation
- -> DIGOXIN TOXICITY
sym:
High dose Beta agonist
-> HYPOKALEMIA ( K shift into IC space + Na-K ATPase pump + NaKKCl cotransporter)
—> LOOP diuretics:
met ALKALOSIS with inc HCO3, loss H+/K/Cl
—> HIGH urine Cl cuz of the diuretic loss!!!!
- > dec DTR
- > muscle wkness
- > fatal arrythmia (VFib)
- > tremor
- > HA
dx:
FIRST : do ELECTROLYTES panel!!! r/o electrolytes + digoxin imbalance
ALS
sym?
etio: chronic inflammatory demyelinating polyneuropathy UMN + LMN sign
UMN + corticospinal tract + corticobulbar tract: hyperreflexia, spasticity, fasciculation !!!!
- -> denervation Ach receptor: longer receive input from NMJ -> hypersensitive to Ach and spontaneously discharge
- -> widespread fibrillation + positive sharp waves
LMN + : flaccid , wkness !!!!!
Bulbar sym: coughing, choking when eating !!!! , WL
- -> resp failure
- –> Reduce TLC, FVC
- –> FEV1/FVC normal
- –> DLCO: NORMAL ( extrinsic muscle wkness, not affect intrinsic lung parenchyma)
rx: non-invasive PPV
- > riluzole ( glutamate inhibitor)
Cyanide toxicity
etio?
antidote?
NO release: nitroprusside!!!!
- > RF
- > AMS, lactic acidosis, seizure, coma
hypertensive ER
rx: Na thiosulfate!!!!
TIA ( transient ischemic attack)
rx?
- -> TIA: internal carotid artery dissection ( young pt) : s/p sports injury/ fall
- -> EDS , OCP, smoking
–>demyelinating plaques MS
- > transiet <24hr
- -> false lumen , aneurysm , intramural hematoma
sym:
- > partial HORNER syn: ptosis , miosis, anhidrosis
- > tinnitus, carotid bruits
dx:
echocardio
–> if suspect EMBOLI, prosthetic valve thrombosis!!!
-> Ct / MR angiography
rx:
ASA ( give within 24 hrs) , statin , dec BP
restless leg syn
rx?
–> Supplement IRON when serum ferritin ≤75 µg/L
- Mild/intermittent symptoms:
- > supportive measures (eg, leg massage, heating pads, exercise)
-> Avoid aggravating factors (eg, sleep deprivation, medications)
- Persistent/moderate to severe symptoms:
!!!! rx: -> DOPAMINE agonists D2, D3 + (eg, pramipexole)
-> α2δ calcium channel ligands (eg, gabapentin)
MS , spasticity
vs
transverse myelitis
Mri?
Sym?
rx?
MRI: Subcortical white matter demyelination, periventricular
sym:
- > lhermitte sign + UMN
* * not affect LMN ( peripheral NS)
- > deficits takes days or weeks (not hours) to improve.
- >optic neuritis
!!!!!! transverse myelitis:
——> infiltration of inflammatory localizes to ≥1 contiguous SC –> rapidly progressive myelopathy
–> motor weakness, autonomic dysfunction (eg, bowel/bladder dysfunction), and SENSORY deficits with a DISTINCT sensory level!!!
dx:
-> MRI: no compression lesion, T2 HYPERINTENSITY
LP: inc WBC, inc IgG index
rx:
- > IV glucocorticodis
- > IVIG
- > Baclofen ( muscle spasity)
** LP NOT needed: -> when dx is clear!!! CSF: oligoclonal IgG bands
diffuse axonal injury
MRI?
moa
-> Sudden acceleration-deceleration or rotational forces during BLUNT MAJOR head trauma can cause shearing of the long, white matter tracts (ie, axons) of the brain.
MRI:
-> affects gray-white matter junction
- > numerous minute punctate hemorrhages in the white matter (ie, axons)
- > blurring of the gray-white interface (due to edema).
blunt head trauma
MRI?
- > tonsillar herniation
- > subfalcine herniation
- > lateral shift in midline st
SAH
etio? sym? comp? Mri? rx?
etio:
rupture berry saccular aneurysms
sym:
- > thunderclap HA
comp:
-> rebleeding within
first 24 hr
-> vasospasm + infraction s/p 3 days
dx: -> urgent noncontrast CT scan !!! -> LP r/o : xanthochromia -> MRI: white, hyperdense regions in the brain parenchyma ( basal cisterns)
rx:
-> CCB, endovascular therapy stenting
exertions syncope
etio?
cadiogenic syncope
- -> severe AS
- —> occur at REST without warning sym!!!
- > pulsus parvus and tardus ( delay slow raising and weak carotid pulse)
- > S3 heart sound
- > mid-late peak systolic murmur
dx: continous ECG monitoring : r/o Vent arrhythmia
cardioecho!!!
echo
sarcoidosis
sym?
dx?
rx?
- > hilar LAD, interstitial infiltrates ( restrictive pattern)
- -> dec diffusion capacity of the lung
- —> INC A-a Gradient : hypoxemia > hypercapnia ( LATE finding) !!!
- -> dec TLC, FRC, RV
- > inc elastic recoil
- > erythema nodosum : red nodules at shins
- > facial nerve palsy: reactivation neurotrophic virus ( HSV)
-> Bilateral parotid gland swelling
–> hypercalcemia
( 1-a hydroxylase +): inc intestinal Ca, Po4 absorption, inc renal reab Ca, Po4
-> dec PTH
—> NONcaseating granulomatous inflammation !!
-> hyperacusis
dx: CXR
- > bronchoscopy + biopsy
rx: prednisone
parotid gland tumor
sym?
painless intrparotid mass, cervial LN swelling
-> slow growing, UNIlateral
SAAG =?
serum albumin - fluid albumin
> 1.1 = water only, portal HTN
——-> inc hydrostatic pressure
<1.1 = absence portal HTN
——> inc capillary permeability
IE
sym?
arthralgia , fingertips pain
- > osler nodes
- > active urine sediment
acute pancreatitis
complication?
- -> referred visceral pain affecting back
- -> relief by leaning foward!!
- severe pancreatitis –> release local + pancreatic enz –> inc vascular permeability
- voln retroperitoneum
- systemic inflammation : sepsis , shock
rx: IV fluid
dx:
–> AMYLASE/LIPASE >3 x upper limit
NO NEED confirm CT!!
–> CT scan
D-xylose absorption test: NORMAL absorption!!! enz deficiency
comp:
pseudocysts -> 3-4 wks dev
LES
sym?
asymmetric muscle wkness, flutuating
UMN NOT present!!
rate control AFib?
rhythm control?
STABLE patient:
!!!! 1. RATE: digoxin , beta blockers, CCB (dilitazim) II, IV
–> se/ CCB: arteriolar dilation: inc capillary hydrostatic pressure + fluid extravasation into interstitium –> peripheral edema
- RHYTHM: used for unable to achieve adequate HR control / recurrent sym eposodes/ HF sym in LVSD
- -> amiodarone, flecainide (I, III)
UNSTABLE patient:
—-> persistent tachyarrhythmia:
hypotension, AMS, shock, ischemia shock, Acute HF
**electrial + cardioversion + ibutilide –> restore sinus rhythm
adenosine
rx?
vasodilator stress testing?
AV node
- > supraventricular tachy (PSVT)
- -> sudden onset, regular, narrow -complex tachycardia
- –> AVNRT : inverted P waves w.in QRS complexes
moa:
- -> INC PNS tone in heart !!!!! interrupt AV nodal reentry tachycardia pathway + terminate PSVT
- -> slowing AV node conduction + inc AV node refractory period !!
alternate rx:
-> carotid sinus massage
vagal maneuver
COLD water IMMERSION / diving reflex !!!!
Dx: vasodilator stress testing
–> marked INC BF in normal artery , dilate LESS degree in BF in STENOTIC arteries
vent tachycardia
ecg?
rx?
- –> abnormal electrical activity around ischemic scar tix / abnormal of vent conduction system
- —> AV dissociation
rx:
amiodarone/ lidocaine ( heme stable pt with wide QRS complex tachycardia)
–> cannon A wave : intermittent, prominent A waves
JVP:
>- A wave ( Rt atrial contraction TV close)
–> absent A wave AFib
-> C wave ( rt vent contraction against TV)
- > V wave ( rt atrial filling,)
- -> prominent V wave in TR
diverticulosis
sym?
lower GI bleeding in Adults
- -> painless, large Voln bleeding : bright red BLOOD !!
- > LH
dx: coloscopy
** hemorrhoids: LESS blood compare to diverticulosis
intravascular hemolysis
lab?
dx?
anemia - progressive
- > reticulocytosis ( inc RBC breakdown)
- -> fatigue, jaudice, dark urine
thrombocytopenia
smear: schistocytes ( helmet cells)
rx: TTE
TTP
lab?
ADAMTS-13: def plasma protease ( autoab formation)
Acute anemia (MAHA) !! !!!! pt < 10,000 ( schistocytes, normal PT, PTT, inc BT, inc reticulocytes) !!! AMS RF Fever
rx: Plasma exchange ( LIFE threatening!!)
- > steroids
- > rituximab
mix cryoglobulinemia
type 2, 3
etio?
syn?
lab?
etio: chronic HCV, HIV, SLE
IC deposits
- > palpable purpura ( thrombocytopenia)
- inc pt destruction, dec pt production, splenic sequestration
- > arthralgias
- > renal dx: hematuria, pnuria, glomeronephritis
Lab:
- > low C4 complements: inc risk impaired CELLULAR Immunity ( HIV dx)
- -> poxvirus
- > viral hep
rx: plasmophresis
Immunosuppression
type 1 cryoglobulinemia
lab?
dx?
dx: BM biopsy
serum pn
-> electrophoesis
-> neg RF -
left ventricular aneurysm
time frame?
s/p STEMI 5 days - several MONTHS !!
- > thin dyskinetic myocardial wall
- > @ LAD
- > persistent ST elevation ECG
dx: cardioecho
free wall rupture
time frame?
within 5 days- 2 wks
—> loc @ LAD
- > pericardial effusion with cardiac tamponade
traid: HYPOTENSION + muffled heart sound, JVD !!!!! - > shock, cardiac arrest
rx: PERICARDIOCENTESIS!!!
