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.
viral conjunctivits
etio?
sym?
adenovirus
sym:
- > watery, scant , stringy
- > no reappearing after wiping
- > asso with URI (eg, rhinorrhea, sore throat, cough)
rx: warm / cold compresses
- > antihistamine / decongestant drops
Dipeptidyl peptidase-4 inhibitors (eg, sitagliptin)
moa?
se?
similar to GLP-1 agonist
not cardioprotective
weight neutral
brief psychoitc dx
sym?
> 1 day < 1 month
- > sudden onset
- > acute dev paranoid delusion + bizarre behavior from stressor
- > full return to function
Entamoeba histolytica
sym?
dx?
rx?
sym: developing country
- > 90% of patients asymptomatic
- > Colitis (diarrhea, bloody stool with mucus, abdominal pain)
- > amebic Liver abscess (RUQ pain, fever)
- > Complications: rupture to pleura/peritoneum
dx:
- > Stool ova & parasites, stool antigen testing (colitis)
- > E histolytica serology (liver abscess)
Rx: Metronidazole & intraluminal antibiotic (eg, paromomycin)
open-angle glaucoma (OAG
sym?
rx?
sym:
- > elevated intraocular pressure (IOP)
- -> atrophy of the optic nerve head (eg, optic disc rim thinning, increased cup/disc ratio [“CUPPING”]).
sym:
- > gradual loss of PERIPHERAL vision!!!!
rx:
1. topical prostaglandin (latanoprost) : inc drainage of aq humor thru uveoscleral pathway
- topical beta blocker added
- -> caution with asthma
dx: ocular tonometry : measure IOP
** atropine : dilates pupil facilitate eye exam –> contra OAG
cholestasis : extrahepatic / intrahepatic biliary ob
lab?
dx?
lab:
- > elev conjugated direct hyperbilirubinemia
- > elev ALP > 1.5 limit
dx:
abd U/S: biliary dilation : extrahepatic cholestasis
absence dilation: intrahepatic cholestasis
PPV = TP/ TP + FP
when inc TP + FP ?
PPV = decreases !!!
dep on prevalence of the disease in the pop BEGING TESTED!!!
PREVALANCE inc = inc PPV , dec NPV
False negative = 1- NPV
higher NPV = LOWER dx PREVALANCE
—> pt without dx is GREATER !!!
Behçet disease
sym?
dx?
- > multiple ORAL and GENITAL ulcers that are recurrent and PAINFUL.
- > Uveitis is common.
dx:
PATHERY test: 20G needle into skin check for >2mm papule
aplastic anemia
moa?
sym?
etio?
damage to multipotent hematopeietic stem cells
-> alter to stem cell surface Ag -> cytotoxic T cell destruction
etio:
- > aplastic anemia
- > inf, vit def, Rx
sym:
- > absence of splenomegaly
- > pancytopenia peripheral smear
lab:
- > low reticulocyte count
- > hypocellular marrow, no myeloid infiltration/ fibrosis , inc stroma /adipocytes
** NO BONE PAIN !!!
Myelofibrosis
AML
moa?
sym?
moa:
collagen or reticulin deposition in BM –> diminished (or increased) peripheral blood counts.
sym:
- > HSM ( extramedullary hematopoiesis)
- > peripheral blood smear: immature leukocytes + fragmented megakaryocytes
risk: AML
- –> t ( 15, 17) auer rods
- –> inc risk of pancytopenia: hemorrhage + consumptive coagulopathy ( DIC) !!!
- -> inc LDH
rx: all trans retinoic acid
B12/ folate def
moa?
etio?
impaired DNA synthesis in precursor cells
–> B12 def : terminal ileum
-> MCV >100
etio:
Chronic METFORMIN :
-> neuropsy : myelinated fibers in brain
-> sensory ataxia: dorsal columns
-> + BANBSKI sign: lat corticospinal tract
lab:
- > methylmalonic acid
- > homocysteine level
cancer related pain
rx?
inital:
- > NSAIDS, ketorolac
severe pain:
- > short-acting opioids
- > morphine , hydromophone
- -> dose adjustment + calculate
- > transdermal fentanyl patches
** avoid long acting opioids prevent resp depression
recurrent pneumonia
etio?
dx?
SAME region:
1. external bronchial compression : LAD, CA
- internal bronchial ob: foreign body, bronchiectasis, bronchial stenosis
- recurrent aspiration:
- > seizure
- > dementia!!!
- > etho
- > gerd, dysphagia
–> etio: foul smelling, poor dentation : oral !!!! ANaerobic
rx:
-> CLINDAMYCIN!!
-> metronidazole + amoxicillin, amox-clavulanate/ carbapenem
dx:
-> ct scan chest
** bronchoscopy : to obtain lung tix biopsy when mass identified on CT scan!!!
disseminated Mycobacterium avium complex (MAC)
dx?
rx?
CD4 < 50
lab:
-> elev ALP
sym:
- > LAD, nonsp symptoms
- > HSM
rx:
- > macrolides + ethambutol
- —> NOT given for PPX
- TMX-dapsone: rx: PCP
- TMX-SMX/ pyrimethamine: rx: toxoplasmosis
vomiting
vs
diarrhea
lab?
Vomiting: loss NaCl + H+ : GI losses!!!!!
conseq:
- -> met alkalosis , ph inc
- > inc HCO3
- —-> DEC urine Cl- cuz body tried to reabsorb back into body!!!
rx: IV fluid + K supp
Diarrhea + RTA: loss HCO3
- -> met acidosis non-AG change , dec Ph
- -> inc K
Shoulder joint capsulitis (ie, frozen shoulder)
moa?
sym?
- > gradual-onset shoulder stiffness + reduction in both passive/ active ROM in multiple planes.
- > Reflexes are unaffected.
cervical radiculopathy @ C6 nerve root
sym?
rx?
Osteophyte formation in facet -> neural foramina narrowing !!!!
-> compression of the nerve root due to HIVD ( acute symptom onset)
–> pain in neck + upper ext + loss sensory/ motor deficits + dinimish reflexes
-> progressive spinal spondylosis (evidenced by subacute or progressive symptom onset).
MC in middle-aged men
-> develop after repetitive exercise (eg, golf).
dx:
should abd relief test
–> NO MRI needed
rx: NSAIDS, PT
CML
vs
Leukemoid rxn
rx?
CML: BCR-ABL t (9,22) -> leukocytosis >100,000 + basophilia , left shifts ------> LAP LOW ----> Metamyelocytes < Myeocytes ( more)
rx: TK inhibitor : imatinib
Leukemoid rxn:
- -> > 50,000
- > severe Infection
- —–> LAP HIGH
- > more mature metamyelocytes > myelocytes
- -> NO basophilia
estrogen affect on thyroid ?
estrogen up-regulate production of TBG in liver -> DEC free T4, T3 level
lab:
- > inc TBG
- > inc TSH
- > dec free T3, T4
rx:
inc levothyroxine dose
IDA risk in pregnancy
dx?
dx: hemoglobin electrophoresis -> diff btwn thalassemia : target cell (AR), sickle cell Hg C/E
psychogenic ED?
vs
organic ED?
psy ED -> sudden onset
sym:
-> Persistence of nocturnal + early-morning penile erections
organic ED: -> progressive, slowly , advance age
medication overuse headache (MOH)
eg. OCP
sym?
rx?
near daily HA
-> preexisting HA dx ( migraine) > 3 months
- > worsen upon awakening , quick rebound
- > transition from episodic migraine to chronic migraine / dev new HA pattern
——> with AURA: avoid OCP pills : inc risk ischemic stroke !!!
- ** Migraine w/o aura:
- -> n/v, photophobia
- -> pulsatile , throbbing, UNILATERAL
Tourette syndrome
rx?
-> Behavioral therapy (habit reversal training)
-> AntiDA:
Tetrabenazine (VMAT2 inhibitor)
- > Antipsychotics (receptor blockers): RISPERIDONE
- > Alpha-2 adrenergic receptor agonists: guanfacine, clonidine
myoclonus
moa?
prolonged hypoxia
- > acute : generalized , poor prognosis
- > chronic : focal, weeks
hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
sym?
AD disorder
sym:
- > diffuse telangiectasias (eg, ruby-colored papules that blanch with pressure)
- > recurrent epistaxis, and widespread arteriovenous malformations (AVMs)
- -> Pul AVM, digital clubbing
-> reactive polycythemia
schizophrenia
mri?
lateral ventricular enlargement
- -> freq anxiety , acute psy episode
- -> avoid BZD : risk of abuse + dependence !!!!
** OCD: Structural abnormalities in the orbitofrontal cortex and BG
rx: antipsy
FAMILY THERAPY!!!: reduce re-hospitalization
Wernicke encephalopathy
etio?
sym?
rx?
etio:
- > Chronic alcoholism (MCC)
- > Malnutrition (eg, anorexia nervosa, CD)
- > Hyperemesis gravidarum
sym:
- > Confusion
- > Ataxia
- > Nystagmus
rx: thiamine B1 + glc
Korsakoff syn: retrograde + anterograde amnesia + confabulation
nitrates
NG
rx
- > primarily vasodilators and dilate veins, arterioles ( dec afterload), and coronary arteries by relaxing vascular SM.
- > Systemic VENOdilation lowers preload + dec LVEDV –> REDUCES myocardial O2 demand by REDUCING WALL STRESS!!!!!! !!!!
** NOT have direct effect on HR, ventricular compliance, CONTRACTILITY EF
wilson’s disease
etio?
sym?
rx?
AR mutation of ATP7B → hepatic copper accumulation → leak from damaged hepatocytes → deposits in tissues (eg, basal ganglia, cornea)
sym: NHP
- > hepatic LF, CIRRHOSIS
- > NEURO: PARKINSONISM , gait, dysarthria
- > PSY: depression, personality change, pyschosis
rx: chelators, D-Penicillamine, trientine
- > zinc interferes with copper absorption
huntington disease
sym?
- > parkinsonism
- > chorea
- > dementia, personality change
- > delayed saccades
- > motor impersistence
- > Family Hx
** NO liver disease!!! occur MID-life
autoimmune hepatitis
lab?
sym?
-> young women
sym:
——-> ANTI-SMOOTH MUSCLE AB!!!
- > ASX
- > large inc liver enz
- > inc bilirubin
- > hypergammaglobulinemia + gamma gap (total pn- albumin = > 4)
–> with comorbid autoimmune dx ( vitiligo, auto thyroiditis)
rx: steroids
Multiple myeloma
etio?
sym?
lab?
etio:
Plasma cell neoplasm produces monoclonal paraprotein (IG)
—-> ELECTROLYTES disturbance !!!
- —> AL amyloidosis
- > hyperCa : constipation
- > Renal failure ( granular casts)
- > Anemia
- > Bone pain, !!! OSTEOLYTIC / osteopenia
- > recurrent infection : strep pn, UTI
- —> waxy , TIGHT SKIN ( epidermal deposits)
dx:
- -> serum pn electrophoresis (SPEP)
- > bone biopsy
lab:
- > hyperCA
- > M-spike
*** NOT elev ESR!!
- ** waldernstrom macroglobinemia :
- -> inc risk HYPERVISCOSITY syn: blurred vision, diplopia, confusion
- > HSM, NEUROPATHY
- -> rouleaux formation
- –> “sausage link” : dilated, segmented, tortuous, RETINAL VEIN
Mixed connective tissue disease
sym?
lab?
dx?
similar to SLE, polymyositis
lab:
- > anti-U1 ribonucleoprotein
- > ANA
- > RF, anti-CCP
- > elev CK
- > anemia
dx: muscle biopsy
acute liver failure (ALF) due to acetaminophen toxicity.
lab?
-> elev liver enz > 1000
- > hepatic ENCEPHALOPATHY!!!
- > hepatic necrosis : NAPQI toxic
- -> coma, BS herniation, death
- > synthetic liver dysfunction
- > prolong PT, INR >1.5
rx:
- -> hemodialysis
- > liver transplantation
PCOS
moa?
rx?
- > inc testosterone: hirsutism, severe acne, androgenic alopecia)
- > inc estrogen
- > LH/FSH imbalance
dx:
-> OCTT : type 2 DM common in PCOS
rx:
- > weight loss (1st)
- > OCP MC regulation
- > letrozole ( aromatase inhibitor) ovulation induction
** leuprolide: GNRH agonist: rx endometriosis -> plevic pain, dysmenorrhea
** spironolactone (androgen receptor antagonist) : rx hirsutism only
premature ejaculation
rx?
- > SSRI
- > lidocaine
- > psychotherapy, joint/ couple therapy
toxoplasmosis
mri?
rx?
- > ring enhancing lesions @ gray -white matter junction + BG
- > CD4 < 100
rx:
TMP-SMX
** fluconazole : rx/ coccidioidomycosis
*** TMP: blocking ENaC @ Collecting tubules : hyperkalemia + elev Cr!!! –> inc risk HYPERKALEMIA
fibromyalgia
rx?
rx:
- > exercise
- > TCA
vasovagal syncope
sym?
etio:
-> EMOTIONAL stress, prolonged standing
sym:
!!! RAPID recovery < 1-2 mins
-> PRODROME: nausea, diaphoresis, pallor, LH –> follow LOC
-> cardioinhibiotry response –> inc PNS !!!!!
–> sinus BRADYCARDIA + asystole sinus arrest
rx: counterpressure tech: leg crossing with tensing muscle, hand-griping, tensing arm muscle : inc VR + CO : abort syncope episode
phenytoin ind
inhibits voltage gated Na+ channels
se?
acute toxicity:
–> cerebellar dysfunction: HORIZONTAL NYSTAGMUS, ataxia, hyper-reflexia, AMS
-> folic acid deficiency : impairs folic acids : def impairs DNA synthesis –> megaloblastic anemia
!! —–> FETAL HYDANTOIN syndrome
-> gingival overgrowth / hyperplasia absorption in jejunum
rx: FOLIC acid supp
- –> slow taper rx
** inhibits p450 system: TMP-SMX inc risk of toxicity!!!
Methylxanthines (eg, aminophylline, theophylline)
+
ipratropium
moa?
rx?
methylxanthines:
- > PDE inhibitors that cause bronchodilation.
ipratropium:
–> Anti-muscarinic agents!!!
rx:
-> chronic management of patients with uncontrolled asthma or severe COPD
** no benefits in acute exacerbation COPD
- ** Beta blocker: cell surface receptor blocker
- –> WORSEN sym
platelets transfusion
rx?
<50,000
G6PD def
x- linked
lab?
etio: TMP-SMX, nitrofurantoin , fave beans
G6PD activity - > LOW sensitivity!!!
lab:
- > inc indirect bilirubin
- > BITE cells + HEINZ bodies ( dark red erythrocyte inclusion)
- > coombs negative
- > low Hbg
- > inc LDH
- > dec HAPTOGLOBIN
Pyruvate kinase deficiency
moa?
sym?
AR
- > dec ATP -> rigid RBC -> extravascular hemolysis
- > inc 2,3 BPG
sym:
- > chronic hemolysis, -> hepatosplenomegaly, -> skin ulcers
- > pigmented gallstones.
Sickle cell crisis
smear?
dx?
rx?
sickle cells, howell -jolly bodies!!!!!!!!
- -> dec Hbg, dec haptoglobin, dec PT,
- -> inc indirect bilirubin, inc LDH
dx: electrophresis !!!
rx: hydroxyurea
cross sectional survey ?
OBSERVATIONAL
- > specific pint in time “snapshot”
- > Can determine PREVALENCE of an outcome in a population
–> PREVALENCE odds ratio
ecological study?
!!!! POPULATIONS rather than individual
eg> national data
reporting bias?
vs
nonreporting bias?
Reporting bias: subjects over- or under-report exposure history due to perceived social stigmatization.
Nonreporting bias:
-> high nonresponse rate
Berkson bias?
vs
neyman bias?
Berkson: disease studied using only HOSP -based pt -> not represent general pop
Neyman ( PREVALENCE)
-> exposure happen long before dx assessment, therefore can miss dx that DIE / recover ( prevalence bias)
ICU induced stress ulcers
risk?
sym?
ppx?
risk :
- > sepsis
- > shock : splanchnic hypoperfusion, reflux bile, acc uremia toxins
sym:
- > GI bleeding, occult ( anemia , + occult blood testing)
- > melena, hematemesis with shock
ppx:
-> PPI
Acute colonic ischemia
sym?
