Review Flashcards
cutaneous drug reactions
- most cutaneous drug reactions are self-limited if DC’d
- triggers: foods, insect bites, drugs, enviro, exercise, infx
TYPE I: IgE MEDIATED (URTICARIA + ANGIOEDEMA)
TYPE II: CYTOTOXIC, AB-MEDIATED (drugs in combo w/ cytotoxic antibodies cause cell lysis)
TYPE III: IMMUNE ANTIBODY-ANTIGEN COMPLEX (drug-mediated vasculitis and serum sickness)
TYPE IV: DELAYED (CELL-MEDIATED) - morbilliform reaction (erythema multiforme)
- sx:
- EXANTHEMATOUS/MORBILIFORM RASH: MC SKIN ERUPTION - “bright-red” macules and papules that coalesce to form plaques; typically begins 2-14 days after med initiation (abx, nsaids, allopurinol, thiazides)
- URTICARIAL: 2nd mc type; occurs w/in minutes to hours after drug admin (abx, nsaids, opiates, radiocontrast)
- ERYTHEMA MULTIFORME: 3rd mc; target lesions may not always be present (sulfonamides, penicillins, phenobarbital, dilantin)
- FEVER, ABDOMINAL OR JOINT PAIN MAY ACCOMPANY THE CUTANEOUS RX
- less common: acneiform, eczematous, exfoliative, photosensitivity, vasculitis
- tx:
- discontinue offending med
- Exanthematous/Morbiliform –> oral antihistamines
- Drug-induced Urticaria/Angioedema –> SYSTEMIC CORTICO, ANTIHISTAMINES
- Erythema Minor –> symptomatic tx
- Anaphylaxis –> epi
erythema multiforme
- TYPE IV HSN - acute self-limited
- skin lesions usually evolve over 3-5 days and last 2 wks
- mc in young adults 20-40y
-Associations: HSV MC, mycoplasma (esp kids), S. pneumo, SULFA DRUGS, BETA-LACTAMS, PHYNYTOIN, PHENOBARBITAL, autoimmune, malignancy
- sx:
- TARGET LESIONS, DULL “DUSTY-VIOLET”, PURPURIC MACULES/VESICLES OR BULLAE in center w/ pale rim and red halo; OFTEN FEBRILE
- EM Minor: target lesions distributed acrally; no mucosal membrane lesions
- EM Major: target lesions w/ INVOLVE MUCOUS MEMBRANE (oral, genital or ocular), more central lesions, NO EPIDERMAL DETACHMENT
- tx:
- symptomatic: dc drug, antihistamines, analgesics, skin care
- oral: STEROID, lidocaine, diphenhydramine mouthwash
burns
rule of nines - not used for 1st degree
-palm = 1% of TBSA
Minor burns:
<10% TBSA in adults
<5% TBSA in young/old
<2% full-thickness burn
-must be isolated injury
-must not involve face, hands, perineum, feet
-must not cross major joints; must not be circumferential
Major burns: >25% TBSA in adults >20% TBSA in young/old >10% full-thickness burn -involve face, hands, perineum, feet -crossing major joints, circumferential burns
Rule of Nines head/neck = 9% total back and front upper limbs = 9% each trunk = 36% total back and front genitals = 1% lower limbs = 18% each
burns
First: superficial
- epidermis
- dry, red, tender to touch
- cap refill intact
- heals w/in 7 days, no scarring
Second: superficial partial-thickness
- epidermis and superficial dermis
- red/pink, moist, weeping, blistering
- most painful of all types
- cap refill intact
- heals 14-21 days, no scarring but pigment change
Second: deep partial-thickness
- epidermis into deep dermis
- red, yellow, pale white, dry, blistering
- not usually painful, decreased 2 point discrimination
- absent cap refill
- heals 3w - 2mo, scarring common (may need graft)
Third: full-thickness
- extends through entire skin
- waxy, white, leathery, dry
- painless
- absent cap refill
- heals in months, doesn’t spontaneously heal well
Fourth
- entire skin into fat, muscle, bone
- black, charred, eschar, dry
- painless
- absent cap refill
- doesn’t heal well, usually needs debridement of tissues and reconstruction
IV Fluid Resuscitation: PARKLAND FORMULA
-LACTATED RINGERS 4ml/kg/%TSA - IV first 24h
(1/2 in 1st 8 hours and other 1/2 over next 16 hrs)
macular degeneration
rf: >50yo, caucasian, F, smoker
- mc cause of permanent legal blindness in elderly >75yo
- macula responsible for central vision and detail/color
-MC dry (atrophic) type: gradual breakdown; DRUSEN = small, round, yellow-white spots on outer retina (accum of waste products)
-wet (neovascular or exudative): new, abnormal vessels grow under central retina and leak blood –> scars
(rare and faster progression)
-sx: bilateral blurred or loss of central vision (detail/color), scotomoas (blind spots), metamorphosia (straight lines appear bent), micropsia (objects look smaller)