-becks traid:
fluid acc -> restrict VR to RV -> dec RV compliance -> shifts IV septum towards LV -> dec LV filling ( dec preload)
** contractility and HR is increased -> SNS + to maintain CO
-> @ LAD
papillary muscle rupture
time frame?
s/p 3-5 days MI
–> inv @ RCA
-> severe MR ( hypotension, pul edema, cardiogenic shock)
—> MR : soft murmur + NO palpable thrill
Prerenal azotemia/ AKI/ ATN?
sym? lab? etio? risk? rx?
AIN ** eosinophiluria, WBC casts, RASH
inc BUN/Cr >20:1
Urinary Na < 20
Low FeNa
!!!!! inc MET ACIDOSIS with AG–> Uremia
AKI: INtrinsic
-> drug induced: cocaine, statin, acyclovir ( direct renal tubule injury: intratubular Ob )
- > RHABDOMYOLSIS!!!!
- > crush injury
- > seizure
lab: dark urine
!!!!!! -> inc K, PO4, AST>ALT
-> inc CK >1000!!!!
-> dec Ca ( reduce PO4 clearance –> caPo4 salt formation)
- > urine sediment NONE
- –> HIGH URINE NA ( > 40 ) !!!!!!
inc risk:
- > acute compartment syn
- > persist to ATN: BROWN MUDDY granular casts ( not always present)
rx:
IV hydration
avoid NSAIDS : worsen vasoconstriction
Pul embolus
loc from?
etio?
dx?
rx?
Proximal : femoral , popliteal >90%
etio:
- > prolonged immobilization
- > atrial fib
- -> malignancy !!!
sym:
- > sudden onset dyspnea, tachycardia, hypoxia
- > pleural effusion : exudate + !! pleural irritation pain
dx:
!!! pericardial effusion: electrical alternans : amplitudes QRS complex vary beat to beat
—> WEDGE SHAPE , pleural based opacification!!!! HAMPTON hump
!!! pul emboli: ECG: S1Q3T3 HIGH A-a V/Q mismatch --> gradient on arterial blood gas ----> PAO2 - PaO2 >15 mmHg -> PaO2 < 70mmHg
dx: CT pul angiography
rx: EVALUATE FIRST for contra to anticoagulation!!! modified Wells criteria + GIVE prior dx !!!
- > LMWH ( EnoXaparin), fondaparinuc ( Xa inhibitor), rivaroxaban
- –> CANNOT be used in Renal failure + risk BLEEDING pt
–> UNfractionated heparin + warfarin bridge it : need to monitor aPTT
*** diffuse ST seg elevation on ecg: acute pericarditis !!!
Vent fibrillation
rx?
MCC : sudden cardiac death!!!!
–> LV systolic dysfunction EF < 30%
rx:
- > beta blockers, ACEI, diuretics
- > persistent : ICD
Stable: persistent, narrow (SVT) or wide QRS complex tacharrythmia: synchronized cardioversion
unstable/ pulseless: Defibrillation
==> following with Epinephrine every 3-5/min
paget diease of bone
sym?
hx?
lab?
- Bone pain & deformity
- > Skull: headache, hearing loss
- > Spine: spinal stenosis, radiculopathy
- > Long bones: bowing, fracture, arthritis of adjacent joints
- > Giant cell tumor, osteosarcoma
hx: OSTEOCLAST dysfunction
Increased bone turnover
-> X-ray: osteolytic or mixed lytic/sclerotic lesions
lab:
- > Elevated ALP
- > Elevated bone turnover markers (eg, PINP, urine hydroxyproline)
- > Calcium & phosphorus are usually NORMAL
rx: bisphosphonates: inhibits osteoclastic activity of bone, stabilize destructive bony tumor
osteomalacia/ rickets
-> vit D def
lab?
dec ca, PO4
inc ALP, PTH
hx: defective mineralization of osteroid matrix + epiphyseal growth plate
neuroleptic malignant syn
sym?
etio drug?
rx?
- > fever >40
- > confusion
-> muscle lead-pipe RIGIDITY Generalized –> rhabdomyolysis with inc CK + leukocytosis
- > autonomic instability
- —–> Central DA receptor bockade ( hyperthermia, dysautonomia)
——> disruption nigrostriatal DA pathway ( rigidity)
** withOUT: hyperreflexia
etio:
DA antagonist
–> haloperidol, olanzapine
rx:
- > supp care, BZD
- > BROMOCRIPTINE (DA agonist)
serotonin syn
sym?
etio drug?
moa:
SSRI- induced activation presynaptic 5HT1A –> inhibition serotonin release + NET decrease in serotonin level.
- > tremor
- > hyperreflexia
- > myoclonus
- > GI sym (vomiting, diarrhea)
- > autonomic dys: diaphoresis, tachycardia, HTN, hyperthermia
etio:
sertaline, citalopram (SSRI), tramadol (analgesic with serotonergic)
!!!! combine with MAOI –> Tranylcypromine, phenelzine, selegiline
rx:
- > supp care
- > cyproheptadine (serotonin antagonist)
- > BZD + ET if severe
social anxitey disorder (social phobia) / PANIC Disorder
vs
performance only anxiety
rx?
- *social anxiety
- > > 1 social situation for >6 months
dx:
-> CBT: exposure therapy: desensitization!!! first line rx
PANIC DISORDER
!!!!!! -> SSRI/ SNRI,
- *performance only:
- -> beta blockers
CBT
generalized anxiety disorder (GAD)
–> more than 1 sym for > 6 months
BZD w/drawl sym?
rx?
se?
—-> present with:
SOMATIC SYM!!!!
buspirone (partial serotonin agonist)
–> slower onset
CBT
SSRI
SNRI: inhibits NE + serotonin reuptake
eg. SNRI: Venlafaxine
- -> se: dose dependent HTN , sexual dysfunction
!!! –> DULOXETINE (SNRI) : rx: DM polyneuropathy
- BZD -> second line rx: risk of abuse , dependence, w/drawal
- —-> psychosis , anxiety , early rebound effect, insomnia
PTSD in kids
sym?
Duration: >1 month!!
-> nightmares
emotional
-> regulation struggles
rx:
- > CBT
- > SSRI, SNRI
- > Prazosin (alpha-1 adrenergic receptor antagonist) for nightmares: dec adrenergic hyperactivity
AD
lab risk?
ApoE4 allele inc risk
sym: dementia
- > early memory sym
- > late personality + beh change, apraxia
- > Urinary incontinence
MRI: medial temporal lobe atrophy
lab:
screen for B12, TSH, cbc
celiac disease
sym?
lab?
hx?
autoimmune dx
sym:
bulky, foul-smelling, floating stools
-> Vit D def ( osteomalacia, osteoporosis, rickets) : GRWOTH DELAY!!
- > length dep axonal polyneuropathy: distal, symmetric , stocking glove distribution
- > atropic glossitis, microcytic anemia ( IDA)
- —> INC risk with TYPE 1 DM!!!
hx:
villous atrophy
lab:
- > inc 2ndry PTH
- > dec Ca, Po4
- > IgA anti-tix transglutaminase
- > IgA anti-endomysial Ab
dx: D-xylose absorption test: CANNOT absorb in intestine , urinary: D-xylose level is LOW!!!
–> Biopsy confirmed celiac dx –> neg results on IgA Ab testing due to selective IgA deficiency !!!
Crohns disease
hx?
rx?
focal ulceration + transmural imflammatory sign on biopsy
-> aphthous ulcer + perianal skin tags + perianal fistulas
—> rectrovaginal fistula : cxn bowel + vagina
rx:
- > anti-TNF inhibitors
- > steroids
lastose intolerance
hx?
dx?
diet related diarrhea
impaired digestion and absorption of lactose : Postprandial GI dx
dx:
- > lactose hydrogen breath test
- > high osm gap >125
- > ph acidic stool
MAOI hypertensive crisis
sym?
when switch SSRI to MAOI need 2 wks WASHOUT period !!!
- > HA
- > HTN
etio: tyramine inhibits MAOI–> inc SNS adrenergic effects –> severe HTN
comp:
IC bleeding, stroke, death
reactive arthritis
etio?
sym?
rx?
Chlamydia trachomatis + GI infection
sym:
- > peripheral oligarthritis
- > enthesitis
- > conjunctivitis
- > urethritis
- -> urethral discharge/ ASX
- -> dx: NAAT, NO organism
- > oral ulcers
- > keratoderma blennorrhagicum
rx:
1. Urethritis: partners need to be RX –> reinfection is common!!!
2. oligoarthritis: NSAIDS ( diclofenac)!!!!!
glucocorticoid-ind myopathy/ leukocytosis
sym?
gradual wk-months
- > mobilization of marginated neutrophil !!!
- >
- immature neutrophil circulating (bands)
- > inhibit apoptosis
- > proximal progressive painless muscle wkness: CATABOLIC effect
- > cushing dx : HIRSUTISM
-> osteoporosis : Osteoblast apoptosis!!!
–> osteroporotic compression fracture: tenderness loc to vertebral bodies
methemoglobin
eg. Dapsone
sym?
antidote?
oxidized form heme -> limit oxygen binding ability -> cyanosis
–> cyanosis , dyspnea, tachycardia
rx: Methylene blus
CO poisoning
sym?
cherry lips, HA, confusion, nausea
cerebral hypoxia -> HA, confusion
- > lactic acidosis
- > hypoxic brain injury @ Globus pallidus
TCA toxicity?
eg. imipramine
sym?
rx?
moa: inhibit fast Na channels in his-purkinje system repolarization, prolong absolute refractory periods
!!! 1. CNS: AMS, seizure, resp depression
- CVS: tachycardia, orthostatic hypotension, prolong PR/QRS/ST, arrythmia
!! 3. antiAch:
-> DRY mouth, DRY SKIN, blurred vision, dilated pupils, urinary retention, flushing, hyperthermia
rx:
-> activated charcoal within 2 hrs ingestion
!!! -> NAHCO3 ( QRS widening/ vent arrhythmia)
-> O2, ET, IV fluid
MTX
toxicity?
folate antimetabolite -> inhibits dihydrofolate reductase
-> hepatoxicity : check HCV, HBV
- > macrocytic anemia
- > stomatitis
- > cytopenias
- > pul fibrosis ( restictive PFT)
Calcineurin inhibitors (eg, cyclosporine, tacrolimus
toxicity?