- > hypoperfusion affect watershed areas
- > crampy left side abd pain
- > overt hematochezia short during/ after hypotension
Dermatomyositis/ polymyositis
sym?
asso: paraneoplastic syndromes: LES, MG, CA breast, lung, ovaries
- > dermatomyositis (muscle fibers)
——> Inf myopathy mediated by CYTOTOXIC T-LYMPHOCYTES
sym:
-> DISTAL muscle wkness, symmetrical, proximal , ERYTHEMATOUS RASH dorsal fingers (GOTTRON sign) , upper eyelids ( HELIOTROPE eruption)
dx: muscle bx
**NO UMN sign!!!
Warfarin is a vitamin K antagonist
inc warfarin effect ( inc bleeding risk)?
vs
reduce warfarin effect?
inc risk: inc INR
- > Ab; APAP
- > azole
- > amiodarone
- > cimetidine
- > grapefruit juice
REDUCE warfarin: dec INR
- > spinach, brussels sprouts
- > phenytoin
- > rifampin
- > phenobarbital
- > carbamazepine
- > st. johns wort
pernicious anemia.
sym?
risk?
B12 deficiency
-> vitiligo , older pt
- > intrinsic factor : ab-mediated destruction
- > target gastric parietal cells : atrophy acid/pepsin producing part of stomach
- -> macrocytic anemia
- -> elev serum gastric level
risk:
- -> intestinal type metaplasia GASTRIC ca: GLOSSITIS
- -> autoimmune metaplastic atrophic gastritis
dx:
EGD
drug induce pancreatitis
etio?
dx?
- > Severe epigastric pain
- > Elevated serum lipase >3 times the upper limit of normal
- > CT scan: pancreatic inflammation
etio:
- > TZD, loops
- > ACEI
- > statin
- > TMP_SMX, insoiazid
moa:
-> hypersensitivity to sulf molecules, pancreatic ischemia reduce BV -> inc viscosity + secretion
lab:
-> hyperTG>1000
organophosphate pesticide, cholinergic toxicity
sym?
antidope?
dx?
-> Muscarinic: Diarrhea/diaphoresis Urination Miosis Bronchospasms, bronchorrhea, bradycardia Emesis Lacrimation Salivation
-> Nicotinic: muscle weakness, paralysis, fasciculations
rx:
- > Atropine reverses muscarinic symptoms
-> Pralidoxime reverses nicotinic and muscarinic symptoms (administer after atropine)
dx:
RBC ACETYLCHOLINESTERASE activity !!!!!
Heparin-induced thrombocytopenia (HIT)
eg. enoxaparin
types?
rx?
types:
type 1 HIT: nonimmune direct effect on heparin on pt aggregation –> first 2 days of exposure
!!!!! type 2 HIT: more serious, immune mediated dx: Ab to pt factor 4 (PF4)
- -> risk of thrombocytopenia
- –> THROMBOSIS (arterial or venous):!!!!
–> >50% drop in the pt count from baseline 5-10 days after the initiation of rx.
Etio caused by: UnFRACTIONAED HEPARIN
rx: discontinue all anticoagulants
- > LMWH
- > enoxaparin, dalteparin
- > fondaparinux
chronic venous insufficiency (CVI)
sym?
rx?
- > venous HTN
- > leg discomfort, pain, or swelling worse in the evening or following prolonged standing
- > pitting edema
- > lipodermatosclerosis , skin ulceration (medical aspect)
rx:
- > improves after walking or leg elevation.
- > compression stocking
dx:
-> DUPLEX U/S: venous reflux!!!!!
acute pericarditis
vs
peri-infection pericarditis ( PIP)
vs
dressler syn
sym?
rx?
pericardial friction rub
ecg: diffuse ST segment elevation + PR seg depression
rx: NSAIDS + COLCHICINE !!
*** NSAIDS + prednisone combination avoided: Renal failure !!!!
**DRESSLER syn:
WKS s/p pericarditis MI
( Ab to myocardial Ag)
- ** Peri-infarction pericarditis ( PIP): 2-4 days s/p MI
- –> PPX/ early CORONARY REPERFUSION!!!
Minimal rectal bleeding
eg> hemorrhoids
dx?
- age < 40 w/o red flags
- > ANOSCOPY - age 40-49 with RED flags
- > sigomoidscopy / colonoscopy - age >50 with RED flags
- > colonoscopy
availability bias?
Allowing recently seen or memorable (high-stakes) cases to sway diagnosis
Confirmation bias?
Emphasizing evidence that supports PRESUMED diagnosis & overlooking information that supports other diagnoses
-> Related to anchoring bias
anchoring bias?
Fixating on INITIAL impressions to make a diagnosis
-> Related to confirmation bias
Framing bias?
Allowing diagnostic approach to be influenced by context & presentation of information
eg. abd pain dx as Opioid w/drawal drug seeking
actual dx: bowel obstruction
Etho hepatitis
lab?
AST> ALT > 2 times ratio ( <300IU/L)
- > elev GGT
- > elev ferritin ( acute phase reactant)
Pul emboli
Wells score?
+ 1 point:
- > hemoptysis
- > cancer
+1.5:
- > previous PE/ DVT
- > HR >100
- > recent sx/ immbolization
+3:
- > clinical sign DVT
- > alternate dx less likely than PE
> 4 PE likely
<4 unlikely PE
Rx:
ACUTE DVT/ PE : rapid ONSET, NO req INR monitoring + NO req OVERLAP rx
—> pt diff with dietary restriction / freq monitoring
–> oral direct Xa inhibitors ( Rivaroxaban, apixaban)
*** VC filter: when failure to control with INR / recurrent emboli / active bleeding
Odds ratio?
odds od exposure in cases
eg. OR= 1
when (given OR = 3.5)
( 3.5 -1 ) /1 = 2.5 =250%
1 = 100%
ADJUSTED OR - account for the effect of potential cofounders : better estimates of asso
*** Unadjusted OR : DOES NOT account !!
Febrile NONhemolytic transfusion reaction (FNHTR)
sym?
rx?
MC adverse transfusion rxn -> benign cause by CYTOKINE !!!! release from leukocytes within donar blood product
- > release cytokines : transient fever, chills, malaise w/in 1-6 hrs
rx: cessation + APAP
PPX:
LEUKOREDUCED blood products
-> mini cyokine production + reduce HLA alloimmunization CMV transmission
** ppx with antihistamine : NOT reduce FNHTR
acute hemolytic transfusion reaction (AHTR)
sym?
-> Mismatched donor and recipient blood.: ABO incompatibility!!!!
Sym:
- > chills, flank pain
- > gross HEMATURIA within 1 hour transfusion.!!!
- -> Acute RF ( ATN)
- -> DIC
- >
- direct antiglobulin (Coombs) test,
- > increased plasma-free hemoglobin, and hemoglobinuria.
anaurosis fugax
sym?
etio?
dx?
painless , rapid, transient (<10 mins), monocular vision loss
- > CURTAIN descending over visual field
etio: retinal ischemia : ATS emboli ( ipsilateral internal carotid artery)
dx: duplex U/S neck
hemochromatosis
sym?
- > IRON overload
- -> elev liver enz
- > DM
- > cirrhosis
- > hypogonadism
- > arthritis (chondrocalcinosis): CPPD pseudogout
- > HF
- -> bronze DM : acanthosis @ sun exposed area: FACE!!!
nonalcoholic steatohepatitis
sym?
ASX
-> HM with elev liver enz
- > fatty infiltration liver
- > obesity , DM, hyperTG
Epidermolysis bullosa (EB)
sym?
moa:
- > inherited disorders by epithelial fragility (eg, bullae, erosions, ulcers) triggered by minor trauma
- -> friction blisters at PALMS + SOLES
- > thickening skin of feet
- > oral blisters with BOTTLE -feeding
–>mutation pn iv in intraepidermal + dermoepidermal adhesion complexes BM zone
types:
1. simplex
2. junctional
3. dystrophic
4. kindler syn
enhanced physiologic tremor ?
—> LOW AMP , relative FAST 10-12 Hz
sym:
fine, fast, symmetric action tremor INC with SNS ACTIVITY
–> IMPROVE with REST!!
–> NON-progressive , dec over time
etio:
- > dose dep drug enhanced eg. SSRI, beta +, lithium ( iron acc in substantia nigra)
- > stress, anxiety, caffeine
- > med condition: hypoglycemia, etho, thyrotoxicosis, liver dx
Herpes zoster ophthalmicus
vs HZ oticus ( ramsay hunt syndrome)
sym?
eye:
- > VZV @ N1
- > elderly
- > fever malaise and a burning, itching sensation in the periorbital region.
- > vesicular rash in the distribution of the cutaneous branch of the V1
Ears: VZV @ N7 , 8
–> vesicular rash auditory canal / auricle -> ipsilateral facial paralysis
upper airway resp infection ( postnasal drip)
rx?
antihistamine H1 ( more effective)
-> not effective 2-3 wks : further dx
fibromuscular dysplasia (FMD).
sym?
dx?
- > women age 15-50.
- > noninflammatory + nonatherosclerotic
sym:
- > HTN, non sp –> 2ndry hyperaldosteronism
- > brain ischemia ( TIA, stroke, amaurosis fugax)
- > carotid bruit
- > inv artery ( renal, carotid, vertebral)
dx:
-> CT abd/ duplex u/s
action tremor ( essential )
sym?
WORSEN with ACTION
-> anxiety , outstretch arms
More pronounced @ “END GOAL directed movement”
-> improves with etho , REST
rx: beta blocker: propranolol
- > anticonvulsants: PRIMIDONE
** Clonidine: central acting A2-adrenergic agonist: adjunctive severe HTN
acute coronary syndrome
s/p stent thrombosis
etio?
noncomplence to rx highest risk !!!
-> DAPT : ASA + P2Y12 receptor blocker ( clopidogrel, prasugrel, ticagrelor)
-> STEMI / non- STEMI/ unstable angina
*** severe AS : concentric LVH : AV stenosis <1 cm
cardiogenic shock
sym?
lab?
-> acute MI
sym:
-> dec myocardial contractility -> LOW CI -> hypotension + reflexive tachycardia -> failure foward blood flow
!!!! — > back up to LUNG –> PUL EDEMA ( dyspnea, tachypnea, hypoxemia)
–> inc PCWP!!!! LA inc
-> SVR inc : vasoconstriction, cool extremities
PUL artery embolism : obstructive shock
lab?
Right side tension pnthorax –> pinching VC –> dec venous return to RA
- > CVP inv ( right side preload)
- > inc SVR
- > dec PCWP + CI ( dec blood delivery to LA)
Patellofemoral pain syndrome
sym?
dx?
-> chronic ANTERIOR knee pain in YOUNG women
dx:
- > negotating stairs, prolonged sitting
- > atrophy / wkness QUARDICEPS / hip adbuctors , varus/ valgus malalignment
-> reproducible with isometric quadriceps contraction (eg, squatting).
rx:
- > MUSCLE EXERCISE: strengthening the quadriceps and hip abductors.
- > NSAIDS
*** rigid knee immboilizers : short term rx patella fracture / rupture of quadriceps/ patellar ligament –> not rx here : can cause MUSCLE ATROPHY!!
ACL tear
sym
dx?
anterior laxity tibia
extensor mech tear of patellar / quadriceps tendon
sym?
loss knee extension
-> swelling + deformity
osgood schlatter dx?
repetitve tenderness at tibila tubercle
- > preadolescent / adolescent during rapid growth spurts
- uncommon in adults
anemia chronic dx
lab?
sym?
chronic inflammations suppression of RBC production by inflammatory cytokines
-> etio: RA , SLE, Ca
dx:
-> cbc, iron studies
lab:
- -> normochromic normocytic RBC
- > transferrin: sat mildly dec
- > MCV: normal/ dec
- > iron dec
- > TIBC dec
- > Ferritin: N/ inc
- > TIBC N/ dec
- > retiuclocyte count: LOW ( impair RBC production)
-> Hepcidin : bind + destroy iron channel on RBC –> dec iron absorption + release .
–> IRON trapping within macrophages , dec serum iron concentration , poor iron available for Hbg synthesis
rx: rx underline dx
per- protocol analysis
vs
intention to treat (ITT)
exam?
PPA: strictly adhered and completed protocol
- > excluding dropouts , true effect , assuming perfect scenario
- > OVERESTIMATES the actual practical clinical setting
ITT: keeping all dropouts , conservative estimate of the effect , REALISTIC clinical setting
lupus anticoagulant ?
lab?
mixing test ?
antiphospholipid ab
mixing study FAILS to correct prolong aPTT
-> risk of fetal loss + thromboembolism
-> DVT
lab:
- > anticardiolipin ab
- > anti-beta2-glycoprotein 1 ab
- VWF def : ASX
- -> easy brusing + mucocutaneous bleeding, prolong aPTT : will CORRECT with mix study (F8)
thoracic aortic aneurysm (TAA
sym?
cxr?
etio:
inv ascending aorta (between the aortic valve and the brachiocephalic artery)
etio:
- degenerative changes : disruption aortic wall medial layer : loss elasticity + AD
- HTN
- cxn tix dx
sym:
-> AXS
CXR:
-> widened mediastinum, enlarged aortic knob, and tracheal deviation
- hiatal hernia : round retrocardiac mediastinal density with air-fluid level
- > GERD
RA complicated by AA amyloidosis.
sym?
!!!! -> renal: nephrotic syn: PNURIA >3.5 !!!!!
- > skin ecchymoses, waxy skin
- > RESTRICITIVE CMP: CHF, LVH, nondilated LV cavity
- > HM, !!!! dysmotility
- > neruo: peripheral neuro, dementia, stroke
lab:
- > ESR
- > normocytic anemia
tix biopsy:
-> amyloid congo red , amorphous hyaline material
- Proliferative GN –> cellular proliferation and glomerular immune deposits : HTN, hematuria, and RBC casts
- —> dec GFR !!!
OCD
rx?
first line: CBT
than: SSRI
xeosis, dry skin
sym?
etio?
-> elderly person in dry environment
- > eczematous plaques
- > improve with moisture
nummular eczema (NE)?
- > idopathic inflammatory dx
- > MC in middle -age older pt
- > “COIN” like !!!
rx:
-> topical glucocorticoids
HOCM
sym?
rx?
- > asymmetric septal hypertrophy and abnormal systolic anterior motion of the mitral valve
- > LV outflow tract (LVOT) obstruction.
- -> harsh cresendo - decrescendo murmur @ left sternal borders
- -> INCREASE with dec LV vol ( valsalva)
- –> DECREASE with inc LV vol ( squatting)
rx: Beta blocker, CCB, disopyramide
- > neg inotropic agents ( prolong diastole + dec myocardial contractility)
macular degeneration
sym?
etio?
- > distortion of STRAIGHT lines such that they appear wavy.
- > macula inv first “drusen deposits”
etio
- > age
- > smoking
urgency Urinary Incontience?
- > detrusor overactivity
- > > 40 yo with prior pelvic surgery
rx:
- > bladder training kegel training
- > anti-muscarinic (oxybutynin): dec Ach activity : dec detrusor contraction , dec sense urgency
se: dry mouth, constipation, blurry vision - Pessary: rx stress urinary incontinence
- -> pelvic organ prolapse (ant vag wall bulge)
chylothorax
sym?
disruption throacic duct
- > malignancy, trauma
- > exudative effusion: high TG , milky white appearance
transudate effusion etio?
- dec intrapleural ( atelectasis) : red perivascular pressure pulls fluid across vascular mem into pleural space
- dec plasma oncotic pressure (nephrotic syn)
- elev hydrostatic pressure (CHF)
exercise ind broncho constriction rx?
trigger: cold, dry air
- > beta agonist, mast cell stabilizers
eg. albuterol 10-20 min prior exercise
- > Antileukotrines agent 15-20 min prior exercise if unable to tolerate beta +
- > combination in high performance athletes
spontaneous intraparenchymal hemorrhage @ right cerebellar hemisphere
MC loc?
sym?
ICH : HTN -----> etio: 1. cerebral AMYLOID ANGIOPATHY 2. s/p HTN
mc loc@ !!! 1. BG (putamen) 2. cerebellar nuclei 3. thalamus 4. pons 5. cerebral cortex
sym: !!!! -> gradual onset min- hrs -> contralateral hemiparesis -> contralateral sensory loss -> conjugate gaze dev TOWARDS side of lesions
dx:
non-contrast CT scan
rx: ER decompression if hemorrhage >3 cm
Contralateral hemiplegia
vs
contralateral hemisensory loss
loc?
hemiplegia:
- > cortical, subcortical, upper BS
- -> injury descending corticospinal tract
hemisensory:
- > @ ascending somatosensory pathway ( dorsal column-medial lemniscal + anterolateral pathway)
alzheimer disease (AD)
sym?
loc @ TEMPORAL LOBE ATROPHY!!
