Medicine Flashcards
Thyroid nodules
Work up
Hot vs Cold
Evaluate labs
1st step: TSH & US
- If RF or sus US (microcalcification, increase vascularity, hypoechoic, indistinct nodule margins) –> FNA
- If no RF & normal US –>
——-Normal or High TSH: FNA
——-Low TSH: Iodine 123 scintigraphy
Hot/Hyperfunctioning: treat
Cold/Hypofunctioning: FNA
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Evaluating labs values
1: measure TSH, Free T3 and T4
If primary labs (low tsh, high t3/t4)—> does the patient have signs of Graves?
Yes? Graves
No? Radioactive iodine uptake
—— High: graves, toxic adenoma, multinodular goiter
—— Low: Thyroiditis, Iodine exposure, exogenous
Thyroglobulin levels will be low with exogenous use
Thyroglobulin levels will be high if gland has lots of activity
If secondary labs (high tsh and t3/t4) –> MRI of pituitary gland
Goiter can be caused by iodine deficiency which are mostly multinodular, and should be surgically removed
Thyroid cancer
Dx, Tx, Pemberton test
1st step: US neck and LN
If <1cm: lobectomy
If >1cm: Thyroidectomy +/- radiation
Pemberton test: raise arm over head for 60 sec –> facial plethora or engorgement of neck veins is suggestive of thyroid source
Thyroglossal duct cyst
Sx, Dx Tx, Comp if not Tx
- Tenderness and pain is often preceded by URI
- Associated with ectopic thyroid tissue (may be the only site for functioning tissue).
Dx: US or CT
Tx: resection of cyst, associated tract and central portion of hyoid bone.
Comp if not resected:
- Recurrent infection.
- Cyst are benign and do not under malignancy transformation. Rarely, patients may develop thyroid cancer from ectopic thyroid tissue WITHIN the cyst, but not from malignant degeneration of the cyst itself.
Gout
What does it look like, Tx
Pseudogout
What does it look lik
Gout
Needle-shaped, Negative birefringent
Tx: 1st line - NSAIDs (indomethacin), colchicine
2nd line: Steroids
Allopurinol: decrease uric acid production –> prevent flares
Pseudogout aka calcium pyrophosphate deposition disease
Rhomboid-shaped, weakly ⊕ birefringent under polarized light (blue when parallel to light)
Acute tx: NSAIDs, colchicine, glucocorticoids.
Prophylaxis: colchicine
Conn Syndrome
2 causes, Sx, Dx, Tx
High Aldosterone d/t
1. B/L adrenal hyperplasia (idiopathic)
2. Unilateral adenoma (most common- Conn syndrome)
Sx:
- Difficult to control hypertension
Dx:
- Elevated plasma aldosterone & low plasma renin
- Hypokalemia, low H+ –> metabolic alkalosis
- Increased na reabsorption –> HTN –> increased renal blood flow & GFR –> increase na excretion therefore, NA IS UNCHANGED
- Absence of aldosterone suppression with oral saline load
- CT scan of adrenal glands
Tx:
- Bilateral adrenal hyperplasia: mineral corticoid receptor antagonist (spironolactone)
- Unilateral adenoma: surgical resection
Cushing syndrome
3 causes, Sx, Dx
High cortisol d/t
1. exogenous –> low ACTH
2. Adrenal adenoma, hyperplasia/carcinoma –> low ACTH
3. ACTH secreting pit adenoma aka Cushing Disease –> high ACTH
Sx: HTN, hyperglycemia, mood swings, osteopenia/osteoporsis, aldosterone-like effect (low K and metabolic alkalosis)
Dx: 24hr urinary free cortisol level or 1mg overnight dexamethasone test – should suppress ACTH –> suppress cortisol
Adrenal insufficiency
Primary, secondary, tertiary causes, Sx, Tx
Inability of adrenal glands to generate enough glucocorticoids +/− mineralocorticoids for the body’s needs.
Primary: Deficiency of aldosterone and cortisol production due to loss of gland function. Acute or Chronic aka Addison.
Skin and mucosal hyperpigmentation
Secondary: Seen with decreased pituitary ACTH production. no skin discoloration and no hyperkalemia (RAAS intact)
Tertiary: Seen in patients with chronic exogenous steroid use, precipitated by abrupt withdrawal.
Sx: Weakness, fatigue, orthostatic hypotension, muscle aches, weight loss, GI disturbances, sugar and/ or salt cravings.
Tx: glucocorticoid/ mineralocorticoid replacement.
Adrenal mass management
Common but require workup for hormones hypersecretion or malignant
1. serum electrolytes
2. Dexamethasone suppression testing
3. 24hr urine catecholamines, metanephrine, vanillylmandelic acid
4. 17-ketosteroid
Surgical excision is recommended for all functional tumors, all malignancy tumors and all tumors >4cm
A fib
EKG finding, RF, Tx, Comp,
Postop Afib
Irregular, irregular with No p wave
RF: AGE (strongest) and comorbidities that cause atrial dilation (HTN, HF, mitral valve disease) , Can also be postoperatively.
Tx:
- Stable: Rate control with beta-blockers or non-dihydropyridine Ca channel blockers (diltiazem, verapamil)
- Unstable: Cardioversion
Comp: stroke
Most patients with no history of atrial fibrillation who develop POAF following cardiac surgery will spontaneously convert to sinus rhythm within a few days. However, such conversion to sinus rhythm does not signify resolution of atrial fibrillation and freedom from its associated complications. The development of POAF likely indicates substantial underlying substrate, and many patients will have re-occurrence of fibrillation, both during hospitalization and following discharge, placing them at risk for complications, including embolic, stroke and heart failure. This is also associated with increased long-term mortality.
Supraventricular tachycardia
Path, Sx, EKG, Tx
WPW (comp and tx)
- Secondary conduction pathway that allows abnormal cycling of cardiac conduction and formation of re-entrant circuit.
- Abrupt on set on palpitations
- EKG: narrow complex tachycardia with regular R-R intervals. P waves are usually inverted and often buried within QRS complexes
- Tx:
—Stable: vagal maneuvers, adenosine
—Unstable: urgent synchronized cardio version.
Association: WPW pattern + symptomatic tachyarrhythmia –> WPW syndrome
- Can also develop Afib –> syncope which is especially dangerous
Tx: Catheter ablation if syndrome occurs
Acute HF (Cause, Dx, Tx)
Chronic HF (Cause, Dx,Tx)
HF w/preserved EF (Def, RF, Tx)
Decompensated HF (factors to determine dx)
Acute HF
Most common cause: MI
Dx: TTE
Tx:
- O2
- IV diuretics (furosemide) or IV vasodilators (Nitroglycerin) to decrease preload –> decrease PCWP & reduced pulmonary edema
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Chronic HF
Causes:
- Most common: CAD –> ischemia
Dx:
- Echo
- Stress testing to r/o CAD
Tx:
Initial optimized therapy
1a. ACE’s & ARB’s: slows disease progression & improved mortality
1b. Beta blocker (Metoprolol, succinate, carvedilol, or bisoprolol): reduced hospitalization & improved mortality
1c. Diuretics +/- metolazone: improve sx & reduce hospitalization
2nd step of optimized therapy
2. Aldosterone antagonist (Spironolactone, Eplerenone, Amiloride, Triamterene): reduced hospitalization & improve mortality
3rd step in optimized therapy
3. SGLT-2 inhibitor: Reduce sx & improve mortality
Supplementary agents
4a. Isosorbide denigrate + hydralazine: Improve symptoms & may improve mortality
4b. Digoxin: reduced hospitalization but NO mortality benefit
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HF w/reserved EF
- Cause: LV dysfunction d/t impaired relaxation
- RF: chronic HTN, obesity, CAD
- Tx: spironolactone, SGLT2 inhibitors, Loop diurectics, Anti-HTN
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Decompensated HF
- Most important in the following order: S3 (MOST IMPORTANT) > orthopnea > crackles > JVD > LE edema > dyspnea
- Patient with slowly progressive decompensation may have minimal or no pulmonary edema because of increased lymphatic drainage.
Dystonia
What is it, Tx
Focal dystonia affects single muscle or a group of related muscles. Usually last specific
Can be triggered by increased sensory input (light, touch)
Can be temporarily relieved by sensory output as well
Oromandibular dystonia is an example
Focal: botulinum toxin (1st line)
Generalized: Carbamazepine
Back Pain
3 important things to look for + Dx
Uncomplicated vs Spondylolysis: Dx + Tx Rupture of anulus fibrosus presentation
Poor prognostic factors
Must always rule out serious disease with careful history.
1. Neurologic deficits (urinary/fecal issues, LE weakness)
2. Malignancy(cancer hx, wt loss, RF)
3. Infection (fever, midpoint spinal tenderness, immunosuppression) Ex Abscesss
Dx for above presentation: MRI
- Uncomplicated/Nonspecific:
Dx: Pain w/straight leg test suggest lumbosacral radiculopathy - Spondylolysis: overuse injury –> unilateral or bilateral fracture of pars interarticularis
Dx: pain worse with extension, tenderness with deep palpation, radiculopathy as slippage progesses - Rupture of anulus fibrosus leading to disc herniation: worse with flexion, positive straight leg test
Tx:
- Uncomplicated back pain: NSAIDs, heat therapy, massage, exercise .
Spondylolysis: rest for 90 days, allowing fracture to heal
Poor prognostic factors
- Advanced age
- Poor baseline functional status
- Severe self-rated pain & mood symptoms
Psychosocial factors:
- Psychiatric comorbidities (depression, anxiety)
- Maladaptive pain behavior (catastrophizing, avoidance behavior)
- Poor recovery expectations
Others:
- No interest in mobility/exercise (prolonged bedrest)
- Required opioid therapy to manage
Colon cancer
Screening times, RF
RF: Family hx. polyposis syndrome. IBD, African American race, alcohol intake, cigarette smoking, obesity
Screening
- Begins at 45y/o, then every 10 years
- Can do sigmoidoscopy every 5 years
If 1st degree relative has colorectal cancer or high risk adenomatous polyp
- Begins at 40y/o or 10 years prior to age of dx, repeat every 5 years
If you have UC: begin 8-10 years after dx, then every 1-3 years
Tx:
- Colonoscopy is most sensitive
- Flexible sigmoidoscopy is an acceptable alternative if average risk
Post ICU syndrome
Psych: >50% depression, PTSD, sleep disturbances
Neurocognitive: decrease attention/memory, executive function & processing speed
Physical: >50% have decreased mobility & independence
Most impairments last for several years, require chronic health services and are unable to return to work
Mesenteric ischemia
4 common main causes, Sx, Comp, Labs, Dx, Tx
Colonic ischemia
Occurs d/t decrease blood flow by
1. SMA occlusion d/t embolic disease
2. arterial and venous thrombosis d/t atherosclerotic disease and watershed infarctions
3. Hypercoagulable state
4. Hypovolemia
Sx. severe rapid abdominal pain but minimal tenderness (no guarding or rebound tenderness), N/V.
Comp: Can lead to abdominal distension, absent bowel sounds, peritoneal signs, bloody stool
Labs: anion gap metabolic acidosis d/t elevated lactate, and elevated amylase
Dx: CT angiography
Tx: IVF, Abx, NGT for decompression
Colonic ischemia: lateralized pain followed by blood stool, pain is mild/moderate
Hemorrhoids (internal vs external
Perianal vs Perirectal access (Dx, Tx, Comp)
Internal: painless – rubber band ligation, sclerotherapy, or infrared light application
External: painful and pruritic –> surgical
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Simple perianal abscess (be:
- Located within the dermis and subcutaneous tissue.
- Dx: PE
- Tx: I&D at bedside
Perirectal abscess:
- Deeper location, can cause systemic symptoms (fever, tachycardia).