!!! neurotoxicity:
-> headache, seizures, tremor!!!! encephalopathy, and peripheral pain.
—> NEPHROtoxicity: hyperK, hyperUA, gout
—> se/ vasoconstrictive toxicity: AKI + HTN
–> glc intolerance ( inc insulin req) : impairs pancreatic islet cells
–> gingival hypertrophy , hirsutism , alopecia
–> GI disturbance
hydroxycholroquine
toxicity?
retinal toxicity
Tumor necrosis factor (TNF) inhibitors (eg, etanercept, adalimumab)
toxicity?
- > risk for reactivation of latent tuberculosis.
- > neutropenia
- > CHF
most common cause diabetic retinopathy?
** diabetic nephropathy
** Necrobiosis lipoidica
sym?
viteous hemorrhage
-> sudden loss of vision and onset of FLOATERS!!!!
- DM nephropathy:
- -> persistent albuminuria + / dec GFR
- -> proliferative diabetic RETINOPATHY (retinal neovasculization, hard exudates)
- -> persistent hyperglycemia
rx: ACEI
dx; 10g MONOfilament test
- *** GLYCEMIC control:
- -> imp microvascular : retinal, nephro
- -> does NOT reduce MACROvascular: stroke, MI
- *** NECROBIOSIS LIPOIDICA : confluent annular lesions : yellowish - brown hue , dilated BV, epidermal atrophy
- > pertibial skin
Retinal detachment
sym?
moa:
-> separation of the inner layers of the retina.
-> elevated retina with folds / tear
!!!! —> light flashes, FLOATERS, curtains across from visual field
–> start peripheral
asso with:
- > metabolic disorders (e.g., diabetes mellitus),
- > trauma (including ocular surgery)
- > vascular disease, myopia, or degeneration
central retinal vein occlusion
sym?
hx: HTN
sym:
-> PAINLESS loss vision
!!!! “blood and thunder”
-> disk swelling
!!!!!! -> venous dilation and tortuosity,
-> retinal hemorrhages
!!! -> cotton wool spots, AV nicking, copper wiring
Clostridium botulinum toxin
moa?
sym?
rx?
etio: canned foods, cured fish
eg. Soil botulism spores !!! from dust
moa: inhibits PREsynaptic acetylcholine release at NM junction
sym:
ACUTE onset with 36 hrs!!!!
-> Blurred vision, diplopia
-> Facial weakness, dysarthria, dysphagia
-> Symmetric descending muscle weakness
-> Diaphragmatic weakness with respiratory failure (resp acidosis, ph < 7.35, PaCO2 >40)
rx: botulinum antitoxin (equine serum heptavalent)
** MG: similar but papillary function spared!! more progressive onset
dilated CMP
decompensated HF
sym?
rx?
2ndry functional MR
–> peripartum CMP!!!
!!!! POOR heart contraction -> INC LVEDV/ preload
–> reflect back to LA + acute pul edema, HF, JV distention
—-> IMPAIRED myocardial RELAXATION/ inc LV STIFFNESS ( dec complicance)!!!
- -> dec CO
- -> compensate + RAAS (elev CVP) -> vasoconstriction afferent + efferent and Na retention to inc BV to maintain organ + tissue perfusion (ATII)
!!!!!!!! –> S3 gallop: reverberation of the walls : dilated LV during during passive filling phase DIASTOLIC + diffuse hyokinesis
!!!! -> dilation mitral valve annulus
—-> Vent DILATION ( ECCENTRIC hypertrophy)
-> lateral displacement papillary muscles -> taut stretching MV chordea tendineae
dx:
transthroacic echocardio!!!
rx:
diuretics , beta blockers
** does NOT cause sudden inc LA dilation / compliance –> chronic MR/ AR
MVP
moa?
etio: MC in dev countries
moa:
-> myxomatous degeneration of the mitral valve leaflets and chordae
- > mid systolic click follow by MR murmur
- > dec vent voln preload -> causes earlier click
- > inc preload ( inc venous return) : later click
male breast CA
risk?
dx?
risk:
- > Family history
- > BRCA 1/2
- > Abnormal estrogen/androgen ratio: Klinefelter syndrome ( primary hypogonadism)
- -> inc conversion testo -> estrogen/androgen ratio
- > obesity, cirrhosis, marijuana use
dx
- > Mammography
- > Biopsy: invasive ductal carcinoma (hormone receptor–positive) most common
Generalized convulsive status epilepticus
sym?
dx?
rx?
risk?
sym:
- -> EYE OPEN during episode
- > postictal confusion awakening
- Stabilize circulation, airway & breathing
- Benzodiazepines (repeat administration until termination of seizure activity)
- Begin antiepileptic drugs: FOSPHENYTOIN , PHENYTOIN, levetiracetam , valporic acid !!!!!
- EEG monitoring for refractory status epilepticus or failure to regain consciousness
risk:
- -> postictal lactic acidosis : skeletal muscle hypoxia , impair LA uptake
- -> self-limit 90 within mins
dx: observe and repeat exam in 2 hrs !!!
** MRI perform after:
inc risk cortical laminar necrosis ( HALLMARK)!!!
Postpartum blues
vs
Postpartum depression
sym?
rx?
postpartum blue -> 2-3 days resolves within 14 days!!!!
- > mild depression
rx: reassurance
postpartum depression -> 4-6 weeks (can be up to 1 year)
- -> hallucination, suicide risk
rx: - > Antidepressants, psychotherapy
- -> SSRI ( sertaline)!!!!!
hypovolemia hypoNa
moa?
indicates??
inc RAS -> inc Renin -> inc aldosterone -> inc Na reabsorption ( DEC URINE Na) !!! FeNa < 1 %
–> dec K ( due to excretion)
- > inc ADH -> dec serum Na: promotes water reabsorption –> causing dilutional hyponatremia
- –> UREA reabsorption!!!
indicates: HF!!!
high ADH remains till hypovolemia corrected
coxackievirus
sym?
hand-food-mouth dx
- > oral lesion
- > bilateral macular, maculopapular, vesicular rash
bloody diarrhea
etio?
- > E.coli
- > shigella
- > campylobacter
EHEC: shiga toxin
- > bloody diarrhea without fever
- > beef products
rx:
ciprofloxacin
rotator cuff tear follow injury
rotator cuff tendinopathy
sym?
wkness with active shoulder abd + ext rotation
Passive ROM normal!!
adhesive capsulitis
(frozen shoulder)
sym?
glenohumeral joint capsule chronic inflammation, fibrosis, contracture
-> reduction passive + active ROM
inc risk with :
DM, thyroid, chronic immobility
FAP
prophylaxix?
FAP > 1000 polys –> CRC develop
prop:
- > inc screening
** ASA has NOT shown reduction risk for CRC !!!
giardiasis
sym?
dx?
rx?
foul smelling stools, bloating
-> rural area
dx: stool antigen assay ( direct IF/ ELISA)
- > stool microscopy for oocyts + trophozoites
rx: metronidazole
corneal abrasion
sym?
nerve?
trauma
sym:
- > pain, photophobia
- > N5 lesion
dx: fluorescenin staining
** N7 -> facial , taste 2/3 tongue, lacrimation , salivation, eyelid closure –> sensory fibers supplying sensation of ext ear + nasopharynx
Milk-alkali syndrome
sym?
etio?
Excessive intake of Ca & absorbable alkali
- > Renal vasoconstriction & dec GFR -> AKI
- > Renal loss of Na & H2O
- > reabsorption of HCO3
etio:
-> thiazide ( alone will mild inc Ca, but not extremely), ACEI, NSAIDS
lab:
- > met alkalosis ( INC HCO3)
- > hypoPo4, hypoMg, hyperCa
- > suppress PTH
- —> INC CREATININE
ADHD
dx?
before age <12
— need teacher evaluation also!!! 2 settings!!!
rx: 1. methyphenidate
- -> DA reuptake inhibitor and stimuation of DA release
- > Beh therapy
!!!!! 2. ATOMOXETINE: NE reuptake inhibitors
—-> NON -addictive
- > se: dec app, WL, insomnia
- > age 4-5 yr: parent - child beh therapy
STEMI
rx?
** ischemia mycocardial scarring –> monomorphic VT
** primary PPX:
estimate 10 yrs risk of ATS CVD
RV MI -> inc RV preload -> RV dilation + JVD
- > dec LV preload
- > inc SVR
- > hypotension, dec CO!!!!!!
rx:
- > IV fluid
- > avoid: nitrates, diuretics, opioids : dec RV preload, worsen hypotension
- > beta blocker
- > ASA + P2y12 receptor blocker
- > anticoagulant
- > statin: inhibits HMG-CoA reductase ( rate-limiting enz IC biosynthesis cholesterol converts HMG-CoA –> Mevalonate)
- > PCI
dx:
transthoracic echocardiography!!!
persist hypotension:
-> Dopamine
** pacemaker rx: AV block 3rd degree
brain tumor
sym?
Dull headache associated with >1 of the following:
- Nausea and vomiting (due to increased ICP)
- Focal neurologic manifestations (due to tumor invasion or compression)
- Symptoms worsening during the night or with positions that raise ICP (eg, bending, coughing)
dx:
exam: Papilledema (enlarged blind spot)
inc ICP
MRI
vascular dementia
sym?
Mri?
- > sudden stepwise decline!!!
- > Early EXECUTIVE dysfunction: hemiparesis , pronator drift , romberg sign
- > risk factors ( age, HTN)
- > mild memory deficit
MRI: Cerebral infarction &/or deep white matter changes on MRI
Lichen planus
sym?
- > autoimmune CD8 T cell
- > pink or purple plaques and papules, lasting months, relapsing over years
- > associated with severe PRURITIC typically affects the volar surface of the wrists rather than the dorsum of the hands.
