Random Flashcards
SSRIs
CITALAPRAM
FLUOXETINE
SERTALINE
ESCITALAPRAM
SSRI S/E
Sex dysfunction
Dec libido
Prolonged ejaculation
Switch to Bupropion (NRI), does not cause sexual dysfunction and does not cause weight gain. Not an SNRI (venlafaxine).
Her2 +ve breast cancers TrasTuzumab (Titties) s/e
Cardiotoxicity, get an ECHO, check EF.
TamoXifen s/e
- Hot Flashes
- Venous thrombosis (anything will estrogen can cause clots).
- Uterus endometrial hyperplasia
Raloxifene
postmenopausal osteoporosis.
Estrogen agonist on bone & mild antagonist in breast (protective effect against breast cancer)
Venous thrombosis (anything will estrogen can cause clots).
HIV when pregnant
Nucleoside reverse transcriptase inhibitor + protease or integrase inhibitor
Viral load >1000, c/s + intrapartum zidovudine
Postexpore prophylaxis
Syphilis during pregnancy
When born: hepatosplenomegaly, skin lesions (diffuse maculopapular rash involves hands and soles, may desquamate), rhinitis, Abnormal long bone Xray, Blueberry muffin spots (from extramedullary hematopoiesis).
Later: keratitis, Hutchinson teeth, saddle nose, cns probs.
Oxytocin s/e
1 & 2 (similar structure)
Too much oxytocin leads to tachysystole (rapid) of uterus and tetany (long prolonged) of uterus.
Oxytocin is also similar structure to ADH, can cause Hyponatremia (seizures). Tx: Hypertonic fluids, counters the ADH.
Contraindication to oxytocin: prior classical c/s, risk of uterine rupture.
Both Oxytocin and ADH are from the posterior pituitary
Mammogram
every 2 yrs, 50-75y.o
Pap Test
21-65 y.o, every 3 yrs
Start testing for HPV at 30yo.
At 30, do HPV & Pap every 5 yrs.
If woman >45yo & shows endometrial cells, can be from endometrial hyperplasia or cancer. If has risk factors (obesity, chronic anovulation = no kids), next step, Endometrial biopsy.
If the PAP shows Atypical glandular cells, next step is colposcopy + endocervical curettage + endometrial biopsy. Why, AGC means this is cervical (outer cancer) or endometrial adenocarcinoma (inner uterus). This way you look at ectocervix, endocervix and endometrium.
If the PAP shows intraepithelial lesions, next step is colposcopy (look at it) & the loop electrosurgical excision procedure. High-grade squamous intraepithelial lesions are concerning for CIN or invasive cancer. Neoplasia happens at the squamocolumnar junction or transformation zone.
If you can’t visualize the squamocolumnar junction, you can’t risk it (big cancer area). Next step: Endocervical curettage (takes a sample of the transformation zone).
Hyperlipidemia
> 35yo, every 5yrs.
HTN
> 18yo, every 2yrs.
If CIN2 or higher on PAP
Continue Pap for 20 more years or until 3 consecutive negative tests.
Paget disease of breast
From ductal carcinoma, eczematous nipple changes (flaking, crusting skin). Includes areola. Bloody nipple discharge
Doesn’t have a breast mass
Infiltrating ductal carcinoma
breast mass, have bleeding from the duct & have lymph adenopathy.
doesn’t have flaking areola)
Inflammatory breast carcinoma
peau d’orange
Ectopic pregnancy Doppler
increased Doppler flow (blood vessels) around the pregnancy = ring of fire.
Tx if stable: Methotrexate.
TMP-SMX
Contraindicated 1st trimester. Interferes with folate metabolism.
Also, it is contraindicated in the 3rd trimester as it causes Kernicterus.
Low birth weight = <10%.
Complications
Hypoxia (from like DM, HTN, preeclampsia, smoking) leading to Polycythemia (compensation), perinatal asphyxia, meconium aspiration, hypothermia (from low subQ fat), hypoglycaemia, hypoCa.
hypoglycemia and hypocalcemia from decreased cellular uptake.
Cupper IUD
Good for 10 years
Progesterone IUD
Good for 5 years
Preeclampsia Tx for BP
IV Labetalol (don’t give if Pulse <60, will lower it more)
IV Hydralazine
Oral Nifedipine (don’t give if vomiting)
BBlocker, Methyldopa, Hydralazine, CCB
Complete vs. Incomplete moles
Completely molar
completely sperm 46n sperm doubles up.
Incomplete mole 1 egg, 2 sperm, 69n.
Both benign
BHCG looks like TSH
Normal vagina pH
Acidic <4.5, sperm is basic.
Bacterial Vaginosis
Gardnerella (anaerobic bacteria, coccobacillus), fishy (bad odor, amine odor), thin gray white. Wet mount with clue cells. Clue cells = epithelial cell coated with bacteria cells. Positive KOH test.
pH >4.5. No vaginal inflammation (itching, redness). From an imbalance in vaginal flora, lactobacilli colonization decreases. Leads to an increased pH and overgrowth of anaerobic bacteria. Increased incidence in women having sex with women, douching and smoking.
Trichomonas vagialis
Odor, thin, frothy, yellow green discharge. Elevated pH >4.5. Friable macular cervical lesions (strawberry cervix), postcoital bleeding. Vagina will be inflammed (red and itchy).
Dx: Wet mount showing motile, flagellated, ovoid protozoa. Lots of PMNs.
Contractions for labor
2-3 minuntes
Endometrial protective factor
Progesterone, stops proliferation.
Smoking, metabolites estrogen in the liver.
Tocolytics
Nifedipine (CCB), Indomethacin (COX inhibitor)
Terbutaline (Beta agonist)
Nifedipine (CCB): 1st line, 32-34 weeks, s/e: tachycard, flushing, H/A, N.
Indomethacin (cyclooxygenase inhib): 1st line, <32 weeks, s/e mom: platelet dysfunction and gastritis, s/e baby: closes PDA (don’t give after 32 weeks), oligohydramnios. Indomethacin is a non specific cyclooxygenase inhibitor, it decreases prostaglandin production and leads to fetal vasoconstriction. Leads to decreased renal perfusion and fetal oliguria. Therefore, give indomethacin for <48hrs.
Terbutaline (Beta agonist): short term tocolytic, s/e: tachy, hypotension, hyperglycemia, pulmonary edema.
Congenital Toxoplasmosis
Toxoplasm gondii. From undercooked or cured meat or cat feces contact. Symptomatic babies have macrocephaly, hydrocephalus and lesions in the ventricles and basal ganglia (diffuse intracerebral calcifications). We don’t test for toxo in the USA, only after a Pt has symptoms. Can experience chorioretinitis in adulthood from reactivation on the infection.
Dx: Toxo IgM or IgA in serology.
Tx = Sulfadiazine + Pyrimethiamine (TMP variation) + Folate for 1 year.
(CMV is periventricular calcifications & normal head & hearing loss vs. Toxo is diffuse calcifications & big head).
Encapsulated bacteria
S.pneumo, H.Influenza, N.Meningitidis
MAHA
4 things cause it.
Defective prosthetic cardiac valves.
DIC.
HUS – Hemolytic uremic syndrome.
TTP – Thrombotic thrombocytopenic purpura.
VHL – von hippel-lindau disease
Autosomal dominant (means family hx).
Hemangioblastomas of the CNS or retina (risk of vision loss, retinal detachment or glaucoma).
Renal cell carcinoma (or family hx of adrenal tumor).
Risk of pheochromocytomas (adrenal medulla tumor). Associated with MEN2A&B and NF type1.