—> hippocampi + medical temporal lobes
- > memory loss for recent event
- > later psy features ( delusion, hallucination)
rx:
- -> cholinesterase inhibitor : Donepezil, galantamine, RIVASTIGMINE
- > NMDA receptor antagonist : Memantine
chronic obstructive pulmonary disease (COPD) with cor pulmonale
sym?
dx?
- > COPD
- > elev JVP
- > enlarged liver (congestive hepatopathy)
–> impaired RV: pul HTN , OSA, idopathic Pul HTN!!!!
sym:
- > loud P2
- > right vent 3rd heart sounds
- > TR murmur
- > elev JVP with hepatojugular reflex, HM with pulsatile liver , ascites / pleural effusion
- —–> NOT cause BIBASILAR CRACKLES!!!
dx: CLX
- > echo: RVH, TR with RA enlargement
- -> enlarge central pul arteries
- -> Rt axis dev
-> CATHETERIZATION (GS): elev Put artery systolic pressure > 25 without Lt heart dx
uremic coagulopathy.
sym?
lab?
rx?
- > ecchomyoses, epistaxis
- > major BLEEDING : advent of dialysis
lab:
- > PLATELET DYSFUNCTION
- > pt count NORMAL: Chronic RF!!!!
- > Pt , aPTT ,normal
- > BT prolong
rx:
- > desmopressin: inc vwf
- > crypoprecipitate
- > conjugated estrogen
TB meningitis
syn?
dx?
sym:
-> over WEEKS
!!!! -> n/v, nuchal rigidity, HA, CN PALSY , stroke
dx:
-> BASILAR meningeal enhancement & hydrocephalus
- > CSF: WBC count 100-500 (LEUKOCYTOSIS)
- > mildly ↑ protein
- > ↓ glucose,
- > ↑ adenosine deaminase
NAAT or AFB CSF smear
rosacea
rx>
- avoid exposure sun
- topical brimonidine /laser
- papulopustular rosacea:
- > first line: topical METRONIDAZOLE, azelaic acid, ivermectin
- > 2nd line: oral tetracyclines
** topical corticosteroids : not rxm -> rebound worsening sym
caustic ingestion
sym?
rx?
-> injury to the upper aerodigestive tract a
sym:
- > SEVERE pain, dysphagia, and oropharyngeal erythema and ULCERATION.
- > NOT AMS
dx:
-> Full-thickness necrosis of the esophagus can lead to perforation, resulting in either mediastinitis or peritonitis.
–> Esophageal STRICTURES are MC complication s/p weeks to months !!!
–> esophageal SCC YEARS after
rx:
1. secure ABC
2. decontamination: remove clothing
3. CXR
4. ENDOSCOPY within 24 hrs
** Steroids: NOT shown to reduce risk of strictures!!
IBD alarm sym?
rx?
- > GI bleeding, rectal bleeding
- > nocturnal diarrhea , WL, ANemia
- > age > 50 yr
dx;
- > inc fecal calprotectin
- > fecal leukocytes
- -> Colonoscopy: normal mucosa
rx:
FIber supplement
Statin induced myopathy
sym?
rx?
STATIN:
–> red risk of MI and ischemic stroke in ATS CVD risk >7.5 -10%
- > proximal , symmetric muscle, pain/ wkness
- > elev CK
** UMN sign NOT expected
rx: switch MODERATE stain
** FIBRATE : when TG > 400/ low HDL <40
hypothyroid myopathy
lab?
- > young women !!
- > asx
- > elev CK
- > normal/ mild elev ESR, CRP
dx:
TSH, fT4
-> ANA, anti-Jo-1 Ab
muscle biopsy
MDMA “ecstasy” : amphetamine
sym?
delirium, seizures
-> EUPHORIA, INTIMACY
NOT combative agitation
-> hyperthermia
–> HYPONATREMIA!!
Synthetic cathinones, “bath salts,
sym?
amphetamine analogs.
-> increase the release, or inhibit the reuptake, of NE, DA, and serotonin.
sym:
- > severe agitation, combativeness, psychosis, delirium, myoclonus, and, rarely, seizures.
- > inc SNS : inc BP + HR. !!!!!
-> intoxication is the prolonged duration of effect
constrictive pericarditis
etio?
sym?
dx?
- > s/p radiation therapy
- > RHF
- -> PRIOR Cardiac surgery!!!
-> ethio:
scarring and subseq loss of normal elasticity of the pericardial sac.
- ——> DEC RV contractiltiy!!!
- —> DEC CO , HYPOTENSION!!
-> inelastic pericardium prevents VR to the right heart during inspiration and leads –> RHF
sym:
- > peripheral edema, ascites,
- > hepatic congestion with hepatomegaly, -> cirrhosis (cardiac cirrhosis).
- ——-> CLEAR LUNGS!!! not affected
echo:
- > elev JVP with prominent x and y descents
- > hepatojugular reflux
- > Kussmaul’s sign (lack of dec or inc in JVP on inspiration), or pericardial knock (mid-diastolic sound).
complete heart block
sym?
rx?
- > inc JVP
- > hypotension
- > BRADYCARDIA
rx:
Atropine
pacemaker
confounding bias?
vs
Effect modificatiton
confounding bias:
-> fail to ADJUST comorbidities can lead to FALSE conclusion
–» link to BOTH exposure + OUTCOME interest!!!
-> extraneous variable
try to eliminate:
–> matching, restriction , randomization !!!!
EFFECT modificaiton:
- > STRATIFICATION can make the effects of the modifier more apparent.
- –> extraneous variable changes the direction / strength asso btwn risk factor and dx
REM sleep dx
inc risk?
Dementia!!! LEWY bodies / multiple system atrophy ( Shy -Drager syndrome) !!!
-> male > 50 yr
-> muscle atonia
-> alpha-synuclein neurodegeneration
(eosinophilic intracytoplasic inclusion )
—> fluctuating cognition
-> visual hallucination
_> REM sleep beh
!!!!!! -> Parkinsonism
—-> Latter 1/2 of the night: UNABLE to inhibit muscle ATONIA !!!
!!!!! etio: Severe sensitivity to antipsy rx ( DA antagonist)
–> first gen : Haloperiodl
delirium
sym?
etio?
dx?
rx?
wax & wane condition
etio:
- rx
- infection
- electrolyte derangement
- sys illness: CHF, HF, Ca
- CNS : seizure, stroke, head injury, subdural hematoma
dx: UA + electrolytes
rx:
- > antipsy: haloperidol
- > BZD
- > nonopioids
** CBC + iron studies: dx: chronic anemia
PPU
etio?
sym?
dx?
rx?
H. pylori (asia)
-> urease producing organism
sym:
- > dyspepsia “BURNING” sensation
- > postprandial fullness
- > nausea
- > GI bleeding, worsening pain during fasting, nocturnal pain –> duodenal ulcer formation !!!
- > microcytic anemia ( IDA)
dx:
>60 yr: upper endo
—-> elev BUN/CR RATIO!!! HYPOVOLEMIA !!
<60 yr: h. pylori testing, upper endo with high risk pt : GI bleeding, WL, >1 alarm sym
- endo bx: gastric antrum
- -> urea breath testing
- > stool Ag studies
rx:
- > Ab ( amx + clarithromycin) + PPI
Alarm symptoms: 1. Progressive dysphagia 2. Iron deficiency anemia 3. Odynophagia 4. Palpable mass or lymphadenopathy 5. Persistent vomiting 6. Family history of GI malignancy
Avascular necrosis
sym?
dx?
rx?
moa: OSTEONECROSIS of femoral head
etio:
- > SLW
- > steroids use
sym:
- > Groin pain on weight bearing
- > Pain on hip abduction & int rotation: red ROM
- > No erythema, swelling, or point tenderness
lab:
- > NormalWBC
- > Normal ESR & CRP
XR: normal!! Crescent sign (subchondral lucency) in advanced stage
-> MRI: boundary btwn normal and ischemic bone, as well as the zone of hypervascularity.
** osteonecrosis: subchondral fracture will be seen on XR
hyperventilation
rx?
Alveolar min vent inc enough to decrease the PaCO2: induce RESP ALKALOSIS
- ——> kidney compensation : retain H+ and excrete HCO3 to normalize the Ph!!!
- –> urine alkaline (high urine ph) !!!!
- -> tachypnea (ie, inc RR)
- –> GOAL: PaO2 55-80mmHg
- -> O2 sat: > 88-95%
- -> inc TV
- –> inc FiO2 + PEEP
sym: -> parathesia, HA, LH, carpopedal spasm -> cerebral vasoconstriction / alkalosis -ind hypoca + hypophosphatemia
rx: reassurance + deep breathing training (abd diaphragmatic breathing)
- -> BZD (lorazepam)
** paper bag ventilation : NOT recommend -: induce hypoxia !!!
necrotizing malignant otitis externa
(NOE)
sym?
etio?
pseudomonas
sym: -> granulation tix -> think , purulent discharge Ext auditory canal -> elev ESR -> severe , unremitting ear pain -> N7, 10, 11 deficits : facial drooping
comp:
-> bact abscess, MNG, death , TMJ dx
rx:
IV ciprofloxacin
-> surgical debridment
** DM rhizopus : blask eschar
refeeding syn
lab?
- > reintro of carb in pt with chronic malnourishment.
- -> inc INSULIN
- > inc glycogen syn
- > inc pn syn
- > inc IC UPTAKE PO4, K, Mg, thiamine
- —–> DEC serum PO4, K, Mg
- ——> dec serum thiamine
- —–> inc Na, water
lab:
- > hypophosphatemia -> muscle weakness
- > hyporeflexia,
compl:
- > arrhythmias, seizure ( hypoK)
- > congestive heart failure, pul edema, edema ( inc na, water intake)
- > wernicke encephopathy ( dec thiamine)
borderline personality dx
inc risk via ?
-> childhood trauma ( phy , sexual abuse neglect)
rx: BEST dialectial beh therapy
- > antipsy (second gen)
- > antidep
Proctalgia fugax
moa?
sym?
rx?
- > spastic contraction anal sphincter
- -> pudenal nerve compression
RF:
- > female
- > other dx: IBD
- > psy stress, anxiety
sym:
- > Recurrent rectal pain UNRELATED to defecation
- > Episodes lasting sec- mins (≤30 min)
- > No pain between episodes
rx: NG
biotherapy
Coccydynia
sym?
MC women
- > obesity
- > trauma injury
-> pain exacerbated by sitting + DRE
dialysis-related amyloidosis (DRA)
moa?
sym?
lab?
amyloidoses misfolded precursor pn (beta2 microglobulin) —> deposit IC tix, causing organ dysfunction.
sym:
affinity OA :
1. scapulohumeral periarthritis: inc shoulder pain, inc rotator cuff thickness, hyperechogenic deposits
2. CTS: median neuropathy, thenar eminence atrophy
3. bone cysts: fracture
WOMEN: androgen-producing Ca
sym?
lab?
MC postmenopausal women
-> Rapidly progressive hirsutism with virilization (clitromegaly)
lab:
- > Very high serum androgens
- > high DHEA +Testosterone by ovaries + adrenal glands
- > low LH ( neg feedback)
- ovarian tumor:
- -> inc Testosterone
- -> normal DHEA
- > low LH
- PCOS: high LH, testo
- -> low / normal DHEA
Attributable risk percent (ARP) ??
ARP = (risk in exposed - risk in unexposed) / risk in exposed.
ARP = (RR - 1)/RR.
pityriasis versicolour
rx?
selenium sulfide
histrionic personality dx?
PERSISTENT pattern
- > Center of attention, frequently use physical appearance to attract attention, -> behave in a sexually seductive or provocative manner
- > drama communication, exaggerate facial expression + hand gestures, cross arms dramatically
- > rapid shifting emotions, impressionistic speech
intermittent explosive dx?
intermittent verbal / physical aggressive beh disproportionate to objective triggering offense
–> feeling REMORSE after!!!!!
leukocyte adhesion deficiency
etio?
sym?
dx impaired NEUTROPHIL MIGRATION
–> defect LFA-1 intergin CD18
- > recurrent skin inf, mucosal bact
- > ABSENT PUS
- > impaired wound healing
- > DELAY Umbilical cord seperation
lab:
inc Neutrophils, absent at infection site ( no migration)
paroxysmal nocturnal hemoglobinuria (PNH)
sm?
lab?
-> autoimmune hemolytic disorder Intravascular and extravascular hemolysis + hemoglobinuria
- > Aq genetic defect –> lack of the glycosylphosphatidylinositol anchor, cxn pn, including CD55 and CD59, to the cell surface.
- -> pn normally inhibits activation of COMPLEMENT on RBC: absence pn : hemolysis
sym:
-> hemolysis -> hemoglobinuria
-> cytopenia : fatigue, dyspnea
!!! -> hyper-coagulable ( PV THROMOSIS)!! -> abd pain
lab:
- > low Haptoglobin ( hemolysis causing RBC bind to pn transport)
- > elev bilirubin + LDH ( inc RBC breakdown)
- —> RETICULOCYTES
dx:
-> flow cytometry test : absence CD55, 59 pn
Valvular aortic regurgitation (AR)
etio?
sym?
congenital heart dx –> bicuspid aortic valve (BAV)
- > AD
- > freq asso with AS!!
- -> with aortic root dilation :: right UPPER sternal border
sym:
!!!! -> decrescendo, EARLY DIASTOLIC murmur @ left sternal border , leaning forward , EXPIRATION !!
!!!! —–> WIDE PULSE PRESSURE : WATER HAMMER pulse
- -> inc Voln OVERLOAD in LV
- -> LV stretch (inc PRELOAD) allowing inc SV to help maintain CO
- —–> ECCENTRIC HYPERTROPHY : myocardial fiber in series
- —-> inc LV COMPLIANCE
-> initial Asx , eventually LV wall stress -> contractile dysfunction -> decompensated HF
selection bias?
to avoid:
patients are RANDOM assigned to treatments to minimize potential CONFOUNDING variables
psychogenic nonepileptic seizure (PNES)
–> CONVERSION disorder
sym?
etio?
dx?
etio:
-> NOT asso with abnormal cortical activity during the episode.
sym:
- > longer DURATION > 5 mins !!!!!
- > forced eye closure, side-to-side head or body movements
- > memory recall of the event
- > lack of postictal confusion.
dx:
Video-EEG monitoring is gold standard
tumor lysis syn
lab?
–> INC PO4, K, UA: hyperuricemia ( lysed tumor cells met by XO –> UA)
–> Dec Ca
- > AKI: ca- po4 stone obstruction
- > cardiac arrhythmia : HYPERKalemia
rx:
-> IV fluid
ppx: reduce UA level
- > allopurinol
- > rasburicase
- > febuxostat
contact dermatitis
sym?
type 4 HSR
- > acute: pruritic red, indurated plaques with vesicles/ bullae!!!!
chronic: lichenificaiton, fissuring
- sensitization phase: naive T cells after initial exposure
- re-exposure (elicitation phase) : memory T cells proliferation + release inf cytokines promote CD8
rx:
topical / sys corticosteroids
—> TRIAMINCLONE
- ** s. aureus : bullous impetigo
- > enlarging vesicles + bullae rupture exudates + crusts
- > pruritis , NO/little ERYTHEMA
- —-> Rx: Mupirocin!!!
reactive attachment disorder (RAD)
sym?
rx?
sym:
- > Insufficient care (eg, neglect, abuse, inconsistent caregiving)
- > Does NOT SEEK or respond to comfort
rx:
- > early intervention promoting safe environment
- > psy services
*** disinhibited socail engagement dx: over-friendly
Sickle cell trait
sym?
lab?
comp?
sym: ASX
lab:
- > normal Hbg, reticulocytes count, RBC indices
- > Hbg electrophoresis : mut traits : HbA > HbS
comp:
!!!!! -> hematuria/ RENAL PAPILLARY NECROSIS !!!!
-> splenic infarction ( HIGHER ALTITUDES, dehydration, ETHO consumption )
-> venous thromboembolism , priapism
-> exertional rhabdomyolysis
***rhabdomyolysis: myoglobinuria , + u/a for blood, not RBC, muscle pain + wkness
primary sclerosing cholangitis ( PSC)
sym?
dx?
progressive dx: inflammation, fibrosis, stricturing intrahepatic + extrahepatic bile duct
- > asso with UC
- > fatigue, pruritus
lab:
elev ALP, bilirubin
-> inc ESR, IgM, + p-ANCA
———> antiMITOCHONDRIAL AB assay!!!
dx:
MRCP!!!! noninvasive
alternative: ERCP if MRCP not able to perform
-> liver biopsy : onion skin fibrosis
rx: URSODEOXYCHOLIC ACID!! ASAP
- > hydrophilic bile acid -> dec biliary injury + inc biliary secretion + anti-inf
- -> alternate: liver transplant
- *** anti-SM AB: autoimmune hepatitis
- *** HIDA scan: acute cholecystitis
- ** CEA: WL, HM
pronator drift
etio?