- > genitalia LP
- > oral LP
- > “Kobner phenomenon” lacy marking wichkam striae
- —> EROSIVE ORAL LICHEN PLANUS
-> Concurrent scalp lesions would be unusual.
asso with:
HCV
rx: glucoorticoids
** aphthous stomatitis ( cranker sores): painful ulcer, last days
WPW
sym?
rx?
Atrial fibrillation (AF) occurs in 10%-30% of individuals with WPW
—> aberrant / accessory bypass conduction pathway btwn atria + ventricules
ecg:
- > short PR interval
- > widening QRS interval
- > delta wave
rx:
1. Hemodynamically unstable: immediate electrical cardioversion
!!!!! 2. stable patients, RHYTHM control with anti-arrhythmic drugs: intravenous ibutilide or procainamide
** AV node blockers such as BB, CCB, digoxin, and adenosine should be avoided -> increased conduction through the accessory pathway.
Opioid intoxication
eg. Tramadol
sym?
lab?
rx?
mental status changes,
- > respiratory depression, and miosis ( not always present)
- -> dec central Resp drive ( hypoventilation)
->Hypotension, bradycardia, hypothermia, and decreased bowel sounds
lab:
- > resp ACIDOSIS: PaCO2 > 40 mmHg, hypercarbia
- > ph < 7.35
rx: naloxone ( acute)
!!!!! -> buprenorphine ( long term rx)
-> external rewarming after naloxone rx fails
GBS
sym?
dx?
rx?
etio:
-> Immune-mediated demyelinating polyneuropathy
!!!! -> Preceding GI (Campylobacter) or URI, HIV
sym: days- weeks!! NOT hours.
!!!! -> Paresthesia, neuropathic pain ( radicular pain: electric shock like sensation radiation from buttocks down the leg) : NOT DISTINCT UMN sensory level !!!
LMN +
-> Symmetric, ascending weakness ( flaccid)
-> Decreased/absent DTR
-> Autonomic dysfunction (eg, arrhythmia, ileus)
Respiratory compromise
dx:
- > Cerebrospinal fluid:
- > ↑ protein,
- > NORMAL leukocytes, RBC, glc
- > Abnormal EMG & nerve conduction
- > MRI: NORMAL !!!!
rx: IVIG or plasmapheresis
Pulsus paradoxus
asso with?
- > exaggerated fall in systemic blood pressure >10 mm Hg during inspiration.
- -> increased sys VR to the right heart causes the interventricular septum to shift into the left ventricular cavity, reducing LVEDV
- -> This leads to decreased SV, reduced SBP
Asso with:
asthma and chronic obstructive pulmonary disease (COPD).
** panic attack will not have pulsus paradoxus
acute cystitis & pyelonephritis in nonpregnant women
rx?
uncomplicated
vs
complicated
vs
pyelonephritis
UNcomplicated cystitis:
- Nitrofurantoin for 5 days
- TMP-SMX 3 days !!!!!! Narrower spectrum
- fosfomycin single dose
dx: NOT req routine CT!! reserve for 48-72 hrs not improved pt / gross hematuria / ob
COmplicated cystitis:
- fluroquinolones 5-14 days
- –> urine culture prior RX
Pyelonephritis: flank pain + tenderness + fever
lab: Nitrite (e.coli) + esterase ( pyuria)
OPD: quinolone
Inpatient: IV Ab
chronic liver dx
Vaccine?
- Tetanus
Every 10 years - Influenza
Annually - Pneumococcal
At diagnosis & at age 65
–> certain comorbid conditions that increase risk of pneumococcal disease (eg, chronic liver, lung, heart disease; diabetes mellitus; smoking). - Hepatitis A
Initiate series if not immune - Hepatitis B
Initiate series if not immune
Delusional disorder
sym?
subtypes?
rx?
- ≥1 delusions for ≥1 months
- Other psychotic symptoms absent or not prominent
- Behavior not obviously odd/bizarre; ability to function apart from delusion’s impact
- Subtypes: erotomanic, grandiose, jealous, persecutory & somatic
rx: CBT
Antipsy
- *schizotypal personality disorder: Related to schizophrenia
- > eccentric behavior and odd beliefs or magical thinking
eg. wear yellow suits - –> NO DELUSION/ HALLUNICATION!
Schizophreniform disorder
sym?
schizophrenia are present for ≥1 month but <6 months.
-> symptoms include ≥2 of the following: DELUSIONAL, HALLUNICATIONS, disorganized speech (eg, frequent derailment, incoherence), grossly disorganized or catatonic behavior, and negative symptoms (eg, flat affect, social withdrawal)
Dacryocystitis
sym?
- > infection of the lacrimal sac.
- > s. aureus, GAS
->occurs in infants / adults over the age of 40.
sym:
- > sudden onset of pain and redness in the medial canthal region.
- > purulent discharge from punctum.
Hordeolum
sym?
rx?
acute inf dx eyelash follicule / tear gland
–> lid margin
–> S. aureus
rx: warm compresses
- > persistent: incision + curettage
comp: chalazion ( residual granulomatous nodule –> regress slowly over months)
Chalazion
sym?
- > chronic, granulomatous inflammation of the meibomian gland.
- > hard, painless lid nodule.
new-onset atrial fibrillation
-> assessment of systemic thromboembolism risk
CHA2DVAS
rx?
total = 9
> 2 : high risk stroke –> oral anticoagulants
eg. LMWH: apixaban, rivaroxaban, dabigatran)
CHF HTN Age>75 *2 DM Stroke/ TIA/ thromboembolism *2 Vascular dx ( prior MI, PAD, aortic plaque) Age 65- 74 Sex (female)
- ** PAD inc risk CAD!!!
- -> rx: EXERCISE !!! + cilostazol
–> dx: Ankle brachial index ( ABI)
rx: !!!! DASH DIET!!! dec SBP: 11 mmHg -> smoking cessation -> exercise program -> Low dose ASA + STATIN : 2ndry prevent CVD
clozapine
(antipsy)
rx?
reserved for patients who have failed at least 2 antipsychotic trials due to the risk of agranulocytosis.
se: WG, metabolic sym, SEIZURE
- > neurotropenia/ agranulocytosis
- > myocarditis
ziprasidone
rx?
sec gen antipsy
-> LOWER meta risk compare to Olanzapine
se/ BLOCK DA -dep regulation prolactin secretion
—> TSH NOT affected !!!!
acute mountain sickness (AMS
sym?
rx?
Reduced PiO2 at high altitude (>2,500 m
-> AMS: HA, dec PaO2 -> inc CSF flow, hypoxic vasoconstriction , resp distress
rx:
O2, acetazolmaide
DXM ( dec cerebral edema)
descent to lower altitude
** diuretics furosemide-> rx edema from voln overload -> high altitude sickness : voln depletion-> shifted to IV space
Dopamine agonists (eg, pramipexole, ropinirole)
Levodopa
inc risk?
greater risk of PSYCHOSIS : extreme antipsy hypersensitivity !!!
rx:
1st: LOWER DOSE carbidopa-levodopa
-> low potency Antipsy:
-> DA-2 + serotonin 2A receptor blockade
eg.
quetiapine, clozapine, or pimavanserin
malingering?
vs
factitious?
malingering: M for Money! external gain
factitious: fake to be sick!!!
antidepressant rx
varenicline
vs
bupropion
moa?
when one SSRI not effective –> consider switch to SNRI
Varenicline:
- > smoking cession
- > a4-b2 nicotine ach receptor partial agonist
- -> se: dose dep HTN , SEXUAL DYSfunction
bupropion:
-> NE-DA
reuptake inhibitor
rx: MDD + SMOKING cession + WL + NO sexual dysfunction
–> se/ seizure from bulimia patients!!!
Rhino-orbital-cerebral mucormycosis
etio?
sym?
dx?
rx?
DM
sym:
- > necrotic spread to palate, orbit, brain
dx:
sinus endoscopy + biopsy + culture
rx: surgical debridement
- > amp B
latent tuberculosis infection (LTBI)
etio?
HIV
TST > 5 mm
–> req CXR + sym to r/o active TB
rx: latent TB
- > 9 mo : ISN + PYN
- MC etio:
- > endemic areas high risk
sym: TB in older pt
1. anemia ( chronic dx)
2. monocytosis
3. hypergammaglobulinemia ( elev total pn)
4. hypoalbuminemia ( + inflammatory cytokines, Acute phase reactant)
dx:
TST neg CANNOT r/o active TB inf!!!
CKD : inc risk of cell mediated immunity impaired: inc risk latent TB!!!!
Citalopram
SSRI
risk for?
dose dep- QT prolongation
Carbamazepine
anticonvulsants
risk for?
- > gastrointestinal (eg, nausea, vomiting)
- > dermatologic (eg, rash, pruritus),
- > neurologic (eg, drowsiness, blurred vision)
CKD with hyperK
rx?
ecg?
-> K>6.5: Urgent treatment (eg, CALCIUM gluconate, INSULIN plus glucose)
- > oral cation exchange agent (eg, patiromer, zirconium cyclosilicate:
- -> insoluble cpd bind K in colon exchange for Ca/ Na –> excreted in still and elimated K from body
ecg:
- > peaked T waves, widened QRS complex, conduction delay, arrythmia ( vent tachy)
Modafinil
rx?
- > narcolepsy
- > fatigue in ALS
ACEI
—> EC enz blocker
moa on DM?
Diabetic nephropathy
- -> !! inc albuminuria: Cr ratio!!! MOST sensitive
- —> MICROANGIOPATHY
- > inc glomerular hydrostatic pressure -> inc GFR
Glomerular hyperfiltration in early DM ( Glomerular BM changes) :
- inc afferent arteriole vasodilation (eg, natriuretic peptides, prostaglandins)
- efferent arteriole vasoconstriction (eg, angiotensin II)
- interstitial fibrosis , mesangial thickening, nodules ( Kimmelstil-Wilson lesion)
rx: slow progression DM -> blocking AT II mediated renal EFFERENT arteriole vasoconstriction
- -> reduce glomerular hydrostatic pressure !!!
mirtazapine
MDD rx
moa?