retinal detachment
Rhegmatogenous MC type: retinal tear –> retinal inner sensory layer detaches from choroid plexus
- mc predisposing factors: myopia + cataracts
- sx: photopsia (flashing lights) –> floaters –> progressive unilateral vision loss (curtain coming down) in periphery initially –> central vision loss
- dx: fundoscopy = retinal tear, +shafer’s sign (clumping of brown pigment cells in anterior vitreous humor (“tobacco dust”)
- OPTHO EMER - keep supine, no drops –> laser, cryotherapy, ocular sx
ludwig’s angina
cellulitis of sublingual and submaxillary spaces in neck
- MC 2ry to dental infx (anaerobes)
- sx- swelling/erythema of upper neck and chin w/ PUS ON FLOOR OF MOUTH
- dx- CT SCAN
- tx- AMP/SULBACTAM (unasyn) or PCN + metro or clinda
cretinism
CONGENITAL HYPOTHYROIDISM due to maternal hypothyroidism or infant hypopituitarism
- sx- macroglossia, hoarse cry, coarse facial features, umbilical hernia, weight gain
- mental devo abnormalities if not corrected
-tx- LEVOTHYROXINE
thyroid storm (thyrotoxicosis crisis)
POTENTIALLY FATAL COMPLICATION OF UNTREATED THYROTOXICOSIS USUALLY AFTER A PRECIPITATING EVENT (surgery, trauma, infx, illness, pregnancy)
-RARE (1-2% w/ hyperthyroid, high mortality 75%)
- sx- HYPERMETABOLIC STATE: PALPITATIONS, TACHY, A-FIB, HIGH FEVER, N/V, PSYCHOSIS, TREMORS
- dx- INC FREE T3/T4, DEC TSH (may be undetectable)
Treatment is:
1) beta blocker (propranolol)
2) thionamide (propylthiouracil or methimazole)
3) iodine solution
4) glucocorticoids (supportive - inhibits peripheral conversion of t4 to t3 and impairs thyroid hormone production)
- AVOID ASPIRIN (causes increased T3/T4)
myxedema crisis
EXTREME FORM OF HYPOTHYROIDISM
-MC IN ELDERLY WOMEN W/ LONG STANDING HYPOTHYROIDISM IN WINTER
- patient will have acute precipitating factor (infx, CVA, CHF, sedative/narcotics) AND undiagnosed HYPO, noncompliance w/ HYPO meds
- patient will show severe signs of HYPO: BRADYCARDIA, obtunded, hypothermia, hypoventilation, HYPOGLYCEMIA, HYPONATREMIA, HYPOTN
-labs will look like HYPO –> inc TSH, dec T4/T3
- tx- IV LEVOTHYROXINE (give even w/ high suspicion)
- ICU ADMIT, treat underlying, PASSIVE WARMING
Riedel’s thyroiditis
FIBROUS thyroid
FIRM, HARD, “WOODY” NODULE, may devo HYPO
+/- surgery
osteogenesis imperfecta
genetic mutation for type 1 collagen (necessary for bone integrity) - assoc w/ severe osteoporosis, spontaneous frx in childhood, BLUE-TINTED SCLERAE + PRE-SENILE DEAFNESS
Addison’s Dz / Primary
ADRENAL GLAND DESTRUCTION (LACK OF CORTISOL AND ALDOSTERONE)
- AUTOIMMUNE: MC CAUSE INDUSTRIALIZED COUNTRIES –> CAUSES ADRENAL ATROPHY
- INFECTION: MC CAUSE WORLDWIDE (TB, HIV) –> CAUSES ADRENAL CALCIFICATION
- vascular: thrombosis or hemorrhage in adrenal gland
- metastatic dz
- medications: KETOCONAZOLE, RIFAMPIN, PHENYTOIN
- sx-
- HYPERPIGMENTATION (inc ACTH stimulation of melanocyte-stim hormones))
- Dec Aldosterone: ORTHOSTATIC HYPOTENSION, HYPONATREMIA, HYPERKALEMIA, NON-GAP META ACIDOSIS, HYPOGLYCEMIA
- Dec Sex Hormones in Women: loss of libido, amenorrhea, loss of axillary + pubic hair
- dx-
- screen w/ am cortisol??
- SCREEN FOR ADRENAL INSUFFICIENCY: HIGH DOSE ACTH (COSYNTROPIN) STIM TEST (blood or urine cortisol measured before and after IM injection ACTH)
- normal –> rise in blood/urine cortisol levels after ACTH
- ADRENAL INSUFFICIENT –> LITTLE/NO INC IN CORTISOL
- CRH STIMULATION TEST: differentiates btw causes of adrenal insufficiency
- PRIMARY/ADDISON (ADRENAL) –> INC ACTH BUT LOW CORTISOL (opposite)
- secondary (pituitary) –> low ACTH and cortisol
-tx- HYDROCORTISONE 1ST LINE + FLUDROCORTISONE
(hormone replace = synth glucocorticoid and synth mineralocorticoid)
-replace TT for women (adrenals only place it comes from, men have testes)
Cushing’s
cushing’s SYNDROME = SIGNS/SX RELATED TO CORTISOL EXCESS
cushing’s DISEASE = CUSHING’S SYNDROME CAUSED SPECIFICALLY BY PITUITARY INC ACTH SECRETION
- exogenous: IATROGENIC –> LONG TERM TX (MC CAUSE)
- endogenous: CUSHING’S DZ (BENIGN PITUITARY ADENOMA OR HYPERPLASIA –> SECRETES ACTH)
- ECTOPIC ACTH (secretes ACTH - small cell lung cancer)
- ADRENAL TUMOR - cortisol-secreting adrenal adenoma
- sx- 2ry to excess cortisol + glucocorticoids