- Dx: CT scan of pelvis w/contrast to confirm location and extent of infection.
- Tx: surgical drainage in OR w/ IV antibiotics
- Comp: fistula formation
Benign paroxysymal positional vertigo
Vertebrobasilar insufficiency
Labyrinthitis
Vestibular schwannoma
Meniere disease
Vestibular neuritis
What’s occurring, Sx, Dx, Tx (if any)
BPPV:
- Abnormal feeling of motion triggered by certain positions.
- Movement is sensed by semicircular canals which are filled by endolymphatic fluids.
Canalithiasis: presence of crystalline debris in the canals
Dx: Dix-Hallpike maneuver –> vertigo and nystagmus
Tx: Canalith repositioning maneuver (Epley)
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Vertebrobasilar insufficiency
- Reduced blood flow to the base of the brain that mainly affects labyrinth and brainstem
RF: DM, HTN, hypercholesterolemia, arrhythmia, CAD, circulatory problems, smoking
Sx: vertigo, dizziness, dysarthria, diplopia, numbness
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Labyrinthitis
- Causes: Viral illness (MOST COMMON), but can be caused by trauma, bacterial infection, allergies, benign tumor and certain medicatoins.
- Sx: vertigo, tinnitus, nausea, loss of balance
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Vestibular schwannoma:
Sx: unilateral sensorineural hearing loss, sometimes imbalance and tinnitus but symptoms are persistent and progressive
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Meniere disease
- Cause: increased volume and/or pressure of endolymph
- Sx: Episodes lasting 20min-24hrs, vertigo, hearing loss, tinnitus and/or aural fullness
- Dx: Audiogram, MRi to r/o central cause of vertigo
- Tx: Diet and lifestyle, Meds (hydrochlorothiazide, betahistine)
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Vestibular neuritis:
- Cause: inflammatory disorder affecting the vestibular branch of the 8th cranial nerve 2/2 viral infection.
- Sx: rapid onset, N/V, gait impairment. resolved within days.
PTH and Ca
hypocalcemia
Ca correction with albumin
PTH:
Kidney: increased calcium reabsorption and phosphate excretion
Bone: Ca release
Increases Vit D –> absorb Ca and phosphate from gut
Primary hyperparathyroidism:
- High PTH, High Ca, Low Phos
- High Ca: Stones (renal), bones (pain), groans (abdominal pain), thrones (increased urinary frequency), psychiatric overtones (anxiety, altered mental status)
Hypoparathyroidism:
- sx: Asx, perioral or peripheral numbness/tingling, muscle cramps, carpel spasm (Trousseau sign) & facial twitch (Chvostek sign), prolonged CT, tetany, seizures
- Low PTH, Low Ca, High Phos
Pseudohypoparathyroidism
- End organ resistance to PTH –>
- High PTH, Low Ca, High Phos
Vit D deficiency:
High PTH, Low Ca and Phos
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Calcium correction equation
Calcium homeostasis involves blood transport as albumin-bound calcium (45%), ionized calcium (40%) and calcium bound to inorganic and organic anions (15%)
Corrected Ca = measured Ca + .8*(4 - measured albumin)
Hyperthyroidism
Tx (1st then 2nd)
Thyroid hormones cause an increase in sympathetic activity d/t increased responsiveness to catecholamines.
Dx: TSH
Tx:
1st: Beta-blockers: help with hyperadrenergic symptoms and control HR.
2nd: Propylthiouracil (PTU) , Methimazole but can take several weeks
3rd: radioiodine ablation, or thyroidectomy
Subacute thyroiditis
Sx, Labs, Uptake, Path, Tx
- Preceded by viral illness
- Painful
- Transient hyperthyroid sx d/t release thyroid hormones
- High ESR & CRP
- Decreased Radioiodine uptake (not making new T3/T4)
- Inflammatory infiltrate with macrophages & giant cells
- Tx: NSAIDs, beta-blockers, steroids if refractory. Methimazole is not effective
Hashimoto
Sx, Labs, Uptake, Histo, Comp
When to treat hypothyroidism
Conditions requiring high dose of thyroid hormone
- Anti- TPO (thyroid peroxidase) and antithyroglobulin antibodies
- Painless, Mainly hypothyroid sx
- Variable radioiodine uptake
- Hurthle cells (Eosinophilic epithelial cells)
- Comp: Thyroid lymphoma
Hypothyroidism does not require tx unless:
1. Antithyroid antibodies
2. Abnormal lipid panel
3. Sx of hypothyroidism
4. Ovulatory and menstrual dysfunction
Conditions requiring higher dose of levothyroxine
should be taken on an empty stomach with water at least 30-60min before breakfast.
-Malabsorption (celiac disease)
- Drugs that interfere with absorption (iron, calcium) , separate by 3-4hrs
- Drugs that increase thyroxine metabolism (phenytoin, carbamazepine, rifampin)
- Others: obesity, pregnancy, overt proteinuria
Prolactinoma
Pathophysiology, Sx, Tx
High prolactin –> suppress GnRH, LH, FSH, estradiol
Oligo/amenorrhea, infertility, galactorrhea, hot flashes, decreased bone density
Tx: Dopamine agonist (cabergoline, bromocriptine), transsphenoidal surgery
Cerebral venous thrombosis vs arterial thrombosis
Presentation, Dx, Tx
Venous thrombus –> impaired CSF absorption –> Headache, increased ICP, papilledema –> hemorrhage –> seizures
Encephalopathy
Arterial: slurred speech, weakness
Dx: CT –> MRV
Tx: LMWH
Frailty
Criteria, definition of skilled vs non-skilled care
1 or more of the following:
1. Used supportive device
2. ability to leave home only with assistance
3. Medial CI to leave home
Non-skilled care: bathing, grooming, dressing
Skilled care: PT/OT, mediation adherence assistance
Strokes
Ischemic stroke: RF, Dx and Tx, comp of tx and how to fix it
Lacunar strokes: RF, Path, Sx
Subarachnoid: RF, Cause, Dx,Tx,Comp
Ischemic Stroke :
RF: HTN (STRONGEST), Hypercholesterolemia, DM, Smokig
Dx: Noncontrast CT is often normal in the early hours (<6hr) following ischemic events
Tx:
- tPA if within 4.5hrs
- Within 24hrs, obtain CTA or MRI angiography
of head and neck to determine if large vessel occulusion is present.
—If present –> Mechanical thrombectomy
—If not –> anti-platelet therapy then find source.
1. Head MRI which is more sensitive for ischemia
2. US of carotid (70-99%)
3. ECG or ambulatory monitoring for r/o arrhythmia
4. Echo to r/o thrombus (when >4mm, ulcerated) or structure abnormality
If patient can not have tPA or mechanical thrombectomy, they should be treated with aspirin. Should undergo dyspagia screening beforehand.
Patient can also be given ppx heparin to prevent DVT an PE
tPA can cause complications like hemorrhage
1. Repeat imaging immediately
2. Tx with cryoprecipitate (has factor VIII, vWF adn fibrinogen) or antifibrinolytics (aminocaproic acid or transexamic acid)
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Lacunar Strokes:
- RF: chronic HTN
- Path: Hypertensive microangiopathy that occlude small, deep penetrating arteries.
- Sx: Sensory only deficits
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Subarachnoid hemorrhage
RF: HTN, smoking, alcohol use, fam hx, sympathomimetic drug use
Cause: Ruptured saccular aneurysm (most common)
Dx: Noncontrast CT (good for early), if nothing then LP (xanthochromia ~2hr after onset). Cerebral angiogram to identify source
Tx: tPA (if on time), monitor neuro exam, maintain BP <180/105. Wait 24hrs after tPA to give antiplatelet or anticoagulation therapy d/t risk of beeding.
Comp:
- Cerebral vasospasms –> localize stroke
- Communicating hydrocephalus (d/t impair absorption of CSF)
Wernicke : 3 features, Tx
Korsakoff: what is it, what part of brain effected
Thiamine deficiency seen in heavy alcohol drinking.
3 features: encephalopathy, oculomotor dysfunction, gait ataxia
Tx: IV Thiamine
Korsakoff syndrome: Late-stage complication of thiamine deficiency. Mammillary body atrophy
Pancreatitis
Acute: 3 common causes, Dx criteria, Predictor of severity, Comp
Chronic (sx, labs, tx)
Sx: bulky, foul smelling stools d/t fat malabsorption
Acute Pancreatitis:
Causes: Gallstone, Alcohol, Hypertriglyceridemia
2 or 3 criteria:
1. Acute severe epigastric pain (received by sitting up or leaning forward)
2. Elevated lipase or amylase >3x upper limit of normal
3. Imaging (CT w/contrast - low sensitivity in first 72hrs of presentation, MRI)
Predictors that correlate to severity: old age, obesity, hematocrit >44%, CRP, BUN >20
Comp: Pseudocysts
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Chronic pancreatitis
Most common causes are alcohol, CF, ductal obstruction (cancer, stone), autoimmune
Sx:
- episodic or continuous abdominal pain
- steatorrhea
- weight loss
- fat-soluble vitamin deficiency
- diabetes mellitus
Labs:
- Does not regularly have laboratory abnormalities
Dx: MRCP (abd CT is an alternative) showing pancreatic calcification. Can also see pancreatic enlargement, ductal dilation and pseudocyst
Tx:
- 1st line: alcohol and smoking cessation, eating small low fat meals, fat vitamin supplements
- if severe: analgesics (TCA, NSAIDs, pregabalin) and pancreatic enzymes supplements
- Refractory: opioids, procedures, surgery
Acute Limb Ischemia
Sx ,Tx
6 P’s: pain, pallor, paresthesia, pulselessness, poikilothermia (coolness), paralysis
Tx: Anticoagulation (Heparin infusion) and based on severity, emergency revascularization. If mild case: tPA can be use
Mercury Toxicity
Neuro: Tremor, insomnia, irritable
Cardio: HTN, Tachycardia
Mucocutaneous: gingivitis, diaphoresis, desquamation of hands/feet
Renal: tubular damage, proteinuria
Inhibits catecholamine breakdown = mimics pheochromocytoma
MEN1 vs MEN2A vs MEN2B
Pheochromocytoma (Dx, Tx)
MEN1
- Pituitary
- Parathyroid
- Pancreatic
- Associated with angiofibromas, collagenomas, meningiomas
MEN 2A
- Thyroid ( Medullary - high calcitonin)
- Parathyroid
- Pheochromocytoma
—Dx: 1st - 24hrs fractionated urinary metanephrines and catecholamines levels. 2nd - Abdominal CT or MRI
—Tx: Tumor removal but first give alpha blocker
For HTN: IV nitroprusside, phentolamine or nicardipine.
For hypotension: NS volus and pressers
Patient with Medullar thyroid cancer should be screened for pheochromocytoma (with plasma free metanephrines) before tumor resection
MEN 2B
- Thyroid ( Medullary)
- Pheochromocytoma
- Mucosal neuromas
COPD
Exacerbation indication for Tx
Hypoxemia is mainly d/t V/Q mismatch, higher FiO2 compensates for low V/Q ratio alveoli.
Exacerbation Tx:
- Steroids
- Abx if there is increased sputum purulence, sputum volume, increased dyspnea, or require mechanical ventilation.