Se?
a2-antagonist : inc release NE + 5-HT, potent 5-HT2, 5-HT3 receptor antagonist , H1-antagonist
se: WG, inc APPETITE, sedation , dry mouth
tophaceous gout
moa?
etio risk?
- > hyperuricemia and precipitation of UA crystals in the joints, leading to episodic monoarticular arthritis
- > especially in the first metatarsophalangeal joint and knee
etio risk:
- > PCV ( myeloproliferative dx): inc urate production
- > inc red meat + seafood intake
- > inc fructose
- > inc Etho
- —-> recurrent ATTACK max in 12-24 hr !!!
–> rx PCV: phlebotomy, hydroxyurea ( if inc risk thrombosis)
PPX: weight loss!! lifestyle modify
Calcinosis cutis
moa?
- > deposition of calcium and phosphorus in the skin
- > whitish papules, plaques, nodules
eg. ear
Etho withdrawl
sym?
BZD
sym:
- > with 8-12 hrs after last drink
- > acute onset, restless, elevate BP, pulse , diaphoresis, tremor
- -> etho hallucination
- > seizure s/p 12-48 hr
- > delirium tremens s/p 48-96 hrs
BZD:
1. short: Midazolam, triazolam
!!! 2. INTERMITENT:
Clonazepam
Oxazepam, Alprazolam, Lorazepam,
- !!!! long: Diazepam, chlordiazepoxide, flurazepam
digoxin toxicity
sym?
drug interaction?
dx?
- cardiac: life threatening arrythmia
- -> atrial tachycardia with AV block ( affect PR interval, NOT QRS complex) : inc automaticity of conduction atria + inc vagal tone
- -> digoxin competes with K binding : hypoK inc digoxin binding –> worsen toxicity !!! - GI: anorexia, N/V, abd pain
- neruo: fatigue, confusion , wkness, color VISION alteration
- drug interaction:
- > amiodarone : inc digoxin toxicity
dx:
-> blood digoxin level
rx:
-> IV hydration, FAB frag digoxin spicecif- ab
Hodgkin lymphoma
sym?
dx?
inc risk?
-> early adulthood and in those age (15-35）
>60 yr
-> trigger by ETHO
risk:
SLE, IMS rx, EBV
sym:
- > painless lymphadenopathy in the cervical and/or supraclavicular chains ( mediastinal mass)
- > B sym
- > PURITUS
XR:
- > mediastinal mass
- > Positron emission tomography (PET) scan with 18-fluorodeoxyglucose (FDG): high Glc uptake
dx:
- > inc LDH
- > inc EOSINOPHIL
- > LN biopsy : reed-sternberg cells
inc risk:
-> lung CA
** aspergillus : preexisting lung cavity : cavitary mass with air in periphery , not SOLID lung lesion
BS ischemic stroke
etio?
sym?
dx?
etio:
-> carotid artery ATS with thrombosis / embolism
sym:
focal unilateral nero deficits “crossed sign”: ipsilateral CN , contralateral hemiplegia
- > acute onset
- –> central vertigo !!!! NYSTAGMUS NOT fatigable , not inhibited by fixation of gaze!!!
dx: head CT
- > MRI
!!!!!—> when change in conscious / neuro: REPEAT noncontrast CT scan of head !!!!
brain herniation
sym?
sym:
-> rapid increase in intracranial pressure (ICP)
-> diencephalon and midbrain become caudally displaced through the tentorium cerebelli.
sym:
- > unconsciousness
- > midsized , fixed pupils
- > abnormal limb posturing : disrupt descending tracts
- -> decorticate flexor posturing above red nucleus - > change to decerebrate extensor posturing BS injury progresses
scopion sting
sym?
- > neuronal membrane hyperexcitability that leads to uncontrolled, repetitive firing of axons.
- > fasciculations and jerking of the extremities rather than fixed, extensor posturing
- > awake and local pain
Strychnine, an ingredient in rodenticide
sym?
- > blocks inhibitory (glycine) neurotransmission within the SC
- > powerful, uncontrollable muscle contraction
- > fully awake patient
Tetanus
sym?
!!!-> BLOCK inhibitory interneuron neurotransmission within the SC –> painful muscle contractions
- > beginning in the head and neck (eg, trismus, lockjaw) and progressing to the rest of the body (eg, opisthotonus).
- -> resp failure
-> awake, and the pupils are not involved.
rx: Ab ( PNC)
tetanus IG
Salvage therapy?
treatment for a disease when standard therapy fails
-> recurrence Sx
Adjuvant therapy?
treatment given in addition to standard therapy.
-> radiation therapy given at the same time as the radical prostatectomy.
Induction therapy?
-> initial dose of treatment to rapidly kill tumor cells and send the patient into remission
Erythema nodosum
etio?
moa?
sym?
etio:
- > strep
- > IBD
- > sarcoidosis
- > rx
moa:
delayed-type hypersensitivity reaction to various antigens.
sym:
- > Tender, indurated, erythematous nodules
- > Most common on anterior legs
leukocytoclastic vasculitis
moa?
sym?
- > Cutaneous small-vessel vasculitis
etio: trigger by AB
sym:
- > presents as painful, raised, nonblanching, petechial or purpuric lesions (ie, palpable purpura).
Serum sickness
moa?
sym?
moa:
- > immune reaction against blood products or antigens from a nonhuman species (eg, chimeric mouse antibodies [rituximab, infliximab])
- > Rx induced
sym:5-`4 days s/p RX
!!!! -> fever, joint pain, and an urticarial or vasculitis-like rash
—> pnuria + diffuse LAD
thiazide diuretics
moa?
- > HYPONa, HypoK
- > hyper GLUC
- > dec insulin secretion + inc insulin resistance: syngertic for DM
- > increased LDL cholesterol and plasma triglycerides, and hyperuricemia.
binge eating disorder
rx?
CBT
SSRI: sertaline, lisdexamfetamine, topiramate
Anorexia nervosa
rx?
CBT
olanzapine
Bulimia nervosa
rx?
lab?
cognitive:
CBT
SSRI: fluoxetine
rx:
K + normal saline
lab:
met alkalosis , inc PH, inc HCO3
-> dec K, Na
schizoaffective disorder
sym>
- > MDD or manic episode + schizophrenia
- > history of delusions or hallucinations for ≥2 weeks in the ASBENCE of MDD/ manic episode
OCD
rx?
—–> time consuming >1 hr / day / causing sig distress !!!
SSRI
-> fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram
- > TCA clomipramine
- > CBT
dx: st abnormalities orbitofrontal cortex + BG
STD screening?
- > Neisseria gonorrhea (NAAT) : ceftriaxone
- > chlamydia trachomatis (NAAT) : doxycycline
- > syphilis (RPR)
- ——> VDRL: cardiolipin - cholesterol- lecithin antigen: NOT specific ( higher false negative rate)
- ——-> FTA-ABS : AB to specific treponemal Ag ( highest dx sensitivity in early primary syphilis)
-> HIV (4th gen ag/ ab)
women only: -> !!! Trachomanas vaginalis ( wet mount) : metronidazole
-> HSV if lesions
Cryptosporidium parvum + giardiasis
sym?
lab?
rx?
-> profuse, prolonged WATERY diarrhea
- -> contamined water , swimming
- –> HIV risk severe, chronic dx
lab:
- -> RARELY + leukocytes / blood
- -> NEED microscopy with specialized stain dx
rx:
spontaneous resolution 10-14 days
methanol poisoning
sym?
Optic disc hyperemia
–> blurred vison, epigastric pain, vomiting
ethylene glycol poisoning?
AKI- inc Cr damage tubule
rx: FOMEPIZOLE ( competitive inhibitor alcohol dehydrogenase)
- > prevents breakdown ethylene glycol into toxic met / integrals
- -> Hemodialysis
Glucagon-like peptide-1 (GLP-1) agonists
-> eg, exenatide, liraglutide
moa?
sym?
se?
moa:
- > regulate glucose by slowing gastric emptying
- > suppressing glucagon secretion
- > increasing glucose-dependent insulin release
sym:
- > decrease app
- > Weight loss
se:
-> nausea, bloating, abd pain
SGLT2 inibitor
eg. canagliflozin, empagliflozin
moa?
sym?
se?
moa:
- > increased renal excretion of sodium and glucose
- > LOWER blood glucose+ WEIGHT LOSS!!!
sym:
-> Decrease BP and Decrease risk of HF and cardiovascular events!!
se:
-> Hypotension, UTI
contra:
- > type 1 DM
- > DKA
- > renal failure: GFR <30
Sulfonylureas
eg, glimepiride, glipizide
moa?
sym?
moa:
stimulating increased insulin secretion; like insulin
se:
- > weight gain
- > risk of hypoglycemia.
- —> excess insulin: DOWN -regulation insulin receptor expression !!!
Thiazolidinediones
eg, pioglitazone
se?
moa:
- > decrease gluconeogenesis
- > improve insulin sensitivity
se:
- > fluid retention, edema
- > symptomatic heart failure
- > WG
nightmare disorder
sym?
sym:
-> recurrent episodes of awakening from sleep
!!! -> RECALL of highly disturbing and frightening dream content.
-> can usually be consoled.
-> Nightmares occur during (REM) sleep more frequent in the second half of the night.
sleep terror disorder
sym?
NON-REM arousal disorder
-> incomplete awakening
-> unresponsiveness to comfort
!!! -> NO recall of dream content
->1/3 of the night -> marked autonomic arousal and amnesia
rx:
- > reassurance
- > freq episode: low dose BZD
REM sleep beh dx?
repeated episodes of complex MOTOR beh / vocalization during REM sleep
–> related dementia with lewy body
tetanus vaccine and rx?
- revaccination tetanus w/in 5 yrs
- tetanus IG dirty wounds who have not previously received at least 3 doses of tetanus vaccine or whose vaccine status is uncertain.
CURB-65 criteria ?