- CENTRAL (TRUNK) OBESITY, MOON FACIES, BUFFALO HUMP, SUPRACLAVICULAR FAT PADS
- WASTING OF EXTREMITIES, PROXIMAL MUSCLE WEAKNESS, SKIN ATROPHY, STRIAE, inc infx, hyperpigmentation
- HTN, WEIGHT GAIN, HYPOKALEMIA, ACANTHOSIS NIG
- depression, mania, psychosis
- ANDROGEN EXCESS: hirsutism, oily skin, acne, inc libido, amenorrhea
- dx-
- SCREEN:
- LOW-DOSE DEXAMTEHASONE SUPPRESSION: nrml response is cortical supression; NO SUPPRESS = CUSHING’S SYNDROME
- 24 HOUR URINE FREE CORTISOL
- SALIVARY CORTISOL (usually at night)
- DIFFERENTIATING:
- HIGH-DOSE DEXAMETHASONE SUPPRESS –>
- SUPPRESSION = CUSHING’S DZ
- NO SUPPRESSION = ADRENAL OR ECTOPIC ACTH-producing TUMOR
ACTH LEVELS:
- DECREASED ACTH –> ADRENAL TUMORS (produce high levels of cortisol, suppressing ACTH levels via HPA axis)
- NORMAL/INCREASED ACTH –> CUSHINGS DZ OR ECTOPIC ACTH-PRODUCING TUMOR (secrete ACTH independent of HPA axis)
-tx-
-Cushing’s Dz (pituitary) –> TRANSPHENOIDAL SX (alt radiation)
-Ectopic ACTH-secreting or adrenal tumors –> SURGERY
(KETOCONAZOLE in inoperable pt, dec cortisol product)
-Iatrogenic steroid therapy –> GRADUAL STEROID TAPER
hyperaldosteronism
Primary: RENIN-INDEPENDENT
- idiopathic or bilateral adrenal hyperplasia, MC, women
- CONN’S SYNDROME: ADRENAL ALDOSTERONOMA
Secondary: DUE TO INCREASED RENIN
- INC RENIN –> 2ry INC IN ALDOSTERONE VIA RAAS
- MC DUE TO RENAL ARTERY STENOSIS or dec renal perfusion (CHF, hypovolemia, nephrotic syndrome)
- sx-
- HYPOKALEMIA: muscle weakness, polyuria, fatigue, dec DTR, hypoMg
- HYPERTENSION: HA, flushing, NOT EDAMATOUS
- dx-
- labs: HYPOKALEMIA W/ METABOLIC ACIDOSIS (due to dumping K and H in exchange for Na)
- Screen: ALDOSTERONE:RENIN RATIO
- Definitive: Saline Infusion Test
- CT/MRI - look for adrenal or extra-adrenal mass
- tx-
- Conn’s Syndrome: EXCISION + SPIRONOLACTONE (blocks aldosterone)
- Hyperplasia: SPIRONOLACTONE, ACEI, correct electros
- Secondary (renovascular htn): ANGIOPLASTY DEFINITIVE, ACEI
pheochromocytoma
CATECHOLAMINE-SECRETING ADRENAL TUMOR –> SECRETES NOREPI AND EPI AUTONOMOUSLY AND INTERMITTENTLY
- triggers: sx, exercise, pregnancy, meds
- 90% benign
- sx- HYPERTENSION!!!
- “PHE” - PALPITATIONS, HEADACHES, EXCESSIVE SWEAT
- dx- INC 24h URINARY CATECHOLAMINES
- MRI/CT to visualize adrenal tumor
- labs: hyperglycemia, hypoK
- tx- COMPLETE ADRENALECTOMY
- PREOP a-BLOCKADE: PHEnoxybenzamine or PHEntolamine x7-14d –> followed by BB to control HTN
- DON’T INITIATE THERAPY W/ BETA-BLOCKADE to prevent unopposed a-constriction during catecholamine released triggered by surgery or spontaneously (life threatening HTN)
*cocaine mimics same effect, same tx
hyperprolactinemia
PROLACTINOMAS MC CAUSE, hypothyroid, acromegaly, cirrhosis, renal failure
- DOPAMINE ANTAGONISTS (bc dopa inhibits prolactin) - metoclopramide, promethazine, prochlorperazine, SSRIs, TCAs, cimetidine, estrogen)
- pregnancy, stress, exercise
- increased prolactin inhibits gonadotropinRH –> dec FSH/LH
- women: oligomenorrhea, amenorrhea, galactorrhea, infertile
- men: impotence, dec libido, hypogonadism, infertility
-dx- TSH, BUN/Cr, LFTs, B-hCG, prolactin, +/-MRI
- tx- stop offending drugs
- CABERGOLINE or BROMOCRIPTINE 1ST LINE (dopa agonists inhibit prolactin)
- surgical tx in select pt
DKA
INSULIN DEFICIENCY + counterregulatory hormonal excess in DM as RESPONSE TO STRESSFUL TRIGGERS:
-INFECTION MC, INFARCTION, NONCOMPLIANCE W/ INSULIN, dose change, undiagnosed
- cortisol stress hormone –> inc glucose + patients can’t meet demand of inc insulin requirements
- YOUNGER PT W/ TYPE 1 DM
insulin deficiency –> hyperglycemia, dehydration, ketonemia (high anion gap meta acidosis), potassium deficit
-sx- HYPERGLYCEMIA, ABD PAIN, KETOTIC BREATH, KUSSMAUL’S RESPIRATIONS, weak, fatigue, confusion, tachy, hypoTN, decreased turgor
-dx- PLASMA GLUCOSE: >250 Arterial pH: <7.3 mild --> <7.0 severe Serum Bicarb: 15-18 mild --> <10 severe Ketones: POSITIVE Serum Osmolarity: varies
-tx-
initial: ABC, mental status, vitals, vol status, screen for precipitating event
-IV FLUIDS CRITICAL 1ST STEP –> ISOTONIC 0.9% NS UNTIL HYPOTN RESOLVES –> 0.45% NS –> D5 0.45 NS to prevent hypoglycemia from insulin tx