- Short course of steroids
- continuous oxygen is shown to improve long-term survivial to maintain sat’s between 88-92%
Gallstone
Dx/Tx
comp of removal of gall bladder
Dx: RUQ US
Tx:
ERCP can dx and tx if the following is present
If none of these are present and dx is still suspected –> MRCP or HIDA
Gallbladder inflammation
Dx: RUQ US
If US is negative or inconclusive: HIDA scan
Gallstone in the cystic duct
Dx:
- RUQ US showing dilated CBD
- ERCP (dx and tx): done if
1. Visualized stone in common bile duct
2. Dilated CBD and elevated bilirubin
3. Evidence of acute infection (fever, ruq pain, jaundice, hypotension, confusion)
- MRCP if none of the above are present in the patient but choledocholithiasis is suspected
Complication s/p cholecystectomy –> bile salt-induced diarrhea
Tx: cholestyramine (bile salt binding resin)
Kidney stones
Dietary and Pharm Tx
All calcium stones tx:
- Increase Fluids
- Increase citrate: binds to Ca to inhibit stone formation
- Increase K: increase citrate excretion
- Decrease Na: Increase Ca reabsorption
Calcium oxalate stones tx:
- Adequate Ca intake: decrease oxalate absorption
- Low oxalate: decrease urinary excretion
Mediation:
- Thiazides: Increase renal Ca reabsorption
- Potassium citrate:
Sarcoidosis
High CA, ESR and Alk Phos,
- ACE levels are elevated in 75% but can not be used to confirm a diagnosis
Dx: Biopsy revealing noncaseating granuloma. If palpable LN are not available, transbronchial biopsy can be performed.
Pulmonary contusion (Cause, Sx ,Tx)
Cardiac contusion (Cause, Comp, Dx)
Blunt trauma to lungs –> accumulation of edema and blood –> chest pain, SOB, hemoptysis, hypoxemia
Dx: chest x-ray showing irregular localized opacification
Tx: monitor for 24-48hrs, pain control, oxygen
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Blunt cardiac injury –> cardiac contusion –> depressed cardiac contractility and acute heart failure. Can also lead to arrhythmias or myocardial rupture leading to pericardial effusion, tamponade and shock.
Dx: bedside US or FAST to r/o out injuries
Cushing Triad
- Bradycardia
- Hypertension
- Respiratory depression
Early: HA, V, blurry vision, papilledema
Late: Altered level of consciousness dilation of the ipsilateral pupil, CNIII palsy, hemiparesis, decerebrate posturing, respiratory arrest
Bone Tumors
Osteochondroma
Ewing, Osteosarcoma
Osteochondroma
- Most common benign
- Boney spur of cartilaginous cap
Ewing
- 1 of 2 most common malignancies
- Lytic lesion w/mulitlayer periosteal reaction
Osteosarcoma
- 1 of 2 most common malignancies
- ill-defined with aggressive periosteal reaction (sunburst, codman triangle)
Pulmonary Embolism
Predictor of poor prognosis/mortality
Dx stable vs unstable
1 Hemodynamic instability
Other predictors:
- >80y/o, AMS, Hx of cancer, Tachypnea, tachycardia, hypothermia, Sat <90%, high troponin and BNP.
Dx to showing RV dysfunction
- Stable Dx: CTA or V/Q scan
- Unstable: TTE
Tx: thrombolysis
DVT
Tx, PPX
Tx: Anticoagulation (factor Xa inhibitor)
PPX
- If secondary a hypercoagulable state: should be treated for at least 3 months but no longer than 6 months with warfarin
Idiopathic: treat for minimum of 6 months with warfarin
Anaphylaxis
IgE mediated/Type 1 hypersensitivity
If there is a rapid symptom onset & any 1 of the following criteria:
1. Skin/mucosa involvement AND hypotension or respiratory distress
2. Involving >2 organ systems (Cardiovascular, Respiratory, Skin, GI)
3. Hypotension after exposure to allergen
Immediate Tx:
1. Epinephrine (IM preferred, may be repeat x2). Even if initial sx are less severe, give IM epi ASAP. IV for severe/refractory sx
2. IV crystalloid & Trendelenburg positioniong for hypotension
3. Albuterol for bronchospams
4. Early intubation
Others:
1. H1/H2 antihistamines
2. Glucocorticoids
3. Glucagon for patients on beta blockers
4. Hospital admission for observation
Serum Sickness
- IgG Ab against form against foreign components –> immune complex.
- Clearance of these complexes occur without issue when there is minimal antigen because phagocytic system has a large capacity.
- If multiple doses of foreign components are received –> more complexes –> overwhelm phagocytic system –> aggregation of complexes in the bloodstream –> deposit in tissue –> Type III Hypersensitivity reaction –> fever, rash, arthralgia typically 1-2 weeks after exposure.
- Resolve spontaneously after days once complexes are cleared.
Hereditary Angioedema
Path, Dx
- Deficiency or dysfunction of C1 inhibitor –> elevated bradykinin (a peptide that causes vasodilation and increased vascular permeability) –> edema
- Episodes precipitated by minor trauma or emotional stress
- No pruritis or urticaria
Dx: - Low C4 because C1 inhibitor is not present –> C1 activated –> uncheck cleavage of C4.
- Decrease in functional C1 inhibitor level
Testicular cancer
Epi, Sx, Dx, Tx
Age 15-35
RF: family hx, cryptorchidism
Sx: Usual firm/hard testicle with or without painless nodules. Dull lower abd pain, metastatic sx
Dx: Scrotal US then radical orchiectomy to dx, tumor markers, staging with CT scan/chest xray
Tx: Radical orchiectomy, Chemo, cure rate ~95%. Biopsy increases risk of lymphatic spread
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Hydrocele
- Results when the processes vaginalis remains patent and allows peritoneal fluid to accumulate within the tunica vaginalis.
- Painless, scrotal swelling that transilluminates
- Most cases resolved spontaneously in 2 years
CO poisoning
Cyanide poisoning
Inhalation injury tx
CO poisoning
Cause: smoke inhalation, gas motors in poorly ventilated areas, car exhaust
Path: binds to HgH with a high affinity and reduced oxygen delivery to the tissues.
Sx:
—Mild: HA, Confusion, cherry red skin, malaise, dizziness, nausea
—Chronic exposure can lead to polycythemia d/t increased EPO
—Severe: Sz, Syncope, coma, MI, arrhythmia
Dx: ABG for carboxyhemoglobin level. Pulse oxy cannot differentiate between O2 and CO
Tx:
Mild: High flow 100% oxygen
If severe: intubation, hyperbaric oxygen
CI: sodium thiosulfate
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Cyanide poisoning
Causes: fires, occupation exposure, cyanide-containing meds (sodium nitroprusside)
Path: inhibits oxidative phosphorylation –> forces anaerobic metabolism
Sx:
— HTN, cardiac instability –> death
— HA, confusion, anxiety –> sz, coma
— Cherry red skin
— vomiting
—can quickly progress to hypotension and bradycardia
Labs: Elevated anion gap metabolic acidosis due to increased lactic acid
Tx: Decontamination, 100% oxygen, IVF, vasopressors, empiric tx with hydroxocobalamin + sodium thiosulfate
Hydroxocobalamin binds to cyanide and forms cyanocobalamin which can be renally excreted.
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Inhalation injury:
- Upper airway thermal injury +/- lower airway chemical injury.
Strong indicators:
- Oropharyngeal blistering or edema
- Retractions, respiratory distress, hypoxia.
TX:
- 100% oxygen to displace CO2.
- Stable patient with concerning features but no strong indicators: bedside fiberoptic laryngoscope.
- Unstable patient or patient with strong indicators: endotracheal intubation
Polycythemia
Labs, Dx
Elevated HgG (16.5 women, 18.5 men)and Hct
Most likely due to chronic hypoxia 2/2 cardiac or pulmonary disease
Dx:
1. Repeat testing
2. Erythropoietin level
—-if 2/2 hypoxia: high EPO level –> pulse ox
— RCC can also secrete EPO (RF: smoking, obesity, HTN) –> CT scan of abdomen
—-If low: possibly polycythemia vera (myeloproliferative disorder) - JAK2 mutation
RCC
RF, Sx, Labs, Dx, Tx
RF: smoking, obesity , HTN
Sx: flank pain, hematuria, palpable abdominal mass
Labs: EPO production
Dx: CT scan of abdomen showing enhancing mass of the kidney with thickened, irregular septa
Tx: Nephrectomy
Pneumothorax (RF, Dx, Tx)
Pleural effusion (Dx ,Tx, 2/2 liver failure )
Pneumothorax
RF: PPV –> barotrauma –> alveolar rupture –> Pneumothroax
Dx: Bedside US or chest x-ray
Tx:
- Chest tube if tension had not yet developed.
- Needle decompression is appropriate for emergency tension pneumothorax. Always followed by chest tube placement.
_________________________________________________
Pleural effusion
Dx:
- Acute setting: Bedside US is the test of choice
- Nonacute setting: Uprigith PA chest xray
Tx: Needle decompression or chest tube placement
An also be secondary to liver cirrhosis
Thoracentesis can drain but effusion will recurs.
Tx: Na restriction, loop and K sparing diuretics (furosemide and spironolactone)
Myocardial Infarction (MI) (RF, When to resume sexual activity?, Dx, comp and Time frame
Stress test significance
Inferior wall MI (EKG findings, comp, tx)
RF: Non-coronary athletic disease, diabetes, CKD, age > 50, Male, family history of first-degree relative, hypertension, dyslipidemia, cigarette smoking > 1 pack daily
Can resume sexual activity within 1-4 weeks if low risk
Dx:
- EKG: STEMI
- Troponon
- Exercise EKG when possible or Adenosine myocardial perfusion imaging/Dobutamine echo
Time frame of complications
0-24hrs: Ventricular arrhythmia, HF, cardiogenic shock
1-3 days: postinfarction fibrinous pericarditis (Tx high dose aspirin)
3-14 days: Free wall rupture –> tamponade. Primary muscle rupture –> mitral regurg. Intraventricular septal rupture. LV pseudoaneurysm.
2 weeks to several months: Dressler syndrome, HF, arrhythmias, ventricular aneurysm
Stress test significant
- High-risk feature: clinically significant CAD and a high short-term risk of cardiovascular event. Should undergo angiography and possible re-vasularization.
- Low-risk features: have a <1% chance of cardiovascular events within the next year.
Inferior wall MI
STEMI of leads II, III and aVF
- Commonly cause sinus bradycardia and AV block
Tx:
- IV atropine is 1st line to increase CO.
- Transcutaneous followed by transvenous cardiac pacing –> PCI
- If accidentally treated with NO –> give NS bolus
Peripheral Artery Disease (PAD)
- Caused from atherosclerotic narrowing
- Representation of atherosclerotic cardiovascular disease and increase risk of cardiovascular events.
TX: aspirin (decrease risk of stroke), statin (regardless of baseline cholesterol levels)
Sx: Intermittent claudication
Dx: reduced ankle-brachial index
TX:
Stage 1A:
- Smoking cessation
- BP and DM control
- Aspirin (decrease risk of stroke)
- Statin (regardless of baseline cholesterol levels)
Step 1B:
- Supervised exercise therapy
Step 2: Cilostazole (blood thinner)
Step 3: Revascularization with stent/graft
Lymphoma
Follicular vs Burkitt
Follicular lymphoma: most common indolent growing non-Hodgkin lymphoma in adults, B cell, present with painless waxing/waning lymphadenopathy
Burkitt: highly aggressive and rapidly growing non-Hodgkin lymphoma, B cell, associated with EBV
B12 deficiency
Path in RBC formaion, Sx, Tx and its complication
Pernicious Anemia (cause,Dx)
- Single carbon donors for formation of purine and pyrimidine bases. Deficiency impairs DNA replication. Makes RBC more susceptible to hemolysis –> anemia and low retic count because RBC are not made properly
Sx:
- Dementia and subacute combined degeneration, impaired vibration.
