Internal Med & Specialtys Flashcards

Question

Granulomatosis with polyangiitis - CF, Ix, Mx

Answer 1

Small to medium blood vessels Cough, wheeze Rhinitis Sinus pain Nasal ulcers Epistaxis Orbital mass Polyarthritis Nephrytic syndrome C- ANCA and nd anti-proteinase-3 (PR-3) specificity. Best for dx: Open lung biopsy Ttx: cyclophosphamide Most patients require intensive induction therapy. In rare cases, patients have limited disease that does not affect a major organ (eg isolated sinus disease) and treatment can be started with high-dose oral prednis(ol)one in combination with another immunomodulatory drug (eg methotrexate or mycophenolate). Once remission is achieved, a combination of prednis(ol)one and another immunomodulatory drug is usually required to maintain remission. >TIP: Involvers SUPERIOR respiratory tract + Kidneys

Answer 2

Palpalble purpura (small to medium blood vessels) Asthma Rhinitis Polyneuropathy (Mononeuritis multiplex) Nephritic syndrome p-ANCA Peripheral eosinophilia GCS and cyclophosphamide

Answer 3

Small to medium arteries. Arthralgia Subcutaneous nodules Livedo reticularis Digital infarcts Skin ulcers Nephritic syndrome > About 30% of patients with polyarteritis nodosa are positive for hepatitis B surface antigen, and these patients should be considered for antiviral therapy before starting, or stopping, immunomodulatory therapy ANCA negative or p-ANCA Best: muscle biopsy or angiogram GCS and immunosuppressors For polyarteritis nodosa without evidence of major organ or body system involvement (eg disease affecting the skin only, disease characterised by systemic symptoms only) the standard treatment is high-dose prednis(ol)one For disease affecting a major organ or body system (eg patients with polyneuropathy, kidney or liver involvement) intravenous methylprednisolone is used instead. Cyclophosphamide is added if a visceral organ is affected or if disease is progressive despite adequate corticosteroid therapy.

Answer 4

Haemoptysis Cough Dispnoea Nephritic syndrome Kidney biopsy GCS immunosuppressors > TIP: kidney involvement + LOWER respiratory tract

Answer 5

Eurthyroid sick syndrome

Answer 6

Low TSH, T3 and T4 High rT3 It is possible that the early changes in thyroid function (low T3 and elevated reverse [rT3]) during severe illness are protective in that they prevent excessive tissue catabolism. Thyroid function should not be assessed in seriously ill patients unless there is a strong suspicion of thyroid dysfunction, since there are many other factors in acutely or chronically ill euthyroid patients that influence thyroid function tests. When thyroid dysfunction is suspected in critically ill patients, measurement of serum TSH alone is inadequate for the evaluation of thyroid function. In such a patient, TSH and free T4 (and often total T3) are needed to differentiate nonthyroidal illness from a thyroid disorder. However, the diagnosis may still be in doubt

Answer 7

Thyrotoxic myopathy or hyperthyroid myopathy. Hyperthyroidism increases the metabolic rate and much of this energy is ineffectively used to muscle contraction. In turn, the muscles fatigue easily, and become weak and wasted. A hyperthyroid person who has muscle weakness may or may not have other recognizable manifestation of hyperthyroidism (in this case only tachycardia is given). Myopathy can sometimes be the first presentation of the underlying hyperthyroid state. Patient complains of low exercise tolerance, easy fatigability, difficultyof doing certain tasks. Shoulder, hand and pelvic muscles are affected and tasks like climbing stairs, getting up from a low chair or lifting arms above the shoulders become difficult. Due to the weakness, movements become clumsy and effortful. Hyperthyroidism increases the metabolic rate and much of this energy is ineffectively used to muscle contraction. In turn, the muscles fatigue easily, and become weak and wasted. A hyperthyroid person who has muscle weakness may or may not have other recognizable manifestation of hyperthyroidism (in this case only tachycardia is given). Myopathy can sometimes be the first presentation of the underlying hyperthyroid state. Patient complains of low exercise tolerance, easy fatigability, difficulty of doing certain tasks. Shoulder, hand and pelvic muscles are affected and tasks like climbing stairs, getting up from a low chair or lifting arms above the shoulders become difficult. Due to the weakness, movements become clumsy and effortful. Statin induced myositis: from mild to severe muscle pain, usually proximal groups, muscle stiffness and weakness can occur. Neuromuscular junction disorder: needs to be considered although the absence of ocular symptoms (which occurs in 90% of patients with myasthenia) and lack of fluctuating symptoms would be atypical for myasthenia gravis. Cerebellar ataxia: characterised by difficulties maintaining normal upright posture, coordinated walking, unsteady gait, staggering, tripping. Fine motor coordination will include difficulty withhandwriting, cutting food, opening jars, buttoning clothes, typing, playing an instrument. Inflammatory myopathy (Polymyositis, Dermatomyositis): affects the proximal skeletal muscles with evidence of elevated CK and myositis on biopsy. Clinical manifestation includes symmetrical proximal muscle weakness and wasting. Commonly affects pelvic and shoulder girdle muscles leading to difficulties combing hair, standing up from a sitting position and climbing stairs. Tachycardia is not the sign of inflammatory myopathy.

Answer 8

TSH is lower in the first trimester, TSH concentration 0.1 is normal (gestational transient thyrotoxicosis). It is self limiting (after 12 weeks) and does not require treatment. Free T3 tends to be higher throughout pregnancy. Free T4 is lower in the late second and third trimester.

Answer 9

Low risk: Hemithyroidectomy + Levothyroxine + TSH suppression 🔪💊 Criteria: Tumor <4 cm, no invasion, no vascular invasion, non-aggressive histology, complete macroscopic tumor resection, no regional lymph node metastasis 📏🚫 Intermediate risk: Total thyroidectomy + Consider RAIA (Radioactive iodine ablation) + TSH suppression 🏥🔬 High risk: Total thyroidectomy + RAIA + TSH suppression 🏥🔬🔴 Active surveillance for papillary microcarcinoma (<1 cm) with no nodal or distant metastasis. Multimorbid patients with high surgical risk ot short lige expectancy📊👀

Answer 10

Psammoma bodies suggest a suspicion of malignancy 🩸 Especially associated with papillary thyroid cancer 🦠 Their presence warrants further investigation 🧪 Can be a diagnostic clue for malignancy 🚨

Answer 11

Transplacental passage of TRAb can lead to transient neonatal hyperthyroidism 👶🤰 Occurs in women with Graves' disease during pregnancy 🤱 Requires careful evaluation of the neonate if TSH-receptor antibodies are high in the last trimester 📊👶 Neonatal thyrotoxicosis due to TRAb is transient and limited by maternal antibody clearance (8 - 20 weeks) ⏳

Answer 12

TRAb levels can remain elevated despite treatment for hyperthyroidism (surgery or radioiodine) or hypothyroidism (L-Thyroxine) 📈 Monitoring TRAb levels is important in assessing treatment response 🩺💉 Elevated TRAb levels can indicate ongoing autoimmune activity 🦠 TRAb levels should be evaluated during pregnancy and postpartum for appropriate management 🤰🔬

Answer 13

Bromocriptine is a non-selective dopamine agonist binding to D1 receptors in the gut and D2 receptors in the pituitary 🧪🧠 Cabergoline has a longer half-life and is more specific for D2 receptors 🕰️ Cabergoline is recommended as the first-line treatment for pituitary adenoma due to its superior effectiveness and tolerability 🥇 Cabergoline normalizes prolactin in up to 95% of patients, reduces tumor size in about 90%, and controls symptoms in the majority 🩺📉😃

Answer 14

Treatment resistance is defined as less than 50% reduction in tumor size or failure to return prolactin concentration to normal with dopamine agonist therapy 📉💊❌ Occurs in 10% of patients treated with cabergoline and 25% of those treated with bromocriptine 📊 Indicates the need for alternative treatment strategies 🏥🎯

Answer 15

Patients with persistent visual field defects, dopamine agonist resistance, and pituitary apoplexy often require transsphenoidal surgery, radiotherapy, or both 🩸🔬🪓 These interventions are crucial for managing complications and improving patient outcomes 🏥💡

Answer 16

Increased insulin-like growth factor 1 - IGF1 (somatomedin) is a hallmark of acromegaly 📈 The glucose suppression test is used to confirm the diagnosis 🩺🩹 MRI imaging typically shows enlargement of the sella turcica, a characteristic finding 📊🏥

Answer 17

Transsphenoidal surgery and radiation therapy are primary treatments for acromegaly 🏥🪓 Octreotide is a second-line option for refractory tumors 🩸💉 If there is prolactin co-secretion, cabergoline or bromocriptine may be added to the treatment regimen 🤝🔬

Answer 18

Clinical features of adrenal insufficiency include weight loss, skin pigmentation, postural hypotension, nausea, vomiting, diarrhea, and loss of appetite 🤢🏋️‍♀️🌡️

Answer 19

The most common cause of primary adrenal insufficiency in adults is autoimmune disease, typically occurring between 30 and 50 years of age 🧬🦠 Autoimmune conditions often coexist, with thyroid disease being the most common, along with vitiligo, type 1 diabetes, primary gonadal failure, coeliac disease, and pernicious anemia 👥🩺👨‍⚕️

Answer 20

Begin rehydration with normal saline IV at a rate of 15-20 ml/kg 🩸 If corrected sodium is >145 mmol/L, administer half saline IV to avoid overcorrection 🧪 Watch for symptoms of cerebral edema during treatment ⚠️

Answer 21

Administer short-acting insulin via IV infusion 🧬💉 Monitor glucose levels every hour and initiate glucose 5% IV when glucose falls below 15 mmol/L 📊🔬 Monitor potassium (K) levels every 2 hours and start KCl IV when K falls below 5.5 mmol/L 🧪🔍

Answer 22

Administer sodium bicarbonate if the pH falls below 7.0 to correct acidosis 🧪📉 Consider broad-spectrum antibiotics if there is evidence of infection 🦠🦠 Implement DVT prophylaxis measures to prevent thromboembolic events 🩺🦠

Answer 23

Diabetes alone is not a sufficient indication for using aspirin for primary prevention of cardiovascular disease 🩺🚫 Other risk factors and individual patient factors should be assessed to determine aspirin eligibility 📊👨‍⚕️ All adults with diabetes and clinically manifest cardiovascular disease should be treated with low-dose aspirin for secondary prevention 🩸💊

Answer 24

Monitor blood glucose concentration before driving and ensure it is above 5 mmol/L 🩺🚗 If you are driving for two hours or more, recheck your blood glucose level at least every two hours to make sure it stays above 5mmol/L. Maintaining safe blood glucose levels is crucial for road safety 🛣️👨‍🚒 Always carry glucose-containing foods to manage low blood sugar episodes 🥖🍬 Inform the driving license authority about diabetes 🚗📝 IMMEDIATELY eat or drink at least 15 grams of fast acting carbohydrate and Wait 10–15 minutes and check your blood glucose level again.

Answer 25

Individuals with hypoglycemia unawareness should cease driving until they can demonstrate no hypoglycemia over a 6-week period and restore hypoglycemia awareness 🚫🚘 Ensures road safety and the well-being of the driver and others on the road 🛣️👀

Answer 26

Hypoglycemia unawareness occurs when adrenergic (autonomic) symptoms' threshold closely aligns with or falls below the threshold for neuroglycopenic symptoms 🧠💔 This results in the absence of characteristic adrenergic symptoms, and confusion or loss of consciousness becomes the initial sign of hypoglycemia 🚫🤷 It's more common in patients with type 1 diabetes, particularly those with over 10 years of disease duration, but can also affect type 2 diabetes patients, especially those treated with insulin or sulfonylureas 🩸📈 It can develop after repeated episodes of short-duration hypoglycemia, impairing adrenergic responses to subsequent episodes 🔄📉 Individualized glycated hemoglobin (HbA1c) targets may be needed to minimize the risk of hypoglycemia 🎯📊 Hypoglycemia unawareness and defective counter-regulatory hormone responses can potentially be reversed through strict avoidance of hypoglycemia for 2 days to 3 months 🔄⚖️

Answer 27

In addition to hypos, long-term diabetes-related complications can affect the ability to drive safely 🚗🩸 Regular eye check-ups every 12 months or as recommended by the doctor are crucial, and the doctor may clear the individual for driving for 18–24 months 🩺👁️ Similarly, regular foot check-ups every 12 months or as recommended by the doctor are essential 🦶 Seek advice from a doctor or podiatrist promptly if there are any issues, such as numbness, pain in the feet or legs, or difficulty feeling the pedals while driving 🩺🦶🚙

Answer 28

Primary aldosteronism, also known as Conn's syndrome, is characterized by the presence of aldosterone-producing adenoma, leading to sodium and water retention with hypertension 🩸💧 It often results in low potassium levels, causing muscle weakness, cramps, paresthesia, polyuria, and polydipsia 🏋️‍♂️🚰

Answer 29

Secondary aldosteronism can be caused by conditions such as congestive heart failure (CHF), cirrhosis, renal artery stenosis, and nephrotic syndrome 🩺🤕 Unlike primary aldosteronism, secondary aldosteronism is not driven by an aldosterone-producing adenoma 🔄

Answer 30

To differentiate between primary and secondary aldosteronism, both renin levels and aldosterone levels should be checked 📊🩸 In primary aldosteronism, renin levels are typically low (reference range: <1 ng/mL/h), while in secondary aldosteronism, renin levels are often high (reference range: varies by laboratory) 📉📈

Answer 31

Diabetes insipidus is diagnosed by assessing plasma and urine osmolality 🩸🧪 It results from a deficiency of antidiuretic hormone (ADH), leading to increased sodium levels but normal potassium levels 🧠📈📉 Diabetes insipidus is characterized by excessive thirst (polydipsia) and excessive urination (polyuria) with very dilute urine 🚰🚽 Reference values: Normal plasma osmolality: Approximately 275-295 mOsm/kg Normal urine osmolality (concentrated urine): >800 mOsm/kg There are different forms of diabetes insipidus, including central (neurogenic) and nephrogenic, each with distinct causes and mechanisms 🧬🧪

Answer 32

Lipid Profile Reference Values: Total Cholesterol: mmol/L: Desirable: <5.2 mmol/L Borderline high: 5.2-6.1 mmol/L High: ≥6.2 mmol/L mg/dL: Desirable: <200 mg/dL Borderline high: 200-239 mg/dL High: ≥240 mg/dL LDL Cholesterol: mmol/L: Optimal: <2.6 mmol/L Near optimal: 2.6-3.3 mmol/L Borderline high: 3.4-4.1 mmol/L High: 4.2-4.9 mmol/L Very high: ≥5.0 mmol/L mg/dL: Optimal: <100 mg/dL Near optimal: 100-129 mg/dL Borderline high: 130-159 mg/dL High: 160-189 mg/dL Very high: ≥190 mg/dL HDL Cholesterol: mmol/L: Low: <1.0 mmol/L High (desirable): ≥1.6 mmol/L mg/dL: Low: <40 mg/dL (for men), <50 mg/dL (for women) High (desirable): ≥60 mg/dL Triglycerides: mmol/L: Normal: <1.7 mmol/L Borderline high: 1.7-2.2 mmol/L High: 2.3-5.6 mmol/L Very high: ≥5.7 mmol/L mg/dL: Normal: <150 mg/dL Borderline high: 150-199 mg/dL High: 200-499 mg/dL Very high: ≥500 mg/dL

Answer 33

Glucose Profile Reference Values: Fasting Glucose: mmol/L: Normal: <5.6 mmol/L Prediabetes (impaired fasting glucose): 5.6-6.9 mmol/L Diabetes: ≥7.0 mmol/L mg/dL: Normal: <100 mg/dL Prediabetes (impaired fasting glucose): 100-125 mg/dL Diabetes: ≥126 mg/dL HbA1c: mmol/mol: Normal: <39 mmol/mol Prediabetes: 39-47 mmol/mol Diabetes: ≥48 mmol/mol %: Normal: <5.7% Prediabetes: 5.7-6.4% Diabetes: ≥6.5% These reference values are important for assessing lipid profiles and glucose control in individuals and may vary slightly depending on the laboratory and region.

Answer 34

Statins are the drug of choice in treating hyperlipidemia in diabetes 🩸💊 They decrease the risk of coronary events and effectively lower LDL cholesterol levels 📉❤️ Statins may have less effect on triglyceride levels, but the reduction can often bring patients closer to their lipid goals 📊🚫 Niacin can lower triglycerides, raise HDL cholesterol, and lower LDL cholesterol, but it may increase insulin resistance 🔄📈📉 Niacin is sometimes used in combination with statins or alone in patients with statin side-effects 🛠️👥 Fibric acid derivatives primarily lower triglycerides and raise HDL cholesterol, with minimal effects on LDL cholesterol 📊❤️📉 Please let me know if you would like to create more flashcards or if you have any other specific topics or details you'd like to include in the card series.