Mt in VHL tumor suppressor gene.
Start looking for tumors as of a young age.
benign highly vascular tumors, risk of rupture and intracranial hemorrhage.
Dx: Do VHL testing in a patient with a retinal or cerebellar hemangioblastoma.
Tx: Laser therapy for the retinal hemangioblastoma.
Disseminated gonococcal infection
Pustular rash, synovial fluid <50K, blood cultures negative
Theophylline toxicity
Narrow therapeutic window. Cause CNS stimulation (H/A, insomnia, seizure), GI problems (Nausea, vomiting) & cardiac toxicity (arrhythmia). Theophylline is metabolized by cytochrome oxidase in the liver. Levels affected by liver problems, respiratory infections or drugs that increase the concentration (cimetidine, ciprofloxacin, erythromycin, clarithromycin, verapamil).
Ca stones
Na restriction
Aortic stenosis
> 70yo calcification
<70yo Bicuspic Aortic valve.
EF <50, replace.
Pulsus parvis and tardes.
Single soft S2
R upper ICS
Severe valve <1cm^2
Thyroid mass
1.Get a TSH & Thyroid u/s always.
2a. If normal or elevated TSH (elevated tsh means it making product and might be cancer), do an FNA.
2b. If >1cm & high risk sonography (microcalcifications, irregular margins & internal vascularity), do a FNA Bx.
2c. if >2cm and not a cyst on u/s, do a FNA Bx.
- If TSH low, next step, radionuclide thyroid scan using iodine-123.
3a. A hypofunctioning “cold” nodule = decreased isotope uptake = higher risk of cancer, next step FNA.
3b. Hyperfunctioning “hot” nodule = increased isotope intake, low risk of cancer. FNA not needed.
Abnormal BUN
> 18
Prerenal BUN>CRE >20:1
Wide physio S2 split (wider on inspiration) A2————- P2
R bundle branch block
R.V infarction, pulmonary HTN. RV taking longer to close.
New paradoxical splitting (P2- - -A2)
L bundle branch block
Anterior or lateral infarction, Aortic Stenosis.
LV now taking so long to close that P2 closes before it.
Secretory diarrhea
Secretory = <50 mOsm/kg
Normal stool osmotic gap 290 mOsm/kg.
Osmotic diarrhea >125 mOsm
Urine acid stone cause
Causes: Gout, tumor lysis and/or acidic urine pH. chronic diarrhea (loose HCO3-), leads to acidic overall and acidic urine.
Tx uric acid stone: hydration, alkalinization of urine with Potassium citrate and low-purine diet. Alkalinization will solubilize the uric acid.
Anterior cord syndrome
Front of the cord damaged.
Loss of motor fn.
Preserved position, vibration and touch (posterior of cord).
Brown-Sequard syndrome
1/2 side of cord damaged.
Loss of pain & temp 2 layers lower on opposite side (signals cross right away).
Loss of motor & position, vibration same side (from and back of cord).
Central cord syndrome
Cape like distribution.
Loss of motor arms b/l (center of cord) at level of injury.
Incomplete loss of motor below that.
dopaminergic agonists
Cabergoline> Bromocriptine
Dopamine inhibits Prolactin. Tx for prolactinoma.
Cushing Disease (Pituitary making ACTH)
vs.
Cushing syndrome
- test cortisol levels (low dose dexamethasone suppression, late night salivary cortisol, 24hrs urine free)
- ACTH level.
- If elevated ACTH, do high-dose dexamethasone suppression test. If surpresses, pituitary was making.
Low THen High
Adrenal adenoma: labs show low ACTH, feedback inhibition. Low DHEAS, DHEAS is driven by ACTH
Broca’s
Frontal lobe - Broken Speech - Broca
Hydroxychloroquine
SLE drug. S/E: Retinal toxicity 5 years later. Check eyes.
Metformin s/e
Renal insufficiency & lactic acidosis.
30% of patients on Metformin get B12 deficiency after >5 years. Some patients only have the neurologic findings alone and don’t have the macrocytosis problems. Metformin might alter the Ca-dependant B12 absorption.
ASA overdose – Salicylate poisoning
Tinnitus, tachypnea, GI irritation (stops protective mucosa).
Respiratory alkalosis: stim respiratory center in the medulla and causing tachypnea, breathe off CO2.
Gapped metabolic acidosis: uncoupling of ox phos leading to anaerobic metabolism. (MUDPILES).
Together: low CO2 & low HCO & near-norm pH.
Tx: Alkalinization of the urine with NaHCO3 & dialysis.
Type 2 RTA
Non Gapped Acidosis
Na – (Cl + HCO3)
Isolated or Fanconi syndrome (glucose, amino acids & phosphate in urine). Impaired HCO3- reabsorption in the proximal tubule. The distal tubule will still works, so urine pH will be <5.5 (acidic).
Type 1 RTA
Non Gapped Acidosis
Na – (Cl + HCO3)
Genetic problem, has kidney stones (nephrolithiasis). Complication of Sjogren syndrome. Distal RTA. Impaired H exretion in the distal tubule. Will get Hypokalemia from reduced K+ reabsorption. Urine pH >5.5, can’t acidify urine.
Type 4 RTA
Non Gapped Acidosis
Na – (Cl + HCO3)
Problem with Na/K exchange in distal tubule (get hyperK, hyperCl). Reduced aldosterone, leads to H+ & K+ excretion in the collecting duct. HyperK is typical. Urine pH is <5.5
Tx: Give Bicarb HCO3.
Secondary bacterial pneumonia after influenza
young person, likely MRSA
necrotizing pneumonia
Tx: Vanco or linezolid & admit to ICU
PA-PaO2 gradient
PAO2 = FiO2 * (713) - (PaCO2/0.8)
PaO2 = from ABG.
Elevated A-a, if > (Pt age/4 + 4).
Causes of ⬆︎ A-a gradient: Anything that impairs gas exchange.
Diffusion (CHF or Pneumo), VQ miss match (PE), R->L shunt.
Norm A-a gradient:
⬇︎ FiO2, hypoventilation.
Hemorrhagic Stroke
Hemorrhagic = Subarachnoid or intracerebral.
Intracerebral hemorrhage:
Acute focal neurologic signs, worse over mins-hours. As it expands, get elevated ICP (headache (h/a) , V, AMS. Risk factor HTN.
Subarachnoid hemorrhage:
Severe h/a, hx of LOC, n/v.
Ischemic stroke
Abrupt focal neurologic deficits, no h/a, no LOC. hx of TIA.
Tx: <3-4.5 hrs: Alteplase >4hrs: ASA (Asprin).
elevated ICP from a TBI
1.Hypertonic saline. It will draw out water from edematous brain tissue.
2.Elevate head of the bed.
3.Craniectomy.
No mannitol.
Posterior wall MI
ST depression in V1 and V2
Cyclosporine s/e
Hepatically cleared, so CYP450 alterators.
S/E: Nephrotoxic (cause vasoconstriction, leads to an AKI acutely), HTN (from the vasoconstriction of the kidney), Neurotoxic, Glc intolerance, infection, Gingival hypertrophy & hirsutism & GI problems.
Tx: adjust the cyclosporine or tacrolimus dose.
Tacrolimus (macrolide) s/e
Same as cyclosporine, but no hirsutism or gum hypertrophy.
Hepatically cleared, so CYP450 alterators.
S/E: Nephrotoxic (cause vasoconstriction, leads to an AKI acutely), HTN (from the vasoconstriction of the kidney), Neurotoxic, Glc intolerance, infection
Gastric cancer
Epigastric pain, worse when eating. Eastern Asia, Andean part of south America. Diets rich in salt-preserved foods.