- Hyperbilirubinemia, elevated LDH
Tx: supplemental B12. Look out for hypokalemia d/t uptake of K by newly forming RBC. Can pre-transfuse with pRBC to prevent adverse effect
____________________________________________
Pernicious Anemia
Cause: Autoimmune destruction of parietal cells
Dx: causes autoimmune metaplastic atrophic gastritis –> glandular atrophy (many gastric body and fundus), intestinal metaplasia and inflammation
HOCM
Tx: –> beta blockers (metoprolol), non-dihydropyridine CCB (verapamil) and Na channel blocker (disopyramide)
High risk of SCD –> Implantable cardiac defibrillator
Significant LVOT obstruction –> septal ablation or surgical myectomy
Esophagitis
Eosinophilic Esophagitis (Path, Sx, Dx, Tx)
Path: Th2 response to food antigens
Association: Atopic disease (asthma, eczema, food allergy, allergic rhinitis)
Sx: dysphagia, heartburn/epigastric pain refractory to PPI, regurgitation, food impaction
Dx: Endoscopy w/biopsy (concentric rings, strictures, and linear furrows)
Tx: Elimination diet, PPI, Topical steroids (spray)
Gastroenteritis
Mild vs Severe - Sx and Tx
Regular vs blood diarrhea pathogens
What do avoid
Mild: well appearing, hemodynamically stable –> Tx: oral rehydration.
Severe: ill-appearing, hemodynamically unstable –> Tx: IVF and Abx
DO NOT TREAT SHIGA-TOXIN, which is produced by E.Coli (EHEC 0157:H7) or Shigella due to risk of hemolytic uremic syndrome
NONINFLAMMATORY:
Viruses:
- Norovuris: most common
- Rotavirus: most common in unvaccinated age <2, N/V/F
Bacteria:
- Staph Aureus (1-6hrs)
- Bacillus cereus (1-6hrs)
- Clostridium perfringens (>1day)
- ETEC (>1day)
- Vibrio cholerae (>1day)
- Listeria
Parasites:
- Giardia: Malaise, abd cramps, foul-smelling fatty diarrhea >1 week after exposure
- Cryptosporidium
- Cyclospora
INFLAMMATORY:
Bloody diarrhea Pathogens :
Bacteria:
- Nontyphoidal salmonella
- Campylobacter –> rare but can lead to GBS
- Shigella
- Shiga toxin-producing E.Coli
- Yersinia
- Vibrio parahaemolyticus
Parasites
- Entamoeba
Avoid: fructose (fruit juice). transient lactase deficiency can occur
IBS
Definition, Causes, Dx, Tx
Chronic abd pain associated with defecation and changed in stool consistency (diarrhea, constipation or alternating).
Can be precipitated by infectious gastroenteritis
Dx: no mucosal abnormalities on histology
Tx: dietary modification (lactose-free diet)
Loperamide
Heparin Induced Thrombocytopenia
Type 1 vs 2 Path and Tx
Recent heparin exposure
Type 1: non-immune mediated caused by heparin-induced plt clumping arising within 2 days of exposure.
Tx: Resolves spontaneously w/o intervention.
Type 2: life-threatening. Antibodies form against heparin-platelet factor 4 complexes –> thrombocytopenia and AV thrombosis
Tx: Stop heparin, start direct thrombin inhibitor (argatroban, bivalirudin) and fondaparinux
Avoid heparin for life and obtain confirmatory testings (serotonin release assay).
Start direct thrombin inhibitor (argatroban) or fondaparinux to prevent thrombosis
Transition to warfarin after plt are >150,000
Heparin vs Warfarin
Onset, MOA, pregnancy prefernces
Heparin
- Immediate therapy
- Enhances antithrombin which inhibits thrombin and factor X
- CAN BE USED IN PREGNANCY:
For high-risk patient
1. LMWH during 1st trimester
2. Warfarin for 2-3 trimester
3. Unfractionated heparin before delivery Discontinue all at onset of labor.
- Overdose?
—Protamine for LMWH and unfractionated
—Prothrombin complex concentrate for synthetic heparin
Warfarin:
- Takes time to work
- Interfere with gamma-carboxylation of Vit K-dependent coagulation factors
- NOT USED IN PREGNANCY
- Overdose?
Prothrombin complex concentrate (has vit k dependent clotting factors) and Vit K
DNR
Meaning
When to do CRP
Prohibits cardiopulmonary resuscitation
1. Basic life support: chest compressions
2. Advance cardiac life support: defibrillation, cardiac resuscitation medication (epi)
ONLY IN THE EVENT OF CARDIOPULMONARY ARREST
________________________________________________
CPR:
CPR, given oxygen, start defibrillator
1. VF/pulseless VT –> defibrillation
2. Pulseless electrical activity (PEA)/asystole —> CRP, Epi
Acute Compartment syndrome
Causes, Path, Sx (early and late), Dx, Tx
Compare to chronic form
Abdominal compartment syndrome: Cause and Tx
Acute compartment syndrome
Cause: crush injury, long bone fracture, rhabdomyolysis, reperfusion after prolonged ischemia, massive fluid resuscitation.
Path: increased pressure within enclosed fascial space, decreased blood and tissue perfusion
Sx:
- Early: Worsening severe pain, rapid increase in swelling, increase pain with passive stretching, paresthesia
- Late: Decrease sensation, weakness, paralysis, loss of pulses
Dx: diastolic pressure - compartment pressure. <30mmHg is positive.
Tx: fasciotomy
Comp: fixed muscle contracture due to irreversible skeletal muscle fibrosis and shortening. Develop over weeks to months.
________________________________________________
Chronic exertional compartment syndrome:
- nonemergent. self-limiting
- recurrent pain that occurs at the same time, distance, and intensity of exercise.
- pain resolved <10min with rest and exam is normal
________________________________________________
Abdominal Compartment
- Systemic inflammatory response, increased capillary permeability, and rapid third spacing of fluid —> increased intra-abdominal pressure –> decreased perfusion to intraabdominal organs –> dysfunction.
- compress renal vein, diaphragm elevation, IVC
Tx:
- Avoid over resuscitation with IVF, decrease intra-abdominal volume with NG tube, increase abdominal wall compliance with sedation.
- Definitive management is surgical decompression.
Cystic fibrosis
4 important clinical features with explanations, Dx, Tx for pulmonary conditions
Sx:
- Recurrent sinopulmonary infections
- Meconium ileus: intestinal obstruction of the distal Ileum. Can be associated with bilious emesis and abdominal distention, with a right-sided “ ground-glass mass” (d/t the mixture of air bubbles and meconium in the ileum)
- Pancreatic failure d/t ductal obstruction and buildup –> pancreatic DM
Can cause the loss of alpha (glucagon) and beta (Insulin) cells.
- Male infertility
Dx:
- Elevated sweat chloride test
- CFTR mutation on genetic testing
- Abnormal nasal potential difference
Tx:
- Nutritional support
Airway clearance
- Abx coverage for Staph aureus and Pseudomonas
—Vanco for MRSA coverage
—2 drug coverage for Pseudomonas: Cefepime & ceftazidime (cephalosporins), amikacin & tobramycin (aminoglycosides)
DM
Normal fasting glucose, number for DM and most concern
DKA Tx
Dupuytren contracture
Delayed gastric emptying (Dx, Tx)
Primary prevention age to start statin
Neuropathic (Charcot) arthropathy (Cause, Sx,Dx, Tx)
Normal fasting glucose level 70-100
Impaired fasting plasma glucose if 100-126
DM is diagnosed if fasting blood sugar >126
Anyone >100 are at increased risk of coronary artery disease
Tx: diet, activity modification, weight loss and metformin monotherapy.
However, for patients with Hgb A1C >9% should be started on insulin
_________________________________________________
DKA
Definition:
1. Acidosis
2. Hyperglycemia
3. Ketonuria
Management:
1. IVF - Normal Saline - 0.9%
2. Insulin infusion
3. K (if < 5.3)
4. Consider bicarb if pH < 6.9
- Insulin infusion is required until acidosis is corrected (check anion gap) - Once glucose is 200-250: decrease infusion rate of insulin and add dextrose to IV fluids to maintain glucose >200 due to the risk of hypoglycemia - If K gets below 3.3, insulin should be held - Switch to subcutaneous insulin once out of DKA. A sliding scale can be given if bolus insulin is insufficient. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Dupuytren contracture - Associated with DM (40%), Tobacco and alcohol use - Tx: - Modification of hand tools - Needle aponeurotomy, collagenase injection, - Intralesional glucocorticoid injection - Surgery for contractures or advanced disease. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Delayed gastric emptying Dx: - 1st: EGD to exclude mechanical obstruction - Nuclear diagnostic emptying study - Gastroduodenal manometry Tx: 1. Eating frequent small-volume meals. 2. Food high in fat, insoluble fiber, and carbonated drinks should be avoided. - Glycemic control can also reduce symptoms. 3. Metoclopramide (risk for EPS), domperidone, erythromycin \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Primary prevention - Age >40 with DM: start statin \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Neuropathic (Charcot) arthropathy Cause: repetitive bone and tissue trauma d/t impaired sensation and joint proprioception Sx: erythema, warmth, edema Dx: only soft tissue swelling without bone involvement --> inflammation-induced bone resorption showing osseous destruction (phalangeal osteolysis, partial disappearance of metatarsal heads resembling "sucked candy" ) Tx: Acute & subacute: foot cast Chronic: orthotic footwear, infection control, surgical realignment
Sjogren
Ab, Associated cancer
Effects lacrimal and salivary glands
Anti-Ro/SSA and Anti-La/SSB
Associated with B-cell non-hodgkin lymphoma
History: intense periductal lymphocytic infiltrates (focal lymphocytic sialadenitis), often with germinal centers; the glandular tissue is typically atrophic and fibrotic
Aging changes - Men vs Women
Sex hormone changes
Renal changes
Men
- Gradual decline of sex hormones with aging: lower testosterone (total and free), compensatory rise in LH, increased hepatic synthesis of sex hormone-binding globulin
Women:
- Drop in sex hormones at menopause
Both:
- Reduce renal mass (atrophy and fibrotic replacement) and functional glomeruli –> Decrease in GFR and increased creatinine
- Reduced ability to concentrate urine
- Reduced renal blood flow
- Reduce secretion of renin and reduced hydroxylation of vit d
Eye inury
Open globe laceration (Cause, Sx, Tx)
Open globe laceration: small high-velocity particle –> teardrop pupil
Tx: Abx, eye shielding, CT scan or orbits and emergency ophthalmology
Open glove rupture: blunt injury
Delirium
RF: Advanced age and underlying brain disorder (dementia, parkinson, stroke)
Precipitate: polypharmacy, infection, fluid and electrolyte disturbances, malnutrition, immobility, etc.
Dx:
1st- Vital signs
2nd - UA and CMP
3rd- reassurance, orient to environment, constant supervision
4th- low dose haloperidol
Dementia
Sx: agitation, aggression, wandering, delusion, hallucination, paranoia
Non-pharm tx:
- Stable environment
- Structured routine, scheduled activity
- Calm reassurance
- Regular exercise, sleep hygiene
Med Tx:
- Cholinesterase inhibitors
- SSRI
- Antipsychotics
- Avoid benzodiazepines
Skin
Cherry hemangioma (Tx)
Photoaging (Cause, RF, Tx)
Bullous pemphigoid (Sx, Tx)
Seborrheic dermatitis (Cause, Tx)
Atopic dermatitis (Tx)
Tinea capitus (Tx)
Pseudofolliculitis barbae (Cause, Comp, Tx)
Cellulitis (Cause, Sx)
Necrotizing fasciitis (Micro, Path, Sx, Tx)
Plaque psoriasis (Sx)
Urticaria (Cause, Sx, Evaluation, Tx)
Cherry aka Senile:
- Filled with capillaries and post-capillary venules.
- Usually asx and require no treatment.
- Electrocauterization for small lesions. Add shave excision for larger lesions.