UMN: pyramidal / corticospinal tract dx
—>” CLASP knife” : velocity dep reisitance to passive movement to limbs
- -> outstretch arm with palms up eye closed
- -> drift arm DOWNWARDS
- ** ROMBERG test: loss balance
- > Proprioception impaired : Vit B12, tabes dorsalis
brief psychotic dx?
–> 1 day - 1 month
sym:
- > disorganized , biazzare beh
- > disorganized speech
- > hallucination
- > trigger by stressful event
antisocial personality dx
sym?
rx?
after >18 yr
- > violation right of others
- > phsy aggressive + impulsive , repeat fights
- > illegal activities ( drugs, theft)
- > lack of remorse
- > failure to accept responsibility
- > lying
*** CONDUCT dx: <15 yr
rx: CBT , family therapy
- > parent management training
Narcissistic personality dx?
- > exaggerated sense of self importance
- > lack empathy
- –> LESS impulsive , NOT engage violent / illegal activities
blepharospasm , focal dystonia
etio?
rx?
bright light trigger muscle eyelid bil, symmetric contraction –> sensory trick
–> asso with lower face, tongue, jaw : MEIGE syndrome!!
etio:
-> PD, antipsy , idiopathic trigger
rx:
-> B. toxin
acute renal failure
AIN
chronic tubulointerstitial nephritis
etio?
lab?
sym: AIN:
- -> fever, rash, WBC
- -> sloughing renal papilla
- —-> papillary ischemia + vasoconstriction medullary BV ( vasa recta)
**NO RBC, RASH, esoinophil, Cast!!!
etio :
naproxen ( NSAIDS)!!!!
aminglycosides: amikacin
-> rx: pyelonephritis with multi-drug resistance
se/
Nephrotoxicity, neruotoxicity
Ototoxicity
Teratogenic
Molluscum contasgiosum
sym?
rx?
-> small, skin colored papules with indented centers
rx:
- > 1st line: :Liquid nitrogen ( cryotherapy)
- > curettage
- > topic cantharidin
*** localized dermatitis: topic corticosteroids ( Triamciolone)
Delayed sleep-wake phase disorder
–> circadian rhythm disorder
sleep onset insomnia , excessive daytime sleepiness
“night owl”
IgA nephropathy
sym?
lab?
-> few DAYS after URI!!!!!!
- > gross hematuria, flank pain , low grade fever
- > mucosal inf
- > IgA -based IC deposits in glomerular mesangium
lab:
- > U/A : Pn RBC, RBC cast
- > normal C3, C4
- > inc CR
Pulseless electrical activity
rx?
AFib without palpable pulse
–> CPR + vasopressor epinephrine
-> dx: Id 5H, 5P
- **NOT SHOCKABLE ryhthm!!!! NO DEFIBRILLATIOn / SYNCHORONIZED Cardioversion !!!!!
- -> Vent Tach
Lateral medullary (Wallenburg) syndrome)
sym?
- > vertebral artery dissection!!
- -> vertigo
sym:
1. Loss of pain and temp ipsilateral face (spinal trigeminal tract) and contralateral trunk/limbs (spinothalamic tract)
- Ataxia (inferior cerebellar peduncle) and nystagmus (vestibular nucleus)
- Dysphagia and dysphonia due to bulbar muscle weakness (nucleus ambiguus)
- Ipsilateral Horner syndrome (Sym tract)
subconjunctival hemorrhage
sym?
rx?
- > benign , ASX
- > resolve with 24-48 hrs
etio:
simple trauma, rubbing eyes
dx:
-> observe
ototoxicity
etio?
- > aminoglycosides
- > cisplatin
- > salicylates
- > furosemide : co-exit with RF
single brain abscess
etio?
sym?
etio:
- > Staphylococcus aureus
- > Viridans streptococci
- > Anaerobes
patho:
- > direct spread : otitis media, mastoiditis, sinusitis
- > hema spread ( IE)
sym:
- > focal deficits, seizure, fever,
- –> NOCTURAL HA, morning vomiting!!!
dx:
- > MRI: RING -enhancing lesion with central NECROSIS
biopsy: obtain tix + gram stain + culture
rx:
-> metronidazole
- ** Herpes encephalitis:
- -> HYPODENSE lesion TEMPORAL lobe , ring enhancement NOT common !!
median nerve injury
etio?
sym?
brachial artery cannulation
-> IN catheters delivery vasopressor
sym:
->median nerve lies DIRECTLY medial to brachial artery –> lacerated / compressed by post-procedural hematoma / local swelling
-> spontaneous resolution in days to wks
***VASOPRESSOR extravasation : local vasoconstriction effect: venous blanching , pallow surrounding tix –> NOT explain MEDIAN nerve deficits
trigeminal neuralgia
etio?
sym?
rx?
etio:
Multiple sclerosis : autoimmune demyelinating, vascular loop, neoplastic growth
—> COMPRESSION of CN V2, V3 ROOT @ PONS !!!
-> BILATERAL neuralgia
sym:
-> last 2 wks and resolve spontaneously
rx:
- > carbamazepine / oxcarbazepine
- > surgery ( decompression ) severe refractory cases
** herpes zoster viral reactivation : UNILATERAL : V1 branch- blindness
urinary incontinence in elderly
etio?
dx?
Delirium Inf ( UTI) Atrophic urethritis/ vaginitis Pharm ( a-blockers, diuretic) Psy (depression) Exessive UO ( DM, CHF) Restricted mobility ( s/p surgery) Stool impact
dx:
U/A + culture
Fat embolism syn
sym?
dx?
rx?
Fracture of a bone (eg, pelvis, femur)
Sym:
1. Microvascular occlusion in the pul capillaries –> ARDS
- Microvascular occlusion in the sys circulation (eg, brain, dermal capillaries),
- -> neuro dysfunction + petechial rash - Degradation of embolized fat into proinflammatory intermediaries
- -> sys inflammatory response (eg, tachycardia, leukocytosis)
dx:
clx
rx: supportive
O2
Failure mode and effects analysis (FMEA) ?
-> PROSPECTIVE, systematic, team-based approach
–> identifying steps in a process and finding solutions to any problems that may arise
-> goal ensuring safe outcomes
*** ROOT cause analysis / control charts: once problem is IDENTIFIED
primary adrenal insufficiency
(addison)
etio?
sym?
- primary: DESTRUCTION BILATERAL ADRENAL CORTEX
- -> autoimmune adrenalitis (90%), inf, Ca
lab:
- > DEC cortisol:
- > DEC aldo: hypoNa, HyperK, hyperCl, HypoVolemia –> MET ALKALOSIS
- —> SALT craving !!
- !!!!!! > inc ACTH : HYPERpigmentation
- > Eosinophilia + hyperplasia lym tix ( tonsil)
dx: cosyntropin stimulation testing
rx: steroids + hydrocortisone ( synthetic mineralocorticoid)
cutaneous larva migrans
etio?
sym?
- > hookwarm larvae
- > bare foot walk on sand, soil
sym:
- > lower ext
- > intensely pruritic, reddish brown tracts
dx:
eosiniphils
rx:
IVERMECTIN
- SPIDER bites: UPPER arm, inner thigh, thorax
- > central clearing, red plaques/ papule
- > necrotic eschar, less pruritic lesion
carbon monoxide toxicity
rx?
-> carboxyhemoglobin : impairs O2 delivery to tix –> shifting Hb-Oxygen dissociation curve to LEFT
–> inc EPO
- > HA, AMS, seizure, dizziness, come, syncope, HF, arrythymia
- > cherry red lips
rx: 100% facemask O2
*** BZD if continuous seizure
RSV
sym?
sym:
-> wheezing + RARELY < 1 % have diffuse , bil reticular infiltrates
beta-1 AGONSIT adrenergic receptor
eg. Dobutamine
moa?
moa:
!!!! B-1 + receptor: stimulate inc myocardial contractility –> inc cAMP cardiac myocytes –> enhance Ca-mediated binding actin-myosin complex to Toponin C –> + inotropic effect: inprove EF, reduce LVESV
—-> dec LVEDV : dec preload)
–> inc HR ( shorter diastolic filling time
–> CO improve
weak: B2 + : smaller dec (SVR) afterload
weak A-1 : SNS improvement
*** Beta blocker: dec HR, contractility ( neg inotropic effect) , myocardial O1 demand red
meniere dx
sym?
- > RECURRENT episodes lasting 20 mins to several hrs ( not PERSISTENT)!!!!
- > sensorineural hearing loss
- > tinnitus / fullness in ear
—–> inc voln / pressure ENDOLYMPH ( ENDOLYMPHATIC HYDROPS) !!!!
vestibular neuritis
sym?
self limited dx: !!!!! SINGLE episodes last DAYS
- > N8 dx
- > s/p viral URI !!!!
- -> UNILATERAL hearing loss ( labyrinithitis)
- -> head thrust test abnormal
rx:
meclizine , steroids,
perilymphatic (labyrinthine) fistula
etio?
sym?
etio:
complication of head injury or barotrauma that -> leakage of fluid from the semicircular canal.
sym:
-> A perilymphatic fistula causes vertigo, nystagmus, hearing loss, and tinnitus that is triggered by sneezing, straining, or sudden loud noises (Tullio phenomenon).
nocardia
vs
actinomyces
rx?
nocardia:
—-> sys sym, lung nodules disseminated, brain abscess ( seizure)
—> G+, partical acid-fast, filamentous branching rods
rx:
–> TMP-SMX
Actinomyces: ----> ANAEROBIC , not acid-fast ----> sulfur granules, direct extension rx: PNC-G
Hepatitis A
sym?
lab?
- > homeless shelter, drug users
- > men sex with men
lab:
- > inc ALT, AST > 1000
- > RUQ pain, bilirubinuria, pale stool ( lack bilirubin pigment)
- > fever, anorexia, N/V
- > jaundice, pruritus
- -> anti-HAV IgM
- > inc ALP
MEN 1
sym?
Pituitary adenoma
Primary hyperPTH
Pancreatic/ GI Neuroendocrine tumor :
- –> Gastrinoma : recurrent PEPTIC ULCER
- -> VIPoma
- -> Glucagonoma : hyperglycemia, necrolytic migratory erythema
- –> Insulinoma : hypoglycemia
** toxic thyroid adenoma : inc bone turnover –> hypercalcemia :WL, tachycardia
aortic dissection
@ ascending aorta
etio?
sym?
dx?
rx?
chronic systemic HTN!!! MC
- > cocaine
- > age >60 yr
sym:
- > AR!!!!
- > widening mediastinum
- > nonsp ST eev + T wave change
dx:
- > ECG
- > CXR
- > CT angio / TEE
rx:
-> pain morphine
!!! -> IV beta blocker ( esmolol): dec LV contractility: dec aortic wall stress, dec SBP , dec HR
-> Na nitroprusside
-> ER surgery repair ( TYPE A)
*** AVOID : tPA / Heparin : risk BLEEDING !!!! hemopericardium
ITP
moa?
sym?
lab?
MC @ children 2-5 , adolescent
Immune thrombocytopenia
- > autoimmune dx: IgG autoAB against pt membrane glycopn
- > inc pt dest + inhibit pt production
sym:
- > MUCOSAL BLEEDING ( epistaxis, heavy menses, ecchymoses)
- > NORMAL liver span
- > nonpalpable spleen
lab:
- -> ISOLATED THROMBOCYTOPENIA <100, 000
- -> normal Pt, Ptt, fibrinogen
rx: IVIG, anti-D, steroids
NSAIDS
effect on Pt?
block Thromboxane A2
–> impair Pt function
VWF dx?
AD
-> heavy MC bleeding
!!! —> impaired pt-endothelial binding + pt aggregation
—> F8 def
lab:
Pt FUNCTION affected : pt plug formation abnormal
–> Pt count NORMAL
CLUBBING fingers
moa?
asso?
asso:
- > lung CA, cystic fibrosis, and R-to-L cardiac shunts.
moa:
-> megakaryocytes skip normal route of fragmentation within pul circulation –> enter sys circulation (disruption from tumors, chronic lung inflammation)
- > Megakaryocytes entrapped in the distal fingertips: large size and release PDGF + VEGF.
- > PDGF and VEGF have growth-promoting properties that inc cxn tix hypertrophy and capillary permeability and vascularity –> clubbing
functional tremor (psychogenic tremor)
moa?
- > inconsistent tremor
- > ABRUPT onset and cessation
- > present @ rest
- > involuntary movements not related to neuro causes
- -> DEC with DISTRACTION
- > FINGERS are spared!!
- -> changeable features
osteoarthritis (OA)
sym?
RIsk factor?
dx?
lab
- -> WBC <2000
- > PMN 25%
- > brief stiffness < 30 mins
—–> affects LARGE weight bearing joints Lower ext ( Hip, knee)
-> XR: narrowed lumber facent joint space, osteophytes, subchondral SCLEROSIS/ cysts, crepitus + pain
!!! —–> LUMBAR SPINAL STENOSIS
-> synovial effusions : popliteal baker cysts
modifiable:
-> lifestyle, obesity, DM, occupational joint loading
non-MODifiable: !!! -> Prior trauma -> fx hx -> female sex -> advance age -> abnormal joint alignment
dx:
CLINICAL
–> imagine less sensitive , not necessary!!!
agoraphobia
etio?
recurrent , spontaneous anxiety attack
-> avoidance beh
etio:
-> PANIC attack
rx:
-> CBT
*** social anxiety dx: avoid public places, fear social humiliation / criticism
MALT
etio?
rx?
Low grade B cell lymphoma - mucosa asso lymphoid tix
–> H. pylori
-> B + T cell gastric lamina
rx:
- > eradication therapy ( quadruple / triple therapy)
- > complete remission with AB
- > advance dx: radiation therapy, immunotherpay ( rituximab) , single agent CMT
- *** Gastric Ca:
- > risk: smoking, salt , Nitroso cpd food, pernicious anemia
catatonia
sym?
rx?
- > Immobility or excessive purposeless activity
- > Mutism, stupor
- > Negativism (resistance to instructions & movement)
- > Posturing (assuming positions against gravity)
- > Waxy flexibility (initial resistance, then maintenance of new posture)
- > Echolalia, echopraxia
rx:
- > BXD
- > ECT
COPD
sym?
-> air trapping and ob
- > dec VC , inc FRV
- > inc compliance: hyperinflation
- > dec elasticity
- > inc airway resistance : inc Min vent —> inc WORK of BREATHING
rheumatoid arthritis (RA)
sym?
comp?
lab?
rx?
- > inf effusion: WBC 2000 - 100,000
- > PMN > 50%
- > translucent/ opaque appearance
sym:
- > morning stiffness >30 mins
- > synovitis
- > sys sym: fever, fatigue, anemia
- ** extrasym:
- —-> osteopenia/ osteoporosis
lab:
———> Anti-CCP ab
RF +
TNF, IL-1 + : promote inflammatory cytokines
rx:
minimize steroids exercise, vit D, Ca
-> bisphosphonate
flecainide
moa?
se?
class IC antiarrythmic : Na channel inhibiting : depol phase (phase 0)
–> control rhythm control Afib
se:
prolong QRS duration / QT interval : pt with RAPID HR
–> drug less time to dissociate from Na channel –> higher # blocked channel : WIDENING QRS complex!!!
–> use DEPENDENCE
methamphetamine use disorder?
-> “meth,” “crystal,” “ice,” and “glass”
sym:
- > delusion
- > TACTILE HALLUNICATION
- > aggressive beh severe insomnia
- > poor dentition , bruxism
- > skin sore
-> excoriation , skin picking
rx:
CBT
pstipsy rx
- *** Etho withdrawal:
- -> MARKDED TREMULOUSNESS , hallunication , elev Vital
BCC, actinic keratoses
rx?
topical 5-FU
PEEP oxygen toxicity?
ARDS : low tidal voln vent ( LTVV)
goal?
mech vent improve O2 by inc FiO2 + PEEP
prolong high FiO2 –>
O2 free radical
Goal : FiO2 <60% more SAFE
!!! LOW TIDAL VOLN VENTILATION : 4- 6 ml/g/kg body weight. : went w/o causing further injury + provide adeq oxygenation + vent
——> LTVV prevents OVERDISTENSION alveoli !!! Improves MORTALITY!
***** PaCO2: pul min vent = TV x RR
no need to adjust !!
paranoid personality dx?