Mets to liver.
Liver transplant complications
<1 month: Bacterial infections or from the hospitalization.
1-6 months: Opportunistic infections. From being on high dose steroids.
> 6 months. Community acquired things at higher rates.
Aortic regurgitation
Early diastolic murmur, decrescendo.
bounding pulses = water hammer (hammers bound).
Pulsus bisferiens (biphasic pulse) = 2 strong systolic pulses. From increased stroke volume causes abrupt rise is systolic bp.
Widened pulse pressure.
Best heard on R. Sternal border = Aortic root disease/dilation (turbulent flow in aortic root).
Best heard L. Sternal border 3&4 ICS = valvular disease (like IE, or prosthetic valve dysfunction or bicuspid valve mcc developed countries).
Organophosphate poisoning
Organophosphate = inhibit acetylcholinesterase.
Too much Ach and get massive parasympathetic symptoms.
Also used as a chemical weapon (sarin gas). Colorless, tasteless, fruity odor
Dx if needed: RBC Achesterase activity levels. Or just give Atropine and see if resolves.
Tx: ABCs, Atropine immediately (competitive inhibitor at the muscarinic receptor) + clothing removal (absorbed through the skin).
Tx later: Pralidoxime (works at both muscarinic and nicotinic receptors, reverses the neurotoxicity and reactivates cholinesterase activity). Only give Pralidoxime after Atropine.
Bucket-Handle Fracture – Metaphyseal corner fracture
From forcible pulling or twisting an extremity. Red flag for child abuse.
Next step: Skeletal survey for additional Fx. Various stages of healing. Look for retinal hemorrhages. Report to CPS.
Nocardia
GM+ve filamentous rods, weakly acid fast.
Tx: TMP-SMX.
Giant cell temporal arteritis
Can aortic aneurysm.
Steroids before Bx. Can’t afford to be wrong.
If eyes involved, admit with high dose pulse steroids. methylprednisolone 500 - 1000mg daily.
Cimetidine, SSRIs, Ketoconazole, Macrolides, Fluoroquinolone (Ciprofloxacin), HIV protease inhibitors, grape fruit juice, Tylenol (w/ warfarin), nsaids.
CYP 450 enzyme inhibitors:
Stops liver enzymes from metabolizing the drug (breaking it down. The drug stays more and has more effects).
Rifampicin, Barbiturates, Phenytoin, Chronic EtOH, Glucocorticoids.
CYP 450 enzyme inducers:
Break it down faster. Drug clears faster.
Otitis Media with low fever & > 6 months.
Watch and wait.
Otitis externa
Tx: 1. Topical ciprofloxacin (fluoroquinolone) if adult & ok for kids if uncomplicated infection.
Piperacillin or ceftazidime.
HCOM Tx
Harsh crescendo-decrescendo systolic murmur best at the apex and L lower sternal border. (Mitral valve having a weird motion).
- BB 2. Non-DHP CCB Verapamil, disopyramide.
(prolong diastole and decrease myocardial contractility, lets the heart fill more).
Abdominal Anneurysm
> 3cm at renal arteries
Myasthenia gravis Tx
Ab for Ash Receptor.
Therefore Tx is Achesterase inhibitors. Pyridostigmine
Lynch syndrome
hereditary nonpolyposis colorectal cancer
Family of colon cancers. mt DNA mismatch repair gene. screening colonoscopy.
High risk endometrial carcinoma. Endometrial Bx from 30s. Risk ovarian cancer. Prophylactic hysterectomy & BSO at 40 or after kids.
Echinococcus granulosus
(Echi the dog, treat with albendazole).
Hydatid cysts. Dog tapeworm in rural and developing countries. Sheep farming. Humans get from eating food or water with dog feces. Eggs hatch in SI go to liver and get multiple cysts. Asymptomatic for years, illness when cysts large or rupture. Eggshell calcifications on CT.
Dx: U/S (showing smooth, round cyst)+ Serology for Echinococcus IgGs.
Tx: small cysts (<5cm) Albendazole, large cysts percutaneous drainage or surgery.
(Echinococcus = cysts (multiple)).
HyperNa - Hypernatremia Tx.
Severe Hypovolemic HyperNa: Tx = 0.9% Saline, once normal volume status, switch to 0.45%.
Less severe Hypovolemic: Tx = 5% Dextrose in 0.45% Saline.
Bleeding in the cerebellum.
Often from HTN.
Decussate 2X, ipsilateral symptoms.
Ipsilateral hemiataxia of trunk if in the vermis.
Ipsilateral hemiataxia of limbs if in the cerebellar hemispheres.
Methotrexate
Before Methotrexate, test for Hep B, Hep C, TB. No
Methotrexate if prego or want to get preg.
No Methotrexate if liver or kidney problem, causes hepatotoxicity (avoid alcohol).
Do regular CBCs and LFTs.
Methotrexate: Anti-Folate immunosuppressant.
Romberg sign
Sensory ataxia
swaying when standing with eyes closed
damage of the dorsal column
SAAG
SAAG = Serum albumin - Peritoneal fluid albumin. (blood should have higher album)
> 1.1 = Portal HTN: (LFTs albumin 3.1- paracentisis albumin 1.1 = 2.0)
Tx: Furosemide & spironolactone & Na Restriction. Get a cell count and diff to r/o SBP.
<1.1 = Non-portal HTN: (=peritoneal fluid has a lot of albumin).
Causes are malignancy (persistently bloody fluid, mcc Hepatocellular carcinoma, 2. Mets from ovaries or prostate. Get Alpha-fetoprotein & cytologic analysis), pancreatitis (pancreas has proteins in it, serosanguinous), nephrotic syndrome (loosing), TB (fever, night sweats, yellow coloured).
hemorrhagic stroke
(hyperdense fluid collection with irregular margins).
Coccidioides
South West develop CAP (community acquired pneumonia) >1 week. Arthralgias and erythema nodosum.
CXR: Unilateral infiltrate w/ ipsilateral hilar LAD (lymphadenopathy).
Bx: spherules with endospores.
Dx: Serology testing.
Tx: If severe or risk factors (HIV, DBM, immunocompromised) = ketoconazole or fluconazole. If not severe, supportive.
Howell-Jolly bodies
Single blue inclusions on Wright stain in an RBC.
Spleen usually would have cleared these nuclear remnants.
Therefore conditions with functional asplenia (Eg. Sickle cell) or splenectomy.
Heinz bodies
The bite cell.
G6PD deficiency or thalassemia.
Hb getting oxidized and precipitating as denatured.
Bite cell, Heinz body (the rigid precipitate) geet’s phagocytosed out
Helmet cell
=schistocyte
MAHA: 4 things
DIC, HUS, TTP, Prosthetic valve
Basophilic stippling
From ribosomal precipitations, blue granules in the cytoplasm of RBCs. Nonspecific.
Thalassemias, lead poisoning.
Hypertensive retinopathy
hard exudates, AV nicking, flame, sliver wiring
Diabetic retinopathy
microaneurysms
Leukemoid reaction
High LAP score, fever, no basophilia, late myeloid cells (metamyelocytes & bands).
CML vs. AML
40-59, >30% blasts = AML.
40-59, <30% blasts = CML.
ALL
Lymphoblasts (lack peroxidase +ve granules).
PAS +ve.
TdT +ve (pre B & pre T lymphoblasts).
CML
Middle age (40-59)
WBC >100000, basophils, neutrophil precursors. Low leukocyte alkaline phosphatase score, large spleen. Lots PMNs. (Early myeoloid cells (promyelocytes & myelocytes).