____________________________________________
Photoaging
- Intrinsic aging: fine wrinkles on otherwise smooth surface
- Photodamage: course deep wrinkles on rough skin surface with keratosis, telangiectasias and brown liver spots
- Smoking can make wrinkles worst
- Tx: Tretinoin
__________________________________________
Bullous pemphigoid
Cause: Ab against hemidesmosomes (dermal-epidermal junction)
Sx: pruritic, tense bullae, rare mucosal involvement, prodrome of eczematous/urticaria-like rash
Histo: subepidermal cleavage
Dx: skin biopsy
Tx: topical vs systemic steroids, doxycycline
_____________________________________________
Seborrheic dermatitis aka cradle cap aka dandruff
Cause: Malessezia
Tx:
- Topical anti-fungal (selenium sulfide, ketoconazole)
- Topics steroids (low potency)
- Oral antifungal for severe cases (itraconazole, ketoconazole)
- Maintenance/intermitted re-treatment may be required to prevent recurrence every 1-2 weeks
______________________________________________
Atopic dermatitis aka eczema
Moisture barrier + steroids if severe
_______________________________________________
Tinea capitus
Tx: Griseofulvin
________________________________________________Pseudofolliculitis barbae
- Small, painful papules
- Penetration of the hair shaft into interfollicular skin , either through the lateral wall of the follicle or by curving back into the skin after exiting the follicle.
- Most prevalent in black men who have tightly coiled facial hair
- Shaving with a multi-blade razor increases the risk.
Complications: hyperpigmentation, secondary bacterial infection, and occasionally keloid formation
TX: discontinuation of shaving, adjusting shaving routine to single blades proceeded by warm compresses
_______________________________________________
Cellulitis
Most common bug: Strep pyogenes (GAS) or Staph aureus
Poorly demarcated, involved deep dermis and subcutaneous fat, +/- fevers
________________________________________________
Necrotizing fasciitis:
Infection of the subcutaneous tissue that spread rapidly along the facial planes and lead to extensive tissue necrosis and shock
Micro
- Type 2 occur in patients with no medial illness: Strep pyogenes (GAS)
- Type 1 occur in patients with underlying DM or peripheral vascular disease: Staph aureus, clostridium perfringes (causes crepitus), polymicrobial
Path:
Bacterial spread rapidly through subcutaneous tissue and deep fascia, undermining the skin. Mostly involves the extremities and perineal region.
Sx:
- Often minor trauma
- erythema of overlying skin
- swelling, pain out of proportion to exam
- systemic sx: fever, hypotension
Tx: surgical debridement and abx
- Piperacilli/tazobactam or carbapenem: GAS and anaerobes
- Vancomycin: MSSA and MRSA
- Clindamycin: inhibits toxin formation of Strep and staph
_______________________________________________
Plaque psoriasis
- Erythematous plaques with silvery scales
- Asx or pruritic
- Can also cause arthritis, nail changes, and ocular inflammation
- Koebner phenomenon: worsening symptoms from skin trauma
_______________________________________________
Urticaria
80-90% are idiopathic
Can be associated with atopic & rheumatologic diseases
Sx:
Symptoms >6 weeks without apparent trigger. Pruritic, round/serpiginous erythematous plaques, individual lesions lasting <24hrs, +/- angioedema
Evaluation:
- CBC, CRP, ESR, LFT, UA
- Skin biopsy to exclude urticarial vasculitis or mastocytosis
Tx:
- Initial: 2nd generation H1 antihistamines (loratadine, cetirizine)
- avoid aggravating conditions (head, NSAIDs)
- If persistent, progress to 1st generation (hydroxyzine), leukotriene receptor antagonist (montelukast), oral steroids
Prog: usually self limiting that resolve in 2-5 years
Rectal prolapse
Tx (medical vs surgical)
Pelvic organ prolapse (RF, Sx, Tx)
Rectal Prolapse:
- Medical tx used for non-full thickness prolapse
- Fiber and fluid intake, pelvic floor muscle exercise
- Possible biofeedback therapy for fecal incontinence
- Surgery for full thickness or debilitating sx (fecal incontinence, constipation, sensation of mass)
_______________________________________________
Pelvic floor:
RF:
- Obesity, multiparty, hysterectomy, postmenopausal age
Sx:
- pelvic pressure
- obstructed voiding
- urinary incontinence
- constipation
- fecal urgency, incontinence
- sexual dysfunction
- vaginal bleeding
Tx:
- Weight loss
- Pelvic floor exercises
- Vaginal pressary
- Surgical repair (if patient is a good candidate)
Urinary incontinence
Stress vs Urge vs Overflow
Sx, Tx
Vesicovaginal fistula (RF, Sx, Dx
Stress
- Leaking with COUGH, sneezing, laughing, lifting
- cause: intrinsic sphincter deficiency or urethral hypermobility
- Tx: pelvic floor exercise, pessary, urethral sling
Urge:
- SUDDEN overwhelming frequent urge d/t overactive or spastic bladder
- Tx: bladder training, antimuscarinic
Overflow:
- Constant DRIBBLING, incomplete bladder emptying
- Tx: intermittent catheterization, correct underlying etiology.
Vesicovaginal fistula
Abnormal track between vagina and bladder
RF: Surgery, irradiation, prolonged labor/childbirth trauma, GI malignancy
Sx: painless, continuous urine leakage from vagina –> malodorous
Dx: PE, dye testing, cystourethroscopy
Cardiac death vs Brain death
Organ donation (CI, comp)
Cardiac death:
- Irreversible electrical or mechanical asystole.
- Apnea
- Confirmed by observation period (~5min)
Brain death
Prerequisites:
1. Clinical or brain image of devastating cause
2. Absence of confounding factor (sedatives, metabolic
3. No evidence of ongoing drug intoxication or poisoning.
4. No hypothermia or hypotension
Neuro exam:
- Irreversible coma without confounding factors
- Absent brain originating motor responses (posturing)
- IRREVERSIBLE ABSENCE OF CEREBRAL AND BRAINSTEM REFLEXES (pupillary light or corneal, oculovestibular, cough, gag, suck, swallow, extensor reflex). Biceps reflex would still be intact
can still see spontaneous limb movements
NEXT STEP
- Apnea formal test must be performed : no spontaneous breaths for 8-10min
If still highly suspicious, Other test:
- EEG: absence of brainstem-invoked potentials
- Absence of intracranial blood flow on imaging
A 2nd independent examination, generally performed after a 12hr observation period, is required in children
________________________________________________
- Organs do not need to be in pristine condition for donation, some degree of preexisting dysfunction is common.
CI of organ donation
- Patients <18y/o
- Lack of mental ability to make an informed decision
- Uncontrolled hypertension, HIV, DM
- Active or partially treated cancer
- Acute infection
- High suspicion of donor coercion
- High suspicion of illegal financial exchange from recipient to donor
- Uncontrolled/untreated psychiatric illness
- Active substance abuse
For organ donations from a live patient, risk are as followed:
—-Short term: deep vein thrombosis, and hospital acquired infection. Risk is low.
—Long-term risk: immediate decrease in net GFR following removal of one kidney, however, remaining kidney compensates by hypertrophy, leading to no increased risk of end-stage renal disease.
—-In female donors, there is an increased risk of gestational complications: fetal loss, preeclampsia, gestational, diabetes, gestational hypertension.
_________________________________________________
Decorticate (flexor) posturing—lesion above red nucleus, presents with flexion of upper extremities and extension of lower extremities.
Decerebrate (extensor) posturing—lesion at or below red nucleus, presents with extension of upper and lower extremities. WORSE PROGNOSIS
Caloric stimulation: performed by irrigation of the external auditory canal with cold water
Normal: transient, conjugate, slow deviation of gaze to the side of the stimulus followed by saccadic correction midline.
A caloric response cannot be voluntarily suppressed, therefore, the normal reaction = nothing is wrong
Iron deficiency (IDA)
RF, Labs, order of depletion, Tx and duration
Absolute vs functional iron deficiency (path/labs)
RF:
Prematurity
Lead exposure
- GI blood loss
Age<1 (delay introduction of solids/primarily breastfeeding after 6 months, consumption of cow, soy or goat milk before 1y/o)
Age >1 (consumption of >24oz cows milk per day, <3 servings of iron-rich foods)
Labs:
- Mentzer index (MCV/RBC) >13
- 1st decease in Ferritin –> decrease in serum iron and transferrin saturation –> decrease reticulocyte count as bone marrow is unable to produce prerequisites for RBC –> decrease MCV (microcytic) and MCHC (hypochromatia)
Tx: iron supplement with vitamin C
- retic count increases in 1-2 weeks
- Hgb and hematocrit increase ~1month
________________________________________________
Absolute iron deficiency
- Depleted iron stores, low ferritin, high iron responsiveness
Functional from erythropoiesis-stimulating agent:
- insufficient iron to accomodate accelerated erythropoiesis, Normal to high ferritin, High iron responsiveness.
Functional from anemia of chronic disease:
- iron sequestered in macrophages and cannot be mobilized. normal to high ferritin, low iron responsiveness
Achilles
How to test complete rupture
Plantarflexes the food
Complete rupture - Dx with calf squeeze test aka Thompson test –> absence of PASSIVE plantar flexion
ACTIVE plantar flexion can still be present with complete rupture because action fo accessory muscles
Osteomyelitis
Dx
Dx:
- Superficial wounds cx are inaccurate and should not guide therapy
- Bone biopsy with culture are gold standard!
Tumor Lysis Syndrome
Labs, Tx
Occurs with the initiation of chemotherapy
Labs
- HyperPhos + CaPhos stones –> AKI and Hypocalcemia
- Hyperkalemia –> arrhythmia
- Hyperuricemia –> Uric acid stones –> AKI
Tx: IVF + Rasburicase (metabolizes uric acid that is already made).
Allopurinol and febuxostat: prevent production of uric acid
Emergency airway if intubation failed
Signs of failed extubation
Cricothyrotomy is faster, easier and lower risk of hemorrhage. Does not need full anesthesia
Tracheostomy needs full anesthesia therefore not used emergently.
Signs of failed extubation
- post-extubation stridor with no improvement with conservative measures
- RR >25
- hypoxemia
Multiple Myeloma
Sx, Dx
Sx:
- C - Hypercalcemia d/t bone demineralization with osteoLYTIC lesions –> Tx: hydration and dexamethasone, bisphosphonate
- R - Renal insufficiency d/t congestion of glomerulus with light-chain –> Tx plasmapheresis or dialysis
- A - Anemia
- B - Back pain –> Bisphosphonate helps prevent
Dx:
- Serum or urine protein electrophoresis
(Urine dipstick usually detects albumin)
- Cross-secional imaging with whole-body CT, MRI or positron emission tomography scan.
- Some cases also have cryoglobulins (type 1) and precipitate intravascularly, causing symptomatic occlusion.
Comp: Hyperviscosite syndrome d/t excessive monoclonal IgM –> Tx with plasmapheresis
Images for cancer
Technetium-99m pertechnetate scan –> Meckel’s
Technetium-99m bone scintigraphy scan –> detects bone remodeling, osteoblastic bone lesions
Plan xray and positron emission tomography (PET) are better for osteolytic lesions
Poison Ivy
Tx
Remove contaminated apparel
Cool compress
Topical corticosteroids
- Antihistamines are not effective
Boerhaave syndrome (Sx, Dx, Tx)
Mallory-Weiss (What, Dx, Tx)
Eosinophilic Esophagitis (Path, Sx, Dx, Tx)
Diffuse esophageal spasm (Path, Sx, Dx, Tx)
Barretts esophagus (Path, RF, Dx, Tx)
Boerhaave:
- Transmural esophageal rupture –> mediastinitis –> fever. Mediastinitis has a high mortality rate if not treated within 24hrs. Can also cause a pleural effusion, pneumomediastinium, pneumothorax
- Dx: Chest xray, Esophography or CT with water-soluble contrast
- Tx: acid suppression, Abx, NPO, Emergency surgical consult
______________________________________________
Mallory:
- Partial tear of mucosa –> hematemesis
- Dx: Upper GI endoscopy
- Tx acid suppression but will heal spontaneously.