Answer 35

Metformin, belonging to the biguanide class, is the first-choice glucose-lowering medication for most patients with type 2 diabetes 🩸💊 It increases insulin sensitivity in peripheral tissues, predominantly muscle, and reduces hepatic glucose output 🫁🔽 Metformin is effective only in the presence of insulin and primarily decreases hepatic glucose output 🍽️📤 It increases insulin-mediated glucose utilization in peripheral tissues and has an antilipolytic effect, lowering serum free fatty acid concentrations 🍖🍬 Metformin also increases intestinal glucose utilization via non-oxidative metabolism 🍽️🫀 It does not cause hypoglycemia but may lead to lactic acidosis due to the accumulation of lactate 🩸🧪 Lactic acidosis may occur because Metformin inhibits gluconeogenesis by blocking pyruvate carboxylase, the first step of gluconeogenesis 🧪🔒 Common side effects include gastrointestinal symptoms like metallic taste, anorexia, nausea, abdominal discomfort, and soft bowel movements or diarrhea 🤢💩 These side effects are usually mild, transient, and reversible with dose reduction or discontinuation 🔄❌ Metformin is not metabolized and is entirely cleared by renal excretion, requiring dose adjustment in patients with stable renal impairment 🚽📉

Answer 36

Papillary Carcinoma of the Thyroid is a type of thyroid cancer characterized by papillary structures within follicles with epithelial cells having nuclei with cleared centers, often referred to as "orphan Annie eyes" 👁️🔍 This type of thyroid cancer accounts for 60% to 70% of all thyroid cancers and tends to be more frequent in younger patients but can be more aggressive in the elderly 👴👵 It typically presents as a single dominant nodule in the thyroid gland, and this nodule is "cold" on thyroid scan, meaning it does not take up radioactive iodine 📡🚫 Papillary Carcinoma of the Thyroid has a relatively better prognosis compared to other types of thyroid cancers, especially in smaller lesions that can be treated with thyroid lobectomy alone 📈✅ Larger or more diffusely spreading lesions may require complete thyroidectomy, sometimes followed by the ablation of any residual thyroid tissue using large doses of Iodine 131 (radioactive iodine) 🩺🔬 Distinguishing from other thyroid conditions: Follicular Carcinoma of the Thyroid lacks the papillary structures and orphan Annie nuclei seen in papillary carcinoma and can be challenging to differentiate from normal thyroid tissue 🤔 Graves Disease is characterized by hyperthyroid symptoms and a symmetric, diffusely enlarged goiter, not a single dominant nodule 🌀😓 Hashimoto Disease results in a diffuse goiter with an intense lymphocytic infiltrate and follicle destruction on biopsy, often leading to hypothyroidism symptoms 🛡️😥 Nontoxic Goiter may present with a smooth or multinodular goiter but typically lacks a single dominant nodule and has a wide range of follicle sizes on biopsy, with patients usually being clinically euthyroid 🦋🩸 If you'd like to create more flashcards or have specific topics or details to include in the card series, please let me know. User i need it to be a little more concise (WITHOUT LOOSING CONTENT) or be split in two ChatGPT Certainly, I can make it more concise while retaining the key content. Here's a more concise version: Papillary Carcinoma of the Thyroid Papillary Carcinoma of the Thyroid is the most common type of thyroid cancer. It is characterized by papillary structures within follicles with unique "orphan Annie eyes" nuclei. Accounts for 60-70% of thyroid cancers. Common in younger patients but can be more aggressive in the elderly. Typically presents as a single dominant "cold" nodule on thyroid scan. Better prognosis, especially in smaller lesions treated with thyroid lobectomy. Larger lesions may require complete thyroidectomy and radioactive iodine ablation. Distinguishing from other thyroid conditions: Follicular Carcinoma lacks papillary structures and is challenging to differentiate from normal thyroid tissue. Graves Disease shows hyperthyroid symptoms and a diffusely enlarged goiter. Hashimoto Disease results in a goiter with lymphocytic infiltrate and hypothyroidism. Nontoxic Goiter is typically euthyroid without a single dominant nodule. If you'd like to split it into two flashcards or have any specific adjustments, please let me know

Answer 37

Hypertension is defined as a sustained blood pressure ≥130 mm Hg systolic or ≥80 mm Hg diastolic. Initial evaluation should identify complications (e.g., chronic kidney disease) and comorbid conditions (e.g., hyperlipidemia). Laboratory tests include: Renal function tests (serum electrolytes, creatinine, urinalysis). Endocrine tests (fasting glucose or hemoglobin A1c, lipid profile, TSH).

Answer 38

Tests for hypertension also include: Cardiac tests (ECG, optional echocardiography). Other tests (complete blood count, optional uric acid). Screening for diabetes with fasting blood glucose or hemoglobin A1c is advised for patients age >40 years every 3 years. Consider screening at younger ages (18 years above) for those with additional risk factors. ECG may be recommended to identify signs of left ventricular hypertrophy. Further assessment with echocardiography is specific but may have low yield in young patients with mild hypertension and normal ECG. Testing for sleep apnea is indicated for symptomatic patients and may be considered for those with refractory hypertension.

Answer 39

Osteosarcoma 🦴 is the most common primary bone tumor in children and young adults. It primarily affects boys aged 13 to 16. 👦👦 Commonly occurs at the metaphyses of long bones (e.g., distal femur, proximal tibia, proximal humerus). 🦴🔍 Constitutional symptoms like fever, weight loss, and malaise are usually absent. 🚫🤒📉 On physical examination, a tender soft-tissue mass is a significant finding. 🩺💡 Characteristic X-ray findings include a spiculated "sunburst" pattern and periosteal elevation known as the Codman triangle. 🌞🔍 Elevated alkaline phosphatase and lactate dehydrogenase levels result from turnover of damaged osteocytes; high levels may correlate with an adverse prognosis. 📈🩸 Increased erythrocyte sedimentation rate (ESR) serves as a nonspecific marker of inflammation. 📈🩺 Differential diagnosis: Distinguish from Ewing sarcoma, which is the second most common primary bone malignancy. Ewing sarcoma may have systemic symptoms and shows an "onion skin" appearance on X-ray. 🧅🔍 Osteoid Osteoma 🦴 appears as a sclerotic, cortical lesion on imaging with a central nidus of lucency. It typically causes pain that worsens at night and is unrelated to activity. 🌙🩺 Pain is quickly relieved by nonsteroidal anti-inflammatory medications. 💊📉

Answer 40

Primary Adrenal Insufficiency (PAI), also known as Addison's disease, results from autoimmune destruction of the bilateral adrenal cortex. PAI presents with the following clinical features: Mineralocorticoid deficiency leads to renal salt wasting, hypotension, weight loss, hyponatremia, hyperkalemia, and dietary salt craving. 🌊🧂 Glucocorticoid deficiency causes fatigue, anorexia, and various psychiatric manifestations (e.g., irritability, depressed mood), contributing to hypotension. 😴🍽️🧠 Androgen deficiency results in loss of libido and suppression of secondary sexual characteristics, typically seen in women due to continued androgen production in men. 🚻🔻 In patients with suspected AI, salt craving and hyperpigmentation are specific to PAI and help differentiate it from secondary AI. 🧂🌞 The diagnosis of PAI is confirmed through stimulation testing with cosyntropin, a synthetic form of ACTH. Low cortisol production following cosyntropin administration is diagnostic of PAI. 🩺🔬 Please review this card, and if it aligns with your expectations, we can continue creating more cards or make adjustments as needed.

Answer 41

Clinical Features of Cushing's Syndrome in Women: Anxiety 😰 Tremulousness 🤯 Weight gain 🏋️‍♀️ Severe fatigue 😴 Menstrual irregularities 🩸 Hypertension 🩺 Hyperglycemia 📈 Thin, easily-bruising skin 🏥 Purplish pink striae may be present on buttocks, thighs, abdomen, and breast 🪡 Proximal muscle weakness 💪 Diagnosis of Cushing's Syndrome: Screening: Overnight dexamethasone (1 mg) challenge test is performed. High-Dose Suppression Test: Patients with unsuppressed cortisol levels undergo a high-dose dexamethasone suppression test. Definitive Diagnosis: If high-dose dexamethasone fails to suppress serum cortisol levels, a 24-hour urine cortisol level measurement is the most definitive diagnostic test. 🩺🔍

Answer 42

Causes of Hypoglycemia: Excessive insulin secretion in relation to glucose levels, often seen in patients taking exogenous insulin. Vulnerability to exercise-induced hypoglycemia in insulin-treated patients due to continued insulin release despite falling glucose levels. Altered skin perfusion during strenuous exertion leading to increased insulin absorption. Delayed clearance of insulin by the kidneys in patients with chronic kidney disease. Additional risk factors such as altered nutrition and autonomic dysfunction. Manifestations of Hypoglycemia: Neurogenic symptoms: Sweating, tremor, palpitations due to autonomic activation. Neuroglycopenic symptoms: Confusion, impaired consciousness due to inadequate CNS glucose supply. Differential Diagnosis: Patients with diabetes and coronary artery disease may present with atypical anginal symptoms such as fatigue, dyspnea, and nausea, but mental confusion is more consistent with neuroglycopenic effects. Pheochromocytoma presents with headache, palpitations, diaphoresis, and severe hypertension, but confusion is less typical. Orthostatic hypotension leads to presyncope or syncope symptoms and is unlikely to cause confusion

Answer 43

T-score of -2.5 or less indicates osteoporosis 🦴 T-scores between -1 to -2.5 suggest osteopenia 🦴 T-score of -1 or above is considered normal bone density 🟩 For prevention, maintain a high-calcium diet with a total daily calcium intake of 1300 mg, with diet being the preferred source of calcium 🍽️💊 Encourage patients with low dietary calcium intake to increase their intake of calcium-rich foods instead of supplements 🥛🧀 Limit the dose from a supplement to 500 to 600 mg of elemental calcium daily, ideally achieved from dietary sources 🚫 Bisphosphonates are used for treatment of established osteoporosis or osteopenia, not for prevention 🚫 Calcium supplementation is used when adequate calcium intake cannot be ensured through diet 🚫 Exercise has additional benefits but is not the primary preventive measure 🏋️‍♀️ Exposure to sunlight is necessary for vitamin D production, which aids calcium absorption but is not the primary preventive measure ☀️ Maintain a serum 25-hydroxyvitamin D concentration above 50 nanomol/L in patients taking drug therapy for osteoporosis 🌞

Answer 44

To monitor osteoporosis treatment, use actual BMD values; T-scores and Z-scores are not appropriate 🦴 Measure BMD at the lumbar spine and hip: 2 years after starting treatment 1 to 2 years after a significant change in treatment 📊 Consider more frequent BMD measurement (but not more often than once a year) in patients with severe osteoporosis or high risk of bone loss, including those taking high-dose glucocorticoid therapy ⏳ If BMD is stable or improving, subsequent measurement is not required for at least 2 years; an interval of up to 5 years may be reasonable 📈 If BMD decreases by more than 5% or 0.05 grams/cm2 at any major site, or if a fracture occurs, consider investigation for new or unrecognised risk factors, and check adherence to therapy. A change of therapy may be appropriate. 🚑

Answer 45

Measure bone mineral density (BMD) in patients with significant risk factors for fracture, and in patients 70 years and older. Calculate absolute fracture risk using online calculators (eg Fracture Risk Assessment Tool [FRAX]) Start osteoporosis drug therapy for patients aged 70 and older with T-scores of –2.5 or less. Consider treatment for younger patients with declining BMD or high fracture risk; seek specialist advice when needed. Ensure sufficient calcium and vitamin D intake and advise on fracture prevention. After a minimal-trauma fracture, assess BMD, and treat if T-score is osteopenic or osteoporotic. For normal T-scores, investigate other causes of fracture and consider treatment based on fracture site and risk factors. If BMD measurement isn't possible, start drug therapy for hip or vertebral fractures, and consider follow-up BMD when available

Answer 46

Alendronate: Oral dosing 🩸, Low cost 💰, Can cause or exacerbate upper gastrointestinal tract irritation 😫, Absorption reduced by food, antacids, calcium, magnesium, and iron 🚫, Requires more frequent dosing than intravenous options 📅, Not recommended in severe kidney disease 🚑. Risedronate: Oral dosing 🩸, Low cost 💰, Enteric-coated formulation available (may have a lower incidence of gastrointestinal adverse effects, and absorption less affected by food, antacids, calcium, magnesium, and iron) 🍽️, Can cause or exacerbate upper gastrointestinal tract irritation 😫, Absorption reduced by food, antacids, calcium, magnesium, and iron 🚫, Requires more frequent dosing than intravenous options 📅, Not recommended in severe kidney disease 🚑, Enteric-coated formulation only available as a weekly dose (non–enteric-coated formulation available as a monthly dose) 🗓️. Zoledronic Acid: Intravenous administration avoids gastrointestinal adverse effects 💉, Yearly dosing can improve adherence 🗓️, Intravenous administration not acceptable to some patients 🚫, Not recommended in severe kidney disease 🚑, Can cause transient influenza-like symptoms 🤒, Can cause uveitis (uncommon) 👁️, Can cause hypocalcaemia (particularly in patients with impaired kidney function, vitamin D deficiency, or a malabsorption disorder) 🚑. Denosumab: Subcutaneous administration avoids gastrointestinal adverse effects 💉, Dose adjustment not required in kidney disease 🚑, 6-monthly dosing can improve compliance 🗓️, Subcutaneous dosing not acceptable to some patients 🚫, Adherence to 6-monthly dosing regimen is essential to prevent loss of bone mineral density between doses 📅, Therapy must be either indefinite or replaced by a bisphosphonate if stopped 🔄, Withdrawal or interruption of treatment (dose delayed by more than 4 weeks) is associated with an increased risk of multiple spontaneous vertebral fracture 🦴, Can cause hypocalcaemia (particularly in patients with impaired kidney function, vitamin D deficiency, or a malabsorption disorder) 🚑.

Answer 47

Alendronate: 70 mg orally, once weekly on an empty stomach 💊🍽️, Low cost 💰, Limited by upper gastrointestinal irritation 😫, Absorption affected by food, antacids, calcium, magnesium, and iron 🚫, Frequent dosing required 📅, Caution in severe kidney disease 🚑. Risedronate: 35 mg orally, once weekly on an empty stomach 💊🍽️, Low cost 💰, Enteric-coated formulation available for reduced gastrointestinal adverse effects 🍽️, Can cause or exacerbate upper gastrointestinal tract irritation 😫, Absorption affected by food, antacids, calcium, magnesium, and iron 🚫, Frequent dosing required 📅, Caution in severe kidney disease 🚑, Monthly dosing option available 🗓️. Zoledronic Acid: 5 mg intravenous infusion once a year 💉, Avoids gastrointestinal adverse effects 💊🍽️, Improves adherence with yearly dosing 📅, Risk of transient influenza-like symptoms 🤒, Risk of uveitis (uncommon) 👁️, Risk of hypocalcaemia, especially with risk factors 🚑. Denosumab: 60 mg subcutaneously every 6 months 💉🗓️, Increases BMD and reduces fractures 🦴, Need for patient adherence to 6-month regimen 🔄, Considerations upon therapy cessation leading to rapid bone turnover and loss of BMD 📈🦴, Risk of hypocalcaemia, especially with risk factors 🚑, Requires calcium and vitamin D sufficiency 🍽️🌞, Discussion with patients on the importance of adherence and therapy continuation or replacement 🗣️.

Answer 48

Effects of Glucocorticoids on BMD: Reduce bone formation, increase bone resorption, affect osteoblast function, hinder intestinal calcium absorption, cause osteocyte dysfunction, lead to hypercalciuria, and suppress gonadal function 🦴📉. Fracture Risk with Glucocorticoids: Increased fracture risk regardless of BMD, higher risk compared to non-users with similar BMD 🦴📈. Factors Affecting Bone Loss: Highest bone loss rate in the initial 3 to 6 months, dose and duration-dependent bone loss, prednis(ol)one dose ≥ 7.5 mg/day or equivalent associated with highest risk, increased risk even with low doses (≥ 2.5 mg/day) 📆. Prevention and Management: Assess fracture risk, measure BMD, ensure sufficient calcium and vitamin D intake, optimize other fracture risk factors, advise on minimal-trauma fracture prevention 📊🍽️🌞. Treatment Options: Bisphosphonates (first-line), Denosumab, Teriparatide (strict eligibility criteria), Estrogen therapy (for postmenopausal women) 💊🦴. Monitoring: Consider BMD measurement every 12 to 24 months initially, with less frequent monitoring if stable and acceptable results 📏🔄.

Answer 49

Definition: Rare demineralizing condition, primarily affecting the hip, but can impact other joints. Mechanism unknown 🤰🦴. Distinguishing Factors: Differentiate from physiological bone mass loss during pregnancy and lactation. Presents in the third trimester with severe atraumatic anterolateral groin pain, anterior thigh radiation, acute or insidious onset 🚼🤕. Bone Mineral Density: Hip BMD significantly reduced compared to lumbar spine 📏. Resolution: Self-limiting, typically resolves 2 to 6 months postpartum 🔄. Management: Requires specialist assessment and management 👩‍⚕️.