BCR-ABL fusion chromo 22 (Translocation 9-22), this causes tyrosine kinase to be constantly on.
Tx: Tyrosine kinase inhibitors (imatinib).
CLL
Lymphadenopathy, hepatosplenomegaly. Needs PCP prophylaxis. Treat only the symptomatic. Predominate lymphocytes.
Dx: lymphocytosis, mature lymphocytes, smudge cells, flow cytometry.
Tx: Rituximab, monoclonal Ab for CD20 Antigen on B lymphocytes.
Hemolytic transfusion reaction
Heme pigment injury. From a clerical error (mismatched blood). <1hr, fever, chills, pain at the IV site, hypotension (from cytokine release), hemoglobinuria (dark urine), flank pain. Get an intravascular hemolysis (RBCs getting destroyed). Leads to Hb build up in the kidney, renal tubular cell injury and acute renal failure. Dx: Direct coombs test showing Ab coated RBCs. Tx: 1. Stop transfusion 2. IV normal saline (prevents kidney injury or DIC progression
Graft vs. Host
Within weeks Donor T cells
Rash, fever, GI symptoms,
pancytopenia (low cell counts).
Sleep apnea
Get low Cl.
Get chronic CO2 retention (makes acid).
kidney compensates and keeps HCO3. stopping the HCO3/Cl exchanger.
By increasing HCO3-, you decrease Cl-.
Hyperechoic
increase in echoes from pathologic changes in tissue density.
Positive Babinski
Big toe extends up and small toes fan out.
Syphilis
bilateral lymph nodes, 1 ulcer
Painless
secondary, involves the palms and soles
- Penicillin IM. 2. Doxycycline if Penicillin allergy
LGV – Lymphogranuloma Venereum: (lymphnode draining pus)
Chlamydia trachomatis. Painless, singular ulcer.
Then get +lymph node, tender.
Tx: Doxycycline.
Chancroid
H.Ducreyi. Painful ulcer, singular large 1-2cm.
gray/yellow exudate.
+ve lymph node (pusy node), tender.
Developing country, rare in US.
Dx: gram stain (GM negative rods) & clinical.
Tx: Azithromycin or Ceftriaxone.
FPG focal proliferative glomerulonephritis
From SLE
Mixed connective tissue disease
SLE + Scleroderma + Polymositis.
Anti-U1 ribonucleoprotein (RNP).
Phosphorus level
3.0-4.5 = normal
Acute interstitial nephritis (A.I.N)
NSAIDS, beta-lactams, PPIs.
Septic shock Tx.
- Broad spec ABX 2. Bolus the shit 3. Pressors.
A1c >9%
Start on Insulin.
S/E of Ondansetron (serotonin receptor antagonist)
Constipation
Pheochromocytoma
Young person. H/A, tachycardia, sweating/hot flashes, anxiety.
Catecholamines (epi, nore, dopamine) inhibit insulin secretion, leads to hyperglycemia
(Remember stress response leads to gluconeogenesis).
MEN1
3Ps (MEN gene problem)
Pituitary adenoma: prolactin, GH, ACTH, vision prob.
Primary HyperPTH: mltp adenoma or hyperplasia, HyperCa (Bone breaking down to release the Ca, Kidney stones, polyuria). Depression, poor sleep. Can cause HTN from increased renin secretion.
Pancreatic tumor: Gastrinoma or Insulinoma.
MEN2A
(RET proto-oncogene)
Medullary thyroid cancer (calcitonin, parafollicular C cells).
Pheochromocytoma.
Parathyroid hyperplasia.
MEN2B
Medullary thyroid cancer (calcitonin).
Pheochromocytoma.
Mucosal neuromas/marfanoid habitus.
If Pt has medullary thyroid cancer, check for ret gene before you do the thyroid surgery. Might have a pheochromocytoma undiagnosed and go into crisis.
Massive hemothorax
> 1500ml or >200ml/hr for 2 hours.
Mitral stenosis
Loud first heart sound (opening snap = early diastolic sound). The murmur itself, if the stenosis is mild, late diastolic. As the stenosis progresses, mid-diastolic.
Often a young person with rheumatic heart disease.
(atrial myxoma, the valve itself is healthy and therefore has no opening snap)
CHF long-term survival with systolic dysfunction
Metoprolol succinate, carvedilol, bisoprolol.
Sumatriptan = 5-HT agonist
Leads to vasoconstriction
statins & colchicine (Gout)
statins & colchicine (Gout) are direct myotoxins.
Get Rhabdo.
CPK >1000U/L
When to add a statin
TAG >150 mg/dL, increased cardiovascular risk
LDL >190 mg/dL
> 40yo with diabetes
> 7.5%
History of CVD
If high risk or has
Meglitinides (Repaglinide)
Insulin secretagogues.
Inhibits ATP-sensitive K channels on pancreatic beta-cells. Causes L-type Ca channels to open, similar to sulfonylureas.
Taken with meals, rapid onset and short duration of action. Good for controlling postprandial glucose levels. Good for patients that occasionaly have large meals or irregular dietary schedules.
Metabolized in the liver, good for patients with chronic kidney disease.
Won’t lead to hypoglycemia.
(Sulfonylureas have a longer duration of action and risk of causing fasting hypoglycemia).
HTN management
Goal BP >60yo <150/90mmHg. Add Rx if systolic >150 or diastolic >90.
Goal BP <60yo with CKD or DBM, <140/90. Add Rx if systolic >140 or diastolic >90.
Treatment choice:
If you’re black: Thiazide diuretic or CCB (alone or in combo). ACEI/ARB not first-line.
If you’re not black: Thiazide diuretic, ACEI, ARB or CCB. Alone or in combo.
If you’re not black & have CKD: ACEI or ARB (they are renal protective, they activate the RAAS system causing a decreased GRF by decreasing aldosterone).
BB are unfavorable in DM Pts, they affect insulin sensitivity.
Direct hernias
more common in older men
Post ERCP (for choledocystitis (blocking the common bile duct)) complication
Pancreatitis (mc).
HyperCa
causes fatigue, constipation & depression.
causes a nephrogenic diabetes insipidus. This is why the Tx of HyperCa is IV 0.9% hydration, they will be hypovolemic.
Atelectasis Day 2-5
shallow breathing causes poor recruitment of the lung bases.
hypoxia which stimulates increased respiratory rate (tachypnea). Causes low pCO2. Get low pCO2 & low O2.
Preoperative surgery ABX
based on how clean the wound is.
Clean wounds, worry about skin flora.
1st & 2nd Gen Cephalosporins.
If penicillin allergic (cephalosporins are structurally similar) Tx: Vancomycin or clindamycin.
Hepatic Hemangioma
MC benign liver tumor.
Triphasic CT shows centripetal enhancement (enhancement moving from periphery to center).
No central scar.
Found incidentally.
Hepatic adenoma
Benign liver tumor.
R lobe of liver.
Women on estrogen OCPs or pregnant women.
No centripetal enhancement on triphasic CT. No central scar present.
Elevated alk phos & GGT from compressing the biliary system. Normal LFTs.
Do not Bx, risk of bleeding.
Dx: Ab u/s showing a solid mass (solitary hyperechoic lesion, well demarcated).
Tx: Surgical excision.
Complication: Rupture leading to shock or malignant transformation.
Liver Focal nodular hyperplasia
MC benign nonvascular liver lesion.
Usually asymptomatic and incidental.
central stellate scar
Fills on arterial phase of CT.
Most <5cm, solitary lesion. Well-circumscribed, hyperdense lesion.