-> pervasive DISTRUST + Suspiciousness
- ** delusional dx , persecutory type: believe being conspired against , sym > 1 mth
- -> no ODD dressing
meningococcal meningitis
sym?
dc?
rx?
-> neisseria MNG
MC young adults
sym:
-> initial: nonsp fever, HA, V, myalgias, sore throat
!!!!!!! -> RAPID ONSET w/in 12-24 hr : PETECHIAE/ PURPURA ( MOTTLEE skin/ pallor)
-> meningeal sign, AMS
rx: ceftriaxone
comp: shock
- > DIC
- > adrenal hemorrhage
diptheria
lab?
-> throat culture
- > sore throat, fever
- > gray, adherent , posterior pharyngeal pseudomembrane
sys sclerosis ( scleroderma)
dx?
CREST
–> anticerntromere ab
DIffuse:
- –> anti-topoisomerease i ( anti-sScl 70) + anti-RNA polymerase III
- > ANA +
POSTprandial hyperglycemia
moa?
DM type 2
–> elev HbA1c despict normal fasting glc
rx:
comb regimen : LA BASAL insulin ( control fasting glc)
+
rapid BOLUS acting mealtime insulin ( control postprandial glc)
insulin neutralizing ab ?
very high insulin dose req
–> Fasting + non-fasting hyperglycemia
dawn phenomenon ?
early morning hyperglycemia surge : diurnal inc GH + cortisol secretion
–> elev FASTING hyperglycemia
hemophilia A, B
lab?
X-linked recessive
sym:
-> delayed / prolong bleeding after trauma
!!!! -> recurrent HEMARTHOSIS, IM hematomas
-> GI bleeding
-> IC hemorrhage
-> hemophilic arthopathy!!!! : hemosiderin deposition in joints + trigger synovial inflammation + fibrosis + destruction !!!
lab:
- > inc APTT
- > normal PC, PT
- > absent / dec F8 / F9
rx:
- > factor replacement
- : desmopressin
diabetic neuropathy
sym?
N3 palsy
–> ISCHEMIC NEUROPATHY
–> inner somatic fiber: 4 EOM
“down and out gaze)
–> sup PNS fiber: sphincter iris + ciliary muscle ( controlling pupil constriction)
*** nerve COMPRESSION: aneurysm, tumor : !!!! PNS fiber + pupillary response ( MYDRIASIS)
*** Nerve inflammation ( vasculitis, autoimmune ) :
HCV testing?
2 steps process:
- -> + serology testing : anti-HCV IgG Ab
- -> confirm test: molecular testing HCV RNA
rx:
once confirm :
—> direct acting antiviral agents ( Ledipasvir- sofosbuvir)
central tendency all EQUAL?
mean = median = mode!!!
fibrocystic breast changes
sym?
- > bilateral , nonfocal, chest pain
- —> glandular tix proliferation : diffusely nodular breasts
-> Cyclic premenstrual tendernes
rx:
relief with NSAIDS, OCP
** cyclic mastalgia: NO asso BREAST NODULARITY / MASSES!
fibroadenoma
sym?
estrogen sensitive
- > vary in size, tenderness on MC cycle
- -> solitary , unilateral, well circumscribed, mobile mass
Takayasu arteritis
sym?
large artery vasculitis
- -> young asian women
- -> fever, arthralgias, WL, BP discrepancies ( UPPER ext)
- > pulse deficits, arterial bruits
LOWER -> arterio-occlusiove sym ( claudication, ulcers)
dx:
-> ESR, CRP
-> CXR: Aortic dilation , widen mediastinum
_> MRI/CT: wall thickening, narrowing lumen
rx: steroids
Aortic coarctation
sym?
-> pulse deficits + BP discrepancies
—> Narrowing descending aorta ( distal to origin to Left subclavian artery)
Upper :
- -> HTN : EPISTAXIS, HA
- -> More affect LOWER ext!!! : claudication , underdev
- -> left interscapular sys / continuous murmur !!!!!!
ecg:
- -> LVH : high voltage QRS complex, lateral ST seg depression , lat T wave inversion
dx: ECHOcardio
- -> neonates, young childrens
- > not asso with constitutional sym / ESR
hypercalcemia
humoral hypercalcermia maligancy (HHM)
sym?
rx?
- -> Cancer ind
- -> confusion, coma, stupor, rapid Ca raise
- —-> LOW PTH
- —–> MARKED Ca, PTHrP
- severe: Ca >14 !!!! / sym:
- -> short term/ immediate: NS + calcitonin !!!!!!!
- -> avoid LOOPS !!!!!!!
- -> long : bisphosphonate - moderate : ca 12-14: no immediate rx
- ASX: ca <12
- -> no immediate rx
- > avoid TZD, Li, dehydration , prolong bed rest
presbycusis
moas?
–> Cochlear hair cell loss + cochlear neuron degeneration
–> age- related brain atrophy, exposure to loud noises
–> high freq affect first
otosclerosis
moa?
- –> younger pt
- -> conductive hearing loss
- -> paradoxially improve speech with noise
abnormal BONE deposition –>
stiffening ossicular chain
sym hypocalcemia
sym?
rx?
- evaluate Ca
- –> corrected ca = [measure ca] + 0.8 x (4.0 - serum alb)]
- –> measure ALBUMIN level
!!!!!! 4. measure PTH:
- —–> LOW/ normal PTH:
- -> r/o hypocalcemia : blood transfusion, citrate bind to ion ca
- > hypoMg: resistance to PTH
- —–> high PTH:
- > Ca, inflammatory, Tumor lysis syn, PTH resistance
- serum 25-hydroxyvitamins D : r/o vit D def
- -> poor sun exposure, malabsorption
- **FGF23 : lowers PO4 –> dec interstitial absorption: inc Urinary excretion PO4
- -> CKD ( 2ndry hyerpPTH)
** ALP : poor sensitivity
tension type HA
sym?
stress, BILATERAL, DULL, non-throbbing w/o asso sym (n/v)
- -> non-changing from prior HA
- -> last 30 mins - i week .
- > muscle tenderness Head + neck
–> rx: ibuprofen
TCA
panhypopituitary
sym?
- central adrenal insuff: LOW CORTISOL + ACTH
- –> mild hypoNa + mild hypotension : 2ndry : aldo not affected NORMAL - Hypogonadotropic hypogonadism : Low FSH, LH, testo
- -> measure : PROLACTIN!!!!! - central hypothyroidism : LOW free T4, normal / low TSH
Isoniazid toxicity?
-> INH hepatotoxicity
ALT, AST <100 IU/L
w/in few weeks of rx
–> self limited , miaintain rx and f/u closely
** severe toxicity >10 x times upper limit of normal!!!
- ** Drug -ind liver injury:
- -> rash, fever, leukocytosis, eosinophilia
** Idiosyncratic rxn: not dose dep:
Isoniazid , chlorpromazine, antiretroviral rx
polyarteritis nodosa
sym?
- > HBV/HCV
- > transmural fibrinoid necrosis arterial wall -> luminal narrowing + thrombosis -> tix ischemia
- > int/ ext elastic lamina damage -> microaneurysm formation -> rupture + bleeding
sym:
- > mononeuritis multiplex > 2 noncontiguous peripheral nerves
- -> vasculitis (PAN)
- > skin: livedo reticularis
- > renal failure
- > GI: mesenteric arteries ischemia
lab:
inc ESR
anemia chronic dx
-> tix biopsy
COPD long term supp O2 therapy
REQ ?
!!! 1. PaO2 <55 mmHg
->SaO2 <88% room air
- PaO2 <59
- > SaO2 <89% cor pulmonale (RHF)
- > Hct >55% !!!
RX:
SMOKING cessation + O2 therapy!!
*** vaccine against influenza + pncoccus : no studies demo dec mortality!
ACA stroke
sym?
- > contralateral motor / sensory deficits
- > LOWER ext»_space; upper
- > Urinary incontinence
IV septum rupture
sym?
acute w/in 3-5 days
- > acute cardiogenic shock
- > @ LAD / RCA
!!!! -> New holosystolic murmur : L->R vent shunt
-> inc O2 level from RA to RV
- > biventricular failure
- > shock
- > chest pain
Multiple Sclerosis acute exacerbation
rx?
- > IV steroids (ACUTE)
- > plamspheresis ( refractory to steroids)
- > interferon beta/ glatiramer acetate : chronic maintenance rx , relapsing - remitting / 2ndry progressive form MS
breast cancer
vs
CXR/ chest CT
vs
colonscopy
screening
vs
ECG
vs
lipid profile
recommend?
- > MAMMOGRAM q2 year : 50-74 yr
- –> over > 75 yr : not routinely rxm
*** CXR/ CT scan : rxm smoking hx
***Colonoscopy: q10 yr: start age 45 yr
** ECG: @ 65 yr
** lipid : @ 40 yr / q3- 5 yr
migraine
ppx?
- > Topirmate
- > divalproex na
- > TCA
- > beta blocker
Dm routine health maintenance ?
- lifestyle changes
- A1c <7 %
- screen CVD : HTN <130/80
- urine alb/ cr ratio < 30 mg/g
- foot neuropathy + retinopathy
*** mod inc albuminuria 30-300 mg/g + HTN : ACCEI / ARB 2ndry PPX
central retinal artery occlusion ( CRAO)
sym?
dx?
rx?
- -> embolized plaques ( AFib)
- > ipsilateral carotid artery
-> sig permanent visual deficits, PAINLESS MONOCULAR vision loss !!!!
fundoscopy: !!! --> whitened retina ( edema) --> macula, central fovea is red !!!! -> cherry red spot -> defect afferent pupil reflex
rx:
-> ER!!!
-> asa, statin
warfarin
dx: noninvasive imaging cartoids evulate stenosis
UNruptured IC aneurysm
sym?
- > ASX
- > HA, N3 palsy, facial pain
- > pupillary DILATION
*** wkness + neck pain : NOT expected!!
Lyme dx
rx?
Erythema migrans : slow expanding erythematous macule / patch with central clearing
-> doxycyline
–> pregnant women: oral AMOXICILLIN!!!9
*** Azithromycin: less EFFECTIVE ! unless allergic rc
HYperTG
rx?
- TG: 150-500
- -> WL
- > ETHO moderate intake
- > inc exercise
- > STATIN!!!!!!! most beneficial!!! - TG >1000:
- > fibrates!!!!!
- > fish oil
- > Etho cessation !!
pill esophagitis
etio?
sym?
-> direct effect on esophageal mucosa
etio:
- > tetracycline (Ab)
- > KCl, iron
- > bisphosphonate
- > NSAIDS, ASA
sym:
- > sudden onset odynophagia, retrosternal pain
- > mid esophagus by compression aortic arch / enlarge LA
dx:
endoscopy
*** Esophageal Ca: unintentional WL, progressive solid food dysphagia
risk factors -> smoking, etho, barrett, GERD, obesity
LES
sym?
rx?
- > small cell lung ca
- > autoab directed against voltage gated calcium channel in presynaptic motor nerve terminal
- -> symmetric proximal muscles wkness + depress DTR
- > autonominc dys ( dry mouth , erectile dysfunction)
rx:
- > guanidine
- > 3,4 diaminopyridine : inc presyn Ach level
- > steroids
ASA overdose:
-> inc risk arrythmia
- -> mix AG met acidosis with high AG + resp alkalosis!!!!
- -> hyperventilation
- -> lactic acidosis , hyperthermia
- > confusion
- > epigastric pain
otitis media with effusion?
- > S. pneumonia
- >TM perforation
cholesteatoma ?
- > keratin producing sq cell tapped in the middle ear space
- > erode surrounding st
-> edematous swollen canal , pain
severe
exacerbate asthma
sym?
-> inc vagal tone + bronchial reactivity
–> rx:
SABA, inhaled ipratropium, sys steroids
–> resp failure: intubation!!!
—> risk factor: prior intubation + recent poor asthma control !!!
brain MTS:
non-small cell lung Ca (NSCLC)
-> seizure + mri @ gray + white matter junction
- single MTS:
- -> good status: surgical resection !!! - multiple brain MTS: whole brain radiation therapy (WBRT)!!!
- > rx: glucocorticoids reduce swelling + palliate sym
- *** Brain MTS : small cell lung ca, lymphoma, choriocarcinoma:
- -> CMT!!!
- -> NOT effective in NSCLC
*** brachytherapy: conjunction with surgery / after recurrence follow WBRT/ surgery!
secondary adrenal insuff
sym?
lab?
Secondary: distupt HPA
- > CHRONIC steroids rx, infiltrative dx ( SHEEHAN syn)
- —> destruction PITUITARY / hypothalamus
dx: cosyntropin stimulation testing
lab:
- > dec cortisol : SIADH inc ( cortisol acts to INHIBIT ADH)
- —> HYPONa
- -> Dec Lh, FSH, TSH
- > NORMAL ALDO: euvolemia, mini electro imbalance , less severe sym
- -> normal K !!!
!!!! -> dec ACTH: NO hyperpigmentation
Factor V Leiden ?
MC inherited hypercoagulable dx
- -> AD pt mutation in gene factor V : unable to respond to activated Pn C
- -> continue thrombin formation + slowed degradation of F8
- > caucasian pop
- > inc risk DVT, PE
- > normal Pt, PTT
achilles tendiopathy
sym?
rx?
- > abrupt inc athletic activity
- > quinolones
sym:
-> ankle pain, swelling, tender 2-6cm proximal insertion tendon
rx:
- > cold compression, ice
- > NSAIDS
- > chronic sym: rehab ECCENTRIC resistance exercise rxm
small bowel ob ( SBO)
sym?
- > diffuse abd pain + dilated loops of small bowel
- > high pitched initially
Spontaneous bacterial peritonitis (SBP)
sym?
dx?
rx?
-> CIRRHOSIS pt
- > low grade fever, abd discomfort
- > subtle AMS
- > hypotension, hypothermia, paralytic ileus with severe inf
dx:
Diagnositic LAPAROSCOPY!!!
—–> e. coli, klebsiella
- > PMN >250
- >
- culture, GNB ( e. coli, klebsiella)
- > pn <1 g/dl
- > SAAG >1.1 g/dl ( cirrhosis)
–> Reitan trail test: time connect the # test: detect subtle AMS change in SBP
rx:
- > empiric : 3rd gen cepha!!
- > quinolone PPX
Chronic Etho use
lab?
- > poor nutritional intake
- > etho- ind renal losses, diarrhea
lab:
- > diarrhea: hypoMg
- > REFRACTORY hypoK
- —> IC Mg inhibits K secretion by renal outer medullary K channels ( ROMK) @ CT kidney.
- –> low Mg => excessive K loss
—> dec PTH secretion : resistance persist
rx: correct Mg level
babesiosis
lab?
dx?
rx?
- > babesia microti
- > ixodes scapularis tick bite
- > NE USA
- —> inc RISK in splenectomy!!!
sym:
- > fever , fatigue, myalgias, HA
- > ARDS, DIC, CHF, splenic rupture
- > anemia, thrombocytopenia , inc bilirubin/ LDH/LFT
- -> Leukocytosis!!!
dx:
thin blood smear “ INTRAERYTHROCYTIC RING” maltese cross
rx: atovaquone + azithromycin
- > quinine + clindamycin ( severe)
ehrichiosis ?
- > tick borne
- > non-sp sym
-> leukopenia !! thrombocytopenia
Atypical mood reactivity (MDD)
sym?
2 mths of MDD
sym: atypical mood:
- -> WG, hypersomnia
- > leaden paralysis ( heavy feeling in limbs)
- > hypersensitivity to rejection
- > enjoy family reunion
dysthymia?
persistent depressive dx > 2 years !!!
hemarthrosis
etio?
- > trauma (MCC)
- > vascular damage
- > coagulopathy ( hemophilia)
liver transplant
s/p 2 wks
sym?
- <1 month :
RAPID ONSET
-> high fever, hypotension, RUQ pain, tachycardia, leukocytosis, SEPSIS !!!
- –> BACTERIA from operative comp: hepatic abscess, biliary leak , wound inf
- –> hosp IUC, ext drain
- month 1-6 :
opp path : !!!!CMV, Aspergillus, mycobact TB in ICP
!!!! —-> tix invasive CMV dx ( pneumonitis, gastroenteritis, hepatitis)
- > 6 mo:
ICP : CAP
Acute cellular rejection ?
<90 days s/p transplant
–> fever, RUQ pain, elev LFT
descending aortic dissection ( type B)
risk?
sym?