Answer 50

Decreased Libido Psychosis

Answer 51

Treatment with calcium (1200-1600mg daily) and vitamin D is recommended for all patients with AN. 🥛🌞 Calcium and vitamin D can't restore bone density but can prevent further bone loss. 🛡️🦴 Alendronate and other bisphosphonates are first-line treatments for postmenopausal women with established osteoporosis but are not routinely recommended for premenopausal women due to teratogenicity and insufficient safety data. ⚠️💊 Estrogen therapy is secondary to weight gain as the most effective treatment. 🩺💪 Weight-bearing exercises have equivocal results and are less effective for athletes. 🏋️‍♀️❌ Androgens have shown no benefit in AN-related osteoporosis. 🚫🦴

Answer 52

Hypothyroidism is characterized by elevated TSH levels and decreased T3 and T4 levels. 📉🩸 Subclinical hypothyroidism involves elevated TSH beyond the normal limit but normal T3 and T4 values. 📈

Answer 53

Laboratory findings consistent with hyperthyroidism include subnormal TSH with elevated serum T4, T3, or both. 🩸🔬 Subclinical hyperthyroidism is characterized by subnormal TSH with normal T3 and T4 levels. 🔬🩸 Symptoms are essential in diagnosis, as patients with subclinical hyperthyroidism may still exhibit hyperthyroid symptoms despite normal T3 and T4 levels. 💡👩‍⚕️Graves disease is the most common cause of both subclinical and overt hyperthyroidism. 👁️‍🗨️💼 Toxic nodules can also be a cause but are less common than Graves disease. 📊

Answer 54

Primary hyperparathyroidism and malignancy are common hypercalcemia causes. ⚕️ Malignancy often results in higher calcium levels and more symptoms than primary hyperparathyroidism. 📈 In atypical presentations, measuring intact PTH can distinguish between them. 🩺 Intact PTH is usually low in malignancy and elevated in primary hyperparathyroidism. 📉📈 Rarely, concomitant conditions like PTH-secreting tumors can complicate diagnosis. ⚠️

Answer 55

Common cause of hypercalcemia with elevated intact PTH levels. 🩺🔬 Symptoms include bone pain, kidney stones, and GI issues. 🦴🤕 Diagnosis: Serum calcium, intact PTH, imaging (e.g., ultrasound). 📈🩺📸 Treatment when indicated: Parathyroidectomy. 🏥🔪

Answer 56

Often presents with severe hypercalcemia and pronounced symptoms. 🩺🤯 Symptoms: Fatigue, confusion, constipation, muscle weakness. 🚽🤕 Diagnosis: Undetectable/low intact PTH, imaging, tumor markers. 📉🩺📸 Management: Address underlying malignancy, hydration, bisphosphonates. 💧🩺🩹

Answer 57

The most important initial step in DRFU management is debridement of the ulcer. 🩹 Debridement allows for a thorough assessment of the wound, wound bed, and actual wound size. It can convert a chronic wound into an acute one with accelerated healing. 🩺📈

Answer 58

After debridement, swabs should be taken for bacteriological assessment and culture. 🧫🔬 This should be performed before starting antibiotics. 🚫💊 Empirical antibiotic treatment should be guided by the characteristics of the ulcer. 📊 Antibiotic therapy should be initiated if indicated based on the ulcer's characteristics. 🦠🩺

Answer 59

For acute, mild diabetic foot infection without recent antibiotic use and low risk of MRSA: Use dicloxacillin 500 mg orally, 6-hourly. OR Use flucloxacillin 500 mg orally, 6-hourly. OR For delayed nonsevere hypersensitivity to penicillins, consider cefalexin 500 mg orally, 6-hourly. OR For immediate or delayed severe hypersensitivity to penicillins or increased MRSA risk, consider clindamycin 450 mg orally, 8-hourly. OR Use trimethoprim+sulfamethoxazole 160+800 mg orally, 12-hourly for MRSA risk. 💊 Modify therapy based on culture and susceptibility results. Duration: Typically 1 to 2 weeks. ⏳

Answer 60

For moderate infection, use initial intravenous therapy. For oral therapy, it is suitable if there's osteomyelitis without systemic inflammatory response syndrome. For patients at low MRSA risk, use amoxicillin+clavulanate 1+0.2 g intravenously, 8-hourly (or 6-hourly for bone infection). 🦴💊 For nonsevere hypersensitivity to penicillins, consider cefazolin 2 g intravenously, 8-hourly PLUS metronidazole 500 mg intravenously, 12-hourly. 🩺🦠 For severe hypersensitivity to penicillins or MRSA risk, use trimethoprim+sulfamethoxazole plus metronidazole. Consider ciprofloxacin plus clindamycin or lincomycin for severe cases. 💉 Switch to oral therapy after improvement. Modify therapy based on culture and susceptibility results. Duration varies, seek expert advice for deeper tissue involvement. ⚕️

Answer 61

For severe diabetic foot infection, use piperacillin+tazobactam 4+0.5 g intravenously, 6-hourly. 🌡️ For penicillin hypersensitivity, consider ciprofloxacin 400 mg intravenously, 8-hourly PLUS clindamycin or lincomycin. 💉 Consider vancomycin for severe or life-threatening MRSA risk. Modify therapy based on culture and susceptibility results. 🩺🔬 Switch to oral therapy after improvement. Duration varies; typically 3 weeks for severe cases. Seek expert advice for deeper tissue involvement. ⏳⚕️

Answer 62

Teriparatide is a synthetic parathyroid hormone that primarily stimulates osteoblasts (bone-forming cells) and induces new osteoblast formation. 💉🦴 It is a costly medication, and its effectiveness typically requires at least 18 months of continuous use. ⏳ Teriparatide is reimbursed by the PBS (Pharmaceutical Benefits Scheme) for patients with severe osteoporosis and a very high risk of fractures who meet one of the following criteria: BMD T-score of ≤ -3.0. OR 2 OR MORE minimal trauma fractures. OR At least ONE SYMPTOMATIC fracture after at least 12 months of continuous therapy with an anti-resorptive agent in adequate doses. 📊🩺 BMD (Bone Mineral Density) begins to decline approximately 12 months after the cessation of teriparatide therapy. ⏳🦴 Therefore, it is generally recommended to continue therapy with an anti-resorptive agent, typically a bisphosphonate, after teriparatide treatment. 🩺💊

Answer 63

Bisphosphonates are the most commonly prescribed anti-resorptive agents for osteoporosis. 🦴💊 In Australia, the following bisphosphonates are available: Alendronate (10mg/day or 70mg/week, orally). 🟠 Risedronate (5mg/day or 35mg/week, orally). 🟢 Zoledronic acid (administered intravenously). 🔵 Bisphosphonates should be used for at least 12 months before their efficacy in the treatment of osteoporosis is assessed. ⏳🦴

Answer 64

Hormone therapy, including estrogen and tibolone, can be considered in postmenopausal women younger than 60 years, especially those with other indications for hormone therapy (e.g., menopausal symptoms). 🌸 SERMs also have a preventive effect on breast cancer, making them suitable for postmenopausal women with a family or personal history of breast cancer who are concerned about vertebral fracture due to osteoporosis. 🩺🌼 While there is excellent evidence (Grade A) that raloxifene reduces the risk of vertebral fractures, there is limited evidence supporting its effect on non-vertebral fractures. Jane, who also has osteoporosis in her femur, may not be the ideal candidate for raloxifene as a first-line oConsider hormone therapy (estrogen, tibolone) for postmenopausal women under 60, especially with other indications like menopausal symptoms. 🌸 Raloxifene (a SERM) is an option for young postmenopausal women with spinal osteoporosis, particularly those at risk of breast cancer. It's reimbursed by PBS for postmenopausal osteoporosis. 🦴💊 SERMs also reduce breast cancer risk, making them suitable for those with a family or personal history of breast cancer concerned about vertebral fractures due to osteoporosis. 🩺🌼 Raloxifene primarily prevents vertebral fractures (Grade A evidence), with limited data on non-vertebral fractures.

Answer 65

Pheochromocytoma is a rare adrenal tumor causing excess catecholamines (epinephrine, norepinephrine) production. 🫁 Symptoms include palpitations, flushing, sweating, headache, tremor, and anxiety due to catecholamine excess. 🌬️😰 Severe hypertension is common, but up to 15% of patients may have normal blood pressure. ⚡🩺 Diagnosis relies on tests like plasma metanephrine (high sensitivity, lower specificity) and 24-hour urinary metanephrines (high sensitivity, high specificity). 🩸🚽 Test selection depends on risk factors, with plasma metanephrines for high-risk patients and 24-hour urinary collection for others. 📝📉

Answer 66

Similar symptoms can occur in thyrotoxicosis, hypoglycemia, anxiety/panic attacks, hyperthyroidism, adrenal issues, familial dysautonomia, and brain lesions. 🌡️🧠 Certain tumors like neuroblastomas and related tumors may also mimic pheochromocytomas. 🫀🔍

Answer 67

PTH high, Calcium low, Calcium excretion low - Secondary PTH high, Ca high, Excretion high, Low Phosphate - Terciary PTH low, Ca high, Exc high - Ectopic bone mtx PTH normal, High ca, low excretion - Genetic (familial benign Hypocalciuric hypercalcaemia)

Answer 68

Primary aldosteronism

Answer 69

🩺 Primary aldosteronism is often caused by an aldosterone-producing adenoma. 🌊 It results in increased sodium and water retention, leading to hypertension. 🉑 It also causes low potassium levels, leading to symptoms like muscle weakness, cramps, paraesthesia, polyuria (excessive urination), and polydipsia (excessive thirst).

Answer 70

💔 Congestive Heart Failure (CHF) 🩸 Cirrhosis (liver disease) 🩺 Renal artery stenosis (narrowing of the renal artery) 📉 Nephrotic syndrome (kidney disorder)

Answer 71

🩸 In primary aldosteronism, renin levels are low. 🩸 In secondary aldosteronism, renin levels are high

Answer 72

🩺 To diagnose diabetes insipidus, plasma and urine osmolality are checked. 🌡️ Diabetes insipidus results from deficient antidiuretic hormone (ADH), leading to increased sodium levels but normal potassium levels. 🩸 It is characterized by excessive urination and increased thirst.

Answer 73

The choice of respiratory device depends on the desired fraction of inspired oxygen (FiO2) 💨 Standard nasal cannulae provide FiO2 of 0.24 to 0.35 at 1 to 4 liters per minute of oxygen flow 🩸 Venturi masks offer FiO2 ranging from 0.24 to 0.60 ⚙️ Simple face masks deliver FiO2 of 0.35 to 0.60 at 5 to 10 liters per minute of oxygen flow 😷 100% non-rebreather reservoir masks provide FiO2 greater than 0.60 at 15 liters per minute 🌬️ High-flow nasal cannulae provide FiO2 from 0.21 to 0.80 and generate continuous positive airway pressure (CPAP) 🚀 High-flow nasal cannula therapy is used in various clinical situations but should be applied with expertise or consultation with a specialist center, especially in children 🧒👶

Answer 74

Oxygen therapy is not generally indicated unless the patient is hypoxaemic ❗️ Indications include SpO2 less than 92% or SpO2 less than 88% in patients at risk of hypercapnia 📈 Oxygen therapy is also recommended in critical conditions like cardiac arrest, shock, and major trauma ⚡ Choose the oxygen delivery system based on desired FiO2 💨 Monitor acute oxygen therapy with pulse oximetry and consider arterial blood gas analysis in patients at risk of hypercapnia 📊

Answer 75

Asbestos exposure is linked to an increased risk of bronchogenic carcinoma, mesothelioma, gastrointestinal cancers, and asbestosis among workers. ☠️ Adequate screening for asbestos-related diseases is currently unavailable. 🚫 Even minimal or accidental asbestos exposure can lead to significant disease, warranting evaluation. ⚠️

Answer 76

Diagnostic measures include taking a complete history, performing physical exams focusing on the respiratory system, chest X-rays, and pulmonary function tests. 📋💉📷🫁 Chest X-rays may initially be inconclusive but should be repeated at 3-5 year intervals. 📷🔄 Pulmonary function tests can detect possible restrictive patterns caused by asbestosis. 🫁 In work-related cases, involvement of a respiratory or occupational physician is essential to assess exposure's impact on other workers and workplace safety measures. 👩‍⚕️🏢 Employers must institute a medical surveillance program for employees exposed to asbestos at or above permissible limits. 👨‍💼🏭 Referring asymptomatic patients to respiratory specialists is not necessary; general practitioners can carry out surveillance. 👩‍⚕️ Reporting workplace safety breaches to authorities may be considered if there's a risk to other employees, but initial evaluation and surveillance planning are crucial. 🚧

Answer 77

FVC is the amount of air a patient can exhale in a single expiration after a deep inspiration, regardless of the time it takes. 💨 FVC is diminished (less than 80% predicted) in restrictive pulmonary disease and severe obstructive diseases. 📉

Answer 78

FEV1 reflects airway flow and is expected to be within the normal range in patients with restrictive pulmonary disease due to no airflow obstruction. 🫁 FEV1 is diminished in obstructive diseases. 📉

Answer 79

The FEV1/FVC ratio is the best indicator of obstructive vs. restrictive pulmonary disease, with a normal range of 0.75 – 0.85. 📊 In obstructive diseases, the FEV1 is decreased, while the FVC remains unaffected or mildly decreased, resulting in a decreased ratio. 📉 In restrictive diseases, both FEV1 and FVC decrease, leading to a normal or slightly increased ratio. 📈

Answer 80

The FEV1/FVC ratio is the primary indicator. If it's reduced, further evaluation is needed. 📊 If the FVC is normal, a pure obstructive disease (e.g., asthma) is likely. 🫁 A decreased FVC suggests a reduction in lung volume (mixed pattern) or severe obstruction with increased residual volume. 🫁📉

Answer 81

Sodium cromoglycate is indicated in the prophylactic treatment of asthma, including prevention of exercise-induced bronchospasm. It is not useful in management of an acute asthma attack.

Answer 82

PEF (Peak Expiratory Flow), measured as the maximum exhalation rate after a deep inhalation, is valuable in asthma assessment. 🫁 PEF correlates with FEV1 and serves as an alternative tool when FEV1 is unavailable for evaluating asthma treatment response. 🏥 While not used for diagnosing asthma, peak flow meters are crucial for measuring asthma severity and treatment effectiveness. Higher PEF readings indicate recovery, while lower readings signal airway constriction. 📊💨

Answer 83

LABAs should be used cautiously in children whose asthma is not well controlled with inhaled corticosteroids alone. 🧒 Options for improving control include increasing inhaled corticosteroid dose or adding a leukotriene receptor antagonist. 📈 For children with activity-related symptoms, a leukotriene receptor antagonist is often the preferred choice. 🏃‍♂️ Evidence suggests limited efficacy of LABAs in reducing acute asthma exacerbations in children, with potential risks such as increased exacerbation frequency and short-acting beta2 agonist tolerance. 🚫 LABAs are not recommended as first-line medications for preventing exercise-induced asthma, as they may reduce the protective effects of short-acting beta2 agonists (SABA). Instead, SABAs like salbutamol are preferred. 🏋️ LABAs do not replace the need for preventers like inhaled corticosteroids (ICS). Low to medium doses of ICS are the primary preventive option, with combination therapy (ICS and LABA) considered only after other measures have failed. 🌬️💊

Answer 84

Corticosteroid therapy is recommended for all cases of acute asthma in adults and children 6 years or older, except for the mildest cases. 🌬️ It is also recommended for all cases of severe acute wheezing in children aged 1 to 5 years. For mild to moderate wheezing in this age group, corticosteroids may not provide significant benefit. 🧒 Corticosteroid therapy should be initiated as soon as possible, preferably within the first hour of presentation. 🕒 For adults, use prednis(ol)one 37.5 to 50 mg orally or dexamethasone 16 mg orally within 1 hour of presentation, followed by a repeat dose for dexamethasone the next day. Total treatment duration is 5 to 10 days. 💊 If oral therapy is not tolerated in adults, administer hydrocortisone 100 mg intravenously every 6 hours for up to 24 hours, then switch to an oral corticosteroid. Reduce IV frequency to 12-hourly if needed beyond 24 hours. 💉 For children, use prednis(ol)one 1 mg/kg (up to 50 mg) orally or dexamethasone 0.6 mg/kg (up to 16 mg) orally within 1 hour of presentation. The total treatment duration is 3 days. 🧑‍⚕️

Answer 85

Patients who had any feature of acute life-threatening asthma, or any feature of acute severe asthma that persisted after initial treatment, should be admitted to hospital. No single physiological measurement can define whether a patient is safe for discharge. consider spirometry or peak expiratory flow (PEF) findings (these can often be performed after 1 hour of management); a low forced expiratory volume in 1 second (FEV1) or PEF may indicate a need for hospital admission. If symptoms improve or resolve, salbutamol can be used less frequently or stopped. Monitor the patient for at least an hour after symptom resolution in case symptoms recur.