From hyperplastic response to hyperperfusion from a large artery at the center of the lesion (aberrant congenital artery).
Dx: Triphasic, helical CT scan.
Tx: Nothing, doesn’t grow. Don’t have to d/c OCPs.
Fe + Vitamin C
Take Fe with Vitamin C. because, Fe is best absorbed in acidic environment.
Fe if best on a empty stomach. Get constipation. Fe must be continuous for several months to replenish stores.
Cecal volvulus
congenital mobile cecum.
Needs emergent laparotomy & resection of volvulized segment (right colectomy)
Sigmoid volvulus: - coffee bean or inverted U
Chronic constipation leads to colonic dysmotility redundantly in the sigmoid colon
inverted U or coffee bean shaped
flexible sigmoidoscopy
endoscopic reduction of the twisted
Ogilvie syndrome (Acute colonic pseudo-obstruction)
cecum and ascending colon
Electrolyte imbalance can precipitate
Bowel rest/NPO & colonic decompression
Asthma management
Intermittent: <2days/wk symptoms or SABA use; <2x/month nighttime. awakenings. Tx: SABA: Albuterol, Pirbuterol.
Mild Persistent: >2days/wk not daily SABA; 3-4x/month nighttime. Tx: low dose inhaled steroid.
Moderate: Daily; >1x/wk at night. Tx: LABA salmeterol or formoterol.
Severe: every day; 4-7x/wk at night. Tx: Oral prednisone. Or others.
If Pt has no symptoms for 3 months, consider a step down therapy.
Bronchodilator response is >12% in FEV1
Nephrotic
> 3.5 g/dL / 24hr, hypoalbuminemia, edema, hyperlipidemia and lipiduria. Hypercoaguable (from losing antithrombin3, protein C & S imbalance), most common is renal vein thrombosis.
Primary glomerular: membranous, Focal segmental, minimal change.
Secondary: DBM, amyloidosis
Minimal change
If the child is <10, don’t do a Bx.
Tx. Emperic Prednisone-Corticosteroids.
Nephrotic
Focal segmental: MC nephrotic adults, teens & blacks. HIV, Heroin, Obese.
Membranous: 2nd MC nephrotic, solid cancers. Hep B (unvaccinated Pt, immigrant, HBsAg and HBeAg, negative anti-HBsAg Ab). MC to get renal vein thrombosis. HBeAg or antibody deposits in the glomeruli.
Minimal change: MCC kids <6yo, NSAIDS or lymphomas (Hodgkin) adults.
Long term O2 for COPD
PaO2 <55mmHg or SaO2 <88% on room air (55LB Plugs Offenses, 88 the wide receiver Score on Offense).
If RHF, start O2 a little earlier.
5-Fluoruracil & methotrexate
antimetabolite chemo drugs s/e: BMS, get a BX
Bleomycin s/e
Pulmonary fibrosis. Get PFTs.
TMP-SMX s/e
S/E: Hyper K, via inhibitors Na channels in collecting duct.
Macrolide s/e
S/E prolong QT and cholestasis
Non-seminoma (yolk, choricar, embryonal)
⬆︎ AFP & bHCG.
Seminoma
⬆︎ BHCG, norm AFP.
Ludwig angina
Cellulitis of submandibular (under mouth) space from dental infections in the mandibular molar. Spreads from the teeth root to the sublingual space. Polymicrobial. Displaces the tongue posteriorly. May lead to an acute airway obstruction.
Neck described as “woody” or “brawny”.
Next step: Secure the airway.
Dx: CT of neck.
Tx: IV ABX (ampicillin-sulbactam, clindamycin).
EPI
SE = SD/√N.
95% CI of mean = mean +- 1.96 *SE.
EPI
Disease status
Positive Negative
Exposure positive: a b
Exposure negative: c d
Odds and Probability are similar for rare diseases
PPV and NPV
+ve disease -ve disease
Positive test TP FP PPV
Negative test FN TN NPV
Sensitivity specificity
PPV = (TP/ (TP+FP)) if move cut-off point left, both TP & FP will increase. Therefore PPV will decrease. (use the alcohol example).
NPV = (TN/ (TN+FN))
PPV = what are the chances the person actually has the disease if the test is positive.
NPV = what are the chances the person does not have the disease given the negative test result.
high pretest prob (belongs to high risk group) of having a disease, will have low NPV
Number needed to harm
NNH= 1/AR.
AR: a/(a+b) – c/(c+d).
Number needed to treat
NNT=1/ARR (absolute risk reduction).
ARR of 4% = 0.04.
NNT=1/0.04.
ARR= Control Event rate – Experimental Event rate.
(Drug reduces the rate from 50 to 30%, ARR = 0.5-0.3 =0.2.
Attributable risk percent:
(When they take a study and ask you to compare it to a whole population).
The excess risk in a population that can be explained by exposure to a particular risk factor.
ARP=(risk exposed - risk unexposed)/risk exposed.
ARP=(RR-1)/RR.
casts
Muddy brown casts: ATN, hypovol shock. BUN/Cr <20:1.
Broad casts: Chronic renal failure.
RBC casts: glomerular disease or vasculitis.
WBC casts: pyelonephritis, acute interstitial nephritis (AIN).
Fatty casts: Nephrotic syndrome.
Lyme in kids <8yo or pregnant or lactating woman
No Doxy, give Amoxicillin
Rhogam
At 28-32 weeks and up to 72hrs of delivery.
High titers means immunized.
Aortic dissection
If has CKD or is unstable, to a transesophageol echo
Aspiration pneumonia
Tx.
Aspiration pneumonia:
Foul smelling sputum, poor dentition. Think gram negative anerobes.
Tx: Clindamycin, Augmentin (Amox-Clavulanate), Metronidazole + Amoxicillin, Carbapenem.
Anareobes make beta-lactamase inhibitors.
Internal Abscess
Tx
if <3cm fluid, IV ABX.
if >3cm, CT guided percutaneous drainage.
if 5th day not better, surgical drainage and debridement.
Hepatitis infection
HBsAg: surface antigen, first evidence of infection.
HBeAg: marker of viral infection & replication (can you infect someone).
IgM anti-HBcAg: Ab to core antigen.
IgM anti-HBc & HBsAg.
Acute HepB
HBsAg, HBeAg, IgM, Viral DNA.
Early phase
IgM, Viral DNA (HBsAg leave and waiting for anti-HBs to appear).
Window phase
IgG, Anti-HBs, Anti-HBe.
Recovery
HBsAg, IgG.
Chronic carrier
HBsAg, IgM, IgG, Viral DNA.
Chronic activated
Anti-HBs.
Vaccinated
Had in passed and cured
IgG (anti-HBc), Anti-HBs.
(vaccinated are anti-has and not anti-HBc, because the vaccine only had pieces HBsAg parts, it didn’t have the virus parts).
For asymptomatic or mild HyperCa (<12)
Tx
Bisphosphonates
Hydroxyurea s/e
Myelodepression
MCL Tear
won’t have hemarthrosis or tons of swelling
AAA
> 3cm = anneurysm
Risk of rupture >5.5cm
Leriche Syndrome
PAD at the bifurcation of the aorta
Tx HTN of PCKD
ACEI to inhibit RAAS
Hereditary telangiectasia (Osler-Weber-Rendu)
Auto Dominant. Telangiectasia, recurrent epistaxis, widespread AV malformations. Chronic disease, so clubbing. Telangiectasia can lead to AVMs, subject to high-pressure flows and risk of hemorrhagic stroke in a child.