_______________________________________________
Eosinophilic Esophagitis
Path: Th2 response to food antigens
Association: Atopic disease (asthma, eczema, food allergy, allergic rhinitis)
Sx: dysphagia, heartburn/epigastric pain refractory to PPI, regurgitation, food impaction
Dx: Endoscopy w/biopsy (concentric rings, strictures, and linear furrows)
Tx: Elimination diet, PPI, Topical steroids
_______________________________________________
Diffuse esophageal spasm
Path: Uncoordinated simultaneous contractions of the esophageal body
Sx: intermittent CP, dysphasia of solids & liquids
DX:
- Manometry: intermittent paralysis, multiple simultaneous contractions
- Esophagram: corkscrew pattern
TX: CCB, Alternates – nitrites and tricyclics
______________________________________________
Barrett esophagus
- Intestinal metaplasia in distal esophagus (replacement of squamous with columnar thats red and velvety)
- Premalignant condition for adenoma
RF: Chronic GERD, white, race, family sx, age >50, obesity, smoking
Management: PPI. If dysplasia –> scope
Prerenal AKI
Acute tubular necrosis
Postrenal AKI
Causes, BUN/Cr, FeNa
Diabetic Kidney disease (tx)
Prerenal:
- decrease renal perfusion
- BUN/Cr >20
- FeNa <1%
Acute tubular necrosis:
- Tubular injury
- BUN/Cr normally (10-20)
- FeNa >2%
- Muddy brown cast
Postrenal:
- Urinary obstruction
- BUN/Cr variable
- FeNa variable
- AKI is rarely caused by unilateral urethral obstruction because thAme renal functional reserve of the contralateral kidney allows filtration of the entire blood supply, creatinine remains normal.
Diabetic kidney disease
- Hyperfiltration–> increased hydrostatis pressure –> glomerular capillary sclerosis and the gradual progression.
- Tx: ACE and ARB inhibitors decrease GFR –> reduce hydrostatic pressure –> slowing progression of DKD
Amputation care
- Wrap in sterile gauze, moistened with saline and placed in a sealed, sterile plastic bag.
- The bag should then be placed in a chill container with ice and saline or sterile water.
Ankylosing spondylitis
Sx, Dx, trending progress, Comp, helpful practices, life expectancy
Sx:
- back pain with morning stiffness which improves with exercise. Reduce range of forward flexion and chest expansion.
Dx:
- Plan x-ray of sacroiliac joint to see spondylitis. If negative and there is high clinical suspicion, CT or MRI can be used.
- Repeat x-ray used to check disease progression (lumbar, cervical and sacroiliac joint and hip) in addition to ESR.
Comp:
- Restrictive lung disease
- Cauda equina syndrome
- Regular aerobic exercise (swimming, walking, bicycling) can improve joint stability, strength and overall function.
- No change in life expectancy
GBS
Cause, Tx
Preceded by a GI illness (campylobacter) or respiratory infection –> cross-reacting antibodies to peripheral nerve components.
Must trend vital capacity and negative inspiratory force to monitor respiratory status.
Tx:
- Plasma exchange or IVFIG if nonambulatory and within 4 weeks of sx onset.
- Those who are ambulating and recovering do not require treatment.
The weakness may improve spontaneously, but tx shortens the time required for recovery.
Campylobacter tends to worsen presentation and course of illness.
Cardiac tumors
Myxoma: Sx, histo, Comp
Rhabdomyomas: hx
Myxoma
- Most common
- “ball valve” obstruction in the left atrium (associated with multiple syncopal episodes)
- Histo: mucopolysaccharides stroma/gelatinous material and blood vessels- - Comp: Can embolism –> strokes
Rhabdomyomas:
- Most frequent 1° cardiac tumor in children (associated with tuberous sclerosis).
- Histology: hamartomatous growths.
ITP/TTP
Cause, Sx, Labs, Tx
ITP
- Viral illness –> platelet autoantibodies
- Sx: petechiae, ecchymosis, mucosal bleeding (epistaxis, hematuria)
- Labs: isolated thrombocytopenia <100,000, few plts on peripheral smear
- Tx:
—Children: acute and self-limiting, observe if cutaneous sxs only. IF ACTIVELY BLEEDING: glucocorticoids, IVIG, or anti-D
—Adults: chronic, observe if cutaneous AND plt >30,000. If bleeding OR plt <30,000: Glucocorticoids, IVIG, or anti-D
- Rituximab if failed above therapy.
- Splenectomy is last resort.
TTP:
- Acquired or hereditary autoantibodies –> decrease ADAMTS13 activity –>uncleaved vWF mulitmers –> plt trapping and activation –> disseminated microvascular thrombosis
- Sx: Always (abd pain/nausea, petechial rash). Sometimes (kidney failure, neurological manifestations, fever)
- Labs: MAHA, thrombocytopenia, schistocytes, high LDH
- Tx: plasma exchange, steroids, rutuximab.
- Caplacizumab: prevent plt from binding to vWF and forming new clots
Uveitis (Sx, Dx, Tx)
Infectious keratitis (fungal vs viral vs bacterial)
Sx, Dx, Tx
Endophthalmitis (RF, Sx, Dx, Tx)
Anterior uveitis (iritis)
Sx: Pain, redness, visual loss, constricted and irregular pupils.
Dx: slit lamp exam showing leukocytes.
Tx: antibiotics or topical steroids
________________________________________________
Infectious keratitis (infection of cornea):
Sx: severe photophobia with difficulty keeping eyes open.
Dx: Penlight exam shows corneal opacity or infiltrate.
Comp: permanent visual impairment or blindness
- Baterial: most commonly Staph aureus and Pseudomonoas. RF: improper contact lens use, corneal trauma, foreign body. Dx: ulcer, stromal abscess, purulent discharge. Tx: topic antibiotic
- HSV: common in immunocompromised or HIV patients. Dx: branched dendritic ulcers, decreased corneal sensation, watery discharge. Tx: topical or oral antiviral
- Fungi: most commonly Candida. common in immunocompromised with corneal injury with contaminated soil. Dx: ulceration with feathery margins & satellite lesion, purulent discharge. Tx: topic or oral antifungal
______________________________________________
Endophthalmitis
- infection of the structures and fluid chamber of the eye
- RF: hospitalized patients with indwelling catheters, GI preformation, immunocompromised, total parenteral nutrition.
- Sx: Begin with floaters –> loss of visual acuity –> eye pain
- Dx: Blood culture, vitreous fluid sampling and culture
- Tx: fluconazole or voriconazole , vitreous injection with amphotericin B or voriconazole, and vitrectomy (eliminated fungal microabscesses)
Burn injuries
Hypermetabolic response (Path, Sx, Tx)
Electrical burns
Hypermetabolic response
- Within first 5 days of event
Path: Release of inflammatory mediators from damaged tissue —> increase catecholamines, glucocorticoids & glucagon.
Sx:
- Increased basal body temperature
- Hyperdynamic circulatory response: HTN, tachycardia
- Increase gluconeogenesis and insulin resistance –> persistent hyperglycemia.
- Increase protein and lipid metabolism –> lean muscle wasting
Tx: nutritional support, anabolic steroid therapy ie.Oxandrolone which is a synthetic testosterone analog that enhances protein synthesis and decreases protein catabolism.
For electrical burns:
Evaluation includes EKG, urine myoglobin (to evaluate for excessive muscle tissue breakdown)
For high-voltage: serum electrolyte, creatinine phosphokinase, kidney function, and troponin
Substance overdose/ingestion
Caustic ingestion,
Oropharyngeal damage –> hoarseness, unable to control secretions, edema, necrosis with grey pseudomembrane, respiratory distress.
LARYNGOSCOPY should be used to assess impending airway compromise. Then undergo endoscopy within 24hrs to determine severity.
Raynauds
Tx
- Dihydropyridine calcium channel blockers (act on smooth muscles): Amlodipine, clevidipine, nicardipine, nifedipine, nimodipine.
- Diltiazem also proven to help
- If resistant, obtain further work up with ANA, RF, CBC, CMP, UA and complement levels.
Zenker diverticulum
Pathogenesis
Cause: Abnormal spasm or diminished relaxation of the cricopharyngeal muscles during swallowing (cricopharyngeal motor dysfunction). This increases intraluminal pressure –> herniation of pharyngeal mucosa through a zone of muscle weakness (false diverticulum) in the posterior hypopharynx (Killian triangle).
Insomnia
Tx
CBT is preferred initial therapy, esp in the elderly.
Lupus
predisposed conditions
Lupus nephritis (Labs, Dx, Tx, Monitor)
Significant risk of development of premature coronary atherosclerosis and CAD d/t HTN, hyperlipidemia, chronic inflammation and glucocorticoid use.
Lupus Nephritis
- Labs: proteinuria, hematuria, dysmorphic RBC and casts
- Dx: renal biopsy
- Tx: steroids and cyclophosphamide
- Monitor renal disease activity: Complement and Anti-dsDNA
Carpal tunnel
Tx, Dx
Tx:
1st. Wrist splinting
2. glucocorticoids injection
3. Surgery
Can be used preoperatively or to diagnose if unsure: Nerve conduction studies or Electromyography
Anemia of chronic disease
important cytokine
Consequence of chronically elevated inflammatory cytokines, most importantly hepcidin.
Fat embolism Syndrome
Time frame, Dx, Prevention
Onset usually 24-72hrs following inciting events
Sx:
- Respiratory distress
- Neurological dysfunction
- Petechial rash
Prevention & Treatment
- Early fracture immobilization & fixation
- Supportive care
Gilbert
Path, Sx ,Tx
Path: decrease hepatic conjugation of bilirubin
Sx: recurrent episodes of mild jaundice provoked by stress (febrile illness, fasting, dehydration, vigorous exercise, menstruation, surgery)
Tx: benign, no tx
Alzheimer disease
Test, Pathology, Tx
Cognitive test: MMSE, Montreal Cognitive Assessment, Mini-COG
Lab test: CBC, Vit B12, TSH, CMP. Possibly folate, syphilis, vit D levels. Rarely CSF
Imaging: CT scan or MRI or brain. Rarely EEG
Path: amyloid build up –> neuronal stress –> excitotoxicity (glutamatergic NMDA overactivity ) –> neuronal degeneration –> diffuse cortical atrophy
- Loss of cholinergic neurons –> impairs memory and cognition
Tx:
- Acetylcholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine
- NMDA receptor antagonist: memantine, serves as a neuroprotective role
No medication is disease-modifying but for symptomatic treatment
- Respite care an help with home services, adult day centers, and overnight are
Scleroderma (Systemic sclerosis)
Path, Sx, Labs, Tx, Comp
Path:
- Progressive tissue fibrosis
- Vascular dysfunction
- Abnormal deposition of collagen in multiple organ systems
- Pulmonary arterial HTN d/t abnormal inflammatory and fibroproliferative signaling –> thickening and luminal narrowing.
- Fibrotic interstitial lung disease d/t lung parenchymal inflammation and collagen deposition: This would lead to a restrictive lung disease.