Answer 86

Initial rapid assessment: Start treatment with both salbutamol and ipratropium. 💨💉 Oxygen saturation (SpO2) less than 92%: Begin supplemental oxygen therapy, titrate to target SpO2 of 92 to 96%. 💨🌡️ Escalation: If the patient worsens or doesn't respond well, consider escalation to life-threatening acute asthma treatment, possibly including intravenous magnesium sulfate. ⚠️💊 Bronchodilator therapy for a child (1-5 years old) with severe acute asthma: Salbutamol: 6 actuations via pMDI with spacer (repeat every 20 minutes for the first hour). 💨💨💨 Ipratropium: 4 actuations via pMDI with spacer (repeat every 20 minutes for the first hour). 💨🌼 Bronchodilator therapy for an adult or child (6 years or older) with severe acute asthma: Salbutamol: 12 actuations via pMDI with spacer (repeat every 20 minutes for the first hour). 💨💨💨 Ipratropium: 8 actuations via pMDI with spacer (repeat every 20 minutes for the first hour). 💨🌼 Use intermittent nebulisation if unable to breathe through a spacer. Mix nebuliser solutions and drive the nebuliser with air (unless oxygen is needed). 🌬️💨 Bronchodilator therapy for a child (1-5 years old): Salbutamol: 2.5 mg via intermittent nebulisation every 20 minutes for the first hour. 💨💨 Ipratropium: 250 micrograms via intermittent nebulisation every 20 minutes for the first hour. 💨🌼 Bronchodilator therapy for an adult or child (6 years or older): Salbutamol: 5 mg via intermittent nebulisation every 20 minutes for the first hour. 💨💨 Ipratropium: 500 micrograms via intermittent nebulisation every 20 minutes for the first hour. 💨🌼

Answer 87

Consider intravenous magnesium sulfate if the patient worsens or doesn't respond promptly to bronchodilator and oxygen therapy. 🤔💨💉 Not suitable for children younger than 2 years. 🚫👶 Magnesium sulfate may have bronchodilator effects, improving lung function and reducing hospital admissions, especially in the sickest patients. 🫁🏥 For severe or life-threatening acute asthma not responding to initial treatment: Administer magnesium sulfate 10 mmol. 💉🧪 For children 2 years or older, use 0.1 to 0.2 mmol/kg (up to 10 mmol). 💊📏 Dilute in 100 mL of a compatible fluid. 🥤 Administer by slow intravenous injection over 20 minutes. 🕒💉

Answer 88

Inhaled corticosteroid (ICS) is the first choice for those with: Frequent symptoms (e.g., weekly daytime or nighttime symptoms) Symptoms limiting activity or sleep History of severe flare-ups (e.g., needing emergency department or hospital treatment). ICS could also be preferable when: Atopy is present Blood eosinophil count is elevated (if known). For children aged 2 and over, consider montelukast as an alternative when: Child can't or won't use a pMDI + spacer/mask Significant allergic rhinitis requires treatment Parents decline ICS or have concerns about its adverse effects (likely poor adherence).

Answer 89

Prescribe montelukast as a treatment trial. Review effects after 4-6 weeks. Discontinue if there's no response. Note that the response to montelukast may be genotype-dependent. Advise parents/carers about potential adverse psychiatric effects of montelukast. 💊🧠

Answer 90

🌬️ Step 1 therapy is for patients with symptoms less than twice per month and without risk factors for exacerbations. 🌬️ Options for Step 1 therapy include: As-required short-acting beta2 agonist (SABA) As-required low-dose budesonide+formoterol. 🚦 For Step 1 as-required therapy, use one of the following: 🚦 Budesonide+formoterol 200+6 micrograms by inhalation via pMDI with spacer or via DPI, as required. 🚦 Salbutamol 200 micrograms by inhalation via pMDI with spacer, as required. 🚦 Terbutaline 500 micrograms by inhalation via DPI, as required.

Answer 91

🌬️ Step 2 therapy is indicated for patients with symptoms or the need for reliever therapy twice per month or more. 📜 Options for Step 2 therapy include: Regular daily low-dose inhaled corticosteroid (ICS) with as-required short-acting beta2 agonist (SABA) As-required low-dose budesonide+formoterol. 🔄 As-required budesonide+formoterol is as effective as regular daily low-dose ICS therapy for reducing exacerbations in mild asthma, with a lower total dose of ICS. However, it's less effective at improving asthma symptom control and lung function. 🚫 Other combination products (e.g., beclometasone+formoterol) are not approved for Step 2 as-required therapy. 📝 For Step 2 therapy with as-required low-dose budesonide+formoterol, use budesonide+formoterol 200+6 micrograms by inhalation via pMDI with spacer or via DPI, as required. 📝 For Step 2 therapy with regular daily low-dose ICS with SABA reliever therapy, use a SABA as required, PLUS one of the following: Beclometasone 50 or 100 micrograms by inhalation via pMDI with spacer, twice daily Budesonide 100 or 200 micrograms by inhalation via DPI, twice daily Ciclesonide 80 or 160 micrograms by inhalation via pMDI with spacer, once daily Fluticasone propionate 50 or 100 micrograms by inhalation via pMDI with spacer or via DPI, twice daily.

Answer 92

🌬️ Step 3 therapy is indicated for patients who remain uncontrolled on optimised Step 2 therapy or those with troublesome asthma symptoms on most days. 🌃 It can also be considered as initial therapy for patients with frequent waking due to asthma, especially if they have risk factors for adverse asthma outcomes. 🔵 Step 3 therapy consists of regular daily low-dose inhaled corticosteroid plus long-acting beta2 agonist (ICS+LABA) therapy, along with an as-required reliever. 🔄 Always administer ICS+LABA therapy as a combination inhaler to prevent the patient from taking a LABA without an ICS, which can increase the risk of exacerbations and asthma-related death. 🔴 Patients using ICS+formoterol maintenance therapy with either budesonide+formoterol or beclometasone+formoterol can use the same inhaler for reliever therapy, known as ICS+formoterol 'maintenance and reliever therapy,' associated with a lower risk of exacerbations than ICS+LABA maintenance plus SABA reliever therapy.

Answer 93

🌬️ Step 4 therapy is indicated for patients who remain uncontrolled despite optimised Step 3 therapy and is rarely indicated as initial therapy. 🧪 Consider referral to a respiratory physician if the diagnosis is in doubt. 🔄 Step 4 therapy consists of regular daily medium-dose inhaled corticosteroid plus long-acting beta2 agonist (ICS+LABA) therapy, along with an as-required reliever. This approach is most likely to be beneficial in patients with type 2 airway inflammation, identified by elevated blood eosinophil concentration (more than 300 microlitres) or elevated fractional exhaled nitric oxide (FeNO) (more than 25 parts per billion). 💊 Alternatively, triple therapy can be used, which includes a low-dose ICS+LABA (Step 3) with a long-acting muscarinic antagonist (LAMA), plus an as-required reliever. This is most likely to be beneficial in patients without type 2 airway inflammation.

Answer 94

🌬️ Step 5 therapy is indicated for patients with uncontrolled asthma despite optimised Step 4 therapy. Patients in this category should be referred to a respiratory physician for consideration of alternative treatments. 🩺 Except in young patients, while awaiting respiratory physician review, consider starting Step 5 therapy. 👨‍⚕️ Few patients require long-term treatment with Step 5 therapy. 🔄 Step 5 therapy consists of either increasing to high-dose ICS+LABA, which is most likely to be beneficial in patients with type 2 airway inflammation (identified by elevated blood eosinophil concentration [more than 300 microlitres] or elevated fractional exhaled nitric oxide [FeNO] [more than 25 parts per billion]), or starting a long-acting muscarinic antagonist (LAMA), which is most likely to be beneficial in patients without type 2 airway inflammation.

Answer 95

🩺 Specialist referral is recommended for severe asthma, which is described as asthma that remains uncontrolled despite optimised therapy, including management of comorbidities and other contributing factors. 📈 Additionally, specialist consultation is recommended for asthma associated with anaphylaxis. 🏥 It is also advised following a life-threatening asthma exacerbation requiring hospitalization. 🚑 For patients who have frequent asthma-related emergency department or urgent general practitioner visits. 🌬️ Asthma in patients who appear to have good lung function but experience frequent symptoms or exacerbations. 👨‍⚕️ For patients with poor self-management skills (if referral to a practice nurse or asthma educator has not helped). 🤔 If there is doubt about the diagnosis of asthma. 👷‍♂️ For suspected occupational asthma.

Answer 96

😃 Good control: All of the following features - daytime symptoms on 2 or fewer days per week, need for SABA reliever on 2 or fewer days per week, no limitation of activities, no symptoms during the night or on waking. 😐 Partial control: One or two of the following features - daytime symptoms on more than 2 days per week, need for SABA reliever on more than 2 days per week, any limitation of activities, any symptoms during the night or on waking. 😞 Poor control: Three or more of the following features - daytime symptoms on more than 2 days per week, need for SABA reliever on more than 2 days per week, any limitation of activities, any symptoms during the night or on waking.

Answer 97

A pMDI with a spacer and facemask should be used in children younger than 4 years and children who are unable to form a lip seal around the spacer mouthpiece.

Answer 98

The findings of ABPA include recurrent episodes of asthma-like attacks, migratory pulmonary opacities on chest X-ray, central atelectasis on chest X-ray, peripheral blood eosinophilia, elevated IgE levels, and a positive skin test for Aspergillus fumigatus. Treatment for ABPA involves oral corticosteroids, as inhaled corticosteroids are not effective. Antifungal agents may also be added to the treatment regimen.

Answer 99

Adenocarcinoma

Answer 100

If PaO2 is >60 mmHg (SaO2 >90% by oximetry): PaCO2 is normal (36-44 mmHg) or high (>44 mmHg), and pH is normal (7.36-7.44) or low (<7.36): Reduce oxygen flow to maintain PaO2 closer to 60 mmHg (SaO2 90%-92%) and monitor ABG. ⬇️💨👨‍⚕️ If PaO2 is >60 mmHg (SaO2 >90% by oximetry): PaCO2 is normal (36-44 mmHg): Continue with the same oxygen flow. ➡️💨👨‍⚕️ If there's a large rise in PaCO2 (>50 mmHg) and it's low, or if the pH is low: Consider assisted ventilation and monitor ABG. Reduce oxygen flow to maintain PaO2 at 60 mmHg (SaO2 88%-92%). ⬇️⬇️👨‍⚕️ If PaO2 is <60 mmHg (SaO2 <90% by oximetry): PaCO2 is normal or low, and pH is normal: Increase oxygen flow but monitor ABG. ⬆️💨👨‍⚕️ If there's a large rise in PaCO2 and it's low: Consider assisted ventilation and monitor ABG. ⬇️⬇️👨‍⚕️

Answer 101

Pancoast tumors, also known as superior sulcus tumors, are neoplasms located at the apical pleuropulmonary groove near the subclavian vessels. 🫁🩺 These tumors often cause shoulder or arm pain, which can radiate to various areas, due to invasion of the brachial plexus and surrounding structures. 💔💪 Pancoast's syndrome, characterized by Horner's syndrome (ptosis, miosis, anhidrosis) and hand muscle weakness and atrophy, can occur when the tumor invades the stellate sympathetic ganglion in the neck. 👁️‍🗨️🤝🤚 Other common findings in patients with superior sulcus tumors include ipsilateral flushing, decreased sweating of the face, neurologic complications in the upper extremity, and, in some cases, weight loss and lymph node enlargement. 🌡️🤒🧠 Radiologically, these tumors may appear as a unilateral cervical cap, asymmetry of bilateral cervical caps, an apical mass, and local bone destruction. 📸🦴 Diagnosis involves techniques such as biopsy (often percutaneous needle biopsy or video-assisted thoracoscopy), CT scanning of the chest, and MRI to evaluate involvement of adjacent structures. 🩹🖥️🧲

Answer 102

The definitive diagnosis of Pancoast tumors typically involves biopsy procedures, with percutaneous needle biopsy being a common method. 🩹🌡️ CT scanning of the chest provides valuable information about the tumor's extension and associated findings, such as satellite pulmonary nodules, parenchymal disease, and mediastinal lymphadenopathy. 🖥️🫁 MRI is preferable for evaluating the involvement of structures like the brachial plexus, subclavian vein and artery, and chest wall. 🧲🦴 Radiologic features of Pancoast tumors include the appearance of a cervical cap of more than 5 mm (unilateral or asymmetrical bilateral), an apical mass, and local bone destruction. 📸🦴💥 While diagnostic yields from bronchoscopy and sputum cytology are less favorable due to the tumor's peripheral location, they may still detect unexpected endobronchial tumors. 🩺🧫🩸

Answer 103

Bronchial carcinoma is the leading cause of cancer-related deaths in Australia for both sexes. 🇦🇺☠️ Approximately 90% of bronchial carcinomas are directly related to smoking. 🚬🫁 All four types of lung cancer (squamous, small cell, large cell, and adenocarcinoma) are associated with smoking. 🚬🫁 Adenocarcinoma is the primary type seen in non-smokers, although it can still be related to smoking to some extent. 👤🚬 Smokers face a significantly higher (10 times) risk of developing lung cancer compared to non-smokers. 🔟🫁 While quitting smoking can reduce the risk, it may not lower it to the level of non-smokers. 🚭📉 Unfortunately, there is no effective screening test for early detection of bronchial carcinoma. ❌🔍

Answer 104

Bronchial carcinoma has several types, including squamous cell carcinoma (c), small cell carcinoma (c), large cell carcinoma (p), and adenocarcinoma (p). 🫁🔍 Squamous cell carcinoma can release a PTH-like hormone, leading to the activation of osteoclasts and an increase in blood calcium levels (↑ Ca++). ⬆️🦴 Small cell carcinoma is highly aggressive and responds to chemotherapy but is rarely curative. It is associated with paraneoplastic syndromes like SIADH, Cushing Syndrome, and Lambert-Eaton Syndrome. 🚑💉🧪 Large cell carcinoma is a less common type of bronchial carcinoma characterized by its large, undifferentiated cells. Its features may differ from other types. 🧬 Adenocarcinoma, while common in non-smokers, can still have a relationship with smoking. 👤🚬 Note: Lambert-Eaton Syndrome is a rare autoimmune disorder in which antibodies attack the neuromuscular junction, leading to muscle weakness. It is often associated with small cell carcinoma of the lung

Answer 105

👥 Cough - most common presenting symptom, chronic cough x 3 months (in Elderly) à Ca. until proven otherwise! 🩸 Haemoptysis (any chronic cough) – 🏋️‍♀️ Wt. loss – 😓 dyspnoea 🫁 Recurrent pneumonia (post-obstructive pneumonia), e.g., Pneumonia treated, then 6m. later: cough – fever – ↑WBC, CXR: infiltrate in the same area – usually (middle lobe), where you don’t get aspiration BUT obstructive pneumonia occurs. 🗣️ Hoarseness (mets. outside the lungs), mets. to vocal cords & laryngeal n., any metastatic Lung Ca. outside the lung is NON-RESECTABLE 💧 Effusion: Most cases of Lung Ca. ass. w/ effusion are NON-RESECTABLE! Mets to the PLEURA (mets. outside the lungs) ->1st do Thoracocentesis -> examine the fluid & look for malig. Cells -> both Dx. & staging 🧫 Sputum cytology: If Lung mass + malig. Cells -> diagnostic (no further tests!!) 🫁 Bronchoscopy -> central lesions 🪡 Needle Bx. -> peripheral lesions 🫁 Lung mass + Effusion ->1st STEP? -> Cytology of effusion fluid 🪦 Mediastinoscopy: -> aggressive & last procedure, for difficult cases where you did Bronchoscopy and biopsy and still no diagnosis

Answer 106

📊 Is the Ca. resectable? Look for metastases! 📷 CT 📷 MRI 📷 PET scan 🧐 If YES, is the patient a surgical candidate? Pulmonary function tests -> FEV1 > 50% (many lung Ca. pt. have extensive COPD, makes them non-surgical candidates) 👨‍⚕️ For the sake of management, Lung Ca. is divided into: 🔍 Small cell Ca. -> Chemotherapy 🔍 Non-small cell Ca. -> Surgery (based on staging)

Answer 107

Community-acquired pneumonia (CAP) Common causes: Streptococcal pneumoniae (most common), Heamophilus influenza Often follows a viral respiratory infection 🦠 Presentation: Rapid onset of illness with high fever 🌡️, dry cough 😷, pleuritic pain 💔 1-2 days later, cough may become productive with rusty-colored sputum 🗣️ May lead to rapid shallow breathing 🫁 X-ray: Lobar consolidation 📷 Treatment: Simple penicillin 💉 Atypical pneumonia Common organism: Mycoplasma pneumoniae (common in young adults) 🧪 Presentation: Fever 🌡️, malaise 🤒, headaches 🤕, minimal respiratory symptoms, non-productive cough 😷 No signs and symptoms of lobar consolidation, infection is patchy 🧩 X-ray: Diffuse (patchy) infiltration 📷 Diagnosis: Serology 🧫 Treatment: Roxithromycin or Doxycycline for 10-14 days 💊