Confusion Urea>20 Resp >30/min BP SBP<90/ DBP<60 age >65
Each 1 point:
1: low mortality: OPD
–> CAP: doxycycline
1-2: intermediate mortality: InPatient rx
3-4: high mortality: urgent inpatient admission
–> CAP: beta-lactam + macrolides/quinolone
>4: ICU
Ankylosing spondylitis (AS)
spondyloarthropathies
rx?
dx?
lab?
inc risk?
inc risk: -> AS !!! ---> ENTHESITIS ( achilles tendon pain) -> psoriatic arthritis -> reactive arthritis --> limited spinal motility !!!
- > Vertebral fracture : osteopenia/ osteroporosis: inc osteoclast activity : TNFa, IL-6 +
- > spinal rigidity
- > hyerkyphosis
Rx: first line
prostaglandin E2 inhibit:
NSAIDS, COX-2
alternate:
- > TNFa inhibitor ( progressive despite nsaids)
- > anti-IL-17
dx: confirm diagnosis !!
XR sacroiliac joints
lab:
HLA-B27 (not specific)
Clostridioides difficile infection (CDI)
etio?
sym?
lab?
etio:
- > recent hospitalization and severe comorbid illness IBD
- > adv age
- > PPI: gastric acid suppression, inc difficile proliferation
sym:
-> watery stools (≥3 episodes in 24 hours) with no frank blood or melena
lab:
- > leukocytosis
- > stool assay testing C. difficile toxins
* * abd CT : severe CDI ( adb distension, hypovolemia), susp perforation
rx: VNC/ fidaxomicin
Bronchiectasis
sym?
moa?
dx?
CF: prior adulthood!!!
related to:
—> CF : defect Cl + Na transport : impair mucociliary clearance
sym:
- > nonsmoking with chronic cough productive of large amounts of purulent sputum
- > hemoptysis, dyspnea!!!!!
- > exacerbation via bacteria
- > bloody diarrhea
- > pancreatic insuff ( malabsorption)
moa:
-> inf insult in comb with impaired bact
clearance ( immunodef st airway defect)
–> pseudomonas , upper lung lobe
dx:
cxr
high resolution CT scan
NNH= ?
NNT= ?
NNH= 1/AR
AR= rate rx- rate placebo
NNT= 1/ ARR
ARR = Risk control - Risk rx
RIsk control = # / total pop control
Risk rx= # / total pop rx
Abdominal aortic aneurysm (AAA)
dx?
-> one time abd u/s
risk:
- -> smoking, male, age 65-75
HIV vaccine prophylaxis?
-> antiretroviral therapy regardless of CD4 count to reduce HIV-related morbidity and death
—> VZV vaccine ( live attenuated virus): give to HIV pt CD4 >200 with low virulence infection after inoculation
——> NOT rxm CD4 <200 live vaccine: VZV, Zoster, MMP!!!
- > primary prophylaxis against Toxoplasma TMP-SMX only CD4 counts <100/mm3.
- > Primary prophylaxis against CMV not indicated regardless of CD4 count
- > used in some organ transplantation recipients (CMV-seropositive recipients).
cancer-related anorexia/cachexia syndrome
rx?
Progesterone analogues (megestrol acetate and medroxyprogesterone acetate) and corticosteroids
-> inc app + WG
glucocorticoid-induced psychosis
sym?
dx?
-> acute onset of psychosis (hallucinations) that is temporally
** delirium: wax and wane , poor attention + oriented
dx: first
URINE TOXICOLOGY screen !!!
first-time seizure in an adult
dx?
r/o
- > metabolic (eg, hypoglycemia, electrolyte disturbances)
- > toxic (eg, amphetamine use, benzodiazepine/alcohol withdrawal) causes.
-> ECG
somatic syn dx
def?
risk ?
rx?
—> > 1 unexplained sym; excessive thoughts, anxiety, heb response to sym
highest asso with:
-> sexual abuse, childhood neglect
rx: provide GOOD news that seious illness is r.o!!
rx:
schedule regular visits
-> SSRI
-> CBT
acute HIV inf
sym?
-> mononucleosis-like syndrome consisting of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea.
!!!!!! —> KOebner phenomenon : flares sudden onset of guttate psoriasis
–> KAPOSI sarcoma : multiple violaceous papules : inc vascularity , LAD
-> oral ulceration
—> TINEA CORPORIS: autoinculation
-> GI sym
Lumbosacral strain
sym?
dx?
rx?
triggered by twisting, lifting, or physical exertion.
sym:
-> lumbar paravertebral muscles that does not radiate below the level of the knee.
dx:
Straight-leg raising testing is usually negative
rx: NSAIDS
eosinophilic esophagitis
sym?
-> young men frequently !! -> ATOPIC disorders ( asthma, ezcema, allergies) -> refractory -> stricture formation -> heartburn
-> intermittent solid food dysphagia and refractory heartburn.
dx:
endoscopy with esophageal biopsy
—> CIRUCLAR rings + esophageal furrows
–> > 15 eosinophils
rx:
- > dietary mod
- > 2 month PPI
bronchial carcinoid tumors
sym?
- > recurrent pneumonia
- > proximal airway
- > young adults
- > Nueorendocrine tumor bronchial kulchitsky cells
dx:
CT scan lung
DM Symmetric distal sensorimotor polyneuropathy
ETOH neuropathy
sym?
rx?
DM + ETHO:
- SMALL fiber injury
- > Positive symptoms (eg, BURNING pain, paresthesia, allodynia)
- -> axonal neuropathy - LARGE fiber -> negative symptoms (eg, numbness, loss of proprioception and vibration sense, diminished Ankle DTR).
DM–> hammer toe deformity!!!
rx:
- > cessation etho
- > anticonvulsants: !!!! GABAPENTIN: dec deoplariztion neurons in CNS -> TCA : refractory pain ( caution in age >65 yr: antiAch effects)
Degeneration of the cerebellar hemispheres
etio:
- > ETHO >19 years
- -> cerebellar vermis degeneration
sym?
- > gait disturbances due to incoordination of the limbs.
- > dysmetria (eg, abnormal finger-to-nose test, pednular knee reflex muscle hypotonia)
- > dysarthric speech, and intention tremor ( postural)
renal vein thrombosis
sym?
nephrotic syn:
- > hematuria
- > flank pain
- > hypercoagulability: loss antithrombin III
- > pnuria >3.5 g/day (hypoalbuminemia ): low plasma oncotic pressure –> inc Hepatic lipoprotein synthesis
!!! inc risk: DVT, pul embolism , RVT
–> ATS dx (HTN, DM)
** JVP is reduce / normal
Cryptococcal meningitis
CD <100 ICP!!!!!
sym?
dx?
prophylaxis?
sym:
-> elev ICP : vomiting, PAPILLEDEMA !!!!! CLOGS arachnoid villi
-> indolet sym: progressive DAYS - WKS
ABSENT: neck stiffness, photophobia, compress N6 ( lateral gaze palsy + diplopia)
dx:
- > cryptococcal Ab testing CSF LP:
- > lymphocytosis
- > mild elev WBC
- > low glc
- > mild elev pn
START RX first:
- induction therapy:
- > liposomal AmpB + FLUCYTOSINE >2 wks till acute sym resolve - consolidation rx: high dose oral fluconazole >8 wks to prevent relapse
- maintenance rx: low dose oral fluconazole indefinitely / CD4> 100 for 3 months on ART
decompensated cirrhosis
rx?
Etho cessation !!!
spironlactone with furosemide
paracentesis
TIPS
cavernous sinus thrombosis
moa?
sym?
moa:
- > facial/ophthalmic venous system is valveless, uncontrolled infection of the skin
- > sinuses, and orbit can spread to the cavernous sinus. -> Inflammation subsequently results ICH
sym:
- > HA, papilledema, ICH
- > N 3, 4, 51, 52, 6
- > binocular palsies, periorbital edema, hypoesthesia, or hyperesthesia in V1/V2 distribution
Periorbital (preseptal) cellulitis
sym?
sym:
- > mild infection of the eyelid anterior to the orbital septum
- > fever and eyelid erythema/edema.
-> NOT extend beyond orbital septum
Diabetic gastroparesis
sym?
rx?
-> autonomic neuropathy, dest enteric neurons, freq hypoglycemia
rx:
-> metoclopramide, erythromycin
Herpes simplex keratitis
sym?
sym:
- > DENDRITIC corneal ulcer,
- > pain, photophobia, and decreased vision
** NOT cause typical vesicular rash / sys sym
immunosuppressive therapy + solid organ transplantation
risk for?
dx?
rx?
PCP + CMV
dx:
-> bronchoalveolar lavage.
rx:
- > TMP-SMX !!!!
- -> Pentamidine ( alternate )
-> paO2 <70, !!!! A-a gradient > 35: STEROIDS concomittant!!!
- CT : cannot confirm dx
- ** pimaquine: high se: hypotension, nephrotoxicity, arrythmia, hypoglycemia
Malignant effusions
sym?
types?
PROGGRESSIVE SOB
over several days or weeks (subacute) rather than with sudden-onset chest pain
**inc risk from: Cancer!!
- Uncomplicated:
- -> INC flow of sterile exudate into pleural space : small / moderate free flowing, Ph, glc near serum, low Leukocyte + LDH level
- –> Rx: AB - Complicated effusion: pleural membrane disruption + contiguous bact spread from pneumonia –> pleural space:
* * NOT WEDGE shape: vascular distribution , less hemoptysis !!