Sx:
Skin : telangiectasia, sclerodactyly, digital ulcer, calcinosis cutis
- Extremities: arthralgia, myalgia, contractures
- GI: esophageal dysmotility, dysphagia, reflex
- Lungs: dyspnea, dry cough
- Vascular: Raynauds
Labs:
- ANA
- Anti-topoisomerase Tyle 1 (Anti-Scl 70) (diffused SSc)
- Anticentromere (limited SSc)
Tx:
- ACE (esp captopril): renal crisis
- Nitroprusside for a short duration): lower BP
- Calcium channel blocks for Raynaud’s
Comp:
- Lung: interstitial lung disease, pulmonary arterial HTN
- Kidney: HTN, Scleroderma renal crisis (severe HTN, AKI, MAHA)
- Heart: myocardial fibrosis, pericarditis, pericardial effusion
Bacterial peritonitis
Sx, Labs, Tx
Sx: changed in temp, abd pain/tenderness, paralytic ileus , AMS, Hypotension
Ascitic fluid
- Neutrophils >250
- Positive culture
- < Proteins
- Serym ascities albumin gradient >1.1
Tx: 3rd gen Cephlosporine and albumin , Fluoroquinolones for ppx
Predictor of mortality: bili, INR, creatinine, Na
Cocaine
Sx, Tx
Sx:
- Hypertension and tachycardia
- Coronary vasoconstriction
- Increase platelet activity and thrombus formation
- Myocardial ischemia and infarction
- Aortic dissection
- Neurologic ischemia or stroke
Tx:
- 1st line: Benzodiazepine and nitroglycerin
- 2nd line: CCB for persistent CP
- Another 2nd line: Phentolamine (alpha-blocker)
- Beta-blockers should be avoided
- Percutaneous coronary intervention for myocardial infection
Aortic dissection
RF:
- #1: Chronic HTN
- Underlying aortopathy (Marfan syndrome)
- Cocaine use
Sx:
- sever, tearing cast pain or back pain
- Variation of SBP between arms by >20mmHg
- Hypertension usually present
Dx:
- ECG: normal or nonspecific ST & T-wave changes
- Chest x-ray: mediastinal widening
- CT angiography and TEE for definitive diagnosis
Tx:
- Pain control (morphine)
- IV beta blockers (esmolol)
- Sodium nitroprusside (if SBP >120 after beta blocker)
- Emergency surgery repair for ascending dissection
Desmoid tumor
What is it, Dx, Tx
- Locally aggressive benign tumor arising from fibroblastic elements within the muscle or fascial planes (connective tissue).
- They are characterized by their locally invasive behavior and high recurrence rates, but they do not metastasize.
- Associat3d with familial adenomatosis polyposis (Gardner syndrome)
- Can be located in trunk /extremity, intraabdominal bowel and mesentery, and abdominal wall.
- Can cause intestinal obstruction and bowel ischemia
- Dx: CT or MRI w/histology
- Tx: surgery
Brain tumors
Pineal gland (sx)
Pituitary adenoma (Path, Dx, Tx)
Prolactinoma (Labs, Tx)
Pineal gland
Parinaud syndrome:
- limitation of upward gaze
- light-near dissociation (pupils reactive to accommodation but not light)
- Convergence retraction nystagmus and bilateral eyelid retractions
- Ataxia
- obstructive hydrocephalus
_________________________________________________
Pituitary adenoma:
- Gonadotrophs secrete LH and FSH which have an alpha and beta subunit. Dysfunctional gonadotrophs adenomas secrete only alpha subunit.
- Thyrotrophs secrete TSH –> elevated TSH, T3 and T4 –> hyperthyroid sx
- Radioiodine uptake diffusely increased
Dx: MRI
Tx: transsphenoidal surgery
_______________________________________________
Prolactinoma:
- Prolactin >200
- Tx: Cabergoline
________________________________________________
Craniopharyngioma and pituitary tumor:
Suprasellar and compress optic chiasm
Idiopathic intracranial hypertension
RF, Path, Sx, Dx
Aka pseudotumor cerebri
Risk factors
- Female gender
- Tetracyclines
- Obesity
- Vitamin A excess
- Danazol
Path: Increased ICP d/t impaired CSF resorption and intracranial venous hypertension
Sx:
- HA (worse when lying flat), N/V
- Vision changes - CN VI palsy (impaired abduction)
- Pulsatile tinnitus (rhythmic whooshing sound)
- Retrobulbar pain/neck pain/back pain
Dx:
- Papilledema and enlarged blind spot
- 1st image:CT or MRI to r/o mass, hydrocephalus
- MRV to rule out venous thrombus
- If negative, the perform LP
- Opening pressure >250mmH2O is diagnostic
Tx:
- Weigh loss, including bariatric surgery
- Carbonic anhydrase inhibitor (acetazolamide, topiramate)
High altitude sickness
Path, physiology, comp
Path: reduced PiO2
Physiologic response:
- Hyperventilation: increases PaO2 but decreases PaCO2
- Erythrocytes: more O2 unloading in tissues
- Kidney: increase EPO production and increase HCO3 excretion
Comp
- Acute mountain sickness: HA, fatigue, N
- Cerebral edema: increased cerebral blood flow –> lethargy, confusion, gait disturbances
- Pulm edema: hypoxic pulmonary vasoconstriction –> increase pulmonary arterial pressure –> alveolar-capillary membrane disruption –> dyspnea, cough, +/- hemoptysis, respiratory distress
Tx: supplemental oxygen, descent to lower altitudes
Hepatic Adenoma
( Path, Sx, Dx, Tx, Comp)
Benign epithelial liver tumor
Primarily young women on oral contraception
Sx:
- Often asymptomatic
- Episodic abdominal pain
- LFT wnl
DX:
- CT scan with contrast showing a well-demarcated lesion w/peripheral enhancement
TX:
- Asx and < 5 cm: stop oral contraception
- Sx or > 5 cm: surgical resection
Comp:
- 10% malignant transformation
- Rupture and hemorrhage
Lung Cancer
Screen criteria
Small Cell
* Cushing’s Syndrome: ACTH , bilateral adrenal hyperplasia & diluted hypernatremia
* Syndrome of Inappropriate ADH secretion (SIADH)
* Myasthenic like syndrome/Lambert Eaton Syndrome
* Gastrin releasing peptide –> ulcers
* Calcitonin
* Growth Hormone secretion
Squamous Cell
* Hypercalcemia: PTH related peptide
* Dermatomyositis
Dx:
CT or PET scan and radionuclide bone scan to determine nodal involvement and distant metastases to determine treatment approach
Screening
Age 50-80: Low dose CT scan of chest YEARLY if
1. >20 pack year history AND
2. Currently smoking or quit smoking within the past 15years
- If you stop smoking >15 years ago if you have medical condition that limits life expectancy, you can stop screening.
Smoking cessation reduced the risk of COPD exacerbation (decreases progression of pulmonary function decline), and lung cancer
Field Cancerization
Describes a large area of cells within a field that are “primed” to develop cancer because of widespread exposure to mutagens (ex tobacco). Even with adequate treatment of the initial malignancy, the area affected by field cancerization remains at high risk for the development of multiple primary malignancies.
Common for HNSCC, basal cell carcinoma, colorectal carcinoma
Transverse myelitis vs spinal epidural abscess
Transverse:
- segmental spinal cord inflammation –> extreme weakness
- Clear sensory level
- No focal vertebral tenderness
Dx: MRI to rule out masses vs abscess, but can also show enhancement of affected spinal cord
Tx: 3-5 days of high dose steroids
Spinal epidural abscess
- Fever, focal/severe back pain, neurologic changes, Increase ESR
Asthma exacerbation
Management
If patient has AMS, silent chest, high WOB with normal or high PaCO2, or sever hypoxemia –> ICU,trial noninvasive, intubate if needed
If none of the above sx are present: SABA + SAMA, IV mag, steroids
Bicuspid aortic valve
Mechanical valve + anticoagulation
Usually familial with AD inheritance
Most common congenital heart disease in adults
Can be isolated or associated with other cardiac abnormalities
- Bicuspid aortic valve is also a risk factor for aortic dilation and can lead to aortic aneurysm and dissection
_________________________________________________
Mechanical value
All patients must be on lifelong anticoagulation after valve implantation.
Warfarin (Vit K antagonist) is the only acceptable oral anticoagulation agent.
Aspirin is only added if patient also has a separate, strong indication.
Want to keep INR 2-3
Mitral valve has increase risk so INR should be 2.5-3.5
Prostate cancer
Tx
Tx:
- Hormone therapy
- Chemo
- If refractory to hormone therapy: Focal external beam radiation therapy
Surveillance:
Radionucleotide whole body scan is preferred in this case
Hyperkalemia management
1: Insulin: drives K into the cell
2. Glucose: counter insulin hypoglycemia
3. Calcium gluconate: stabilize cardiac membrane
Comp: Iatrogenic hypoglycemia
Most monitor glucose closely.
Diabetic Neuropathy
Sx testes
Loss of cremaster reflex, diminished testicular sensation, bladder dysfunction, inability to masturbate
Adult Vaccine
Td/Tdap: >19y.o then every 10 years
Influenza: Annually
Zoster: >50 y.o, 2 dose series 2-6 months apart
Pneumococcus:
- 19-65 y/o with increase risk with DM, heart, lung, liver or kidney disease, current smoking or alcohol disorder, impaired immune function: 1 dose of PCV20 OR sequential PCV15 + PPSV23 (8 weeks apart)
- >65 y/o: 1 dose of PCV20 OR sequential PCV15 + PPSV23 (>1 year apart)
CONJUGATE JUST BE GIVEN FIRST, THEN POLYSACCHARIDE
Hypertensive emergency effects the organs
Hypertensive emergencies typically occur in patients with pre-existing essential hypertension and may be induced by medication non-compliance, resulting in rapid increase in systemic blood pressure. These are acute changes
Kidney: malignant nephrosclerosis
1. Fibrinoid necrosis: cell death and excessive fibrin deposition within the arterial walls –> circumferential, amorphous, pink material with sludge, necrotic endothelial cells that lack cytologic detail
2. Hyperplastic arteriolosclerosis: activated, platelets and injured endothelial cells released growth factors —> concentric hyperplasia and layering of smooth muscle cells and collagen —> intimal thickening and an onion skin appearance.
Eyes: papilledema, retinal hemorrhages
Lungs: pulmonary edema
Heart: acute coronary syndrome
Brain: encephalopathy, stroke
Hidradenitis suppurative
Tx
- Abscess formation with purulent or serosanguineous drainage
- Multiple recurrent nodules with sinus tracts, comedones and scarring.
Tx:
- weight loss, smoking message
- Daily skin cleaning
Mild stage:
- Topical clindamycin
- Intralesional steroids or oral antibiotics for flare-ups
Moderate stage:
- Oral Tetracycline
- Oral clindamycin + rifampin in refractory cases
Severe stages:
- Biologic TNF alpha inhibitors (infliximab)
- Oral retinoids
- Surgical excision
***Try to avoid I & D because it does not provide long-term improvements.
Juvenile Myoclonic Epilepsy (Description, Dx, Tx)
Temporal lobe epilepsy
Juvenile
- Adolscents
- Absence seizures
- Morning myoclonus
- Generalized tonic-clonic seizures
Dx: Bilateraly polyspike & slow wave activity
Tx:
- Valproic acid
- Avoid triggers (alcohol, sleep deprivation)
____________________________________________
Temporal lobe
Focal seizures occurring in a small part of the cortex (temporal is most common)
Sx:
- Automatism (fumbling, picking, lip smacking)
- Sensory aura (smell, taste, fear, deja vu)
- Short postictal confusion (<1hr)
- Impaired awareness
- Secondary generalization of tonic-clonic seizures
Dx: EEG or MRI
Paget’s disease
Sx, Labs, Dx, Tx
Sx:
- Most patients are asx
- Bone deformities with enlargement, hearing loss, dizziness
- Bone, pain, spinal stenosis, nerve compression
- Bowing deformities of long bones with increasing risk for fracture.