-> extend from subclavian to iliac vessels
> > ANTERIOR SPINAL CORD ISCHEMIA !!!
risk: ANT SC ischemia T10-12 !!!
sym:
- > urinary retention ( bladder paresis)
- > motor paresis Lower ext
- > loss crude touch/ pain sens ( ant/ lat spinothalamic tracts)
- > diminish reflexes ( days -wks )
*** DORASL column SC ( vib , sens, proprioception) preserved!!! + UPP ext INTACT !!
Aortic dissection ascending Type A
sym?
dx?
VERTEBRAL ARTERY!!!
- > ischemic stroke, HA, neck pain
- -> sig HTN
- > decrescendo diastolic murmur: AR
- > POSTERIOR SC ischemia
- > loss proprioception/ vib sensation below lesion + mild wkness
dx:
- CXR / ECG
- norma; Cr + no contrast allergy ?
- TEE !!! sens + specific / CHEST CT
- MRI
lliotibial band syn?
-> LATERAL knee overuse injury
Osgood schlatter dx?
Apophysis of TIBIAL tubercle
-> progressive knee pain over se young adults
–> pain stops once growth stops
Nonallergic rhinitis
sym?
rx?
- > nasal congestion, rhinorrhea, sneezing, postnasal drainage
- > LATER ONSET >20 yr
- > NO obvious allergic triggers
- > WORSEN with season change
rx:
-> INTRANASAL anti-histamine/ steroids!!!!
hypothyroidism
inc risk?
- > CVD!!
- > dec LDL turnover
- > dec expression activity LDL receptor : inc total cholesterol + LDL
- -> dec lipoprotein lipase : hyperTG!!!
isolated systolic HTN ?
SBP > 140
DBP <90
—> inc CV morbidity + mortility
- –> elderly pt
- -> INC STIFFNESS / dec COMPLIANCE aortic + arterial walls
***Inc plasma renin -> renovascular HTN ( RAS) : 3ndry HTN : inc BOTH SBP + DBP !!!!
Acanthosis nigricans
etio?
BENIGN:
- > Insuline resistance
- > GI CA
- > Obesity
- > PCOS !!!
–> inc insulin + insulin like -GF –> + epidermal + dermal proliferation
-> skin tags ( acrochordons)
MALIGNANT:
- > Ca : GI/ GU
- -> WL
type 1 DM hypoglycemia?
–> long standing DM : blunt autonomic response : hypoglycemia with reduce awareness
asthma vs copd
dx?
Spirometry before + after SABA !!!
- > asthma: complete reversal
- > copd: wk / partial reversibility ; airway ob is fixed!!
Marfan syn
sym?
- > Arachnodactyly
- > pectus deformity, scoliosis, kyphosis
- > joint hypermobility
-> ectopic lentis
- > AD, AR, AD (type A):
- ——-> AORTIC ROOT DILATION: chronic AR–: EARLY decrescendo diastolic murmur!!!! @ Rt upper sternal border!!!
-> MVP
first degree av block
vs
Second degree AV block:
Mobitz type 1
vs
type 2?
First degree: ---> ASX --> PR interval prolongation ( delay conduation w/in AV block) rx: OBSERVATION
Second degree:
type 1: AV node : PROGRESSIVE prolongation –> follow by a dropped QRS complex
rx: observation
type 2: below AV node ( his bundle)
- –> CONSTANT PR interval with RANDOM drop QRS complexes
rx: pacemaker
erysipelas
etio?
sym?
Strep A pyogenes
- > superificial UPPER dermis + lym
- > raised , sharply demarcated edges
- > RAPIDLY spread, onset
- > fever early in course
eg. ext ear
- —> comorbility with DM
rx: IV Ab : cetriaxone, cefazolin
- > w/o SYSTEMIC sym: oral amoxicillin
Cellulitis ( NON purulent)
etio?
sym?
S pyogenes
MSSA
- > DEEP dermis, subcutaneous fat
- > flat edges with POOR demarcation
- > indolent ( days)
- > localized ( systemic fever later)
cellulitis (purulent)
etio?
sym?
MSSA ( s. aureus)
MRSA
PURULENT drainage
-> folliculitis : infected hair follicle
- > furuncles: folliculitis -> dermis -> abscess
- > SystemicL fever, leukocytosis, inc ESR
-> carbuncle: multiple furuncles
dyshidrotic eczema ( acute palmoplantar eczema)?
Recurrent, pruritic , vesicular rash
–> affects palms, soles, SIDES of digits
dx: CLX
biopsy: intraepidermal spongiosis, lym infiltrate
-> rx: high potency topical steroids
False + D-xylose test:
etio?
sym?
dx?
rx?
etio: DM, chronic opiate use, altered small bowel motility , s/p surgery, scleroderma
- > delay gastric emptying
- > impaired GFR
- > small int BACT overgrowth (SIBO)!!!
dx:
- -> JEJUNAL aspiration : high bact conc
- -> Carb breath test: early peak
—-> alter small int flora : bact ferm of
D-xylose before it can be absorbed
rx: RIFAXIMIN, neomycin ( AB )
leprosy
sym?
dx?
rx?
-> mycobacterium leprae
–> THICKEN, HYPOPIGMENTATION, macular, anesthetic SKIN lesion with raised borders> 1 areas
- > nodular , painful peripheral NERVE nearby, loss of SENSORY / motor function
dx: FULL THICKNESS BIOPSY of skin lesion ( active edge)
rx: DAPSONE + RIFAMPIN
- > + CLOFAZIMINE severe
AFIB
etio ?
atrial remodeling —> abnomral automaticity disorganized atrial electrical activity : originating PUL VEIN OSTIA
- -> IRREGULAR IRREGULAR RR interval , narrow QRS complex
- –> absence P wave
- –> paroxysmal AF
- –> inc Atrial enlargement !!!
etio: inc with AGE!!!
dx:
CHECK TSH : evaluate HYPERTHYROIDISM !!!
vertebral compression fracture
sym?
- -> Asx
- -> low back pain
- > dec spinal mobility after sudden bending, cough , lifting
—> loc tenderness AT AFFECTED LEVEL!!!
etio:
- > osteoporosis
- > chronic steroids
HIVD
sym?
sciatica
+ SLT
metformin
ACEI / ARB
avoided in ?
sepsis
–> cause lactic acidosis in AKI
LAXATIVES abuse
eg. loops , biascodyl, polyethylene containing laxatives
lab?
MET alkalosis
- -> loss NAKKCl
- -> inc HCO3 in serum
com:
-> melanosis coli : dark brown discoloration colon with pale patches lymph follicules
hist: pigment macrophages lamina propria
dx:
positive stool screen
chagas dx?
protozoal dx
- -> megacolon
- > CHF ( myocarditis )
amiodarone - induced thyrotoxicosis ( AIT)
se?
- > thyroid dysfunction :
- > AIT -1 : hyperthyroidism
- AIT -2 :
hypo-thyroidism ( large IONINE load suppress synthesis TH : WOLFF Chaikoff effect)
-> inc LFT : hepatocellular injury
- > cardiac conduction abnormal
- > skin
- > peripheral neuropath
verapermil
CCB
se?
- > constipation
- > impaired cardiac conduction + contractility
- > worsening bradyarrhythmias
- > CHF
pituitary Microadenoma < 10 mm
prolactinoma
rx?
microadenoma
-> galactorrhea + low estrogen
prolactinoma
- > elev prolactin > 200!!!!!
- –> suppress GNRH , LH, estradiol
- -> TSH: normal / low
–> HA, visual field defects
rx:
sym tumor: DA agonist ( cabergoline , bromocriptine)
–> fail rx: large tumor > 3 cm : transsphenoidal resection !!!
primary polydipsia
lab?
!!! excessive inc water intake
- –> serum osm LOW
- -> serum Na LOW
- -> urine DILUTED
beta blockers toxicity
sym?
- > bradycardia
- > hypotension
- > hypoglycemia
- > bronchospasm !!!!!
- > AMS
- > seizure
—–> competitive ANTAGONIST catecholamine receptors : prevent hep glucose production + prevent glycogen breakdown : HYPOGLYCEMIA
antidote: IV fluid
atropine
glucagon !!!!
EBV (MC)
vs
CMV
dx?
EBV: heterophile ab monospot test
- —> atypical lymphocytosis
- > transient hepatitis
!!! prolonged course > 1 month -> fever -> exudative pharyngitis/ tonsilitis + exudates -> tender LAD - > HSM -> fatigue RASH after amoxicillin !!!
CMV: less common
postherpetic neuralgia
> 4 months
rx?
acute: shingles
- -> steroids, valacyclovir
chronic:
!!!! —> gabapentin / pregabalin
–> TCA ( amitriptyline)
-> opioids ( oxycodone) : not as effective
prostate mts ca
hist?
-> axial skeleton ( vertebral bodies, rib)
- > focal , sclerotic bone lesions
- > progressive BACK PAIN
- > motor wkness, incontience
-» PURE OSTEOBLASTIC
lab:
low/ normal Ca
-> inc ALP
2ndry hypogonadism
sym?
etio?
low serum testosterone
-> low / normal LH
sym:
- > fatigue, dec libido, testicular atrophy
- > hot flashes, osteoporosis, depression
etio:
!!!! -> OPIOIDS : SUPPRESS GNRH + LH secretion —> LH + testosterone synthesis , dec spermatogenesis , testicular atrophy
- steroids, exogenous androgen ( w/drawal)
- chronic/ severe illness
- hemochromatosis
- eating dx ( severe WL)
- pituitary tumor, hyperprolactinemia
oppositonal defiant dx?
- -> less severe compare to conduct dx
- > NOT inc stealing/ aggressive beh, violation of right of others
tardive dyskinesia
sym?
rx?
EPS:
- > orofacial dyskinesia
- > trunk dyskinesia
-> prolong 1st gen antipsy rx
rx:
- > reduce antipsy dose
- > switch to VMAT2 (valbenazine / deutetrabenazine)
- > switch cross tapering with lower tendency : CLOZAPINE / quetiapine
high potency antipsy
risk in?
se?
Parkinson disease
dx?
Parkinson dx:
dx by clinical !!! 2/3 needed
–> resting tremor, rigidity, bradykinesia
——> HYPOKINETIC GAIT!!!! ( slowing all motor activity)
*risk in: haloperidol , risperidone ( easier to cause EPS at high dosage:
- acute dystonia
- -> add benztropine: AntiAch
- > DIPHENHYDRAMINE: antiHistamine
- > amantdine: drug induced Parkinsonims not dystonic rxn!!! - Akathisia: Add: beta blocker + lower antipsy rx
–> EPS: ADAPT: No tachycardia !!!
CTS
dx?
—> MEDIAN nerve
nerve conduction studies
- > Phalen test
- > tinel test
melanoma
sym?
“UGLY ducking “ sign
-> ABCDE criteria
lentigo
sym?
intraepidermal melanocytes hyperplasia
-> older pt
Pes anserinus pain syn?
localized pain + tenderness MEDIAL TIBIAL condyle
- -> overuse
- > obesity, DM
- > OA
- > angular deformity of knee
dx: XR knee
rx:
strengthening exercies + NSAIDS
iliotibial band syn?
LATERAL femoral epicondyle tenderness
internal validity?
relationship btwn dep variable vs independent variable
-> how the study was designed , conducted , analyzed
external validity?
generalization to other population
aspergillosis ?
pulmonary local infiltrates + mediastinal NODULAR
adenopathy ICP!!!
-> prolonged neutropenia
–> ABPA ( allergic bronchopulmonary aspergillosis) : promotes Th2- based allergic response , production IgE + eosinophilia
viral esophagitis
etio?
sym?
- candida albican : oral thrust MC
- —> pseudohyphae
- –> Rx: azole 1st
- —-> if no improve: endoscopy! - HSV: orolabial round /ovoid lesion “volcano like”
- –> multinucleated giant cells - CMV: large , linear ulcer distal esophagus
- —> intranuclear / intracytoplasmic inclusion
viral esophagitis: sym: -> SEVERE ODYNOPHAGIA -> no dysphagia -> no thrush
dx: endoscopy
CUSHING syn
etio?
syn?
sym:
- > Cushingoid body habitus
- > Proximal muscle weakness
- > Hyperglycemia
etio:
- > exogenous steroids intake
- > ectopic ACTH production ( small cell lung ca)
- > ACTH-producing pituitary adenoma ( cushing dx)
lab:
- > Urine free cortisol
- > low dose DXM suppression test
- > ACTH level : dep/ independent
- —> HYPERK
exercise asso hypoNA
sym?
lab?
–> prolonged exercise + ingestion large amt HYPOTONIC fluid ( water , sports drinks)
sym:
serum OSM > 285 !!!!
—–> lossing WATER: higher serum OSM ( Na+ in body)
–> SEVERE sym ( seizure, profound confusion)
sick sinus syndrome
sym?
–> AGE related degeneration
with fibrosis of sinus node
—–>
- -> ischemia
- > sarcoidosis, amyloidosis
sym:
- -> bradycardia, fatigue, dyspnea, LH, confusion, syncope, pre-syncope
fibrosis: paroxysmal A. arrythmias
ecg:
- > sinus pauses ( delayed P waves)
- > SA nodal exit block ( dropped P wave)
- > chronotropic incompetence
rx:
- > Pacemaker
- > rate -control rx: beta blockers
carboxyhemoglobin
etio?
sym?
etio:
- > smoking inhalation
- > defective heating sys
- > gas motor operating poor vent
lab:
- > reduce O2 carrying capacity
- > dec O2 unloading in tix ( Hbg dissociation curve LEFT shift)
- > impairs O2 utilization ( disrupted mito oxidative phosphorylation)
- -> confusion, LA, met acidosis with AG
- > myocardial ischemia
- > NO hyperthermia !!!
rx: 100% O2
splenectomy
susceptible to?
—> Encapsulate org:
S. pn, H, influenza, N. meningitidis
—> Humoral immune response with Ab-mediated phagocytosis ( opsonization ) + Ab-mediated Complement activation
–> splenic macrophages
rx: VACCINE !!
CGD
sym?
impaired oxidative burst
-> recurrent bac / fungal inf
- -> CATALASE -producing org
eg. Aspergillus nidulans, S. aureus
cerebellar hemorrhage
sym?
- > occipital HA
- > neck stiffness (extension blood into 4th ventricle)
- > N/V , nystagmus
- > IPSILATERAL HEMIATAXIA (cerebellar vermis) , limbs
—> hemiparesis + sensory loss absent unless extension to BS (ipsilateral facial palsy
porphyria cuntanea tarda
sym?
: blisters at sun exposure areas, —–> NO oral mucosa inv
pemphigus vulgaris
sym?
- -> flaccid bullae inv ORAL mucose + skin painful erosion,
- -> NOT palm / soles
-> age 40-60 yr
dx: skin biopsy
- -> ab against desmosome comp ( desmogleins 1 + 3)
rx: sys steroids, rituximab
bullous pemphigoid
hix?
sym?
rx?
hix: SUBEPIDERMAL cleavage
IF: linear IgG/ C2 deposition along BM
serology: autoAb to bullous pemphigoid Ag ( Hemidesmosomes)
sym:
- > pruritic , TENSE bullae
- > RARE mucosal inv!!!!!
rx:
-> topical: high potency steroids
-> sys: steroids, DOXYCYCLINE
accuracy =?
TP/TN/ TP + FP + TN + FN
sjogren syn
sym?
- > immune med dest lacrimal + salivary glands
- > asso SLE, RA
- > dry eyes, mouth, skin
- >
- RRA ( anti-Ro) , + SSB ( anti-La)
comp: NKL
- > CORNEAL DAMAGE, dental caries
complex regional pain syn
sym?
dx?
etio:
s/p surgery/ trauma 4-6 wks
—-> inf CYTOKINES +
- > severe pain, regional ( NOT dermatonal) burning/ stinging Out of proportion inciting event
- > ALLODYNIA (worsen by movement / light contact)
- > edema
- > erythmea , alter skin temp
dx: XR: patchy DEMINERALIZATION
- > bone scintigraphy: INC uptake affected limb
dx:
- > exercise, PT
- > NSAIDS, pregabalin, TCA , alendronate
acute closed angle glaucoma
sym?
etio?
TCA ( TRIHEXPHENIDYL ) : anticholinergic
–> rx: PD
sym:
- > inc ICP : impaired drainage aq humor thru pupil into ant chamber
ACTIVE TB rx?
initiate empiric therapy while awaiting test results :
ISN + rifampin + PYZ + ethambutol 2 months
–> 2 rx: ISN + Rifampin 4 months
*** 2 rx : inc risk resistance!!!
MCA stroke ?
–> speech
-> brocas area ( posterior inferior FRONTAL gyrus)
Wernike : temporal lobe lesions: receptive aphasia , repetition
—> INTACT expressive speech , motor , sensory
parvovirus in SCD?