ARDS
Will be bilateral. PaO2/FiO2 <300 mmHg. Risk factors infection, trauma (24-48hrs after), massive transfusion. ARDS = Noncardiogenic pulmonary edema. Leads to leakage of bloody and proteinaceous fluid into the alveoli. Alveoli will collapse due to a loss of surfactant. Leads to impaired v/q and decrease lung compliance (less stretchy). Leads to PAH from hypoxic vasoconstriction. PaO2 decreases meaning you need more FiO2. PaO2/FiO2 is decreased. PCWP in normal.
Tx: Mechanical ventilation with low TV ventilation to prevent overdistending the alveoli and causing a barotrauma (pneumothorax).
Tx: keep O2 >88% or PaO2 55-80. By increasing PEEP (15-20), not by inc FiO2.
Peak pressure
What happens to both when a pneumothorax
Measure of air flow from the ventilator
Plateau pressure
Measure of compliance, the ability to expand.
Graft vs Host
Problem is host Donor T cells and the patient’s MHC.
Graft rejection
Host T lymphocytes acting on the donor organ.
Acute rejection is the first 6 months. The organ will show signs of decreased function and tenderness.
Dx: Biopsy showing Tcell infiltration.
Tx: High dose IV steroids and adjust the dose of their immunosuppression meds.
Mitral Regurge
MVP mcc of Mitral Regurge in the US.
Tricuspid regurgitation
prominent V waves (persistent RA pressure). Holosystolic murmur L lower sternal boarder. 90% are secondary causes
Pulsus paradoxus:
Drop in systolic >10mmHg on inspiration or systolic BP that varies with respiration
Cardiac Tamponade (pressure on the pericardial sac, LV and RV have to compete), severe asthma or COPD
syncytiothrophoblastic giant cells. B-hCG high
Seminoma
Nonseminomatous germ cell tumor
Choriocarcinoma (B-hCG really high, really high), teratoma & yolk sac tumors (AFP).
Yolk sac tumors
An ovarian germ cell tumor. From cells that differentiate into fetal yolk sac and GI tract. Makes Alpha-fetoprotein
Lyme Tx Kid <8yo or pregnant
“Migrans travel to camping and get lyme”
No Doxy, Amoxicillin
Erythema Migrans is the rash.
Babesiosis
Maltese cross
North eastern part of USA. Tick bite. Intravascular hemolysis & anemia.
Dx: Blood smear for the Maltese cross.
Tx: 7-10 days of atovaquone + azithromycin or quinine + clindamycin (severe disease).
GERD Tx
Tx if symptoms <2x/wk: Lifestyle changes weight loss, elevate head of the bed & histamine 2 recepto antagonists Famotidine, Ranitidine.
Tx if severe or frequent symptoms: PPI = esomeprazole, omeprazole, pantoprazole for 8 weeks.
Emphysematous cholecystitis.
Feel crepitus in the abdominal wall.
Common in Pts that have immunosuppression (DM or >50yo) and vascular disease. U/s is less sensitive, hard to see air-filled structures.
Tx: Emergent cholecystectomy & broad spectrum parenteral ABX (piperacillin-tazobactam).
Hypoattenuating round lesion on u/s
Abscess
Entamoeba histolytic - amebiasis
Protozoan (No eosinophilia) cause colitis or liver, brain illness to people who live or travel to developing countries. From the consumption of contaminated food and water. Get a liver abscess (U/S: single, subcapsular, low-density lesion in R lobe (more portal blood supply)). Protozoa enter the colon, they spread to the liver via the portal supply. Some get Dysentery (bloody stools with mucus & Ab pain). Don’t drain the abscess. Prolonged diarrhea 2-3wks, that progresses to colitis (tenderness and bloody diarrhea). (No eosinophils).
Dx: Serology of stool E Histolytic antigen by PCR or enzyme immoassay.
Tx: 1. Metronidazole (for the abscess) & 2. Intraluminal ABX (paromomycin) to stop the intestinal colonization.
Dx: Stool ova & parasites.
(Giardia and prolonged diarrhea that is watery and has fat malabsorption, greasy smelly stools).
(Echinococcus has cysts, cysts need surgical drainage. Entamoeba causes an abcess and that needs ABX).
Echinococcus = Tape worm = cysts.
best predictors of lung function to survive post surgery
FEV1 & DLCO. Want greater than 40%.
PCP pneumocystis pneumonia
Dx & Tx
LDH is high. Can not be cultured, needs a special stain by bronchoalveolar lavage or sputum.
Tx: TMP-SMX + steroids if PaO2 <70 or A-a gradient >35 on room air(decreases mortality). 2nd line Dapsone + TMP or Primaquine + clindamycin. 3rd line Atovaqone.
As paCO2 ⬆︎,
CBF (cerebral blood flow) increase in brain , if CO2 is increased, send more blood to the brain
Meconium aspiration syndrome
Risk of pneumothorax. Meconium plugs the airway and prevents proper alveolar expansion leading to rupture
Coxsackie A
Coxsackievirus causes pericarditis and myocarditis.
Acne Tx order
- Topical retinoids or benzoyl peroxide
- Topical ABX erythromycin
- PO ABX tetracycline
Pertussis
really bad cough
Dx: Clinical during the cough. Lymphocytosis is a clue. PCR if need to confirm
Tx: Emperic Macrolide
Macrolide to all close contacts for 3 weeks. regardless of immunity status, vaccination can wane.
<1month old: Azithromycin for 5 days (erythromycin has risk of pyloric stenosis in neonates).
> 1month old: Any macrolide (erythromycin, azithromycin).
Hospitalize if <3 months old, risk of apnea. Respiratory isolation first 5 days of abx tx.
Prevented by: 5 doses of DTaP as a kid + Tdap booster at 11-12yo.
Wilms
WAGR: Wilms, Aniridia, GU problems, Retardation & Beckwith-Wiedemann.
Mets to lungs. WAGR syndrome = 11p deletion syndrome.
Dx: 1. Ab u/s 2. CT or MRI to confirm 3. Pathology.
Tx: surgery & chemo/radiation. Good survival rates.
VZV post exposure prophylaxis
VZV vaccine
Live vaccine
2 doses, age 1 & age 4. Postexposure prophylaxis for a child >1yo exposed in last five days, give the live vaccine.
If cannot receive live vaccine (neonate, immunocompromised, pregnant women), give varicella Ig (passive immunity). Effective for baby if mom got chicken pox 5 days before to 2 days after delivery.
Varicella is largely contagious via respiratory droplets, highly contagious. 2 weeks after exposure, Varicella has a prodrome of fever and malaise 24hrs before the rash. The vesicular rash will be in different stages.
Breakthrough virus is possible, (Eg. Question will give a 3yo, that hasn’t received the second dose of VZV vaccine).
VACTERAL Syndrome
Vertbral, Anal Atresia, Cardiac, Tracheoesophageal fistula, Renal, Limb
(Vacteral is anal atresia, charge is choanal atresia, missing eye piece and ear problems).(charge syndrome nose (choanal) is above the anus, c is before v).
CHARGE syndrome
C oloboma (missing eye part) H eart defects A treasia choanes R etardation of growth/development G enito-urinary anomalies E ar abnormalities.
a bunch of things don’t develop
Genetic testing if suspect CHARGE syndrome. Do an echo and renal u/s.
(if choanal atresia, make sure to investigate for charge syndrome
Acute bacterial rhino sinusitis
Causes
Strep pneumo, H influenza.
Prader-Willi syndrome
Dx: Karyotype & methylation studies. Then in-situ hybridization. Then microsatellite probes.
Tx: Obesity related, screen for OSA & DM.