-when the blood glucose is < 200 mg/dL, treatment involves adding dextrose to the intravenous fluids
-INSULIN (REG) - lower serum gluc –> dec gluconeogenesis, recuced ketone production
-POTASSIUM: despite serum K levels, pt is always total body K deficient (correction of DKA will cause hypokalemia) If serum K high, wait til normal and then replete
+bicarb if severe acidosis
metabolic syndrome
- dx - at least 3 of the following:
- dec HDL: <40 men, <50 women
- inc BP: >135 systolic or >85 diastolic (or meds for BP)
- inc fasting trigs: >150 (or meds for trigs)
- inc fasting blood sugar: >100 (or drug tx)
- inc abdominal obesity: waist circ >40” men, >35” women
MEN-1
Rare inherited disorder of 1+ overactive endocrine gland tumors (3 P’s) - most tumors are benign (esp <30yo)
PARATHYROID (90%), PANCREAS (60%), PITUITARY (55%)
-MEN 2a (90%): MEDULLARY THYROID CARCINOMA, PHEOCHROMOCYTOMA, HYPERPARATHYROIDISM
- MEN 2b (5%): medullary thyroid carcinoma, pheochromocytoma, NEUROMAS, MARFANOID
- assoc w/ presence of mucosal neuromas, and have a more aggressive form of thyroid cancer (presents in infancy)
schizophreniform disorder
meets criteria for schizophrenia but <6 mo duration
personality disorders
A - “ALONE” - not w/ social norms
B - “BATSHIT” - erratic, wild
C - “CONCERNED” - anxious
schizoid personality - HERMIT, ANHEDONIA, FLAT
schizotypal - APPEARANCE, INAPPROPRIATE AFFECT OR SPEECH, “MAGICAL THINKING”
antisocial - DEVIATING FROM NORMS, MAY COMMIT CRIMINAL ACTS, MAY BEGIN IN CHILDHOOD AS CONDUCT DISORDERS
paranoid
borderline - UNSTABLE, UNPREDICTABLE MOOD AND AFFECT, UNSTABLE SELF IMAGE AND RELATIONSHIPS, HARM TO SELF
histrionic - SELF-ABSORBED, TEMPER TANTRUMS, CENTER OF ATTENTION, SEXUALLY PROVOCATIVE, SEDUCTIVE
narcissistic - INFLATED SELF-IMAGE - CONSIDERS SELF SPECIAL, ENTITLED, REQUIRES SPECIAL ATTENTION BUT FRAGILE SELF ESTEEM
avoidant - DESIRES RELATIONSHIPS BUT AVOIDS RELATIONSHIPS DUE TO “INFERIORITY COMPLEX”
dependent - CONSTANTLY NEES REASSURANCE, RELIES ON OTHERS FOR DECISION MAKING AND EMO SUPPORT
ocd personality
treat benzodiazepine intoxication?
cocaine intoxication?
alcohol withdrawal?
FLUMAZENIL
BENZODIAZEPINE, neuroleptics and blood pressure reduction
- IV BENZOS –> POTENTIATES GABA-MEDIATED CNS INHIBITION (etoh mimics gaba at receptors)
- IV FLUIDS + THIAMINE + MAGNESIUM (PRIOR TO GLUCOSE ADMIN), multivitamins (B12/folate) - intoxication may cause hypoglycemia
renal cell carcinoma
tumor of proximal convoluted tubule (v metabolically active so most prone to dysplasia)
parasympathetic = cholinergic (use acetylecholine) what effects?
constrict pupils, constrict bronchioles (inc secretions), decrease HR, dilate BV, increase GI mvmt and salivation, bladder contraction
aldosterone
inc aldosterone –> inc Na reabsorption (in exchange for inc secretion of K + H+) in collecting duct
-normal stimuli: HYPOvolemia and/or HYPERkalemia
acute glomerulonephritis
immunologic inflam of glomeruli causing protein and RBC leakage in urine; often after URI, GI infx or GABHS
aki phases
- oliguric (maintenance phase) (dec output <400ml/d, azotemia, hyperK, metabolic acidosis
- diuretic phase (inc output, hypotension, hypoK)
- recovery
pre-renal from hypoperfusion MC
acute tubular necrosis (intrinsic type of aki)
- epithelial, muddy brown +/- waxy casts (formed in damaged tubules)
- low specific gravity (unable to concentrate urine due to damaged cells)
- hyperK, inc phosphatemia
ADH = vasopressin
-inc secretion (posterior pituitary) in hypovolemia or hyperosmolar
SIADH - too much (and polycystic kidneys?)
diabetes insipidus - too little MC or not sensitive to it
hypotonic hyponatremia
TRUE hyponatremia
- kidney unable to excrete free water (make dilute urine, increased ADH)
- volume status gives clue to cause (hypovolemic, euvolemic, hypervolemic)
hypoMg
inc DTR tetany hypoCa (Mg needed to make parathyroid hormone) palpitations (due to associated hypoK) prolonged PR + QT interval TORSADES
hyponatremia and hypernatremia fluid rate
correct <0.5 mEq/L/h to prevent demyelination (hypo) or cerebral edema (hyper)
critical hyponatremia:
hypertonic saline + loop diuretic (furosemide)
-with neurologic symptoms require treatment with hypertonic (3%) saline.