- Bone tumor: osteosarcoma, giant cell tumor.
Labs:
- Calcium and phosphorus are normal
- Alkaline phosphate is elevated
DX: radionuclide bone scan.
TX: #1 - bisphosphonates to reduce bone turnover. Calcitonin can also be used
Intrapulmonary shunt effects vs anatomical dead space
With pulmonary edema, alveoli become flooded and unable to fill with gas. There is still perfusion but no ventilation, leading to V/Q ratio reaching zero.
Shunting:
Because blood passing through the lungs return to the left atrium without being oxygenated, this situation is analogous to right to left anatomical shunting and is termed intrapulmonary shunt effect. This situation is not corrected by 100% supplemental oxygen, however, PEEP reduces the shunt by propping the alveoli open and increasing the surface area.
Anatomical death space
Refers to the volume of air that never reaches the alveoli. Increase in anatomical space causes less air to reach the alveoli leading to worsening hypoxia.
Scombroid poisoning
Sx, Tx
- Caused by ingestion of poorly stored seafood
- Histidine can undergo decarboxylation and form histamine
Sx: - flushing,
- throbbing HA
- Palpitation
- abdominal cramps
- Diarrhea
- Oral burning
- Skin erythema, wheezing, tachycardia, hypotension
Self limiting
Multiple Sclerosis (MS)
MRI of brain
CSF with oligoclonal bands
CSF IgG elevated
Impaired adduction with contralateral nystagmus
Sx of transverse myelitis
Bronchitis
Sx, Tx
- cough >5 days but <3 weeks
- purulent yellow/green sputum is common and not a sign of bacterial infection
- absent systemic findings( fever, chills)
- wheezing or rhonchi, chest wall tenderness
Dx:
- Clinical
- Chest x-ray only if PNA suspected
- Symptomatic treatment
- Abx NOT recommended
Dyspepsia management
Epigastric pain/burning
Postprandial fullness, early satiety, bloating
Dx:
Low malignancy risk ( <60 & no alarm sx)
- Test and treat for H. Pylori
High malignancy risk (>60 or alarm sx)
- Upper endoscopy
Alarm sx*
Bleeding, weight loss, IDA, lymphadenopathy, dysphagia, odynophagia, persistent vomiting, palpable mass, family history of upper GI cancer
Tx:
- Treat underlying cause
- Trail PPI if no cause found
Common malabsorption diseases
Lactose intolerant:
- Diarrhea after lactose-containing meals
- Increase stool osmotic gap
- Decrease stool pH
- Positive lactose hydrogen breath test
Celiac disease
- Increased stool osmatic gap
- Microcytic anemia, iron deficiency anemia
- Villous atrophy with lymphocytes
Cancer histology
SCC:
- Nest and sheets of polygonal cells with abundant eosinophilic cytoplasm that invade the submucosa and surrounding structures
- intercellular bridges and keratin pearls.
Squamous papilloma:
- fibrovascular core surrounded by squamous epithelium
Adenocarcinoma
- glandular structures with drops of mucin
Hematuria Management
Orthostatic proteinuria
1st step: UA and urine cx
Infection ? –> Abx
Proteinuria or cast? –> glomerular dx –> renal US, urine studies, possibly biopsy
Other cause suspected? –> CT, cystoscopy, or urine cytology
Proteinuria Management
urine protein creatinine ratio
_____________________________________________
Orthostatic proteinuria
- Higher protein excretion when upright vs laying down
- Can collect urine protein creatinine ratio when both supine and standing.
- Can compare protein excretion in a split 24hr urine collection divided into daytime and nighttime.
- Benign condition that resolved spontaneously
Endocarditis
Comp
Comp:
septic embolism –> mycotic aneurysm –> hemorrhage
Amyotrophic Lateral Sclerosis (ALS)
Tx
Ocular, sensory, bowel, bladder and cognitive function is preserved
Tx: Riluzole (glutamine inhibitor) which can help prolong survival and delay need foe tracheostomy
Headaches
Migraine
Acute: NSAIDs, Triptan, Dihydroergotamine
PPX: Lifestyle changes, Amitriptyline (TCA), Beta blockers, topiramate, valproate
Tension:
Acute: NSAIDs, Acetaminophen
Chronic: Amitriptyline (TCA)
Cluster
Acute: Sumatriptan (Triptan- 5HT agonist), 100%O2 for 15min
PPX: Verapamil, lithium, topiramate
Can also perform MRI to r/o structural causes
Interstitial nephritis (Cause, Sx, Dx, Tx)
Renal papillary necrosis (Cause, Sx)
Interstitial nephritis
Causes:
- Meds: Abx, NSAIDS, PPI
- Rheumatologic disease: SLE, Sjogren, Sarcoidosis
- Infection: Legionella, TB, CMV
Sx:
- New medication exposure
- AKI
- Arthralgias, malaise
- Classic triad: Fever, skin rash, eosinophilia
Dx:
- UA: WBC and WBC cast +/- mild RBC & proteinuria
- Peripheral eosinophilia
- Renal biopsy: tubulointerstitial inflammation & edema
Tx:
- Discontinue offending drug or treat underlying condition
- Systemic steroids
- Supportive hemodialysis if needed
________________________________________________
Renal papillary necrosis
- sloughing of necrotic medullary cells caused by prolonged renal ischemia (sickle cell disease) or oxidative damage (analgesic nephropathy)
Sx: hematuria, flank pain
Pressure ulcer
Stages
Stage 1: nonblanchable erythema of intact skin
Stage 2: superficial causing partial thickness loss of epidermis, dermis or both
Stage 3: deeper causing full thickness loss with damage to subcutaneous tissue but may extend to but not through underlying fascia.
Stage 4: very deep causing full thickness with extensive tissue destruction that can damage adjacent muscle, bone and supporting structures.
Tx:
- Partial thickness require occlusive or semipermeable dressing.
- Full thickness require debridement of necrotic tissue
- All: repositioning , pain control, nutritional support
Obstructive sleep apnea
S - Snoring
T - Tiredness (day time)
O - Observed apnea or choking/gasping
P - Pressure (high)
B - BMI >35
A - Age >50
N - Neck size. Men (>17in). Women (>16in)
G - Gender (male)
Can have chronic respiratory acidosis , which is a clue for comorbid obesity hyperventilation syndrome
Autopsy:
when mandated
Legally mandates if:
- Suspect a crime, suicide, medical malpractice
- Unexplained death in otherwise healthy person
- Infectious disease or other public health concerns
- Inmate death
***Medical examiner is most likely the designated person to determine if autopsy is mandated. If determined, it is not optional and does not require consent from family.
Peritonsillar abscess
Sx, alarming signs,, sx for deep neck infection & peritonsillar abscess, Tx
Sx:
- severe sore throat
- Fever
- “Hot potato” voice
- Dysphagia
Tx:
Alarming signs
- Tripod position
- Inability to lie flat
- Severe respiratory distress
Tx: Secure airway, ENT consult, drain in OR, Abx
Signs of deep neck space infection
- Neck pain or stiffness on extension
- Neck tenderness or swelling
- Bulging of posterior pharyngeal mucosa
- Chest pain
Tx: CT neck w/contrast
Clinical dx of peritonsillar abscess:
- Trismus (cant open mouth) ***
- Unilateral swelling
- Uvular deviation
- Fluctuant bulging of soft palate
Tx: Need aspiration or I&D, Abx
Painless vision loss
Central retinal artery occlusion
- Severe vision loss w/temporal sparing
- Pale fundus with “cherry red spot”
Central retinal vein occlusion
- Acute onset, monocular
- Blurred vision to severe vision loss
- Fundus with retinal hemorrhages & optic disc edema
Retinal detachment
- Floaters, photopsia “flashing lights”, progressive field defect
Vitreous hemorrhage
- Hazy vision +/- red hue or vision loss
- Floaters/shadows
Pelvic insufficiency fracture
RF, PE, Dx, Tx
RF:
- Advanced age and other osteoporosis RF
- Weeks to months of pain in groin, hip, or back
- Atraumatic or following minor trauma
PE:
- Leg length discrepancy
- Local tenderness
- Inability to raise leg or pain with active flexion
Dx:
- Plan x ray
- MRI if xray is negative
Tx:
- Medication for pain relief
- Early mobilization (nondisplaced fracture) or surgical intervention, depending on fracture type
PFO
RF
A PFO (patent foramen ovale) does not directly cause DVT (deep vein thrombosis) or pulmonary embolism, but it can significantly increase the risk of paradoxical embolism, where a blood clot from a DVT travels through the PFO to the systemic circulation, potentially leading to a pulmonary embolism if the clot lodges in a lung artery; therefore, a PFO is considered a risk factor for developing a pulmonary embolism if a DVT is present.
Hepatic encephalopathy
Precipitating factors, Sx, Tx
Elevated ammonia d/ precipitating events
Precipitating factors:
- Drugs (sedation, narcotics)
- Hypovolemia (diarrhea)
- Electrolyte changes (hypokalemia)
- Increased nitrogen load (GI bleeding)
- Infection (PNA, UTI, spontaneous bacterial peritonitis)
- Portosystemic shunting
Sx:
- Sleep pattern changes
- Altered mental status
- Ataxia and Asterixis
Tx:
- Correct precipitating causes (IVF, Abx)
- Correct electrolytes
- Decrease blood ammonia concentration (lactulose, 2nd line is rifaximin), to a goal of 2-3 bowel movements per day
Radiation-induced cardiotoxicity
2/2 chemotherapy and radiation
Radiation causes diffused fibrosis in the interstitium of the myocardium, along with progressive fibrosis of the pericardial layers, cells in the conduction system, and the cusps and/or leaflets of the valves. it also causes injury to the interim layers, with arterial narrowing typically involving the postal parts of the coronary vessels.
Leads to
1. myocardial ischemia and infarction d/t effect of cardiac arteries
2. restrictive cardiomyopathy and diastolic dysfunction
3. Constrictive pericarditis
4. Valvular abnormalities (mitral or aortic stenosis/regurg)
5. Conduction defects (sick sinus syndrome or variable degrees of heart block).
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Anthracycline class drugs use dilated cardiomyopathy
Diverticulitis
Sx: abd pain, N/V, altered bowel movements, fever, possible sterile pyre
Dx: CT scan of abdomen
Tx: bowel rest, abx (ciprofloxacin, metronidazole), liquid diet, Colonoscopy in 6-8 weeks after resolution.
Comp: abscess, obstruction, fistula, perforation
Most abscesses require percutaneous drainage, IV abx followed by possible colectomy every weeks later
Traumatic brain injury
Concussion
Post concussion syndrome
Any form of traumatic brain injury can lead to postconcussive syndrome, which includes the following constellation of symptoms: headache, confusion, amnesia, difficulty to concentrate or with multitasking, vertigo, hypersensitivity to various stimuli, mood alterations, sleep disturbances, and anxiety. Can take weeks to months to resolve and can be persistent for >6 months.
Falls in the elderly
Prevention
Some helpful preventions
- Muscle strength and balance training
- Withdrawal of psychotropic medications
- Home hazard evaluation and modifications by a trained professional
Total parenteral nutrition (TPN)
Electrolytes to monitor
critically ill patient typically develop intracellular phosphate deficiency
TPN has dextrose –> increased insulin –> more phosphate into cells for oxidative phosphorylation –> hypophospatemia
Patients on TPN should be monitored for Mg, Phosphate and triglycerides
Anamalous origin of coronary arteries (Sx ,Dx)
HOCM (exam)
Sx:
- CP, lightheaded, syncope
- Death
Dx:
EKG: wnl
- TTE can sometimes make the diagnosis
- CT coronary angiography pr coronary MRI is the best test
HOCM
Murmur increase in intensity with standing = decreased VR