Answer 108

PJP (Pneumocystis jiroveci pneumonia) Previously called PCP (Pneumocystis carinii pneumonia) 🦠 Fungal origin but does not respond to antifungals! 🚫🍄 Clinical Presentation: Dry cough 😷 Exertional dyspnea 🏃‍♂️ Fever 🌡️ Bilateral crepitation upon examination 🔍 CXR (Chest X-ray): Normal or bilateral perihilar interstitial shadowing 📷 Diagnosis: Visualizing the yeast-like fungus organism in: Induced sputum Bronchoalveolar lavage Lung biopsy specimen 🔬 Treatment (Rx): TMP-SMX (Trimethoprim-Sulfamethoxazole) or Pentamidine 💊 Steroids can be beneficial if severe hypoxemia 🦠🩺 Prophylaxis: Given if the CD4 count is < 200x10^6/L or after the first attack 🛡️

Answer 109

Cystic Fibrosis (CF) Most common autosomal recessive (AR) pediatric illness 🧬 Prevalence: 1 in 25 people carry the gene in Australia 🇦🇺 A baby is born with CF every four days! 🍼 Most prevalent in northern and central Europeans 🌍 Common Mutation: ΔF508 (Delta F508): Deletion at the 508 position of chromosome 7 Diagnosis: Newborn Screening: Immunoreactive trypsin (detects 75%) Heel prick test 👶 Best Initial Test: Sweat test for elevated chloride (≥60meq/L, on two separate days) 🩸 Most Accurate Test: DNA testing for carriers Genetic identification of homozygous mutation Identifies only the most common mutations (75%) 🧬

Answer 110

P. aeruginosa

Answer 111

Cystic Fibrosis (CF) Presentation (Part 1) Meconium Ileus: Earliest sign Next Step: Decompression (gastrograffin enema) If still positive: Surgery Rule out CF (sweat Cl- test) Metabolic Hypochloremic Alkalosis: Tastes salty when mum kisses the baby 👶 Repeated (Chronic) Respiratory Infections: Including chronic sinusitis Early Organisms: S. aureus Most Common: P. aeruginosa Complications: Bronchiectasis Pneumothorax Cor Pulmonale Death 💀

Answer 112

Nasal Polyps Failure to Thrive: Malabsorption with fat-soluble vitamin loss Fat Malabsorption: Diarrhea Steatorrhea (due to pancreatic insufficiency) Rectal Prolapse Genitourinary System: Late Onset of Puberty (both males and females) 95% of Male Patients: Azoospermic Infertility in males Only About 20% of CF Females: Infertile 90% of completed pregnancies produce viable infants, and women with CF are generally able to breast-feed infants normally Impaired Glucose Tolerance: Due to pancreatic insufficiency May need insulin Osteoporosis Arthritis Exercise Intolerance 🏃‍♀️🏃‍♂️

Answer 113

Cystic Fibrosis (CF) Management Most Effective Initial Therapy: Pancreatic Enzymes Replacement 🫁 Multivitamins (high in ADEK) 💊 Treatment of Infections: Therapeutic and Prophylactic Antibiotics (Abx.) 🦠💉 Chest Physiotherapy and Postural Drainage 🫁🏋️‍♂️ Considerations for Lung and Liver Transplant 🫁🩺

Answer 114

Postural Drainage Postural drainage is a chest physiotherapy technique used in CF. It involves positioning the patient to allow gravity to help drain mucus from the lungs. Different positions are used to target specific lung segments. Benefits of Postural Drainage: Helps clear thick, sticky mucus from the airways. Improves lung function and reduces the risk of infections. Enhances breathing and oxygen exchange. Typically, it's combined with percussion (clapping) on the chest to loosen mucus. This therapy can be performed daily to maintain lung health. 🫁🏋️‍♂️

Answer 115

Interstitial Lung Diseases (ILDs) Clinical Presentation Chronic Exertional Dyspnea 🫁🏃‍♂️ Recent Worsening of Dyspnea 📈 Fine Crackles (Crackle) 🔊 Clubbing of Fingers (Clubbing) 👆 Cor Pulmonale 💔 CXR: Reticular Pattern and Ground-Glass Appearance due to chronic inflammation 📸 - Similar pulmonary function tests: Restrictive Lung Disease Pattern 📉 Decreased DLCO (Diffusion Capacity for Carbon Monoxide) 📉 High Resolution CT Scan 📊 Biopsy for Confirmation and Exclusion of Other Diseases 🧪

Answer 116

Acute Sarcoidosis (3 Findings) Erythema Nodosum (Skin Condition) 🩹 Symmetrical Arthropathy (Joint Inflammation) 👣🦴 CXR: Bilateral Hilar Adenopathy (Chest X-ray) 📸

Answer 117

Chronic Granulomatous (Non-caseating) Inflammation 🧪 Unknown Etiology, No Specific Test, No Specific Treatment ❓💊 Common in Young Patients (Usually Females) 👧 Systemic Disease, Often Involves Lungs 🫁 Common Presentation: Bilateral Hilar Adenopathy (Often Asymptomatic) 🏥 Other Possible Involvements: Skin, Eye, Joints, CNS, Peripheral Nerves, GIT, Kidney 🌐 Labs May Show Hypercalcemia (Due to Hyperactivation of Vitamin D by Macrophages) 📈 Diagnosis: Biopsy of the Involved Organ (Non-Caseating Granuloma) 🧪 Treatment with Steroids If Persistent Lung Disease, Eye/CNS Involvement, or Hypercalcemia 💊

Answer 118

Common Occupational Lung Diseases Asbestosis, Silicosis, Coal Workers' Pneumoconiosis (CWP) 🫁 Key Characteristics Positive history of occupational exposure is crucial 📝 Typically manifest 20-30 years after exposure ⌛ Present with classic Interstitial Lung Disease (ILD) symptoms 🤒 Biopsy is mandatory for diagnosis 🧪

Answer 119

Asbestosis Caused by inhalation of asbestos fibers (dumbbell appearance on biopsy) 🪶 Associations: Shipyard workers, insulation, brake lining industries 🚢🏠🚗 Lower lung involvement with infiltrates and pleural plaques (pathognomonic) 🏥 Risks: Bronchogenic Cancer (especially in smokers, 75 times higher risk), Mesothelioma (pleural cancer, but Lung cancer is the most common) 🚬🦠

Answer 120

Mesothelioma Tumor of mesothelial cells, primarily in the pleura (rarely in peritoneum or other organs) 🫁🩺 Associated with occupational asbestos exposure, although the relationship is complex (90% report exposure, but only 20% have pulmonary asbestosis) ⚙️ Latent period between exposure and tumor development can be up to 45 years ⏳ Symptoms: Chest pain, dyspnea, weight loss, clubbing, recurrent pleural effusions (often hemorrhagic) 🤕💧 CXR/CT shows pleural thickening and effusion 📸 Diagnosis is made through histology (pleural biopsy, thoracoscopy) 🧪🔍 Management is symptomatic, often with industrial compensation 🏭💰 Prognosis is generally very poor 😞

Answer 121

Pleural Effusion Normal pleural space holds 10-20 ml of fluid 🫁 Detectable on CXR if >300 ml of fluid is present 📸 Lateral decubitus view (patient lying on the side) is more sensitive, can detect as little as 50 ml of fluid 🛏️ Clinically evident if >500 ml of fluid (significant effusion - mediastinal shifts may occur) 🩺 Can be sub-pulmonary, mimicking a raised diaphragm ⬆️ Common symptoms include dyspnea with large effusion and chest pain in cases of pleuritis, infection, or trauma 🫁🤕 On chest auscultation, stony dull percussion and decreased or absent breath sounds may be observed 🩺👂 The nature of the fluid (transudate or exudate) is diagnosed by aspirate analysis 🧪

Answer 122

Transudate Characteristics: Lights criteria for diagnosis: LDH < 200, LDH ratio < 0.6, protein ratio < 0.5 📊 Almost always bilateral 🫁 Usually caused by systemic diseases 🌐 Causes: Congestive heart failure (CHF) in 90% of cases ❤️ Liver failure with ascites 🩸 Constrictive pericarditis 🫀 Hypoproteinemia, e.g., Nephrotic syndrome 🩸 Hypothyroidism 🦋 Ovarian tumor (right-sided effusion, Meigs' syndrome) 🫀🪙 Exudate Characteristics: Lights criteria for diagnosis: LDH > 200, LDH ratio > 0.6, protein ratio > 0.5 📊 Almost always unilateral 🫁 Usually caused by non-systemic (lung) diseases 🫁 Needs further investigations: Para-pneumonic effusion: Commonly caused by infection 🦠 Haemorrhagic effusion: Associated with TB, cancer, and pulmonary embolism with infarction 🩸 Lymphatic effusion: Associated with TB and lymphoma 🦠🌰 Malignant effusion: Associated with lung cancer, mesothelioma, and metastatic breast cancer 🦠🩺🫁

Answer 123

Causes: Trauma: Often caused by damage to the chest wall or bronchus rupture 🤕 Rupture of Subpleural Blebs: Small air-filled cysts on the lung surface, especially common in tall, thin, white athletic males and smokers 🚬 Spontaneous Pneumothorax: Occurs without a clear cause, more common in certain demographics like tall, thin individuals and those with connective tissue disorders (e.g., Marfan's syndrome) 👤 Clinical Presentation: Chest Auscultation: Findings include hyper-resonance, decreased breath sounds, and increased percussion 🩺 Spontaneous Resolution: Many episodes resolve on their own without intervention, with a maximum lung collapse of around 20% 🩸 Indications for Drainage: Pleural space drainage is required for: Large pneumothorax (>30% pleural area) with persistent dyspnea 🫁 Secondary pneumothorax (never aspirate an already damaged lung) 🫁 Drainage Procedure: Standard intercostal catheter insertion connected to an underwater seal drainage system 🫁

Answer 124

Mediastinal Shift Factors: Trachea as an Index: The trachea serves as an indicator of upper mediastinal position, helping assess mediastinal shifts 🫁 Pleural Pressure Influence: Mediastinal position is influenced by pleural pressures. It shifts toward the side with relatively higher negative pressure 🌬️ Deviations Toward Diseased Side: Atelectasis: Collapse of a lung or a part of it can cause tracheal deviation toward the affected side 🫁 Agenesis of Lung: When a lung fails to develop, it can result in tracheal deviation 🫁 Pneumonectomy: Surgical removal of a lung can lead to tracheal deviation toward the remaining lung 🫁 Pleural Fibrosis: Scarring and fibrosis of the pleura can influence mediastinal position 🌡️ Deviations Away from Diseased Side: Pneumothorax: Accumulation of air in the pleural space can cause tracheal deviation away from the affected side 🌬️ Pleural Effusion: Buildup of fluid in the pleural space can result in tracheal deviation away from the affected side 🩸 Large Mass: Presence of a significant mass, whether in the mediastinum or elsewhere, can cause tracheal deviation 🫁📈 Other Factors: Conditions such as mediastinal masses, tracheal masses, and kyphoscoliosis can also contribute to tracheal deviations 🫁

Answer 125

Confirmation with Microscopy and Culture: To diagnose onychomycosis accurately, positive microscopy and culture of nail samples are essential 🧪🔬 Sampling Methods: Various sampling methods can be employed, including: Scrapings of the Nail Plate: Collecting scrapings from the affected nail plate for examination 📋 Collection of Subungual Debris: Gathering subungual (under the nail) debris for analysis 🌑 Punch Biopsy: Performing a punch biopsy in cases where a deeper tissue sample is needed 🩹 Consideration of Antifungal Use: False-negative results are more likely if antifungal medications have been used in the preceding month. This should be taken into account during the diagnostic process 💊❌ Repeat Sampling for Confirmation: In cases where onychomycosis is strongly suspected despite an initial negative result, it is recommended to take three samples a few weeks apart to confirm the diagnosis. This approach helps account for potential false negatives and increases diagnostic accuracy 🔄🔍

Answer 126

Treatment of Choice: Oral terbinafine is the preferred treatment for onychomycosis 🦠💊 Dosage and Duration: A standard treatment course involves taking 250 mg of oral terbinafine daily for 12 weeks when treating toenail fungal infections 🕒💊 Review After Treatment: Patients should be assessed after completing a full course of treatment to evaluate the results 🩺🔍 Second Course if Healthy Nail Growth: If there is visible healthy nail emerging at the proximal nail fold after the initial treatment, a second course of terbinafine should be administered 🔄👣 Referral if No New Healthy Nail Growth: In cases where there is no evidence of new healthy nail growth, it is advisable to refer the patient to a dermatologist for further evaluation and consideration of alternative treatments, such as laser therapy 📆🩺💡

Answer 127

Patient Selection: Offer a kidney health check with estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (ACR) to the following individuals: Patients with diabetes mellitus (DM) Patients with hypertension Patients with established cardiovascular disease Individuals with a family history of kidney failure Obese individuals Smokers Aboriginal or Torres Strait Islander individuals aged 30 years or older 📋🩺 Urine ACR: Obtain a urinary ACR from a morning first-void sample, as it provides the best predictive value for future kidney disease risk 🌅🧪 Confirmation of Elevated ACR: If the initial urinary ACR is elevated (≥2.5 mg/mmol in men or ≥3.5 mg/mmol in women), confirm the finding with a first-void urine collection within the next three months to substantiate persistent elevated albumin excretion 🔄🧪🔍 Second Confirmation: A third urine collection is warranted if the first test is abnormal but the second repeat urinalysis result falls within the normal range 🔄🔄🧪🔍 Moderate Albuminuria: If at least two urine tests show elevated urinary albumin excretion (between 2.5–25 mg/mmol in men or 3.5–35 mg/mmol in women), this is classified as moderately increased albuminuria, which replaces the previous term 'microalbuminuria' 🧪📈🩺 If normal results for both exams: repeat annually for DM and HAS, or 1-2 yr for the rest

Answer 128

Scalp, trunk and limbs, flexural and face = methylprednisolone 0,1% fatty ointment once daily for 2-6 weeks Palms and soles and nails = calcipotriol + betamethasone 50 + 500 4-6w or 12w each

Answer 129

Acute Kidney Injury (AKI): According to KDIGO, AKI is defined as: An increase in serum creatinine by ≥26.5 μmol/L within 48 hours; or An increase in serum creatinine by ≥1.5 times the baseline, which is known or presumed to have occurred within the past seven days; or Urine output of <0.5 mL/kg/h for six hours 📈🩺🕒 Chronic Kidney Disease (CKD): KDIGO defines CKD as: Abnormalities of kidney structure or function that persist for more than three months 📉🩺🕒

Answer 130

Dose-Related Risk: The risk of developing ulcers with long-term aspirin use is dose-related. Higher doses are associated with a greater risk of ulcers 🩸💊 Optimal Dose: For vascular prevention, the optimal aspirin dose is closer to 100 mg daily 🩸💊💡 Enteric-Coated Formulation: While some patients prefer enteric-coated aspirin, there is little evidence to suggest that it is less ulcerogenic than uncoated aspirin 📉🩸💊 Proton Pump Inhibitors (PPIs): Studies using esomeprazole at doses of 20 mg/day and 40 mg/day have shown a 70–90% reduction in endoscopic ulcers during six months’ follow-up when taken alongside aspirin 🩸💊🔍 Epidemiologic Studies: Epidemiologic studies have also found a similar reduction in ulcer hemorrhage risk when various PPIs are used alongside aspirin 🩸📊🩺

Answer 131

Features of Nail Psoriasis: Nail psoriasis commonly presents with yellow discoloration (oil spots) and black streaks (splinter hemorrhages) on the nails 🟡⚫ Challenging to Treat: Nail psoriasis is known to be very challenging to treat effectively 🩹🤔 Topical Treatments: Topical treatments like potent steroids and calcipotriol are available for nail psoriasis but may require at least three months of use and often have limited success 🧴⏳❌

Answer 132

Dietary Recommendations: Despite the lack of high-quality evidence, a high-fibre diet is still recommended for the prevention and treatment of diverticular diseases. Improved dietary fibre intake has been associated with a decreased risk of developing symptomatic diverticular disease. A vegetarian diet is also linked to a 31% lower risk of admission to the hospital or death from diverticular disease when compared to a meat-inclusive diet. Consumption of nuts, seeds, or popcorn is considered safe and unrelated to the development of diverticulitis or diverticular bleeding. 🥦🍅🌽 Treatment of Choice: Australia's Therapeutic Guidelines recommend oral amoxycillin + clavulanate (875/125 mg) twice daily for five days for patients with systemic features (e.g., fever, elevated white cell count) or those failing conservative medical measures. American Gastroenterology Association (AGA) guidelines now recommend selective antibiotic use based on patient circumstances. 🩺💊🍏

Answer 133

Poor Prognostic Factors: Several factors are associated with poor prognostic outcomes in vitiligo, including: Mucosal Involvement: The presence of vitiligo on mucous membranes. Family History: A family history of vitiligo, suggesting a genetic predisposition. Koebnerisation: The development of new vitiligo lesions on previously unaffected skin due to trauma or injury. Nonsegmental Vitiligo: The presence of vitiligo that is not limited to a specific segment of the body. Leukotrichia: The development of white or gray hair in areas affected by vitiligo. Favorable Treatment Parameters: Certain parameters are associated with better treatment outcomes in vitiligo, including: Shorter Disease Duration: Treatment tends to be more effective when started early in the course of the disease. Darker Skin Types: Individuals with darker skin types may respond better to treatment. Lesion Location: Vitiligo lesions on the face, neck, and trunk often respond more favorably to treatment compared to those on the distal extremities or involving mucosal surfaces.