hyperK
-repeat blood draw to verify not from venipuncture error
- IV calcium gluconate - stabilizes cardiac membrane if significant lab (>6.5) and ECG findings
- insulin w/ glucose to shift K intracellularly
- kayexalate (sodium polystyrene sulfonate) to enhance GI excretion
- beta-2 agonists (albuterol helps move K intracellular)
- lasix to rid extra through kidneys
- sodium bicarb
corrected serum sodium (high glucose) calculation
1.6 mEq/L to the sodium value for every 100 mg/dL of glucose above 100 mg/dL
corrected serum potassium in acidosis
subtracting 0.6 mEq/L from the initial potassium value for every 0.1 decrease in pH from 7.4
std tx
CHLAMYDIA
doxy 100mg x 10d
alt: azithro (1g po)
GONORRHEA
ceftriaxone 250 mg IM
Haemophilus ducreyi (painful ulcers + enlarged lymph nodes in groin)
ceftriaxone 250 mg IM
alt: azithro (1g po)
abortion
MIFEPRISTONE + MISOPROSTOL - safe up to 9 wks
- mifepristone given first (progestin antagonist)
- misoprostol 24-72 after (prostaglandin analog –> contract)
METHOTREXATE + MISOPROSTOL - safe up to 7 wks
- methotrexate, misoprostol 3-7 days after
- methotrexate is folic acid antagonist
prolactin-secreting pituitary adenoma
DEC FSH + LH, INC PROLACTIN (inhibits GnRH)
trichomonas
bacterial vaginosis
- FROTHY YELLOW-GREEN DISCHARGE
- STRAWBERRY CERVIX (CERVICAL PETECHIAE)
- pH >5
- tx-
- METRONIDAZOLE (2G X 1 DOSE) - PO PREFERRED
- MUST TREAT PARTNER
BV
- decreased lactobacilli (maintains pH) –> overgrowth of normal flora GARDNERELLA VAGINALIS, ANAEROBES
- MC CAUSE VAGINITIS
- sx-
- ODOR, itching, asymptomatic, discharge
- THIN, WATERY, GREY-WHITE, ROTTEN FISH SMELL
- pH > 5
- dx-
- WHIFF TEST = FISH W/ KOH PREP
- CLUE CELLS
- tx-
- METRONIDAZOLE X 7d OR CLINDA - dont need to tx partner
uncomplicated pregnancy
Uterus changes:
- LADIN’S SIGN: uterus softening after 6 wks
- HEGAR’S SIGN: uterine isthmus softening after 6-8 wks
- PISKACEK’S SIGN: palpable lateral bulge or softening of uterine cornus 7-8 wks
Cervix changes:
- GOODELL’S SIGN: cervical softening due to inc vascularization (about 4-5wks)
- CHADWICK’S SIGN: bluish color of cervix and vulva at 8-12 wks
gestational diabetes
RF: family or prior hx of gestational diabetes, spontaneous abortion, hx of infant >4000g at birth, multiple gestations, obesity, >25y, AA, Hisp, Asian/Pacific, Native
-caused by placental release of GH, corticotropin-releasing hormone and human placental lactogen (HPL) which antagonizes insulin
- dx-
- screen w/ 50G ORAL GLUCOSE CHALLENGE TEST AT 24-28 WKS –> IF >140 AFTER 1 HR –> 3HR GTT
-CONFIRMATORY (GOLD STD): 3 HR 100G GTT In am after overnight fast, positive if: -fasting >95 -1 hr >180 -2 hr >155 -3 hr >140
- tx-
- daily fingersticks overnight and after each meal, diet and exercise
- INSULIN TX OF CHOICE (DOESN’T CROSS PLACENTA)
- glyburide doesn’t cross placenta (higher risk eclampsia), metformin also safe
- LABOR/INDUCTION AT 35 WKS IF UNCONTROLLED / MACROSOMIA
*50% chance of devo Dm after pregnancy, >50% chance of recurrence w/ subsequent pregnancies
PPROM
premature labor (preterm labor) -Labor: regular uterine contractions (>4-6/hr) with progressive cervical changes before 37 weeks
- dx-
- cervical dilation >3cm, >80% effacement
- NITRAZINE PAPER TEST, FERN TEST
- PRESENCE OF FETAL FIBRONECTIN btw 20-34 weeks strongly suggests preterm labor
- L:S ration <2:1 = fetal lung immaturity
- tx-
- ANTENATAL STEROIDS (BETAMETHASONE) FOR LUNGS
- TOCOLYTICS TO SUPPRESS CONTRACTIONS (INDOMETHACIN, NIFEDIPINE, MAG SULFATE)
- abx prophylaxis (group b strep)
fungal infx
candida
cryptococcosis –> BIRD/PIGEON POOP
-AMPHO B + FLUCYTOSINE X2 WKS, THEN PO FLUCONAZOLE X10 WKS
histoplasmosis –> SOIL CONTAINING BIRD/BAT DROPPINGS IN MISSISSIPPI + OHIO RIVER VALLEYS
- MILD-MOD: ITRACONAZOLE 1ST LINE
- SEVERE: AMPHO B
Pneumocystis jirovecii (PCP pneumonia) –>
- BACTRIM - DOC x21 days +/- PREDNISONE IF HYPOXIC
- HIV PROPHYLAXIS IF CD4<200 –> BACTRIM
aspergillus –> Galactomannan levels (found in walls of aspergillus), BX: DUSKY, NECRTOIC TISSUE (NOSE); SEPTATE HYPHAE W/ REGULAR BRANCHING AT WIDE ANGLES
- ALLERGIC: TAPERED CORTICO, +/- ITRACONAZOLE
- SEVERE/INVASIVE: VORICONAZOLE DOC +/- sx debrid
- ASPERGILLOMA: SX SURGICAL RESECTION
mucormycosis –>-BLACK ESCHARS of nasal mucosa, palate + cyanosis, BX: NON-SEPTATE BROAD HYPHAE W/ IRREGULAR RIGHT-ANGLE BRANCHING
-IV AMPHO B 1ST LINE; may need sx debridement
blastomycosis –> OUTDOOR ACTIVITIES (AROUND SOIL OR DECAYING WOOD) IN CLOSE PROXIMITY TO WATERWAYS –> FLU-LIKE, PNM, skin VERRUCOUS, CRUSTED OR ULCERATED LESIONS