Beckwith-Wiedemann syndrome
Alteration of chromosome 11p15 (has the gene for IGF2, monitor for hypoglycemia).
Risk for tumors like Wilms tumor and hepatoblastoma.
Next step: Abdominal u/s & AFP every 3 months birth to 4 yo. Renal u/s every 3 months age 4-8yo.
Hematopoietic stem cell transplant
For Wiskott-Aldrich and SCID.
Common variable immunodeficiency – CVID:
Abnormal B-cell differentiation. Problems with IgG and IgA, IgM or both.
Respiratory infections with encapsulated bugs (strep & Haemophilus). Get giardia.
Get failure to thrive and chronic respiratory problems (asthma or bronchiectasis). Increased risk of autoimmune disease and malignancies.
Presents later in age, teenager.
B cells normal (total lymphocytes (lymphocytes) – t cell lymphocytes (CD4 + CD8)= b cell lymphocytes).
Low Igs.
Tx: Avoid infections, there IV Ig infusions (replace what they don’t have).
Transient Hypogammaglobulinemia
Low IgG and normal Ab response to vaccines. Has a prolonged physiologic response. Seen after 6 months, when mom’s Abs wane. Asymptomatic or develop recurrent infections (otitis media, resp infections). Has asthma, eczema and food allergies. Normal WBC count.
Dx: Low IgG levels.
Tx: Self-resolves.
(X-linked agamma, Bruton. All Igs low, no Ig response to vaccines, low WBCs).
Neonatal Sepsis
Tx
Ampicillin & gentamicin
(because caused by GBS and want it broad spectrum).
For >1month empiric ABX is 3rd gen cephalosporin + vanco
Lennox-Gastaut syndrome
Age 3-5yo. Intellectual disability & severe seizures. EEG shows slow spike wave pattern.
Turner’s syndrome
Cardiovascular manifestations, bicuspid aortic valve, aortic root dilation, aortic coarctation and HTN. These increase the risk of aortic dissection
Sickle cell disease
from Salmonella (encapsulated, 2/3 of Pts with no spleen) & S.Aureus.
Glu to valine
Tx: Empiric Ceftriaxone (for Salmonella, GM-ve) and oxacillin or Vanco (for Staph A.)
Pseudomonas is not encapsulated.
Tuberous sclerosis complex
Infantile Seizure, Adenoma sebaceous (bumps on face). Skin involvement has hypopigmented macules, angiofibromas, shagreen patches or forehead plaques. Autosomal dominant (family hx). Neurocutaneous d/o or de novo mutation in TS complex genes (seizures). Leads to benign tumors (hamartomas) in the brain, skin and other organs. Eg. Brain hamartomas are subependymal nodules (giant cell tumor). High association with cardiac rhabdomyoma, get an Echo. The mass typically regresses after infancy. Mt in TSC1 or TSC2 gene.
Management: Serial skin and exams. Tumor surveillance. Neuropsych evals.
Sturge-Weber syndrome
Generalized seizures, mental retardation, port wine stain aka nevus flammeus (along trigeminal nerve 1st or 2nd branch, represents cavernous hemangioma aka capillary malformation). Gyriform intracranial calcification look like a tramline (leptomeningeal angiomatosis). Can also lead to vision problems if it hits the occipital lobe. Can get glaucoma.
Dx: MRI with contrast to see the intracranial vascular malformation.
Tx: Control the seizures and decrease intraocular pressure.
Measles (Rubeolla): longer word = more dangerous.
Airborne respiratory droplets (daycare, waiting rooms).
cough, coryza (runny nose), conjunctivitis, maculopapular rash spares soles (the rash can coaless & darken, blanching → nonblanching). Then a high fever (>105), cervical lymphadenopathy. NO arthritis.
Koplik spots (pathognomonic, small white lesions back mouth/buccal mucosa).
Vitamin A reduces morbidity and mortality for Pts with measles by promoting Ab cells and regeneration of epithelial cells (gut, lungs and eyes). So if Pt if vitA def or if Pt is hospitalized (severe measles), make sure you replace Vit A.
Dx: PCR showing rise in Abs.
Tx: Supportive care. Pts who are …
Measles vaccine is 2 doses (1 & 4 yo).
Rubella – German measles
Milder disease, (3 day measles)
Rash face to feet maculopapular (fine pink rash), the rash doesn’t darken. Posterior auricular, suboccipital, posterior cervical lymphadenopathy. Arthralgia (measles does not have arthralgias). Arthralgia & Arthritis is in teens and adults, can persist months after the rash. Long term complication: Subacute sclerosing panencephalitis (dementia). Symptoms 2-3 weeks after inhaling respiratory droplets. Some Pts have petechial or erythematous papules on the soft palate, Forchheimer spots. (No cough, choryza or high fever in Rubella).
Tx: Supportive.
Congenital Rubella (at birth):
Hearing loss, cataracts, PDA (machine-like murmur).
Prevented: Immunize at 1 & 4y.o.
Roseola
Exanthema subtile, 6th disease. (Human Herpes Virus) HHV6. Maculopapular rash after the fever resolves.
Rocky mountain spotted fever
Fever, rash & HypoNa Travel
Fever plus rash distal (palms/soles & wrist/ankles & initially maculopapular) → centripetally. Headache. Low platelets & hypoNa from ADH response to hypovolemia from vascular injury.
Transmitted via the bite of a tick infected with Rickettsia, a bacteria that causes vascular injury. Prevalent during the summer in the eastern and southeast US. Grassy or wooded areas.
Tx/Next step: Empiric Doxycycline. To confirm Dx with serology. Doxy will prevent disease progression and mortality.
Strawberries are bigger than cherries
Strawberry (capillary) hemangioma – Superficial infantile hemangioma
Benign capillary bed tumor. Rapidly grows in the first year of life, the spontaneously regresses during childhood.
Tx: BB Propranolol for complicated ones (Eg. on eye lid), it causes vasoconstriction or the vessels.
Cocaine withdrawal neonate
excessive sucking
hyperactive reflexes
jittery baby. less severe than opiate withdrawal
Chronic Granulomatous disease:
X-linked (boys). Catalase positive (S.Aureus, Aspergillus, serratia m, cepacia). GCD disease gets abscesses, lung and skin. Recurrent bacterial & fungal infections. Neutrophil problem for oxidative burst.
Problem with NADPH oxidase. Have decreased superoxide anions. Phagocytes can’t oxidize anything and granulomas form.
Dx: Dihydrohodamine 123 or Nitroblue tetrazolium test (oxidative burst testing of neutrophils).
Tx: Infection prevention. Need antimicrobial & antifungal prophylaxis with TMP-SMX. INF gamma injections also help.
(Strep pyogenes is catalase-negative. CGD is not left shifted).
Henoch-Schonlein purpura complication
intussusception
Butt and legs. Joint pain knees and ankles.
IgA immune-mediated vasculitis in kid after prev mild illness (URI). Ab pain and palpable purpura, arthralgia, renal disease (hematuria), scrotal pain. Normal platelet count. If Renal B/x, will see IgA in mesangium.
Tx: NSAIDS
Lead poisoning
Houses before 1978
confirm with venous lead.
Tx if screening lead levels >45: Chelate with Dimercaptosuccinic acid (succimer) & remove from house.
Tx if >70: Use EDTA.
D before E
Cystic Fibrosis related pneumonia
MCC in kids <20yo get Staph Aureus. Anticipate resistance with IV vancomycin
MCC >20yo: Pseudomonas (more resistant bacteria), come from all the abx exposure and their poor lung function.
Strep pneumo rarely causes pneumo in CF Pts (but MCC in healthy).