Answer 134

Infections: Infections can be associated with various IBD medications, including corticosteroids, azathioprine, mercaptopurine, methotrexate, and biologics. Patients should be monitored for signs of infection during treatment. Hepatotoxicity and Myelosuppression: Azathioprine, mercaptopurine, and methotrexate are medications that may lead to hepatotoxicity (liver damage) and myelosuppression (decreased blood cell production). Frequent blood monitoring is advised to detect and manage these potential side effects. Pancreatitis: Pancreatitis, inflammation of the pancreas, can be associated with the use of 5-aminosalicylic acid (5-ASA), azathioprine, and mercaptopurine. Patients should be monitored for symptoms of pancreatitis when taking these medications. Heart Failure, Lupus-Like Syndrome, and Demyelinating Disorders: Anti-TNF-α therapies, a class of biologic medications used in IBD treatment, may be linked to adverse effects such as heart failure, lupus-like syndrome, and demyelinating disorders. These potential complications should be considered when prescribing and monitoring anti-TNF-α therapies.

Answer 135

Inducing Remission: Corticosteroids: Examples include prednisolone or intravenous hydrocortisone. They are used to induce remission. Enteral Nutrition: An alternative to corticosteroids, especially in children, adolescents, or young adults with small bowel Crohn's disease. Budesonide: Suitable for mild forms of the disease or when prednisolone is contraindicated. Note that it's not subsidised on the Pharmaceutical Benefits Scheme (PBS) and can be costly. 5-Aminosalicylates (5-ASA): Such as mesalazine, are used in mild cases, particularly when the colon is involved. Biologics: Especially anti-tumour necrosis factor (TNF) agents, are considered if patients are unresponsive to steroids.

Answer 136

Azathioprine or Mercaptopurine: Often used as monotherapy. Methotrexate can be an alternative when azathioprine or mercaptopurine is not suitable. Biologics: There are several options in Australia for maintaining remission. They are considered when there's no response to azathioprine, or if patients are intolerant to the medication. PBS coverage requires ongoing disease activity despite three months of azathioprine. Biologics used in combination with azathioprine include: Infliximab or Adalimumab: Both are anti-TNF-α therapies. Vedolizumab: An anti-integrin biologic. Ustekinumab: An anti-interleukin 12 and 23 biologic.

Answer 137

Dominantly inherited condition High cholesterol levels, mostly LDL High risk of coronary heart disease Tendon xanthomas

Answer 138

Hypertension Remember it as cause of HAS in transplanted patients. Also high doses of corticosteroids

Answer 139

Mechanism of Action: PDE-5 inhibitors prevent the breakdown of cyclic guanosine monophosphate in the corpus cavernosum, leading to prolonged vasodilation and penile erection. They also interact with phosphodiesterase-6, which is needed for normal retinal function. Visual Side Effects: Temporary, dose-dependent visual side effects include bluish tinting, blurry vision, and photophobia. These occur in up to 3% of sildenafil users but are less common with other PDE-5 inhibitors. 🧐 Early changes of diabetic retinopathy (microaneurysm and dot-blot hemorrhage) are common with a prolonged history of uncontrolled diabetes mellitus and are associated with blurry vision, floaters, or painless loss of vision. However, diabetic retinopathy does not cause transient bluish tinting or photophobia. Age-related macular degeneration (AMD) results in painless loss of vision, which usually presents initially as tunnel vision. Yellow or white drusen (dry AMD) or retinal hemorrhages and gray discoloration (wet AMD) are typically seen on funduscopy. Unlike angle-closure glaucoma, open-angle glaucoma is generally asymptomatic and cupping is seen in the fundus.

Answer 140

Likely postviral inflammatory process 🦠 Prominent fever & hyperthyroid symptoms 🤒 Painful/tender goiter 🩺 Elevated ESR & CRP 📈 Low radioiodine uptake 📉 Resolves spontaneously within a few weeks 🔄 May be followed by a hypothyroid phase lasting a few months 🔄 Treatment: symptomatic with beta blockers for thyrotoxic symptoms and NSAIDs for pain relief, glucocorticoids for severe thyroid pain 🩹💊

Answer 141

Rare condition causing high-grade fever and pain at the thyroid gland 🤒🦠 Thyroid gland may be palpably enlarged due to abscess formation 🦋 Patients are usually euthyroid as the involvement of the thyroid gland is focal 🩸

Answer 142

Involved Myocardium: Anterior ST-Segment Elevation Leads: V₃, V₄ Occluded Vessel: LAD (Left Anterior Descending Artery) Additional Info: Anterior STEMI corresponds to the anterior part of the heart, mainly the left ventricle. It typically involves ST-segment elevation in leads V₃ and V₄. The most likely occluded vessel is the LAD. 🩸🔍

Answer 143

Involved Myocardium: Lateral ST-Segment Elevation Leads: I, aVL, V₅, V₆ Occluded Vessel: LAD or LCx (Left Circumflex Artery) Additional Info: Lateral STEMI affects the lateral wall of the heart and is associated with ST-segment elevation in leads I, aVL, V₅, and V₆. It can be due to occlusion in either the LAD or LCx. 🩸🔍

Answer 144

Involved Myocardium: Inferior ST-Segment Elevation Leads: II, III, aVF Occluded Vessel: RCA (Right Coronary Artery) or LCx (Left Circumflex Artery) Additional Info: Inferior STEMI impacts the inferior part of the heart, leading to ST-segment elevation in leads II, III, and aVF. The occluded vessel may be the RCA or LCx. 🩸🔍 The right ventricle is involved in approximately half of inferior STEMIs; involvement is confirmed by ST-segment elevations in leads V R through V R placed in a mirror image on the right side of the chest.

Answer 145

Methotrexate primarily exerts its anti-inflammatory effects by inhibiting dihydrofolate reductase, leading to cellular folate depletion. This mechanism results in impaired DNA synthesis, particularly in rapidly dividing cells, which leads to its anti-inflammatory properties. However, this can also cause side effects. Side effects: 🩺 Oral ulcers/stomatitis 👅 Bone marrow suppression 🩸 Hepatotoxicity 🍏🩸 Ranging from mild hepatic transaminase elevations to chronic liver disease and cirrhosis 🏥 Mitigated by concurrent administration of folic (or folinic) acid 💊

Answer 146

Most important preventable cause of adverse pregnancy outcomes: 🚬🤰 Obstetric and fetal complications: 🤰👶 Interventions during pregnancy: Modestly effective: 💪 6 in every 100 smokers can quit: 6️⃣ Recommended first-line treatment: 🥇 Behavioral counseling and support: 📋🤝 Address smoking at every GP visit during pregnancy: 🩺🤰 Nicotine Replacement Therapy (NRT): 🚭💊 Short-acting forms (lozenge, mouth spray): 🍬👄 Intermittent use recommended: ⌛ Patches, if used, should be removed at bedtime: 🛏️ Larger doses or combination therapy may be needed: 💊🔄 Full course of at least 8 weeks recommended: 8️⃣ Risks and benefits of NRT: 📊 No evidence of increased rates of adverse outcomes compared to smoking: 🚭👶 Expert opinion: NRT is less harmful than smoking: 📢 Prescription medicines varenicline and bupropion not recommended during pregnancy and breastfeeding: 🚭🤰🤱

Answer 147

Patient with established ASCVD: 🩸💔 High-intensity statin therapy (rosuvastatin): 💊 Reduces risk of myocardial infarction and ischemic stroke: 📉❤️🧠 Small risk of adverse effects: 💡 Muscle injury: 🦵💊 Myalgia: 💪 Myonecrosis: 🩸💔 Rhabdomyolysis (severe statin-induced myopathy): 🦵💔❌ Discontinue statin use: 🚫💊 Most muscle toxicity is mild: 💪👍 Alternate high-intensity statin or moderate-intensity statin: Atorvastatin 80 mg: 💊 Pravastatin, pitavastatin, fluvastatin: Lower risk of myopathy. Titrate to maximal tolerated dose: 📈 Subclinical hypothyroidism: 🩺🦋 Associated with increased risk of statin myopathy: 🦵💡 Measure serum TSH level before starting statins or when side effects occur: 📏🩺

Answer 148

Patient with epididymo-orchitis: 👨🏥 Most common cause in men below 35 years: 🏥🔍 Chlamydia trachomatis: 🦠 Occasionally Neisseria gonorrhoeae: 🦠 In sexually active men of any age: 👨👀 Chlamydia trachomatis and Neisseria gonorrhoeae: 🦠 Treatment per Australian Therapeutic Guidelines: 🇦🇺💉💊 Ceftriaxone 500mg in 2mL of 1% lignocaine IMI, stat: 💉🦠🚫 PLUS EITHER: Doxycycline 100mg PO, starting the next day, BD for 14 days: 💊💊📆🔟 OR Azithromycin 1g PO, stat and repeated 1 week later: 💊💊🔟🔄 In sexually inactive men: 👨❌🍆 E. coli is the most common cause of acute epididymo-orchitis: 🏥🦠

Answer 149

Median nerve compression in the forearm: 🦠👋🦾 Eg, pronator teres syndrome: 📝🦠🔍 Manifestations of forearm involvement: 📝👋🦾 Forearm pain and sensory loss: 😣👋🚫 Palmar aspects of the first 3 digits affected: 🖐🖐🖐 Additional sensory loss over the lateral palm and thenar eminence: 🖐👉🖐👍 Differentiation from CTS: 👇🔍 Forearm involvement with additional sensory loss over the lateral palm and thenar eminence: 🤔🔍

Answer 150

Risk factors for ASCVD: 🩸🚬🧔👴 Smoking: 🚬 Hyperlipidemia: 📈🩸 Age: 👴 Male sex: 👨 Calculation of 10-year ASCVD risk: 🔢 Pooled Cohort Equations cardiovascular risk calculator: 📊💻 Statin therapy initiation for primary prevention: 🩸🏥 When estimated 10-year ASCVD risk >7.5%-10%: 📈7.5%-10% Preferred statins: 📦 Atorvastatin or rosuvastatin: 🏴🦠🩺 Statin therapy for primary prevention in specific cases: 🩸🔐 LDL ≥190 mg/dL (suggestive of familial hypercholesterolemia): 📈🧬🚧 Age ≥40 with diabetes mellitus: 👴🩸💉

Answer 151

Indications for pre-lumbar puncture head CT: 📷🧠 Patients with suspected bacterial meningitis who have: 🦠🤔 Immunocompromised status: 🦠🩺🔍 Suspected central nervous system disease (e.g., stroke, mass lesion): 🤕📊🔍 New-onset seizure: 🤯📉 Papilledema: 🩺👁️🔍 Altered level of consciousness: 🧠🔄🔍 Focal neurologic deficits: 🧠🔍 Actions in these cases: 💼🏥 Perform a head CT: 🧠📷 Draw blood cultures: 🩸🧫🔍 Immediate empiric antimicrobial therapy: 🩺🦠📋

Answer 152

Common pathogens causing bacterial meningitis: 🦠🔍 Streptococcus pneumoniae Neisseria meningitidis Group B streptococci Haemophilus influenzae Listeria monocytogenes (more common after age 50) Clinical presentation: 🤒🧠🔍 Presentation can include: 🤕📊📉🩺🧠🔍 Seizures Focal neurologic deficits Diagnosis steps: 💼🔍🩸🧫 Blood cultures and lumbar puncture (LP) Administer antimicrobial agents immediately Head CT indications: 📷🧠 Immunocompromised or suspected CNS disease Papilledema, altered consciousness, new-onset seizure

Answer 153

For adults and children (2 months or older), including those with immediate nonsevere or delayed nonsevere penicillin hypersensitivity: Options: 💊 Ceftriaxone 2 g intravenously (child: 50 mg/kg up to 2 g), 12-hourly Or 💉 Cefotaxime 2 g intravenously (child: 50 mg/kg up to 2 g), 6-hourly Plus 💉 dexamethasone 10 mg intravenously (child: 0.15 mg/kg up to 10 mg) every 6 hours for 4 days. Listeria monocytogenes coverage: For patients >50 years, immunocompromised, pregnant, debilitated, or with a history of hazardous alcohol consumption: Add 💉 benzylpenicillin 2.4 g intravenously (child: 60 mg/kg up to 2.4 g), 4-hourly. Alternative to benzylpenicillin for penicillin-hypersensitive patients: Add 💉 trimethoprim+sulfamethoxazole 5+25 mg/kg up to 480+2400 mg intravenously, 8-hourly. Streptococcus pneumoniae or other considerations: Add 💉 vancomycin 25 to 30 mg/kg intravenously, as a loading dose; individualized dosing for patients with obesity (seek expert advice). Administer vancomycin after ceftriaxone or cefotaxime due to the long infusion time required. Immediate or delayed severe penicillin hypersensitivity: Use 💊 moxifloxacin as a replacement for ceftriaxone or cefotaxime. For Listeria coverage, add trimethoprim+sulfamethoxazole (see regimen above). Consider adding 💉 vancomycin if Gram-positive cocci resembling staphylococci are seen on Gram stain. Moxifloxacin dose: 💊 moxifloxacin 400 mg intravenously (child: 10 mg/kg up to 400 mg), daily. Final considerations: Continue empirical antibiotic regimen for a minimum of 10 days if the pathogen is not isolated, depending on response. If CSF examination is consistent with viral meningitis, consider stopping antibiotics. Continue dexamethasone as indicated for specific pathogens or conditions.

Answer 154

Semen Analysis Reason for test: 📊 To assess numbers, morphology, and motility of sperm. Timing of sample collection: 🕐 After 2 to 5 days of abstinence (retest if the first test is abnormal). Indications to test: 🚹 All males. Serum FSH, Prolactin, Testosterone, and LH Reason for test: 🧪 To distinguish hypothalamic or pituitary causes from primary testicular conditions. Timing of sample collection: ⌚ Any time. Indications to test: 🩺 If semen analysis is abnormal. Test for Chlamydia and Gonorrhea Reason for test: 🩺 To investigate symptoms or signs of a sexually transmitted infection.

Answer 155

In young men, a testicular lump is considered suspicious for testicular cancer until proven otherwise. 🚫 Suspected testicular cancer on ultrasound requires serum tumor marker assessment: 🩺 Alpha-fetoprotein (AFP) 📊 Beta subunit of human chorionic gonadotropin (beta-hCG) 📊 Lactate dehydrogenase (LDH) 📊 Tumor marker elevation varies by cancer subtype, with AFP elevated in some and beta-hCG in most. 📈 Consider both AFP and beta-hCG measurements if testicular cancer is suspected. 📉 Pre-surgery evaluations should include imaging (CT scan), chest X-ray, and laboratory tests (chemistry profile, full blood count). 🏥 Rule out testicular malignancies before providing reassurance. 🚫 Carcinoembryonic antigen (CEA) is not a relevant tumor marker. 🚫 Tumor marker and imaging studies precede surgery. If surgery is planned, use a trans-inguinal approach to minimize risks. 🚫

Answer 156

Initial treatment for mild to moderate urge urinary incontinence includes behavioral and physical therapies such as bladder training and pelvic floor muscle exercises (Kegel exercises). 🏋️ Bladder training is the first-line option for urge incontinence and aims to establish a voiding interval gradually. It involves a bladder diary and increasing voiding intervals over time. 📆 Pelvic floor muscle exercises are part of conservative management, often combined with bladder training, but they're more effective for genuine stress incontinence. 💪

Answer 157

Retrograde ejaculation is the most common long-term complication of TURP, occurring in 80-90% of patients. Other complications of TURP include erectile dysfunction (10%), recurrent prostate enlargement (10% within 10 years), urinary tract infection (UTI, up to 5%), bleeding (approximately 2%, may require blood transfusion), urinary retention (approximately 2%, often resolves), urethral stricture (approximately 4%, leading to urinary symptoms), and urinary incontinence (often urge incontinence, improving within weeks but potentially long-term). 🩺

Answer 158

TURP Syndrome is a rare but serious complication of TURP (transurethral resection of the prostate). It results from the absorption of irrigation fluids used during the operation into the prostatic venous sinuses, causing fluid overload and electrolyte imbalances. Signs and symptoms of TURP Syndrome vary in severity and can be influenced by the type of irrigant used. Common manifestations include central nervous system symptoms (restlessness, headache, confusion), visual disturbances, pulmonary issues (pulmonary edema), cardiovascular problems (bradycardia, hypotension, cyanosis), and systemic symptoms such as hypothermia and abdominal pain. In severe cases, it can lead to coma. 🩺

Answer 159

The most likely diagnosis is Goodpasture syndrome, also known as anti-glomerular basement membrane disease (anti-GBM disease). This disease, although it can affect all age groups, is more common in individuals younger than 30 years of age. Goodpasture syndrome's pulmonary manifestations include shortness of breath, cough, and sometimes hemoptysis due to alveolar hemorrhage. While other conditions can cause lung involvement and nephritis, Goodpasture syndrome typically presents with kidney and lung symptoms alone. The diagnostic standard for Goodpasture syndrome involves detecting anti-GBM antibodies in the serum or kidneys. Renal biopsy often reveals crescentic glomerulonephritis and linear IgG deposition in glomerular capillaries, which are pathognomonic findings. If a renal biopsy is not feasible, an anti-GBM antibody assay is the second most accurate test to establish the diagnosis. 💡