- > aplastic crisis with severe , acute anemia
- –> MALAR surface rash
- > reticulocyte count LOW
- > DEC EPO
DELAYED hemolytic transfusion rxn
sym?
-> rxn > 24hr - 1 month s/p transfusion causing hemolytic anemia
–> inc risk with SCD
!!!
sym: fatigue, jaundice, low fever, AXS
lab:
hemolytic anemia -> inc indirect bilirubin, LDH, ret count
-> dec HBG , Haptoglobin
-> + coombs test
acute erosive gastropathy
sym?
HEMORRHAGIC mucosal lesions erosion after exposure
- > ASA : dec protective Prostaglandin production
- > COCAINE: vasoconstriction !!! red gastric BF
- > ETHO: direct mucosal injury
Felty syn
lab?
sym?
- > RA + neutropenia ( ANC <2000)
- > Splenomegaly
- > HLA-DR4 +
dx:
- > anti-CCP + RF
- > elev ESR > 85
A flutter
ecg?
reentrant circuits around TRICUSPID ANNULUS , slowing impulse thru cavotricuspid isthmus
HYPERthyroidism
sym?
- > proximal muscle wkness ( myopathy) : diff combing hair , wkness getting out/ in chair
- > anxiety , WL , tachycardia
acute thyrotoxic myopathy : severe distal / proximal muscle wkness
-> w/o bulbar / resp muscle inv
Chronic —> MUSCLE ATROPHY
cocaine with myocardial ischemia
rx?
- > IV BZD + O2
- -> reduce sym outflow, dec anxiety + agitation , lower BP + HR, CV sym
- > ASA : slow thrombus
- > Nitrate + CCB : vasodilates
** BETA blocker selective ( A-M) : NOT used to rx till cocaine el from body —> UNOPPOSED alpha -adrenergic + , worsening coronary vasoconstriction
NONinflammatory , comedonal acne
rx?
–> TOPIC retinoids
-> inhibits comedogenesis : normalizing keratinization ,dec epithelial cohesiveness, inc epi turnover
inflammatory comedonal acne
rx?
- topic retinoids : inhibits comedogenesis
+ benzoyl peroxide - topical ab ( clindamycin)
- > estrogen -OCP
Squamous cell Ca
sym?
dx?
rx?
etio: SUN exposed area
- > >60 yr , fair skin
asso:
- -> actinic keratosis!!!!! hyperpigmentation , telangiectasis
- -> HPV : perianal skin, genitalia
- > scaly plaques/ nodules
- > +/- ulceration
-> SCC in situ: well demarcated patched / plaques
dx: BIOPSY
- > dysplastic / anaplastic keratinocytes
rx:
1. Invasive SCC : excision 4-6mm margin
- > Mohs micrographic surgery
- SCC in situ : excision 4-6 mm margins
- > C& E
- > cyrotherapy
- > topical 5-FU , imiquimod
pheochromocytoma
sym?
dx?
onfidence
triad: episodic HA, sweating, palp, tachycardia
- –> RESISTANT HTN/ HTN with unexplain inc GLC
- –> Paroxysmal HTN ( variable BP reading)
-> FX MEN2, NF1, VHL
dx: urine / plasm a metanephrine
- > confirm abd imagine for inc metanephrines
rx:
- > Preop Alpha blocker PRIOR to BETA blockers
- > LP / surgery
confidence interval
wider?
vs
narrow?
wider CI = SMALLER sample size
—> DEC power of study
narrower CI = INC sample size , INC POWER
HSV skin lesion ?
Erythema multiforme
- -> erythematous papules evolve into target lesion
- -> dasky central area
- > red inf zone
autosomal dominant polycystic kidney disease (ADPKD)
sym?
dx?
rx?
sym: -> AXS till 30-40 yr -> flank pain ,hematuria -HTN !!! -> BIL palpable mass -> CKD
comp:
- –> cerebral aneurysm
- > hep + pancreatic cysts
- > MVP , AR
- > colonic diverticulosis
- > ventral + inguinal hernia
dx: U/S renal
rx:
- > ACEI
- > hemodialysis , renal transplant
length dep axonal POLYNEUROPATHY
sym?
etio?
- > rapid progressive sensory loss in distal symmetric, stocking - glove dist
- > distal numbness, tingling, pins, BURNING needles sensation
-> length -dep axonal polyneuropathy
etio:
- > TOXIN (ETHO, metal exp)
- > RX: metronidazole, fluroquinolones
- > uremia
- > long standing HIV
- > DM neuropathy
- > CMT
RESTING tremor
etio?
Parkinson disease!!!!
- > > low amp / low freq 4-6 Hz
- > typically start one hand
- > worsen with MENTAL task
moa: progressive loss DA neurons BG
subdural hematoma
etio?
rupture BRIDGING VEINS
—> crescent shaped hyper-density , cross suture lines
vent arrhythmia
sym?
SUDDEN cardiac arrest in acute MI
-> occur w/in 1st hour of sym onset
—> reentrant vent arrhythmia
“immediately” : phase 1a : w.in 10 mins coronary occlusion
–> “delayed “ phase 1b: 10-60 mins : abnormal automaticity
body dysmorphic dx
rx?
- > high dose SSRI
- > CBT
dermatofibroma
sym?
- > fibroblast proliferation : isolated / multiple lesions
- -> MC lower ext
- > firm, discrete hyperpigmentation nodules <1 cm
- > “BUTTONHOLE/ DIMPLE” sign
dx: clx
rx: cyosurgery
Legionella pn
rx?
- > GN organism
- > QUINOLONES !!!!!
vs/ clindamycin : rx: ANAEROBIC!!!!
klinefelter syn
sym?
nondisjunctional sex chrm 47 XXY
—> testicular fibrosis with SEMINIFEROUS TUBLE DYSGENESIS
- > primary hypogonadism
- > inc long bone length
- > gynecomastia
lab:
- > dec testo
- > inc LH + FSH
- > inc Estradiol
anabolic steroid use
lab?
impair testicular function
-> dec gonadal size + dec sperm count
–> inc LIBIDO , NOT sparse facial / body hair
HIV asso nephropathy
sym?
rx?
- > advance HIV
- > sub Saharan african descent
- > APOL1 gene variant
sym:
- > HEAVY PNURIA
- > rapid progressive RF
- > collapsing focal segmental glomerulosclerosis
rx: ART
ACEI
poor prognosis
septic shock
lab?
- -> hypotension
- > tachycardia
- > dec SVR
- > capillary leak : loss IV voln into surrounding tix
- –> low PCWP
- > inc CI + SV
- > INC PULSE PRESSURE : BOUNDING PERIPHERAL PULSE!!!
obstructive uropathy
lab?
Unilateral: renal calculi (MC)
- > flank pain : renal capsular distension
- > low void voln: mech ob urine outflow
- > w/ or w/o HIGH voln VOIDS (post-ob diuresis)
- > K wasting + dehydration : wkness!!
optic neuritis
sym?
asso with: MS!!!!
- > MONOOCULAR vision loss
- > pain with eye movement
- > WASHOUT color vision
- > AFFERENT pupillary defect +
- > CENTRAL SCOTOMA !!!
dx: fundoscopy: Normal !
vascular ring
sym?
- -> congenital anomaly aortic arch
- > dysphagia, vomiting, food impaction
- -> NO abd pain
dx: INDENTATION at sie of ring
precocious puberty
Premature adrenarche?
vs
premature thelarche?
moa: early + adrenal androgens
ADRENARCHE
- > early 2ndry sexual dev
- > NORMAL bone age
- > ISOLATED PUBIC HAIR dev
THELARCHE
-> isolated BREAST dev !!!
congenital CMV encephalitis:
sym?
dx?
neonate transmitted vertically:
–> multifocal micronodules / ventricular enhancement MRI
–> !!!! PERIventricular Calcification
- -> Sensorineural hearing loss
- > IUGR
- > HSM
- > Jaundice
- > Thrombocytopenia
dx:
PCR CMV urine / saliva
congenital toxoplasmosis
mri?
- > transmitted undercook meat
- > hydrocephalus
- > diffuse PARENCHYMAL calcification
zika virus
mri?
- > microcephaly
- > INTRACEREBRAL calcification
retinitis pigmentosa
sym?
- > genetic mut loss photoreceptors
- > progressive retinal degeneration
- > age 10 - adult
sym: night blindness
- > progressive Visual field loss ( MIDPERIPHERAL)
- > dec VA ( late )
- —-> BLINDNESS by 40 yr
dx: fundoscopy:
- > retinal vessel attenuation
- > optic disc pallor
- > abnormal retinal pigmentation
vit A def
sym?
- > xerophthalmia
- > excessive dryness cornea + conjunctivae + night blindness
chlamydia trachomotous
adults
vs
neonate
sym?
dx?
rx?
–> long standing sym wk-months concurrent urogenital infection
adults sym:
painless ulcer, very small and disappears within few days–> less common in USA)
neonate:
5-14 days
-> mild eyelid WATERY / MUCOPURULENT discharge
-> chemosis ( conjunctival edema)
dx:
Gram stain -
-> PCR testing confirm dx
rx:
oral ERYTHROMYCIN
–> monitor pyloric stenosis
dacryostenosis ?
nasolacrimal ducts ob
-> UNIlateral tearing + mini conjunctival injection
peritonsillar abscess
sym?
dx?
rx?
- > fever, sore throat, diff swallowing
- > TRISMUS
- > HOT potato voice
- > pooling saliva
- —-> ULVAR deviation !!!
- -> bact inf region btwn tonsil + pharyngeal muscle
- –> persistent tonsilitis / pharyngitis —> cellulitis / phlegmon
rx:
-> need asp / incision drainage + AB
herpangia
sym?
coxsackie A virus
- > fever , sore throat , odynophagia
- > vesicles on tonsils + soft palate
laryngomalacia
sym?
dx?
rx?
–> collapse supraglottic tix on inspiration
- > inspiratory stridor when supine
- > peak @ 4-8 month
dx: LARYNGOSCOPY
rx:
- > reassurance close f/u
- > supraglottoplasty severe sym
vascular ring ?
–> anomalous branch of the aortic arch or pulmonary artery encircles the trachea and esophagus.
sym:
-> biphasic or exp stridor –> tracheal compression and feeding diff
dx: barium swallow
- > confirmed CT scan or MR angiography.
retropharyngeal abscess
sym?
- > toddlers
- > fever, dysphagia, neck pain , stridor
dx:
!!!! -> XR: thickening pre-vertebral space
-> ct scan
child VZV live vaccine?
2 dose: age 1, 4 yr
–> IF not complete 2 dose: Immunocompetent : VZV vaccine !!!
–> ICP : VZ IG
epiglottis
etio? sym? rx? rx? ppx?
-> H. influenza type b ( Hib)
sym: tripod position, sniffing, stridor -> distress -> dysphagia , dysphonia, drooling -> high fever
dx: XR: thumb sign
rx:
- > endotracheal intubation
- > ab: CEFTRIAXONE + VNC
PPx: immunization against Hib
*** AMP + gentamicin : Gp B strep + e. coli
neonatal bact MBG
sym?
rx?
comp?
- > S. pn
- > N. meningitidis
sym:
- > fever
- > age <1 : bulding fontanelle, irritability, poor feeding
- > age > 2: inc ICP, MNG sign ( nuchal rigidity)
dx: CSF LP!!!!
rx: ceftriaxone + VNC
+/- DXM
comp: intellectual / beh disaility
- > hearing loss
- > cerebral palsy
- > epilepsy
ped traumatic brain injury
sym?
dx?
high risk age <2 yr:
- -> AMS
- > LOC
- > severe injury fall >0.9 m high
- > nonfrontal scalp hematoma
- > palpable skull fracture : raccoon eye, battle sign
dx:
head CT w/o contrast
observe 4-6 hrs ER
—-> EEG after CT : with seizure!!!!
- ** AGE 2-18 yr:
- -> fall >1.5 m high !!!!
rx: reassurance + discharge
traumatic carotid injuries
etio?
sym?
dx?
etio:
- > penetrating trauma
- > fall with object in mouth
- > neck manipulation
—-> injury post pharynx : cervical ICA : directly lateral + posterior to tonsillar pillars
sym:
- > gradual onset hemiplegia
- > aphasia
- > neck pain
- > thunderclap HA
dx: CT/ MR angiography
todd paralysis ?
- > transient hemiplegia s/p focal onset seizure
- -> may become 2ndry generalized
sym:
- > flaccid wkness / paralysis 1/both ext SAME side
- > LOC
- > postictal confusion
dx: clx
rx; self limiting
cerebral thrombosis ?
- > hemiparesis
- > facial droop
- > aphasia
- –> antithrombin III def : hypercoagulable state
- > inc spontaneous venous trromboembolism : femoral + mesenteric veins
ALL ( acute lymphoblastic leukemia)
sym?
dx?
age 2-5 yr MC child!!!
- > nonsp sym
- > leukemic cell overcrowd BM: pallor/ fatigue : anemia
- > petechiae _ thrombocytopenia : !!!!! Impaired Pt production
- > BONE pain !!!
!!! Extramedullary spread:
- > LAD
- > HSM
- > testicular enlargement
!!! MEDIASTINAL MASS ( T cell ineage) : airway compression + SVC syn
-> leptomng spread: CN deficits
dx: CBC
- > BM bx: >20 blast
- > LP
acute bact rhinosinusitis
sym?
dx?
rx?
etio:
- –> MC: viral URI!!!!
- > nontypeable h. influenzae
- > s. pn
- > moraxella catarrhalis
- > cough, nasal discharge
- > fever
- > face pain/ HA
- —> allergic rhinits !!!
dx criteria (1/3) :
- persistent sym > 10 days w/o imp
- severe onset fever >39c + drainage > 3 days
- worsening syn f/u initial imp
rx: AMX + clavuanate @@@@!!!
*** smoking , chemical : wheezing !!!
irritant contact diaper deramtitis
patho?
sym?
rx?
- > skin breakdown from exp stool/ urine
- > MC diaper rash
sym: erythematous papules , plaques
- > SPARES skinfolds + satellite lesions
rx:
- > topical barrier ( petrolatum , zinc oxide)
- > refractory: low potency steroids
candidal diaper dermatitis
sym?
dx?
-> INC SKINFOLDS + stelliate lesion
–> moist + macerated
rx: topical antifungal
salmonella
non-typhoidal
sym?
dx?
rx?
etio: FOODBORNE ILLNESS
!!!! -> undercook poultry / eggs
-> inadeq fridge prepared food
sym:
- > w/in 3 days
- > fever, V, D
- > abd pain
- > bloody stool ( child)
dx:
stool culture
rx: supp care alone : slef limited
- > AB rarely needed
salmonella typhoidal
sym?
dx?
rx?
-> MC dev countries + poor sanitation
sym:
- > fever + bacteremia
- > abd pain + rose spots
- > late: HSM, int perforation
dx: blood culture
rx: fetal
- > ab (ceftriaxone)
- > drug resistance
NB neonatal dehydration
sym?
rx?
- > dec wet diaper : UA crystals !!!!! pink stains / brisk dust
- > absence tears
- > dry mucosal
- > dec skin tugor
- > dec cap refill
—-> NORMALLY lose up to 4% weight s/p birth !!!
rx:
WL <7%; up to first 5 days
-> continue freq breastfeeding
-> f/u 10-14 days check
WL >7%: oromotor dysfunction
- > assess for lactation failure
- > daily weights
- > formula supp
diamond blackfan anemia
sym?
lab?
rx?
patho: congenital erythroid aplasia ( pure RBC ) !!!!
sym:
-> craniofacial abnormalities
!!!!! -> TRIPHALANGEAL thumb
-> inc CA
lab:
- > macrocytic anemia
- > reticulocytopenia
- > NORMAL Pt, WBC
rx:
steroids
RBC transfusion
fanconi snemia
sym?
PANCYTOPENIC BM failure
vesicouretheral reflex ( VUR)
sym?
dx?
rx?
recurrent UTI
-> retrograde urine from bladder to ureter + renal pelvis
- > dysuria
- > fever
- > suprapubic pain ( cystitis) + flank pain ( pyleonephritis)
lab: pyuria + bacteriuria U/C
dx:
-> renal u/s: fever >39c with bacterial
!!!! -> voiding cystourethrogram ( VCUG)
–> > 2 febrile UTI
rx: Ab ppx
osteomyelitis
etio?
sym?
rx?
MC : S. aureus -> hematogenous spread
loc@ vertebral
sym: fever, localize bony inf ( localized focal tenderness!!!)
comp: epidural abscess : inf extends posteriorly into epidural space : severe back pain !!
motor and sensory abnormal –> paralysis
dx: cbc + ESR + CRP
XR
MRI
CT guide needle asp / biopsy
rx: VNC
VSD
sym?