Transient tachypnea of newborn:
Respiratory distress in a full-term baby.
CXR: Bilateral perihilar linear streaking.
Langerhans cell histiocytosis
Histiocytes (macrophages in tissue)
CNS (get central diabetes insipidus, polyuria and hyperNa).
Dx: Biopsy.
Tx: Curettage or chemo.
Malrotation With Midgut Volvulus
Suspect in any neonate (28 days) vomiting bile. Duodenum ends up in R. abdomen. Bowel ischemia and perforation are complications. If shock or signs of ischemia, do emergency laparotomy.
Dx: 1. X-ray to r/u perforation, duodenal atresia or distal obstruction. Contrast upper GI series (barium swallow) to locate obstruction. Show ligament of trietz on R side of abdomen = malrotation. Contrast in a corkscrew patter = volvulus.
Tx: 1. Stop enteral feeds, NG decompression and IV fluids. 2. Surgery (volvulus gets reduced. If malrotation, Ladds procedure is done).
Desmopressin
= analogue of ADH.
Often used to treat central diabetes insipidus (missing ADH in brain).
It is also used to released vWF and treats heavy menstrual bleeding with vWbrand disease.
Desmopressin S/e: Hyponatremia from excess ADH stimulation (like an SIADH) (HypoNa, high urine osmolality, high urineNa (from increased natriuretic peptide release), euvolemia (no edema or JVD)).
Next step: Serum electrolytes.
Epiglottitis
H.flu type b, non-vaccinated. But Other H.flu strains, Strep and S.Aureus can also cause it (need vanco abx)
Fever, dysphagia, drooling, distress, hot potato voice, respiratory distress. Life threatening. Fast onset (hours), without notable prodrome.
PE: hyperextended neck, tripod position (leaned forward, hyperextended neck) = sign of impending respiratory problem. Risk of obstruction.
TX: 1. Endotracheal incubation in a controlled setting (ER, OR). If it fails, tracheotomy. 2. Broad spec ***Ceftriaxone (H. Influ & Strep) & Vancomycin (MRSA).
Prophylaxis rifampin for all family members to protect anyone exposed.
Don’t need Dx, if clinical suspicion is high, would delay treatment.
Laryngotracheitis = croup = Tracheitis = barky seal cough.
Barky the croupy seal.
Parainfluenza. Steeple sign on CXR.
Bark seal like cough, inspiratory stridor, improves on leaning forward, fever. No drooling. Gradual onset (days).
TX: 1. Dexamethasone (steroid) for mild cases to decrease the edema. 2. Nebulized racemic epi if stridor at rest. If all of that fails or if impending respiratory failure (AMS, poor breathing effort), then intubate (neb epi before intubating). No drooling.
Nebulized epinepherine: Constricts mucosal arterioles in the upper airway leads to decreased edema & reduced secretions. Observe the Pt for 4 more hours.
(Steroid, Racemic Epi, Intubate).
Laryngomalacia
Floppy larynx tissues collapsing on inspiration. Causes inspiratory stridor (mcc).
Worse when lying down. Prone position improves, because the tongue moves forward anteriorly (less obstruction). Exacerbated with feeding or URI. 4-8 months y.o. Crying and feeding make the stridor worse because of increased airflow. Some Pts will also have GERD.
Dx: Flexible fiberoptic laryngoscopy. Showing omega shaped epiglottis & supraglotic structures collapsing when breathe in.
Tx: spontaneously resolves by 18 months. If FTT (failure to thrive), surgery consult.
Legg Calve Perthes disease – idiopathic osteonecrosis of the femoral head
Idiopathic avascular necrosis of femoral capital epiphysis. Age 4-10. Gradual onset. But pain for >1month. X-ray can be negative. As progresses, internal rotation & abduction of hip joint limited. Proximal thigh atrophy. Antalgic gait. Pain can be referred to the thigh or knee. Boys.
Dx: Repeat X-rays (may be normal at first).
Tx: splinting or surgery. Refrain from weight bearing activities. Keep the femoral head in the acetabulum.
Slipped capital femoral epiphysis
Fat teen (not always, or accelerated growth, tall and thin teen). Hip or knee pain (referred pain). If not fixed, risk of avascular necrosis. Superior displacement of the proximal femur. Hypothyroid Pts too (normally TH allows for ossification of the growth plate). If a Pt gets SCFE at an early age, likely to develop bilaterally. Limited internal rotation.
Dx: Frog leg lateral X-ray. Look at both hips.
Tx: surgical pinning femoral head.
Mg toxicity – Magnesium toxicity
Tx
Ca gluconate to stabilize the cell.
Endometriomas on u/s
are unilocular adnexal masses with homogeneous low level/internal echoes (blood) or ground glass appearance
Abnormal uterine bleeding
Likely from uterus endometrial proliferation.
Dx: CBC, Pelvic U/S.
if >45yo: +Endometrial Bx.
if <45yo: First try combo OCPs (will build up and shed the lining). Then do an endometrial Bx.
If <45yo + Obese or + Tamoxifen: +Endometrial biopsy.
Ultimate Tx once r/o cancer: Endometrial ablation.
Urge incontinence
> 40 y.o, history of pelvic surgery. Sudden urge to void, then immediate loss of urine. Involuntary detrusor muscle spasms (overactive bladder). Detrusor over activity. Do a UA and post void residual first.
Tx:1. bladder training (resisting the urge) increases bladder capacity, kegels. 2. Oxybutynin (antimuscarinic) to relax the detrusor and spasms.
(oxybutynin, parasympathetic causes peeing, so antimuscarinic will decrease parasympathetics, and calm the overactive bladder).
Overflow incontinence
Neurogenic bladder (Eg. From Diabetes Mellitus) From diminished contractility of the bladder detrusor. Sx: Incomplete emptying & persistent involuntary dribbling (even at night). Path: Impaired detrusor contractility or bladder outlet obstruction. PVR (>150ml ♀ >50ml ♂) Tx: Peeing = parasympathetics, give cholinergics (bethanecol). “Bethan, call your bladder and tell it to pee”. If severe, intermittent catheterization.
Preterm labor
(Add penicillin if unknown GBS).
Contractions <37 wks, cervical dilation &/or effacement. Risk factors multiple gestations, hx of preterm delivery, hx cervical surgery.
If <34 weeks: tocolytics (indomethacin, nifedipine) to postpone delivery + corticosteroids (betamethasone).
If <32 weeks: tocolytics + corticosteroids + Mg Sulfate (week tocolytic & fetal neuroprotection, worried if deliver will have cerebral palsy).
Volvular Lichen sclerosus
Chronic inflammatory postmenopausal women (can be premenopausal girl too – from low estrogen). Can coexist with autoimmune conditions. Itchy and painful. Vulva thinning Porcelain-white polygonal patches. Cigarette paper like. Scratching can lead to scaring (thickened white vulvar plaques). Involves perianal region, figure 8. The labia minora and clitoral hood can eventually become atrophied which leads to atrophy of the vagina opening. It is premalignant, can lead to vulvar squamous cell carcinoma. The vagina (inside vestibule) itself will not be involved.
Dx: Vulvar punch biopsy to r/u malignancy (since it can become malignant).
Tx: High potency topical corticosteroids (clobetasol) (stop the chronic inflammation). Only once a day or skin atrophy, discoloration and striae. If refractory to treatment, get a biopsy, might be cancer.
Dx for kids: clinical no Bx needed.
Tx for kids: Give steroids.
LPlanus has a propensity to involve the mucous membranes including the mouth and vagina which are rarely affected in LSclerosis
vs. Lichen simplex chronicus is leathery skin from scratching.