Answer 160

AKD can be categorized as pre-renal (hypoperfusion), renal (intrinsic kidney issues), or post-renal (urinary tract obstruction). 🏥💧🫀🚧 Pre-renal causes include hypovolemia, sepsis, heart failure, or liver failure. 💧🦠❤️🫀 Intrinsic causes comprise acute glomerulonephritis, interstitial nephritis, tubular necrosis, vasculitis, and nephrotoxins. 🫀🫁💥🔍 Post-renal AKI results from urinary tract blockages like kidney stones, prostatic hypertrophy, or malignancy. 🚧🪣🫀 Distinguishing the cause involves urinalysis, urinary sodium levels (low suggests pre-renal), renal ultrasonography (for obstruction), and blood tests (if history and examination are suggestive). 🩺🧪🏥🩺

Answer 161

Intrinsic causes of AKD involve direct damage to renal tissue. 🫁 Key intrinsic causes encompass acute glomerulonephritis, acute interstitial nephritis, acute tubular necrosis (resulting from prolonged renal hypoperfusion), vasculitis, and nephrotoxins. 🫀💥🔍

Answer 162

ESWL (Extracorporeal Shock Wave Lithotripsy): Procedure: Utilizes a lithotripter with ultrasonography or X-ray guidance. Delivers shock waves to fracture stones. Allows stones to pass spontaneously with urine. Advantages: Minimally invasive and well-tolerated. Typically doesn't require a stent. Disadvantages: Effectiveness decreases with high BMI. Requires expensive machinery, trained technicians. Limited for certain stone types. Unsuitable in pregnancy and limited availability 🌊🪚🩺🏥

Answer 163

Patients trialing conservative management should strain urine to verify stone passage. They can bring the stone for analysis to confirm it's not a clot. 🚽🧐 Follow-up scans (X-ray KUB or CT KUB) should be scheduled 4 weeks after the initial visit, unless the stone has been collected and verified by a healthcare professional. 📅📊 Referral to a urologist or the Emergency Department is advised for patients with: Stones larger than 7 mm 🏥 Stones not passed after 3 weeks of conservative management 🕒 Ongoing pain despite adequate oral analgesia (severe pain patients should go directly to the Emergency Department) 😫🏥 Hematuria (blood in the urine) after passing stones, preferably for further investigation 🩸🔍 Signs and symptoms of urinary tract infection (UTI) 🤒 Single-kidney patients 🏥 Patients with pre-existing renal problems 🏥 Evidence of complete urinary obstruction, like anuria 🚫🚰 This guidance ensures appropriate management and referral for kidney stone patients. 💡🩺

Answer 164

Laser Lithotripsy: Procedure: A scope is passed perurethrally into the ureter for stone fragmentation using a flexible laser fiber. Stone fragments may be removed with a basket, and a ureteric stent is usually placed for 1-14 days. Advantages: Offers good access to the urinary tract, suitable for stones <20 mm, allows objective clearance, and is widely available. Disadvantages: May require multiple procedures, and the stent can be bothersome for some patients. 🪚🩺🏥

Answer 165

ESWL (Extracorporeal Shock Wave Lithotripsy): Procedure: Utilizes a lithotripter with ultrasonography or X-ray guidance to deliver shock waves to fracture stones, enabling them to pass spontaneously with urine. Advantages: Minimally invasive, usually well-tolerated, and typically doesn't require a stent. Disadvantages: Effectiveness decreases with high BMI, requires expensive machinery and trained technicians, limited clearance of specific stone types, unsuitable in pregnancy, and limited availability. 🌊🪚🩺🏥

Answer 166

PCNL (Percutaneous Nephrolithotomy): Procedure: Involves accessing renal calyces through a 2 cm incision and direct passage of a nephroscope into the kidney. Stone fragmentation is performed using mechanical force or ultrasound/laser. Typically requires a two-day hospital stay. Advantages: Provides excellent access for large stones and high stone clearance rate. Disadvantages: Cannot address ureteric stones, is a higher morbidity procedure, not universally performed by urologists, and necessitates a hospital stay. 🪚🩺💥💉

Answer 167

Post Stone Surgery Symptoms: Common Symptoms: Patients may experience haematuria due to stent irritation, dysuria, urinary frequency, urgency (without UTI), and flank pain during micturition or abdominal straining due to urine reflux up the stent. Management: Reassurance for common symptoms; tamsulosin and anticholinergic medications may help urinary symptoms. Fever or severe flank pain suggests UTI or stent issues. Recurrence: About half of the patients may experience recurrent stones at some point in their lives after the first treatment. 🏥🪚💧🔍

Answer 168

Nodular BCC is the most common subtype of BCC. It is the most common skin cancer. Nodular BCC can be found in both photoexposed and non-photoexposed areas. Characteristic features include a pearly appearance, shiny surface, and telangiectasis. 🩺🌞🔍

Answer 169

Epidermoid cysts have a well-circumscribed lesion arising from within the epidermis. 🩺 They often have a punctum in the center. 🎯 Epidermoid cysts originate from the dermis and are attached to the skin. 🦠 These cysts are related to the pilosebaceous follicle, making them occur in hair-bearing regions like the scalp or scrotum. 🧴 The yellow cheesy material within the cyst is desquamated keratin, not sebum. 🧀 Epidermoid cysts are benign and do not progress to malignancy. 🚫🦠 However, removal is recommended to prevent superinfection and abscess formation. 💉

Answer 170

Molluscum contagiosum presents as pearly dome-shaped papules with central umbilication. 🩺 It is caused by molluscipoxvirus, a member of the poxvirus family. 🦠 The papules are firm, smooth, spherical, and typically pearly white. 🟡 Most papules range from 1 to 3 mm in size, but larger lesions (1-2 cm) can occur due to the coalescing of smaller ones. 📏 Lesions can appear anywhere, with flexures and areas of friction being common sites. 🩹 Anogenital lesions can occur and are not usually associated with sexual abuse in children. 👶🚫 Involvement of the eyelid margins may lead to chronic conjunctivitis. 👁️ Molluscum contagiosum has a benign course, with most lesions resolving spontaneously within 3 to 6 months, though it can take up to 3 years in some cases. ⏳

Answer 171

Barrett's esophagus is metaplasia of squamous epithelium in the distal esophagus to columnar intestinal-type epithelium. 🩺 It is often associated with severe reflux disease, esophagitis, or strictures but can also occur in asymptomatic or minimally symptomatic patients. 💊 This condition is a premalignant one, with a 40- to 125-fold increase in the risk of adenocarcinoma of the lower esophagus. However, the absolute risk is relatively low, at approximately 0.5% per year. 📈 Patients with alarming symptoms like weight loss, anemia, heme-positive stool, dysphagia, or GERD for more than 5 years should undergo endoscopy and biopsy. 📋 The management depends on histological findings and is as follows: For Barrett's esophagus (metaplasia), repeat endoscopy every 2-3 years for lesions ≥ 3 cm and every 3-5 years for lesions < 3 cm. 📆 In cases of low-grade dysplasia, repeat endoscopy is recommended in 6 months. 🔄 High-grade dysplasia warrants distal esophagectomy. 🚑

Answer 172

Smoking and alcohol are the two most common risk factors for squamous cell carcinoma of the esophagus. 🚬🍷 Barrett's esophagus is the most significant risk factor for the development of esophageal adenocarcinoma. 🩺

Answer 173

Primary eosinophilic esophagitis (EoE) is characterized by symptoms related to esophageal dysfunction and eosinophilic inflammation in the esophagus. 🩺 Diagnostic criteria for EoE include symptoms related to esophageal dysfunction, ≥15 eosinophils/hpf on esophageal biopsy, persistence of eosinophilia after a proton pump inhibitor (PPI) trial, and exclusion of secondary causes of esophageal eosinophilia. 🧐

Answer 174

A trial of PPIs is performed because GERD may mimic EoE or coexist with it. EoE is typically diagnosed when symptoms persist after an 8-week course of PPIs. 🤔 This diagnosis is made after confirming eosinophilia and excluding other causes. 😕

Answer 175

The main components of treatment for established EoE include dietary advice and alteration, pharmacotherapy (e.g., topical swallowed steroids like fluticasone, budesonide), and surgical intervention. 🍽️💊🔪 Systemic prednisolone may be indicated for patients unresponsive to other measures. 🩺

Answer 176

Pityriasis rosea (PR) is a common skin disorder, likely caused by a viral infection (possibly herpes virus 6 or 7). 🩺🦠 It predominantly affects healthy individuals, especially children and young adults. 🧑‍🤝‍🧑

Answer 177

PR typically starts with a 'herald patch,' followed by multiple, scaly, salmon-colored macules that are oval, symmetric, and about 1-2 cm in size. 📝🔍 These macules usually appear on the chest, back, abdomen, and nearby areas of the neck and limbs, forming a pattern resembling a Christmas tree. 🎄 PR lesions are usually not found on the face, hands, or feet. The rash may be itchy. 🙆‍♂️🙅

Answer 178

PR generally requires only symptomatic management. Menthol may help alleviate mild itching, while moderately potent corticosteroids are used for more severe itching. ☀️🧴💊 Exposure to sunlight may relieve itching and hasten the resolution of the rash. 🌞 PR typically resolves spontaneously in 6-8 weeks, but some lesions can persist for up to 3-4 months. Post-inflammatory pigment changes may occur, including hypopigmentation and hyperpigmentation. 🕓🎨

Answer 179

The two most common causes of acute pancreatitis are gallstones and alcohol. 🍏🍷

Answer 180

Ultrasound - look for evidence of gallstones

Answer 181

Clinical deterioration Its indicated in suspected or proven acute severe gallstones pancreatitis with: cholangitis jaundice dilated common bile duct

Answer 182

Extensive or invasive investigations for other causes are not recommended for patients 40 years and younger presenting with a first episode of pancreatitis due to its rare recurrence. 🚫 For patients 40 or older, CT can be considered to investigate for pancreatic malignancy if gallstone and alcohol-induced pancreatitis are excluded. Only 1-2% of acute pancreatitis cases are caused by pancreatic cancer. 📊📆

Answer 183

Further investigation is advised regardless of age in patients with more than one episode of acute pancreatitis due to the greater risk of morbidity and possible progression to chronic pancreatitis. 🔍🔬

Answer 184

EUS (Endoscopic Ultrasound) is recommended as the first investigation in patients with pancreatitis of unknown cause and a normal abdominal ultrasound. 🩺🔍 If no cause is demonstrated on EUS, patients may proceed to MRCP (Magnetic Resonance Cholangiopancreatography) or sMRCP. The choice of test will depend on availability and local experience. In high-risk patients, MRCP may be preferred due to its non-invasive nature. 📡🧲 Diagnostic ERCP (Endoscopic Retrograde Cholangiopancreatography) has mostly been replaced by EUS and MRCP, but ERCP should be considered as a therapeutic intervention when required. 🚫🏥

Answer 185

CT is recommended in severe acute pancreatitis to assess the degree of pancreatic necrosis and to evaluate complications such as fluid collections. 📊💧🏥📆

Answer 186

Indications for ERCP include severe pancreatitis of proven or suspected gallstone etiology, the presence of cholangitis, and the presence of jaundice. 🚫🏥

Answer 187

Dumping syndrome is the effect of altered gastric reservoir function, abnormal gastric motor function, and/or pyloric emptying mechanism. Early dumping syndrome occurs 30-60 minutes after a meal. It results from accelerated gastric emptying of hyperosmolar contents into the small bowel. The hyperosmolarity of the bowel content leads to fluid shift from the intravascular compartment into the bowel lumen, resulting in rapid small bowel distention and an increase in the frequency of bowel contractions. With the rapid shift of fluid into the intestinal lumen, circulating volume contraction follows, triggering a vasomotor response that presents with tachycardia, lightheadedness, etc. 🍽️💨🏥🕰️🩺

Answer 188

Late dumping occurs 1-3 hours after a meal. It probably results from the development of hyperinsulinemic (reactive) hypoglycemia. Rapid delivery of a meal to the small intestine results in an initial high concentration of carbohydrates in the proximal small bowel and rapid absorption of glucose, leading to hypoglycemia and a hyperinsulinemic response. The high insulin levels stay for a longer period and are responsible for the subsequent hypoglycemia. 🍽️🕰️🩺📈📉

Answer 189

Dietary modification is the first-line treatment for dumping syndrome. Divide daily energy intake into 6 meals. Restrict fluid intake during and after meals and avoid liquids for at least 30 minutes post-meal. Avoid simple sugars. Milk and milk products are usually not tolerated and should be avoided. Increase protein and fat intake due to restricted carbohydrate consumption. 🥗🍴💧🚫🥛🍖🍔

Answer 190

To manage dumping syndrome, consider dietary fiber supplements, a low-carbohydrate, high-protein diet, and the use of alpha-glucosidase inhibitors. These options are preferable to pancreatectomy for severe cases. Most patients respond well to dietary changes. In postprandial hypotension, lying supine for 30 minutes after meals can delay gastric emptying and minimize the risk of syncope. 🥦🍞🏋️‍♂️🚫💊🛏️

Answer 191

Group A (low risk) patients with specific criteria should undergo surveillance every 5 years or undergo fecal occult blood tests (FOBT) every 1-2 years. 📋 Group B (high risk) patients should have colonoscopy surveillance every 3 years. 📋 Group C (multiple) patients with ≥5 adenomas should have colonoscopy surveillance every 1 year for 5-9 adenomas or sooner if ≥10. 📋 Group D (possible incomplete excision) patients should undergo colonoscopy at 3- to 6-month intervals until no residual adenoma is detected, followed by surveillance at 1-year intervals. 📋

Answer 192

Dermatitis herpetiformis is linked to celiac disease, as both result from intolerance to the gliadin fraction of gluten. Gluten triggers an autoimmune response that targets the intestine and skin, leading to the formation of extremely itchy papules and vesicles. Over 90% of dermatitis herpetiformis patients have gluten-sensitive enteropathy, and 15-25% of celiac disease patients have concurrent dermatitis herpetiformis. 🍞🤝

Answer 193

Suspicious melanoma lesions should undergo an initial excisional biopsy for confirmation, and the primary management for melanoma is excision. Other biopsy methods, like punch biopsy, are not as accurate or recommended. Lesions in sensitive areas like the face and neck may require biopsy by a plastic surgeon. Chemotherapy and radiotherapy are considered for advanced or metastatic melanomas, not at the initial stage. 🩺🔍

Answer 194

Allergic contact dermatitis is a type 4 delayed hypersensitivity reaction that occurs 48-72 hours after allergen exposure. It involves CD4+ T-lymphocytes and cytokine release, causing dermatitis. Common causes include contact with allergens on the skin, like nickel in jewelry, fragrances in perfumes, and substances in hair products. It's prevalent in occupations like metal workers, hairdressers, and healthcare workers. Patients with impaired skin barrier function are more susceptible. Prevention by avoiding the allergen is key. Skin patch tests may identify the culprit. Treatment options include topical and oral steroids, phototherapy, immune suppressants, immune modulators, and skin moisturizers. 🌿🔬👩‍⚕️

Answer 195

Paroxysmal Nocturnal Hemoglobinuria (PNH) is a clonal stem cell disorder characterized by intravascular and extravascular hemolysis and hemoglobinuria. [PNH, Clonal stem cell disorder 🩸, Hemolysis 💥, Hemoglobinuria 🌌] PNH results from an acquired genetic defect leading to the lack of the glycosylphosphatidylinositol anchor, affecting proteins like CD55 and CD59. Their absence allows the formation of the complement membrane attack complex, causing hemolysis. [Genetic defect 🧬, Glycosylphosphatidylinositol anchor, CD55 and CD59 deficiency, Complement membrane attack complex] Manifestations typically occur in the third decade of life and can include hemolysis with hemoglobinuria, cytopenias leading to anemia, and a hypercoagulable state. [Third decade of life, Hemolysis, Cytopenias, Hypercoagulable state 🩺] Hepatic vein thrombosis, anemia, low haptoglobin, elevated bilirubin, and lactate dehydrogenase (LDH) are indicative of intravascular hemolysis. Flow cytometry tests help confirm the diagnosis by assessing the absence of CD55 and CD59 proteins on the surface of red blood cells. [Hepatic vein thrombosis, Anemia, Low haptoglobin, Elevated bilirubin, LDH, Flow cytometry test 🔍]