- postnatal:
- > dec PVR, inc SVR
- > L-> R shunting VSD ( HOLOSYSTOLIC MURMUR) !!!!! - infancy:
-> RV voln overload / dilation
-> pul over-circulation
!!!! -> inc LA preload + LV overload,/ dilation
—–> CXR: enlarge left heart contour!!!
late childhood:
- > inc PVR : pul A vascular thickening
- > R-L shunting thru VSD ( eisenmenger syn)
eustachian tube dysfunction
etio?
sym?
rx?
ET: cxn middle ear -> nasopharynx
- > equalize middle ear pressure
- > drain middle ear fluid
- > prevent Nasopharyngeal secretions into middle ear
–> infection , allergies, envrio : tube OB
–> inc risk in child: SHORTER , NARROW, floppy tube : inc risk acute otitis media (AOM) !!!
sym:
- > ear fullness/ discomfort
- > tinnitus
- > conductive hearing loss
- > POPPING sensation
dx:
otoscopic : RETRACTED TM : neg pressure
-> dilated BV
rx: underline rx : Ab
TM rupture
etio?
sym?
–> hearing loss + tinnitus
-> ACUTE days
apgar score ?
dx?
Appearance Pulse Grimace / rxn Activity / muscle tone Resp effort
max: 10 pts
dx:
-> routine NB care : CHD, pre/ post ductal pulse oximetry !!!!
echocardio
hyperoxia test ( 100% O2) : distinguish btwn pul dx ( improve with O2) vs CHD ( persistent cyanosis )
MDD single episode
vs
MDD > 2 episode, persistent
rx?
SINGLE
rx: continue rx additional 6 months!!
-> dose maintained at same level , not be reduced
> 2 episodes
rx: 1-3 years
scabies rx?
PERMETHRIN
IDA toddlers
rx?
excessive COWs milk
- > dec Hbg
- > low MCV
- > inc RDW
–> rx: IRON rx for 2-3 months once hbg normalizes
mycoplasma pn
ATYPICAL PN
sym?
- > resp droplets
- > close quaters/ military , school
- > fall/ winter
sym:
- > INDOLENT HA, fever , persistent DRY COUGH : gradual , less severe : 2-3 wks !!!
- > Pharyngitis ( non-exudative)
- > MACUALR/ VESICULAR rash
dx:
- > CBC
- > RX: BILATERAL INTERSTITIAL INFILTRATES ( pleural effusion ) !!!!
rx: empiric
- > macrolides/ quinolones
Chiari I malformation
sym?
- > MC , mildest type
- > ASX in childhood
- –> asso with SYRINGOMYELIA : syrinx loc at cervical region , progressive neuro dysfunction
- > sym @ aldoescence :
- -> dizziness, worsening pain with VALSAVA / phy activity straining
-> Inferior displacement cerebellum thru FORAMEN MAGNUM!!!
–> ONLY cerebellar tonsils displaces !!!
Chiari II malformation
sym?
Asso with :
—> Myelomeningocele
–> inc herniation cerebellar tonsils + VERMIS + inf displacement medullar !!!
–> OB hydrocephalus : CSF thru 4th ventricule
tuberous sclerosis complex
sym?
–> HAMARTOMAS
Hamartomas CNS + skin Angiofibromas MR Ash-left spots Rhabdomyoma cardia TS dOminant Mental retardation Angiomyolipomas renal Seizures Shagreen patches
- -> inc risk: Subependymal giant cell astrocytomas
- > ungual fibromas
preseptal cellulitis
sym?
rx?
- > painful eyelid swelling + erythema
- > ANT to orbital septum : break in periorbital skin
-> s. aureus, s. pyogenes enter preseptal space
!!! NOT inv:
- > intraobrital st —–> orbital fat: protyosis
- —-> EOM: ophthalmoplegia ( eye muscle wkness / paralysis ), painful eye movement , visual change
rx: oral Ab ( clindamycin )
orbital cellulitis
sym?
- > sym preseptal cellulitis + PLUS
- > Pain EOM , proptyosis / opthalmoplegia with diplopia
—-> space POSTERIOR to orbital septum : contiguous spread from inf ( sinusitis , dental abscess, preseptal cellulitis)
rx: IV ab + surgery
transent synovitis
sym?
lab?
rx?
- > limp in one / both hips
- > age 3-8 yo
- -> FOLLOWING mild VIRAL illness
- > sym resolve w/in wks
lab: normal WBC, ESR, CRP
rx: conservative rx: NSAIDS
hypospdias
sym?
dx?
- > VENTRALLY displaced urethral opening
- > def failure urethral folds to fuse during early fetal dev
- > incomplete ventral foreskin closure –> dorsal hood appearance ( extra dorsal foreskin with def ventral foreskin)
- > penile curvature
dx: CLX
rx: UROLOGY evaluation : surgical correction
- > circumcision deferred till evaluation
WAGR syn?
Wilms tumor
Aniridia
GU malformation
Retardation mental
dx: renal u/s
juvenile idopathic arthritis ?
- > chronic joint pain + flam
- > rash , fever
- > inc ESR
X-linked agammaglobinulemia
etio?
sym?
lab?
rx?
- > BTK gene mut –> def BTK
- > impaired B cell maturation + Ig production
sym: recurrent sinopul + GI inf @ 2-6 month
-> chronic enteroviral inf
=> small / absent LN ( tonsil/ adenoids)
lab: dec all IG + AB response to vaccine
-> flow cytometry : CD19 B cell dec
normal T cell!!!
persistent pul HTN NB
sym?
risk?
dx?
rx?
-> R –> L shunt across PDA
physio: elev PVR normally dec O2 + vent of lungs
- -> persistent fetal circulation : PVR remains elev : deO2 blood cross pul artery –> aorta + mixes O2 blood from LV
- ——-> lower POSTDUCTAL sat% compare to PREDUCTAL sat%
- —-> normal distal pulses !!!
risk:
- >lung hypoplasia ( congenital diaphragmatic hernia , potter seq)
- > inf ( pn)
- > meconium asp
rx: NO ( pul vasodilator) : prostaglandin E1
- > O2
postconcussion syn
sym?
rx?
prolonged > 4 wks concussion sym after mild traumatic brain injury
sym:
- > HA, dizziness, sleep dist, mood changes, cognitive impair
- > no st IC injury
rx: sym care
viral rhinosinusitis
sym?
rx?
-> common URI VIRAL
- > inf nasal passage + paranasal sinuses
- > purulent discharge + facial pressure /pain exacerabte by leaning foward
- > mild sym imp by 5-`0 days
rx: supp care
hirschsprung dx
sym?
-> failed NC migration during fetal dev enteric NS
- > poor feeding , abd distension
- > failure PASS meconium
- > bilious emesis
- > rectal tone INC + expulsion gas / stool !!!!
dx:
XR: complete bowel ob ( dilated bowel loops, absent rectal air ) w/o perforation ( free air under diaphragm)
- > contrast enema : transition zone btwn narrowed aganglionic seg + normal diameter colon ( megacolon)
- -> rectal suction BIPOSY !!!
meconium ileus
sym?
-> asso : CF
- > delay meconium passage
- > abnormal Cl transport : thick , inspissated meconium, impacted ileum
- > microcolon
tinea versicolor
rx/
Selenium sulfide
- > terbinafine
- > topical ketaconazole
laryngotracheitis ( croup)
sym?
etio?
Barky cough
- > 6 mo - 3 yrs
- > hoarseness, stridor, fever
VEgan diet
def?
def:
Ca, Vit D, B12 , IDA
soy: contains essential AA
foreign body aspiration
sym?
rx?
Young age 1-3 yr !!!
sym: sudden onset cough , dyspnea, cyanosis
- > hx choking episode
- > not relief by O2
exam: wheezing + stridor
- > focal area diminished BS
xr: hyperinflation affected side
_> mediastinal shift towards unaffected side
_ atelectasis ob if complete
—> 30% RX normal !!!
rx: RIDGIT bronchoscopy!!!
primary amenorrhea
dx?
Pelvic u/s :
–> uterus absent : Karyotype :: 46 XY / 46 XX
-> uterus + : check FSH !!!
- ** central cause:
1. —–> Low FSH: TSH, prolactin: hypothyroidism , Prolactinoma, FHA
- —–> Normal FSH: imperforated hymen
*** peripheral causes:
3. —-> high FSH: Karyotype: : 46XX : primary ovarian insufficiency
45XO : TS
resp distress syn
sym?
- > inc risk pnthroax : insuff surfactant
- > meconium aspiration syn : airways traps distal gas
rx: mech ventilation : nCPAP
!!! —-> tension pnthroax: high Intrapleural pressure –> dec VR + CO –> hypotension + hypoxemia
XR: hemithroax transillumination
rx: ER NEEDLE thoracostomy !!
acute unilateral cervical lymphadenitis
sym?
rx?
sym:
enlarge 3-6 cm cervical node , marked tender , warm , erythematous
- > S. aureus, S. pyogenes
- > anaerobes asso periodontal dx
rx: Empirical Ab : clindamycin ( MRSA)
- -> amx + clavulanate
- > incusion + drainage abscess
primary dysmenorrhea
sym?
rx?
-> excessive prostaglandin production
sym:
- > pain 1st 2-3 days menses
- > N, V, D
- > normal pelvic exam
rx: NSAIDS
- > OCP
adenomyosis
sym?
- > > 40 yr
- > endometrial glands + stroma w/in uterine myometrium
-> tender, SYMmetrically enlarged globular uterus
endometriosis
sym?
- > adolescent with dysmenorrhea
- > pain prior MC and THROUGHOUT MC
- > uterosacral ligament tenderness, cul-de-sac nodularity, adnexal enlargement
acute rheumatic fever
sym?
-> Joint swelling
O: carditis: MS (MC)!!!! –> inc LA pressure
- –> elev pul vascular congestion , hemoptysis , RHF
- –> risk : AFIB (LA dilation) , thrombus formation !!!!!
Nodules
Erythema mirginatum rash
Sdyheam cholera
TSS s. aureus
sym?
- > fever , rash “ diffuse sunburn like” palms + soles
- > rapid onset hypotension !!!
- > multi-organ failure
iron poisoning
sym?
-> abd pain, diarrhea, hematemesis ( GI errosive to gastric mucose)!!!
- > hypovolemia shock w/in few HOURS : GI loss
- > met acidosis with high AG
rx: radiopaque tablets!!!
choroid plexus papilloma ?
-> inc CSF production !!!
enlarge head circumference
-> inc ICP : poor feeding, buldging frontanellle, irritability, vomiting
dx: MRI
RSV
sym?
pn < 5yr
primary TB
sym?
-> chronic cough children > 4 wks/ > 8 wks adults
- > hilar LAD( ghon complex)
- > consolidation / pleural effusion ( 2ndry reactivation)
- > Upper lung inv
-> prolong fever, WL, fatigue
dx: PPD / INF-g assy
- > CXR
- > _ AFB smear + culture
HPV vaccine
?
<15 yr : 2 dose
> 15 yr: 3 doses
aquired
sideroblastic anemia
sym?
etio:
- > B6 (pyridoxine) def: TB rx -> ISONIAZID rx
–> def heme synthesis ( mito) + ring sideroblasts (nucleated erythroblasts with mito iron granules surrounding nucleus)
lab:
- > inc lron conc
- > dec TIBC
thalassemia minor
rx?
- > minor: reassurance
- > major: deferoxamine : Iron overload
hepatic hydrothoarx
sym?
etio:
transudative pleural effusion
—> small defects in diaphragm : permits peritoneal fluid pass into pleural space
–> MC right side : less muscular hemidiaphragm
heptopulmonary syn
sym?
intrapulmonary vascular dilation
–> chronic liver dx
-> platypnea ( inc dyspnea upright) / orthodeoxia ( O2 desat upright)
exertional heat stroke
sym?
dx?
- > strenuous activity during hot weather
- > dehydration
- > rx: SSRI, TCA,
sym: temp > 40C with CNS dysfunction
- > organ / tix damage : renal/ hepatic failure , DIC , ARDS
rx: rapid cooling : ice water immersion
- > fluid
papillary necrosis
etio?
NON- glomerular hematuria
```
SAND
Sickle cell dx
Analgesic abuse
Inf ( pyelonephritis)
NSAIDS
DM
~~~
hepatorenal syn
sym?
- > reduce renal perfusion :: SPLANCHNIC ARTERIAL DILATION : dec vascular resistance —> + renal vasoconstriction , + RAAS, + dec GFR
- > GI bleeding, sepsis, excessive diuretics use , SBP
- > NSAIDS use ( constrict afferent )
rx:
hypovolemia, anemia, inf
-> splanchnic vasoconstriction ( midodrine, octreotide, NE)
-> liver transplant
rx:
-> hypo
epileptic seizure
sym?
sym: TONGUE BITING @!!!!
high specificity!
disruptive mood dysregulation dx?
pediatric mood disorder : persistent > 1 yr + freq outburst
– > prior 10 yr
myasthenia gravis
sym?
-> NMJ dx: autoab against Ach receptor in MOTOR END PLATE
- > fluctuating EOM + bulbar muscle wkness
- > symmetric proximal wkness inv NECK + UPPER ext
Riley-Day syn
sym?
-> familial dysautonomia (AR) jewish
-> present at BIRTH
> feeding problem w/ low muscle tone
-> GROSS autonomic NS + severe orthostatic hypotension
cyclothymic disorder ?
hypomanic + mild depression dx > 2 year !
acute HBV
lab?
4-8 wks after infection:
- > HBV ag +
- > anti- HBc IgM +
window period:
-> IgM anti-HBc +
miliary TB
sym?
rx?
- > diffuse reticulonodular pattern ( millet seed)
- > hema spread
EPD : LN, liver, bones, CNS
etio: incarceration + sub abuse
Sickle cell disease
induce RHF?
- > chronic exertional dyspnea : RHF –> PUL HTN
- > IV hemolysis : chronic inf + endothelial dysfunction : hyperplasia + hypertrophy small pul vessels ( vascular remodeling ) + inc PVR
!!!! PVR: dec RV output
- > exertional dyspnea + fatigue
- > HM + edema
- > loud S2
lab: dec DLCO
Normal TLC, FEV1/FVC
chronic lymphedema
sym?
etio?
- –> phy disruption lym drainage !!
- > Lymphadenectomy , radiation!!!!
- > Ca Obstruction
- > parasite
- > congenital ( TS)
- > obesity
sym: deposit subcutaneous collagen + adipose tix : FIRM , thickened skin + nonpitting edema
+ stemmer sign
rx: WL, limb elev, compression bandage, physiotherapy
drug ind acne
sym?
drug- induced acne
: steroid ind folliculitis / steroid acne
etio:
steroids , azathiroprine , cyclosporine
anticonvulstants, antiTB
Niacin
se?
-> flushing + gen pruritus
: peripheral vasodilation
–> release histamine + prostaglandins
rx: ASA
HPV wart ( cutaneous verrucae)
sym?
- > MC cutaneous HPV inf
- > plantar, palmar, genital
- > Young adults, ICP, organ transplant
- > dev wks- months later
hx: hyperkeratotic papules on sole foot
interstitial lung dx ( ILD)
sym?
dx?
- > insp VELCRO ( DRY , FINE) CRACKLES !!!
risk: HF : early ILD
dx: high resolution CT
- –> subtle reticulation / honeycombing
- -> PFT
EPO induced HTN?
-> CKD : hypoproliferative anemia
rx:
+ Erythropoiesis stimulating agents: recombinant EPO + darbepoetin: + RBC
se/ HTN 2-8 wk s/p rx
–> severe EOF
angiodysplasia
sym?
dx?
- -> PAINLESS GI bleeding
- > dilated submucosal veins + AVM
- > inc incidence > 60 yr
- -> MC@ Right colon
asso with : advance Renal dx + VWF dx
-> AS
dx: endoscopy GI , colonoscopy
rx: Cautery
azathioprine
moa?
se?
-> inhibits purine synthesis : rx/ chronic transplant IMS
se/ BM suppression
hepatotoxicity
OSA (ob sleep apnea)
lab?
lab:
-> chronic hypoxia + hypercapnia
inc PCO2
–> compensate with kidney inc HCO3 retention : dec Cl reabsorption ( HCO3-Cl exchanges in intercalated cells in DCT)
–> compensate met alkalosis
aortenteric fistula
sym?
abnormal cxn btwn aortoiliac vessels + GI tract : abd pain. GI bleeding, hypotension