-ITRACONAZOLE 1ST LINE, AMPHO B IF SEVERE
coccidioidomycosis “valley fever” –> SOIL IN ARID/DESERT REGIONS OF SOUTHWESTERN US, MEXICO, SOUTH + CENTRAL AMERICA
- MOST CASES ASYMPTOMATIC/MILD AND SELF LIMITED
- FLUCONAZOLE FOR CNS DISEASE (AMPHO B IF SEVERE)
haemophilus influenza
- MC CAUSE EPIGLOTTITIS, 2ND MC CAUSE CAP
- often assoc w/ sinusitis, otitis media
- RF: underlying pulm dz; COPD, BRONCHIECTASIS, CYSTIC FIBROSIS, ETOH, DM, children <6 + elderly
-tx- AMOXICILLIN -Augmentin if postive for beta-lactamase -alt: FQ, Bactrim IV CEFTRIAXONE FOR EPIGLOTITIS, PNM, MENINGITIS
tularemia
FRANCISELLA TULARENIS - mc rodents + RABBITS
-SINGLE PAPULE AT SITE OF INOCULATION –> ULCERATION OF PAPULE W/ CENTRAL ESCHAR + TENDER REGIONAL LYMPHADENOPATHY
brucellosis
- MC lab acquired infection
- GOAT, SHEEP, CATTLE HOGS MC ANIMAL VECTOR
- ENDEMIC IN MEXICO
- transmission: handling infected tissues or INGESTION OF INFECTED UPASTEURIZED MILK + CHEESE
Q fever
- COXIELLA BURNETII - inhalation or ingestion
- EXPOSURE TO SHEEP, GOATS, CATTLE AND THEIR PRODUCTS (WOOL)
-TX: DOXY
plague
- YERSINIA PESTIS
- transmission: VIA INFECTED RODENTS + FLEAS, PERSON TO PERSON VIA DROPLETS; rare in US
BUBONIC: MC FORM (95%)
-ACUTELY SWOLLEN, EXTREMELY WARM, RED PAINFUL NODES (BUBOES) IN GROIN, AXILLA, CERVICAL
TX: STREPTOMYCIN OR GENT, prophylaxis doxy, tetra
trichinosis (trichinellosis)
- TRICHENELLA SPIRALIS - parasitic round-worm infx
- transmission: RAW OR UNDERCOOKED MEAT, ESP PORK, WILD BOAR, BEAR
- INCAPSULATE IN STRIATED MUSCLE TISSUE
- ALBENDAZOLE
HSV 1 + 2
- PCR MOST SENSITIVE/SPECIFIC, clinical dz
- TZANCK SMEAR: multi-nucleated giant cells and intracunclear inculsion bodies
cytomegalovirus (HHV 5)
BX of tissue: OWL’S EYE APPEARANCE
-GANCICLOVIR TX OF CHOICE
varicella zoster (HHV-3)
HERPES ZOSTER OPHTHALMICUS: involves 1st division of TRIGEMINAL NERVE (CN 5)
- HUTCHINSON’S SIGN: lesion on nose HERALDING OCULAR INVOLVEMENT
- DENDRITIC LESIONS seen on slit-lamp if keratoconjunctivitis is present
HERPES ZOSTER OTICUS (RAMSAY-HUNT SYNDROME):
-FACIAL NERVE CN 7 - otalgia, lesions on ear, auditory canal, TM, facial palsy, auditory sx
creutzfeldt-jakob disease
-PRION-MEDIATED DEGENERATIVE BRAIN DZ –> RAPIDLY PROGRESSIVE DEMENTIA (FATAL W/IN 1 YR)
HIV OPPORTUNISTIC INFX**
CD4 700-1,500 (1ST LN PROHYPLAXIS, 2ND LN)
-dz: Normal, Lymphadenopathy
CD4 >500
- dz: Tuberculosis (1st INH if latent; 2nd Rifampin)
- Kaposi Sarcoma, Thrush, Lymphoma, Zoster
CD4 <200
-dz: PNEUMOCYSTIS (PCP) (1st Bactrim; 2nd Dapsone)
CD4 <150
-Histoplasmosis - routine prophylaxis in select pt
(1st Itraconazole; 2nd AmphoB)
CD4 <100
-TOXOPLASMOSIS (1st Bactrim; 2nd Dapsone +)
-CRYPTOCOCCUS - routine prophylaxis in select pt
(1st Fluconazole; 2nd AmphoB)
CD4 <50
- MAC (1st Azithro or Clarithro; 2nd Rifabutin)
- CMV Retinitis (1st Valganciclovir; 2nd Ganciclovir + Fosc)
Others: Diarrhea (cryptosporidium, isospora, microspora), HPV
SIRS
systemic inflammatory response syndrome –> 2+ sx:
- temp >100.4 or <96.8 (>38 or <36)
- HR >90
- RR >20 or PaCO2 <32
- WBC >12K or <4K or >10% bands
SEPSIS = SIRS + suspected infx/source
SEVERE SEPSIS = sepsis + lactic acidosis (or SBP <90 or drop >40)
-organ dysfx, hypoTN, hypoperfusion
SEPTIC SHOCK = severe sepsis + hypoTN despite adequate fluid resuscitation
iron
-FE DEFICIENT ANEMIA: DEC SERUM FE, DEC FERRITIN, INC TIBC (use up stores –> dec ferritin, and inc bind capacity)
-ANEMIA OF CD: DEC SERUM FE, INC FERRITIN, DEC TIBC
(body makes more ferritin to pick up Fe from serum so not available for mo, binding capacity low bc most ferritins are occupied)
acute phase reactants
- DEC TRANSFERRIN + DEC TIBC –> anemia of chronic disease; transferrin an acute phase reactant aimed at decreasing Fe available for microbes, may also be decreased in iron-overload states
- INC FERRITIN: anemia of chronic disease (inc ferritin sequesters iron, reduce serum Fe levels available to bacteria)
- INC HAPTOGLOBIN: binds free hgb, reducing Fe available for mo
- INC CRP: marker inflam/infx –> causes mo destruction by inc opsonization (marking cell for destruction by macros)
- INC HEPCIDIN: prevents Fe release from macrophages, reducing Fe available for mo
anemia –> lab approach
- RETIC COUNT
- INC: brisk BM response to HEMOLYSIS OR BLOOD LOSS
- -> BLOOD LOSS: tissue or occult loss
- -> HEMOLYSIS: intrinsic/hereditary or extrinsic/acquired