- -> large free flowing/ loculated, low Ph + glc , high leukocyte and LDH level
- —> Rx: chest tube drainage + AB
calcium oxalate stones
rx?
dx?
moa:
Reabsorption of sodium and calcium is coupled calcium-sensing receptor in the thick ascending limb of the loop of Henle
rx:
restrict sodium intake.
dx: abd U/S
- –> noncontrast spiral CT
** excessive Ca intake / HCTZ reduce urinary ca excretion -> inc recurrent stones
*** ca binds oxalate -> form inabsorbable Ca oxalate in GI tract
Ca restriction inc free oxalate absorption -> hyperoxaluria + urinary ca oxalate stone formation
*** inc Vit C intake promotes hyperoxaluria
uric acid stone
risk factors?
rx?
risk:
- > inc UA excretion: gout, Myeloproliferative dx, DM
- > inc urine conc: hot , arid climates, dehydration
- > low urine PH: chronic diarrhea ( loss Hco3 + acidification urine)
lab:
- > radiolucent stones
- > UA crystal
- > urine ph <5.5
rx:
alkalination urine : K citrate
–> allopurinol :Recurrent gout: dec UA production, inhibit XO
–> Colchicine: acute gout:
** TZD : dec urinary Ca excretion -> dec UA excretion , lower urine Ph and inc risk UA stone !!!
chronic kidney disease ind CKD
calciphylaxis
( calcifies uremic arteriolopathy)
lab?
kidney: converting 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D by the enzyme 1-alpha-hydroxylase
impaired 1-a-hydroxylation
!!! –> 2ndry paraPTH
–> !!!! hyperPO4, hypoCa
3rd hyperPTH:
- -> end stage CKD: done cyst + brown tumor
- -> hyperCA ( CALCIPHYLAXIS)
- –> sys arteriolar calcification in soft tix deposits + local ischemia + necrosis
- > inc PTH unresponsive to plasma ca,
Renovascular hypertension -> renal artery stenosis [RAS]
sym?
—-> resistant HTN : uncontrolled despite 3 rx
inc Cr > 30% from baseline
- > recurrent flash pul edema
- > diffuse ATS!!!
- > asymmetric kidney size
- > abd bruit !!!! SYSTOLIC - DIASTOLIC ABD BRUITS !!! lat to one side !!!
- > intermittent claudication sym (PAD)
rx:
First line rx:
—> ACEI / ARB : nephroprotective effects , dec intraglomerular pressure
Microscopic colitis
etio?
dx?
rx?
other secretory diarrhea:
-> VIPoma, gastrinoma, bile salt diarrhea
etio: woman age>60
immune-mediated colitis characterized by watery, nonbloody diarrhea: secretory diarrhea : nocturnal diarrhea
dx:
-> mononuclear inflammatory infiltrate within the lamina propria.
Types:
->Collagenous colitis - thickened subepithelial collagen band
-> Lymphocytic colitis - high levels of intraepithelial lymphocytes
rx:
NSAIDS, PPI, SSRI, smoking cessation
-> diarrhea persists: budesonide, loperamide
exacerbation of congestive heart failure
sym?
crackles, wheezing
hypoxia
hypocapnia
resp alkalosis
*** ACUTE COPD exacerbation: resp acidosis with CO2 retention
- -> Rx: non-invasive PPV + methylprednisolone + ANTIBIOTIC 3-7 days!!! : dec inflammation + imp lung function + hypoxemia
- —-> dec in-hosp mortality
** inhale glucocorticoid therapy: long term rx ASTHMA
bipolar dx type I
rx?
se?
sym: > 1 week of hx
- -> psy features : grandiose themes
–> ANTIDEPRESSENT monotherapy / combine should be AVOIDED cuz risk of precipitating MANIA !!!
rx:
- > LITHIUM
se: renal failure, nephrogenic DI, chronic ATN , hypothyroidism / hyperthyroidism, seizure, tremor, HYPERPARATHYROIDISM
–> rx: Lithium toxicity > 2.5 : hemodialysis!! renal excreted
!!!!! -> 2nd Gen
ANTIPSY Rx: quetiapine, lurasidone, olanzapine IM ( rapid onset) !!!!
–> se/ weight gain , hyperlipidemia , DM
–> anticonvulsant rx: PO lamotrigine (SJS) , valproate
- **valproate acid
se: liver toxicity + thrombocytopenia, NTD ( pregnant women)
Chronic prostatitis/chronic pelvic pain syndrome
sym?
rx?
-> Pain in pelvis, perineum, genitalia >3 months without identiry cause
- > Irritative voiding symptoms (eg, urgency, hesitancy)
- > Hematospermia, pain with ejaculation
dx:
-> sterile urine culture
DRE: swollen, tender prostate
rx:
- > tamsulosin
- > TMP-SMX/ ciprofloxacin for 6 wks
- > finasteride
Vasospastic angina
moa? risk? sym? dx? rx?
moa: Hyperreactivity of coronary smooth muscle
risk:
smoking
sym:
-> occurs at rest/ sleep <15 mins
dx:
- > ecg: ST elev
- > coronary angiography: no CAD
rx:
- > CCB ( preventive)
- -> dilates coronary ARTERIES + prevent anginal episodes: eg. diltiazem
- > sublingual NG ( abortive): inc venous CAPACITANCE
** ASA avoided in vasospastic angina: inhibits prostacyclin -> worsen coronary vasospasm
*** anti-HTN: induce hyperPROLACTINEMIA ( reserpine, methydopa, verapamil)
aortic stenosis
moderate heart sound
vs
severe heart sound
sym?
exam?
rx?
- > Dyspnea on exertion,
- > decreased exercise tolerance
- > Angina pectoris : INC MYOCARDIAL O2 DEMAND!!!!!
- > Syncope (LH)
- > Heart failure
exam:
transthoracic echo:
MODERATE:
-> crescendo-decrescendo systolic murmur
-!!! > PULSUS PARVUS et ARDUS: slow rising ( delayed) + wk carotid pulse
SEVERE:
- > SOFT delay AV closure A2 + delay point during inspiration with almost simultaneous P2 closure.
- –> SOFT + SINGLE S2 during inspiration !!!
rx: AV replacement
** exercise stress testing: severe, sym AS contraindicated -> inc risk of syncope + death
chronic pulmonary aspergillosis
sym?
dx?
immunocompetency pt with pul dx (TB)
sym:
-> >3 MONTHS of symptoms - fever, weight loss, fatigue, cough, hemoptysis, and/or dyspnea
-> Cavitary lesion(s) containing debris, fluid, or an aspergilloma (fungus ball)!!!!
dx:
-> Positive Aspergillus IgG serology
rx: -azole, Caspofungin,
surgery, bronchial artery embolization
Pulmonary changes in pregnancy
sym?
moa:
-> Progesterone-induced hyperventilation
sym:
-> Dyspnea of pregnancy
↑ PaO2, ↓ PaCO2 (respiratory alkalosis)
-> Lung volumes
↑ Minute ventilation ( ↑ tidal volume)
↓ RV & RFC
-> Normal vital capacity & FEV1
- ** obesity BMI > 30 related restrictive rent, prevent expansion of chest wall: VC + TV dec, min vent dec
- —-> A-a gradient NORMAL, PaCO2 > 45mmHg, alveolar HYPOventilation
Anaphylaxis
sym?
- > acute illness involving the skin/mucosa urticarial rash, pruritus, flushing, WHEALS!!!!
- —> rapid onset, >2 organs sys inc
-> respiratory or cardiovascular compromise: vasodilation, hypotension, tix edema, tachycardia. Wheezing, stridor
Risk:
- > immune disorders such as asthma.
- > Medications such as NSAIDs worsen anaphylaxis by nonimmunologinc mast cell activation!!!!
rx:
- > IM epinephrine ( a1 + b2 +: vasoconstriction + bronchodilation, dec mast cells + basophils)
Airway management & Adjunctive therapy (eg, ANTI-H1 blocker, glucocorticoids) --> IV in severe / refractory cases ( higher risk arrythmia)
BCC
sym?
rx?
-> slow-growing, ulcerated, pearly nodule with a rolled border on sun-exposed skin,
rx:
Mohs microsurgery
Pyoderma gangrenosum
sym?
painful, rapidly expanding ULCER with purple/dusky margins.
-> occurs on the trunk or a lower extremity
asso with:
RA, IBD
Pyogenic granuloma
sym?
- > vascular tumor -> red, beefy, friable NODULE grow rapidly over weeks or months.
- > can bleed with minor trauma but are not typically ulcerated.
MDD, Sucicidal beh
csf?
dx?
risk?
–> > 2 wks sym!!!
CSF:
- > Low 5-HIAA serotonin
- > inc cortisol ( inc HPA axis)!!!
dx:
-> cosyntropin stimulation testing: primary adrenal insufficiency : salt craving
responsible for modulating mood and behavior.
–> inc risk : Pancreatic Ca
Rx: CONTINUE rx INDEFINITELY!!!!
–» high recurrent illness, chronic episodes >2 yrs, ongoing psy stressors, severe episodes ( suicide attempts)
!!! ADMIT HOSP : involuntary if necessary !!! active suicidal thoughts, intent / plan
—-> ECT electroconvulsive therapy
- **PSEUDODEMENTIA
- -> cognitive impairment + slowing
- > reversible
inc risk: inc # of depressive episodes
absence seizure
eeg?
A diffuse 3-Hz spike and wave pattern
CJD
eeg?
csf?
mri?
EEG: Generalized slowing with periodic sharp wave complexes
CSF:
- > increased CSF 14-3-3 protein
- > positive RT-QuIC test
MRI:
-> widespread atrophy (cerebrum & cerebellum), cortical enhancement (ie, cortical ribboning), enhancement of putamen & caudate head (ie, hockey stick sign)
aliskiren
moa?
- > Inc natriuresis
- > Dec serum AT-II concentration
- > Dec aldosterone production.
-> direct renin inhibitors
CAP in HIV pt
etio?
dx?
CD4 <200
–> Immunosuppressed ( prednisone use)
dx: CT scan chest
MC:
STREP PN
-> “rusty sputum”
-> cxr: cavitary infiltrate
- s. aureus -> IE
- -> more common risk in : adv age, poor dentition, injection drug user
- -> inc in influenza s/p 2ndry bacterial pneumonia !!! LUNG cavity
- ** influenza: self limited: <1 wk systemic + resp sym ( rhinorrhea, sore throat, nonproductive cough) , leukocytes <15,000
- –> Oseltamivir : w/in 48 HOURS!!!
- -> no need dx testing !!
- -> comp: PN
Trastuzumab toxicity?
vs
tamoxifen toxicity?
transuzumab rx: HER2 + breast ca
-> se: cardiotoxicity
dx: cardioecho
tamoxifen :
- -> Estrogen + breast ca
se: venous thromboembolism , DVT ( factor V Leiden mut) —> MC loc @ cerebral vein !!!
ischemic hepatic injury, or shock liver
sym?
lab?