Answer 196

Polycythemia Vera (PV) is a clonal myeloproliferative disorder characterized by erythrocytosis. Most cases are associated with a JAK2 mutation. [Polycythemia Vera (PV) 🩸, Clonal myeloproliferative disorder, Erythrocytosis, JAK2 mutation 🧬] Patients with PV may be asymptomatic at diagnosis but can present with symptoms related to increased blood viscosity, such as transient visual disturbances, hypertension, thrombosis, and increased red blood cell turnover leading to conditions like gouty arthritis. [Symptoms, Increased blood viscosity, Visual disturbances 👁️, Hypertension, Thrombosis, Gouty arthritis 💎] Common symptoms in PV include itching after warm showers (aquagenic pruritus), facial plethora (ruddy cyanosis), and splenomegaly. [Itching, Aquagenic pruritus 🚿, Facial plethora, Ruddy cyanosis, Splenomegaly 🫁] PV differs from other causes of erythrocytosis like chronic hypoxia and EPO-producing tumors as patients usually have normal oxygen saturations and low EPO levels. The complete blood count often shows an increase in all 3 cell lines. [Comparison with other causes of erythrocytosis, Oxygen saturations, Low EPO levels, Complete blood count 🩹] Serial phlebotomy is the primary treatment for PV as it creates relative iron deficiency and reduces hematocrit levels to the normal range. Bone marrow suppressive drugs like hydroxyurea may be added in high-risk patients. [Treatment, Serial phlebotomy, Hematocrit levels, Bone marrow suppressive drugs 🩸]

Answer 197

Normal CSF values include a WBC count of 0-5/mm³, glucose levels of 40-70 mg/dL, and protein levels below 40 mg/dL. 🩸🧪 In bacterial meningitis, CSF typically exhibits a WBC count greater than 1,000/mm³, glucose levels below 40 mg/dL, and protein levels exceeding 250 mg/dL. 🩸🦠🧬 Tuberculous meningitis presents with a WBC count between 100-500/mm³, glucose levels below 45 mg/dL, and protein levels ranging from 100-500 mg/dL. 🩸🦠 Viral meningitis results in a WBC count between 10-500/mm³, glucose levels of 40-70 mg/dL, and protein levels below 150 mg/dL. 🩸🦠 Guillain-Barré syndrome shows normal CSF values, with a WBC count of 0-5/mm³, glucose levels of 40-70 mg/dL, and protein levels ranging from 45-1,000 mg/dL. 🩸🦠🦠

Answer 198

Fasciculation of the deltoid and small muscles of the hand, along with foot drop, suggests a lower motor neuron (LMN) problem. 🦠🧪 Increased muscle tone (spasticity) and an extensor plantar reflex point toward an upper motor neuron (UMN) lesion. 🧠👣 The combination of LMN and UMN findings in the same area of the body, along with intact sensation, is highly suggestive of ALS, the most common motor neuron disorder. 🦠🧠

Answer 199

The diagnosis of ALS is primarily clinical and relies on the patient's appearance and neurologic examination findings. 🩺🧠 Early in the course of the disease, diagnosis can be challenging, as there are no pathognomonic tests for ALS, and symptoms are initially nonspecific. 📊💡 Diagnosis often requires the exclusion of other possible causes, and it may take several months (average 14 months) before a definite diagnosis is made. 📈

Answer 200

ALS is universally fatal, so management primarily focuses on slowing progression and controlling symptoms. 🚫🏥 Riluzole, a glutamate inhibitor, is a first-line therapy that may improve survival by reducing glutamate-mediated excitotoxicity. 🧪🧠 Edaravone, an antioxidant, is often used in combination with riluzole to slow disease progression, especially in patients early in the disease course. 🧪🌿 Management also includes aggressive respiratory support (e.g., noninvasive positive-pressure ventilation), nutritional support, and multidisciplinary symptomatic management. 🌬️🍎💊 Palliative care strategies are introduced early in the management of ALS. 📦🏥

Answer 201

Interferon beta is used as a treatment for multiple sclerosis, a condition characterized by various neurologic deficits that result from lesions in the central nervous system (CNS). 🩺💊🧠 These neurologic deficits can include symptoms like asymmetric extremity weakness, which may be intermittent or progressive. 🦵🔍 In multiple sclerosis, atrophy and fasciculations (lower motor neuron signs) are typically absent. 📉🚫💥

Answer 202

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzyme deficiency worldwide, affecting approximately 400 million individuals, particularly those of African, Asian, and Mediterranean descent. It is inherited as an X-linked recessive disorder and has over 300 variants. 🌍🧬 G6PD deficiency can manifest as neonatal hyperbilirubinemia and cause episodic hemolysis in response to oxidative stresses or, less commonly, chronic hemolysis. Many affected individuals remain asymptomatic. Interestingly, G6PD deficiency offers partial protection against malaria. 👶💔🩺 The diagnosis of G6PD deficiency is based on a well-documented history, signs of hemolysis, and specific findings on a peripheral blood smear, which may include Heinz bodies (denatured hemoglobin in red blood cells) and 'bite cells.' The gold-standard diagnostic test is measuring G6PD activity during remission. 📝🔬 Suspect G6PD deficiency in patients with non-immune acute hemolysis and no spherocytosis on laboratory testing. 🤔🩸🚫

Answer 203

Lewy body dementia is characterized by dementia with fluctuations in cognitive function, episodes of prolonged staring and disorganized speech, detailed visual hallucinations, early extrapyramidal features, anterograde memory loss, and visuospatial impairment. 🧠👁️‍🗨️🚶‍♂️💭

Answer 204

Thromboangiitis obliterans, or Buerger Disease, is a nonatherosclerotic, segmental, inflammatory disease primarily affecting small to medium-sized arteries and veins in the extremities, leading to occlusive thrombus and distal limb ischemia. It predominantly occurs in men in their 40s, is strongly linked to smoking, and often progresses, with amputation sometimes necessary to manage pain or secondary infection. 🦵💨🚬🩺

Answer 205

Evaluate volume status first. In hypervolemic patients, initiate volume reduction with a loop diuretic (e.g., furosemide, bumetanide, or torsemide). 🩸💊 Start the patient on an ACE inhibitor (e.g., captopril, enalapril) or use angiotensin receptor blockers (ARBs) like losartan, erbisartan, or valsartan for those intolerant to ACE inhibitors. 🤝💊🚫 Once the patient is euvolemic, add a cardioselective beta blocker to the regimen. 🩸🚫 For euvolemic patients, the preferred management includes an ACE inhibitor (or ARB) along with a beta blocker. 🤝🚫 Note: Beta blockers should be initiated if there are no respiratory crackles and minimal peripheral edema. Use an ACE inhibitor or ARB in conjunction with a diuretic for mortality benefit. 🤝💊 Spironolactone (aldosterone antagonist) is indicated for euvolemic patients with GFR>30ml/min and serum potassium <5mmol/L with close potassium level monitoring. It provides additional mortality benefit in patients with congestive heart failure (CHF). Since this patient is hypervolemic, spironolactone cannot be started now. 🩸💊🚫 Digoxin is recommended for patients with EF<35% but should be added only after achieving the maximally tolerated dose of a beta blocker. 🩸🚫

Answer 206

An audiogram is indicated for patients presenting with suspected hearing loss, tinnitus, vertigo, and other ear symptoms. 🦻📊 It's especially valuable when a clear diagnosis of benign self-limiting conditions like vestibular neuronitis, acute labyrinthitis, or benign paroxysmal positional vertigo (BPPV) can't be made based on history and physical examination alone. 🤔📊 Audiometry is also useful for screening hearing loss in individuals regularly exposed to loud noises and for patients taking ototoxic medications, such as gentamicin. 📊🔊 Pure tone audiometry is the standard test for assessing hearing loss in adult patients. It determines independent thresholds in each ear for air conduction (conductive hearing) and bone conduction (sensorineural hearing). 🦻📊🔊

Answer 207

ESCC should be suspected in any patient with a history of malignancy who presents with back pain and neurological abnormalities. Lower extremity motor weakness, hyperreflexia, and bladder dysfunction are common clinical manifestations of ESCC. 🚀 Bowel and bladder dysfunction are late neurologic findings, indicating advanced disease. 📊 Immediate administration of intravenous glucocorticoids is crucial to reduce inflammation and edema around the spinal cord. 💉 A follow-up diagnostic step is performing an MRI (Magnetic Resonance Imaging) to confirm the presence and extent of the spinal cord compression. 🏥

Answer 208

Administer high-dose intravenous glucocorticoids (such as dexamethasone) to reduce inflammation and edema. 🚀 Surgical decompression may be necessary if there is significant cord compression or structural instability. 🔪 Radiation therapy can help shrink tumors causing ESCC and provide pain relief. 📆 Collaboration between oncologists, neurosurgeons, and radiation oncologists is crucial in the management of ESCC. 🔬

Answer 209

Temporal lobe epilepsy is categorized under complex partial seizures, meaning the seizure has a particular focus in the brain (partial), and awareness is impaired during an attack (complex). 🧠 Characteristics of temporal lobe epilepsy include automatism behaviors like fidgeting, chewing, lip smacking, fumbling, or complex acts such as speeding, kissing, violence, or other bizarre behaviors. 🚗💏💢 The duration of an attack is often 1-3 minutes. ⏱️ After the seizure, there is a post-ictal state of 1 to 2 minutes associated with confusion. 🤷‍♂️

Answer 210

Carbamazepine is generally considered the drug of choice for focal (partial) epilepsies. 📊 Medications, such as carbamazepine, are often used as the first-line treatment to control seizures in patients with temporal lobe epilepsy. 💊 In some cases, surgical interventions may be considered, particularly if medications are ineffective. 🔪 Ongoing medical and neurological monitoring is essential to assess treatment effectiveness and make adjustments as needed. 🏥

Answer 211

> 80% Stenosis if Asymptomatic > 70% if Symptomatic

Answer 212

SIADH is a condition where inappropriately high levels of antidiuretic hormone (ADH) are secreted, preventing the kidneys from excreting dilute urine. This leads to hypotonic hyponatremia, with serum osmolality typically below 275 mOsm/kg H2O. 📈 In SIADH, urine osmolality is usually elevated (>100 mOsm/kg H2O), contributing to hypotonicity and hyponatremia. 💧 Patients with SIADH are typically euvolemic, distinguishing them from those with hypovolemia, and urine sodium concentration is typically elevated (>40 mEq/L). 🩸 Serum uric acid levels are characteristically low, serum potassium levels are normal, and acid-base status is normal in SIADH. ⚖️🧪 Common risk factors for SIADH include the use of selective serotonin reuptake inhibitors (SSRIs), which are commonly associated with the condition. Elderly patients are especially at risk. Nausea can further exacerbate SIADH. 🌡️👴🍔

Answer 213

Key diagnostic markers for SIADH include hypotonic hyponatremia (serum osmolality <275 mOsm/kg H2O) and an inappropriately high level of antidiuretic hormone (ADH) secretion. 🧫 Urine osmolality is typically elevated (>100 mOsm/kg H2O), contributing to the condition's hallmark hypotonicity. 🚰 In SIADH, serum sodium concentration is reduced, and serum uric acid levels are characteristically low. Serum potassium levels and acid-base status are typically normal. ⚖️🩸

Answer 214

IF Laboratory results show low testosterone levels, and gonadotropin (LH, FSH) levels are high, it suggests primary (testicular disease) hypogonadism. 🩸 Some causes are: Congenital - Klinefelter syndrome and Varicocele. Acquired - Radiation, Infection (eg, mumps), Trauma, Medications (eg, alkylating agents, glucocorticoids), Chronic disease. Evaluation includes Karyotype and Others based on clinical suspicion IF Laboratory results show low testosterone levels, and gonadotropin (LH, FSH) levels are inappropriately low or normal, it suggests secondary (central) hypogonadism. 🩸 In secondary hypogonadism, low testosterone levels should typically result in increased LH and FSH due to loss of feedback inhibition. Low or normal LH and FSH levels indicate an inappropriate hypothalamic-pituitary response. 🧠 Secondary hypogonadism can result from various factors, including mass lesions in the hypothalamus or pituitary, such as prolactinomas, and severe systemic illness causing gonadotroph cell damage. 🧪 It can also be associated with hyperprolactinemia and long-term use of glucocorticoids or opiates, which suppress gonadotropin-releasing hormone (GnRH). 🩸 Secondary hypogonadism is more common in individuals with obesity or type 2 diabetes mellitus. 🍔🩺

Answer 215

Diagnosis of secondary hypogonadism involves low testosterone levels and inappropriately low/normal gonadotropin (LH, FSH) levels, indicating central hypogonadism. 🧪 Measurement of serum prolactin is recommended in patients with secondary hypogonadism, as well as screening for other pituitary hormone deficiencies, such as thyroid-stimulating hormone (TSH). 🩺 In men with prolactinoma, gynecomastia (only present in ~1/3 of patients) is generally mild, and galactorrhea is uncommon because enough estrogen (primarily derived from androgens) is needed for this process to occur (galactorrhea is more common in women with prolactinoma); Pituitary imaging with MRI is indicated for patients with elevated prolactin levels, mass-effect symptoms (e.g., visual field defects), very low (<150 ng/dL) testosterone levels, or disruptions in other pituitary hormones. 📷

Answer 216

TACO has high VJP and BNP

Answer 217

Whipple disease is a rare multi-systemic illness caused by the bacillus Tropheryma whippelii. It is most commonly observed in white men in the fourth-to-sixth decades of life and often presents with weight loss. 👨‍⚕️🦠

Answer 218

Gastrointestinal symptoms include abdominal pain, diarrhea, and malabsorption leading to distension, flatulence, and steatorrhea. Extraintestinal manifestations encompass migratory polyarthropathy, chronic cough, and myocardial or valvular involvement resulting in congestive failure or valvular regurgitation. 👁️🌡️ Later stages of the disease may exhibit dementia, central nervous system findings like supranuclear ophthalmoplegia and myoclonus, and may occasionally manifest intermittent low-grade fever, pigmentation, and lymphadenopathy. A classical biopsy finding for Whipple disease is PAS-positive material in the lamina propria of the small intestine. 🧠🔬

Answer 219

Prolonged house fire exposure can result in cyanide poisoning, as cyanide is released during the combustion of common household items containing carbon and nitrogen. Cyanide inhibits oxidative phosphorylation, leading to lactic acidosis (e.g., pH 7.15, lactic acid 25) and a switch to anaerobic metabolism. Venous blood remains saturated with oxygen, giving the skin a reddish color. Early acute toxicity causes cardiorespiratory stimulation (e.g., tachypnea, tachycardia), but cardiovascular collapse rapidly occurs without treatment. 🔥🩸

Answer 220

Cyanide poisoning must be treated empirically because serum cyanide levels cannot be measured quickly. Hydroxocobalamin is the preferred treatment, as it binds to intracellular cyanide and forms cyanocobalamin, which can be renally excreted. Sodium thiosulfate, which detoxifies cyanide to thiocyanate, is sometimes administered with hydroxocobalamin. Treatment with 100% oxygen is also continued to maximize oxygen delivery to tissues and address concurrent carbon monoxide poisoning. 🏥🧪

Answer 221

In patients with long-segment (≥3 cm) CLE without intestinal metaplasia or dysplasia, endoscopic surveillance should follow the protocol for long-segment Barrett's esophagus (BE), occurring every 2–3 years. For individuals with 1 to <3 cm of CLE without intestinal metaplasia or dysplasia, a repeat endoscopy in 3–5 years is suggested, with consideration for discharge from surveillance if the repeat endoscopy with Seattle protocol biopsies again shows no intestinal metaplasia or dysplasia. Patients with CLE less than 1 cm without intestinal metaplasia or dysplasia on biopsies should not undergo endoscopic surveillance. 📅🔍

Answer 222

Endoscopic resection (ER) should be considered for patients with intramucosal adenocarcinoma or HGD and visible/nodular lesions. Radiofrequency ablation (RFA) should be considered for patients with HGD within flat segments of BE. RFA is not appropriate in patients with visible abnormalities, as these should be treated by ER. RFA may be the preferred treatment strategy over ER for patients with long-segment BE or circumferential Barrett's due to a lower rate of stricture formation. 🏥🔥

Answer 223

The endoscopic surveillance protocol used by one of the largest prospective studies on surveillance in HGD called for three-monthly endoscopies in the first year. If no HGD was found on two consecutive endoscopies in the first year, the frequency of endoscopy was decreased to six-monthly for the second year. After the second year, repeat at yearly intervals was implemented if no HGD was found. Persistent HGD was managed on an individual basis, with ongoing three-monthly endoscopies, or lesser frequency as per patient wishes or comorbidities. 📆📢

Answer 224

G6PD deficiency is an X-linked enzymatic defect that can cause hemolysis after oxidative stresses such as acute illness or ingestion of specific drugs 🧬🩺 The most commonly implicated drugs in triggering hemolysis in G6PD-deficient individuals are sulfa drugs (e.g., cotrimoxazole), primiquine, dapsone, quinidine, and nitrofurantoin 💊 Also happens with fava beans Infections are the most common type of oxidant stress that can trigger hemolysis, even more so than drugs 🦠

Answer 225

The usual presentation of G6PD deficiency is similar to all hemolytic anemias, characterized by low hemoglobin, high LDH, decreased haptoglobin, elevated bilirubin (mostly indirect), and increased reticulocyte count, all in the presence of a normal MCV 🩸📊 An elevated reticulocyte count is a criterion for hemolysis but is not specific for it 🔄