-DEC: DEFICIENT RBC PRODUCTION (reduced BM response) –> LOOK AT MCV
–> MICROCYTIC (<80): IRON DEFICIENT, LEAD, THALASSEMIA, EARLY Anemia Chronic Dz
–> NORMOCYTIC (80-100): ANEMIA CHRONIC DZ, renal, mixed, endocrine, dilutional, early Fe deficiency
–>MACROCYTIC (>100): B12, FOLATE, liver dz, etoh, hypothyroidism; myelodysplastic syndrome, acute leukemia
-THINK THALASSEMIA IF MICROCYTIC ANEMIA W/ NORMAL OR INC SERUM FE OR NO RESPONSE TO INC IRON
Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency*
DENATURED HGB PRECIPITATES AS HEINZ BODIES which target them for destruction by spleen –> EPISODIC HEMOLYTIC ANEMIA
- Stressors: INFX MC, FAVA BEANS, SULFA DRUGS, ANTIMALARIALS, fluoroquinolones, nitrofurantoin, asa, mothballs
- sx- EPISODIC ACUTE HEMOLYTIC ANEMIA, SPLENOMEGALY
anemia types
hereditary spherocytosis (HS)* –> COOMBS NEGATIVE
autoimmune hemolytic anemia (AIHA)* –> COOMBS POS
-warm (CORTICO) or cold agglutinins (AVOID EXPOSE)
primary hemostasis
secondary hemostasis
DISORDERS THAT AFFECT PLATELETS WILL AFFECT PRIMARY HEMOSTASIS, bleeding time;
- PT + PTT USUALLY UNAFFECTED
- dz examples: thrombocytopenia (ITP, TTP, HUS, DIC, vWD)
- sx- PETECHIAE + MUCOCUTANEOUS BLEEDING
CLOTTING FACTORS respond in cascade to form FIBRIN STRANDS THAT STRENGTHEN THE PLATELET PLUG (from primary hemostasis)
- disorders affecting the EXTRINSIC PATHWAY –> PROLONGS PT and affecting the INTRINSIC PATHWAY –> PROLONGS PTT
- dz examples: hemophilia, DIC, vWD
- sx- DEEP DELAYED BLEEDING (HEMARTHROSIS) + DELAYED BLEEDING AFTER SURGERY
PTT (partial thromboplastin time)*
PT (prothrombin time)*
measures efficacy of INTRINSIC and common coag pathway
- normal PTT time requires Factors 1, 2, 5, –> 8, 9, 11, 12!
- PROLONGED: HEPARIN, DIC, vWD, HEMOPHILIA A/B
measures EXTRINSIC (tissue factor) pathway and common pathway
- normal PT times require Factors 1, 2, 5 –> 7 + 10!
- PROLONGED: WARFARIN TX, VITAMIN K DEFICIENCY, DIC
thrombotic thrombocytopenic purpura (TTP)*
hemolytic uremic syndrome*
idiopathic (autoimmune) thrombocytopenic purpura (ITP)*
- Primary TTP: IDIOPATHIC –> Ab vs. ADAMTS13
- Secondary TTP: malignancy, BM transplant, SLE, estrogen, pregnancy, HIV
- THROMBOCYTOPENIA (petechiae, bruising, mucocutaneous bleeding - skin, oral, epistaxis, GI/GU)
- MICROANGIOPATHIC HEMOLYTIC ANEMIA (anemia, jaundice, fragmented rbc/schistocytes on smear)
- KIDNEY FAILURE/UREMIA (not as common)
- NEURO SX (HA, CVA, AMS)
- FEVER (rare)
- PLASMAPHERESIS TX OF CHOICE
- IMMUNOSUPPRESION - CORTICOSTEROIDS
PLATELET ACTIVATION BY EXOTOXINS –> platelets get depleted –> thrombocytopenia
- MC W/ CHILDREN; usually preceded by ENTEROHEMORRHAGIC E.COLI 0157, SHIGELLA OR SALMONELLA *suspect in children w/ renal failure w/ diarrhea prodrome
- adults: seen w/ HIV, SLE, antiphospholipid synd
- THROMBOCYTOPENIA (petechiae, bruising, purpura)
- MICROANGIOPATHIC HEMOLYTIC ANEMIA (anemia, jaundice, fragmented rbc/schistocytes on smear)
- KIDNEY FAILURE/UREMIA (MORE COMMON THAN TTP)
- lacks fever and neuro sx seen in TTP but labs similar
- OBSERVATION IN MOST (IV fluids for renal perfusion)
- PLASMAPHERESIS +FFP if severe, or complications
- ABX MAY WORSEN CONDITION (INC VEROTOXIN RELEASE BC OF CELL LYSIS)
Autoimmune Ab reaction vs platelets –> spleen destroys platelets (often after acute infection - virus)
- secondary: imm-mediated, assoc w/ SLE, HIV, HCV
- acute: MC CHILDREN AFTER VIRUS
- chronic: MC IN ADULTS (often recurs), F <40y, M >70y
- INC MUCOCUTANEOUS BLEEDING: purpura, bruises, petechiae, epistaxis, menorrhagia, bleeding gums
- ISOLATED THROMBOCYTOPENIA W/ NORMAL PT/PTT
- transfusion of platelets on if <20K to prevent spontaneous intracranial hemorrhage (only if bleeding after cortico + ivig)
disseminated intravascular coagulation (DIC)*
PATHOLOGICAL ACTIVATION OF COAGULATION SYSTEM –> WIDESPREAD MICROTHROMBI (consumes coag proteins) + platelets
- INFX: GRAM NEG SEPSIS MC
- MALIGNANCIES - AML, lung or GI cancer, prostate ca
- OBSTETRIC - preeclampsia, abruption, septic abortion
- massive tissue injury (burns), liver dz, viral, aortic aneurysm
- WIDESPREAD HEMORRHAGE –> VENIPUNCTURE SITES
- THROMBOSIS - renal, hepatic, resp dysfx, GANGRENE
- dx-
- INC THROMBIN FORMATION: DEC FIBRINOGEN, INC PTT/PT/INR, SEV THROMBOCYTOPENIA
- Smear: fragmented RBC/schistocytes
- INC FIBRINOLYSIS = INC D-DIMER
-treat underlying cause! FFP IF SEVERE BLEEDING +/- platelet transfusion
hodgkin’s lymphoma*
non-hodgkin’s lymphoma
- PAINLESS LYMPADENOPATHY - ALCOHOL MAY INDUCE LYMPH NODE PAIN!