Septic shock
!!! -> HYPOtension
-> respiratory failure
-> leukocytosis, fever
lab:
-> inc liver enz > 10,000 : diffuse liver injury due to hypotension
** acute viral hepatitis: large liver enz elev >1000 + hyperbilibinermia, nausea, vomiting
lacunar stroke
loc@ Internal capsule
vs
thalamus
etio?
sym?
risk?
—> OLDER patient with vascular risk ( HTN, DM, Hyperlipidemia, smoking)
etio:
- > microatheroma formation and lipohyalinosis –> thrombotic small-vessel occlusion
- —> HTN !!!!
- > Dm , advance age, inc LDL, smoking
-> @ INTERNAL CAPSULE
sym:
-> pure MOTOR hemiparesis due to injury of the corticospinal (posterior limb) and corticobulbar (genu) tracts.
- > weakness equally involving the contralateral face, arm, and leg.
- > Sensory deficits, mental status changes, seizure, and cortical signs are typically ABSENT.
- *** @ THALAMIC
- -.> PURE SENSORY !!!
- -> PCA branch
- -> contralateral sensory loss
- -> allodynia (paroxysmal burning pain)
Carotid artery thrombosis
stroke
sym?
—> HTN strongest asso !!!
-> PROFOUND neurologic deficits (eg, contralateral homonymous hemianopsia, hemiparesis, hemisensory loss) due to ischemic infarction of the cerebral hemisphere
CLL
lab?
sym?
dx?
lab:
-> dramatic leukocytosis, primarily with lymphocytes
-> hairy projections , smudge cells
sym:
- > HSM, LAD
- > bicytopenia (anemia, thrombocytopenia
- > hypogammaglobulinemia + defects in cell signaling inc risk and severity of infections
dx: flow cytometry ( mature B cells) + smudge cells
+ coombs test
comp:
- > inf
- > autoimmune hemolytic anemia : WARM , IgG / C3
- > richter transformation
Pseudogout
sym?
xr?
lab:
- > calcium pyrophosphate dihydrate (CPPD) crystals !!!!!!
- > chondrocalcinosis (calcification of articular cartilage) into the joint space
- NOT btwn muscle / tendons!!
lab:
- > synovial fluid: inflammatory effusion
- > rhomboid shaped + birefringent crystals
septic arthritis
sym?
transient perioperative bacteremia
—> common realted to : RA, OA, recurrent GOUT
dx:
synovial fluid analysis
lab:
-> leuocytosis >50,000
rx: IV AB + joint drainage
Multiple sclerosis
sym?
*** T4 thoracic level: below nipple area
** supratentorial white matter: Partial / complete hemiparesis , sens changes , contrlateral lesion
- > autoimmune inflammatory demyelinating disorder CNS
- –> HLA-DRB1
INC risk:
- > Uhthoff phenomenon: hot temp worsen the sym!!!
- –> young WOMEN : early POSTPARTUM !!!
- —-> VIT D DEFICIENCY!!!
sym:
- > NERUO deficits disseminated in space and time
- > eg, sensory loss/paresthesias of the extremities, dizziness
- > OPTIC NEURITIS in women age 15-50.
- –> inc risk: DEPRESSION!!
*** NOT affect proximal muscle + EOM!!!!
dx:
MRI: hypo/hyperintense lesion white matter @ periventricular , corpus callosum
adjustment disorder
vs
acute stress disorder
sym?
adjustment dx:
-> within 3 months
-> identifiable stressor
not last longer <6 months
rx: psychotherapy!!!
acute stress dx:
- > > 3 days - < 1 month
- > exposure actual trama
- > dissociative syn “ daze”
- —> monitor PTSD!!!!
rx: CBT
S4
“ten-nes-see”
sound?
!!!! concentric LV hypertrophy –> due to systemic HTN / severe AS/ ACUTE phase MI
-> blood striking a stiff LV during atrial SYSTOLE, just before MV closure (S1)
- ** inc risk: concentric myocardial hypertrophy: acromegaly!!!
- > inc IGF-1
cohort study ?
vs
case control ?
COHORT: RR
——-> det INCIDENCE!!!
exposure status
- > exp vs nonexposed to a risk factor / rx
- -> retrospective cohort : Ascertain risk factor EXPOSURE and then determine the outcome
CASE CONTROL: Odd Ratio
dx/ non-dx
–> determine the SINGLE OUTCOME first then look for ASSO RISK FACTORS > 1
OR = 1.0 ( null value –> Ho)
—> Ho : NO asso
**RARE dx ASSUMPTION:
outcome is uncommon (rare) in POP ( low dx prevalence): odd ratio is close approx of relative risk
OROpharyngeal dysphagia
sym: cough with swallowing, choking, nasal regurgitation
dx?
Videofluoroscopic modified barium swallow study
-> to evaluate swallowing mechanics, degree of dysfunction, and severity of aspiration
*** esophageal motility studies + upper endoscopy:
evaluate ESOPHAGEAL dysphagia: sensation food stuck in esophagus ( not THROAT)
CAD
routine dx?
- low risk : no add dx testing
- intermediate risk: able to exercise?
- -> exercise yes: Normal ECG –> exercise ECG test –> coronary angiography
–> exercise yes: Normal ECG: NOT able to exercise: exercise imagine test –> coronary angiography
NOT able to exercise: pharm stress imaging test –> coronary angio
- HIGH risk : start pharm rx CAD
*** TTE : takotsubo stress CMP : OLDER woman after stress
SIADH
small cell ca
rx?
etio?
lab:
hypoNa
!!!!!! serum osm LOW < 275 (diluted)
!!!!! Urine osm HIGH >100 (highly concentrated)
Urine Na >40 ( concentrated)
rx:
fluid restriction + high salt
** demeclocycline : only after fluid restriction and high salt intake FAILS
postmenopausal : female pattern hair loss
moa?
rx?
moa:
replacement of terminal hairs by smaller vellus hairs (follicular miniaturization)
sym:
-> hair loss gradual thinning of the hair at the vertex and midline
rx:
- > topical minoxidil ( direct vasodilator inc BF to scalp)
- > antiandrogenic agents ( spironolactone, finasteride): once minoxidil fails
Alopecia areata
etio?
sym?
rx?
etio:
autoimmune attack on hair bulb cells
-genetic asso : vitiligo, hypothyroidism
sym:
rounded patches of nonscarring, complete hair loss.
rx: intralesional corticosteroids (triamcinolone)
- >
Disorders of phagocytosis
-> eg, chronic granulomatous disease
Chédiak-Higashi disease
Job syndrome
defective leukocyte adhesion proteins
sym:
severe pyogenic bacterial infection
—–> ENCAPSULATED organism
risk: splenectomy pt!!!
urease producing stone (struviate)
etio?
- > urinary alkalization Ph >8
- > magnesium ammonium phosphate
- > proteus mirabilis
- > klebsiella pn
** E. coli mcc UTI : NOT produce urease !!!
Morton neuroma
sym?
-> Numbness or pain between the 3rd & 4th toes
Mulder sign:
-> Clicking sensation when palpating space between 3rd & 4th toes while squeezing the metatarsal joints
Plantar fasciitis
sym?
Plantar surface of the heel
Worse when initiating running or first steps of the day
follicular lymphoma, a common form of non-Hodgkin lymphoma (NHL)
sym?
lab?
rx?
sym:
- > adults
- > painless peripheral LAD
- > mediastinal, hilar mass
- > B sym
lab:
- > Bcl-2 (18)
- > t (14, 18)
rx: rituximab ( monoclonal ab against CD 20)
Dubin-Johnson syndrome
sym?
lab?
moa:
- > defect in a hepatocyte transporter protein –> unable bilirubin excretion into the biliary system
- > Impaired hepatic excretion of conjugated bilirubin
dx:
liver biopsy
-> grossly black liver and dark, granular pigment accumulation within hepatocytes
lab:
- > inc direct hyperbilirubinemia and bilirubinuria
** Rotor syn: liver biopsy NORMAL!!!
diabetic ketoacidosis (DKA)
etio?
lab?
dx?
rx?
- > type 1 diabetes mellitus
- > Calorie and carbohydrate restriction can cause ketosis !!
- -> young age: GI infection + dehydration
lab:
- > total body K deficit from osm diuresis
- > 2ndary hyperALDO: vol contraction: K excretion + reabsorption Na DCT
–> hyperOSM: draws fluid and K passively out of cells into the extracellular space.
–> insulin deficiency: impairs cellular entry of K by the cells, further increasing EC K concentration.
dx:
fingerstick glc, electrolytes ( K)
rx:
!!!! NORMAL 0.9% saline + IV REGULAR insulin + IV K ( when serum K <5.3)
–> glc <200 : DEXTROSE fluid avoid hypoglycemia + insulin
** HYPERtonic saline: reserve for moderate - severe hypoNa
alcohol use disorder (AUD)
rx?
!!!!! 1. Naltrexone: mu-opioid receptor antagonist
–> se: hepatotoxicity
- Acamprosate: glutamate modulator (preferred in patients with liver disease or opioid use)
- -> help risk relapse - Disulfiram is second-line 2nd line rx in HIGHLY motivated patients
** BZD (chlordiazepoxide) : moderate - severe etho withdrawal !!! not for AUD
linear regression analysis
study type?
association between 1 quantitative DEPENDENT variable (eg, outcome)
and
≥1 INdependent variables (eg, exposures, risk factors)
Primary achalasia
or
pseudoachalasia ( esophageal ca)
sym?
risk factor?
dx?
- primary achalasia (ie, loss of peristalsis in the distal esophagus with lack of lower esophageal sphincter relaxation)
- pseudoachalasia -> esophageal cancer
sym:
1. tabacco
2. sig WL, rapid sym onset < 6 months , age > 60 yr
3. tumor MTS ( mediastinal LN) local inv : widened mediastinum
rx:
endoscopic evaluation:
–> achalasia, normal-appearing esophageal mucosa and a DILATION esophagus with possible residual material
–> pseudoachalasia: not easy to pass!!!
Bacterial conjunctivitis
etio?
sym?
-> S aureus is the most common etiology in adults.
sym:
- > conjunctival erythema and thick, purulent eye discharge
- > reaccumulates within a few minutes after wiping.