- SYSTEMIC “B” SX: (advanced dz) PEL-EBSTEIN FEVER (cyclical fever 1-2 wks), NIGHT SWEATS, WT LOSS, anemia
- EXCISIONAL BIOPSY –> REED-STERNBERG CELL PATHOGNOMONIC “OWL EYE” APPEARANCE
- MEDIASTINAL LYMPHADENOPATHY - PET/CT scan to stg
*HODGKIN’S LYMPHOMA HIGHLY CURABLE COMPARED TO NON-HODGKINS
Lymphocyte neoplasm: diffuse B cell, T cell, follicular
- MC >50y; RF: INC AGE, IMMUNOSUPPRESSION
- PERIPHERAL LYMPH NODES MC
- PAINLESS LYMPHADENOPATHY –> EXTRANODAL SITES COMMON (GI, SKIN, CNS MC)
- BURKITT LYMPHOMA - often presents w/ abd pain (sporadic), jaw involvement - histology “starry sky”
- Systemic “B” sx: fever, night sweats, WL, anemia, pruritis rarer in NHL
blood cancer buzzwords
waldenstrom macroglobulinemia –> B CELL lymphoma –> produces IgM –> DUTCHER BODIES
-hyperviscosity and blood oozing from mouth/nose
multiple myeloma –> proliferation PLASMA CELLS –> INC MONOCLONAL AB (ESP IgG and IgA) –> LYTIC LESIONS, HYPERCA, ANEMIA, KIDNEY FAILURE –> BENCE JONES PROTEINS, ROULEAUX FORMATION
ALL –> lymphoid stem cells in BM –> MC CHILDHOOD
–> Pancytopenia, FEVER MC, HEPATOSPLENOMEGALY
HYPERCELLULAR W/ >20% BLASTS; WBC: 5-100K
AML –> -MC ACUTE FORM LEUKEMIA >50yo –> PANCYTOPENIA, SPLENOMEGALY, GINGIVAL HYPERPLASIA –> >20% BLASTS (WBC)
+AUER RODS, TUMOR LYSIS SYND
CML –> OLDER MALES, >50y –> PHILADELPHIA CHROM
-WBC > 100K, acute: >30% blasts
CLL –> -B CELL, MC LEUKEMIA IN ADULTS OVERALL –>
-FATIGUE MC, –> SMUDGE CELLS (fragile B cells), WELL-DIFFERENTIATED LYMPHOCYTES
polycythemia vera (primary erythrocytosis)*
JAK2 MUTATION
PRIMARY ERYTHROCYTOSIS = INC HCT W/OUT HYPOXIA
DUE TO INC RBC: HYPERVISCOSITY OR THROMBOSIS
- ha, dizzy, tinnitus, blurred vision, PRURITUS ESP AFTER HOT BATH, fatigue
- ERYTHROMELALGIA: episodic burn/throb of hands/feet w/ edema
- SPLENOMEGALY, FACIAL FLUSH
-INC HGB/HCT AND WBC, PLATELETS (secondary polycythemia - wbc and platelets normal)
hand/wrist fractures
colles fracture –> FOOSH w/ wrist extension –> transverse distal radius fracture –> bone fragment angles posterior
smith fracture –> FOOSH w/ wrist flexion –> transverse distal radius fracture –> bone fragment angles anterior
complex regional pain syndrome (CRPS) aka reflex sympathetic dystrophy
-autonomic dysfx following bone or soft tissue injuries, MC upper extremities
Stage 1: pain out of proportion, ANS sx (swelling, color change, inc nail/hair growth)
Stage 2: waxy or pale skin, brittle nails, loss of hair
Stage 3: joint atrophy and contractures
-Vitamin C prophylaxis after frx may reduce incidence
finger deformities
mallet (baseball) finger –> flexed at DIP joint, unable to extend
boutonniere deformity –> flexed at PIP joint, hyperextended at DIP jt
swan neck –> hyperextended at PIP and flexed DIP
gamekeeper’s (skier) thumb –> sprain/tear of ulnar collateral ligament of thumb (forced hyper-abduction of thumb)
boxer’s frx –> fracture at neck of 5th metacarpal (+/- 4th) from punching w/ clenched fist (maybe loss of knuckle on exam)
bennett fracture (and rolando's) --> intraarticular fracture through base of 1st metacarpal bone (one side of base) --> rolando's frx: comminuted bennett's fracture (both sides of base)
hip issues
DISLOCATION –> posterior MC (90%) - leg shortened, internally rotated and adducted w/ hip/knee slightly flexed
FRACTURE –> leg shortened, externally rotated, abducted
legg-calve-perthes disease –> idiopathic avascular osteo of femoral head in kids –> mc children 4-10y, 4x mc in boys - painless limping x weeks (worse w/ activity)
slipped capital femoral epiphysis –> -slips posterior and inferior at growth plate –> mc 7-16 yo, obese, AA males during growth spurt - tx non-weight bearing crutches –> ORIF
ottawa ankle rules
ankle films:
pain along lateral malleolus, pain along medial malleolus
foot films:
navicular (midfoot) pain, 5th metatarsal pain
inability to walk >4 steps at injury + in ER
foot fractures
jones fracture –> transverse frx through diaphysis of 5th metatarsal –> *repeat xrays bc often NONUNION
-tx- no weight-bearing 6-8wks
pseudo jones fracture –> transverse avulsion fracture at base of 5th metatarsal (less serious –> walking cast 2-3w
lisfranc –> disruption vtw articulation of medial cuneifrom and base of 2nd metatarsal + FLECK SIGN (frx at base of 2nd metatarsal - pathognomonic) –> ORIF, cast 12 wks
herniated disc
MC L5-S1 bc jx btw mobile and non-mobile spine (also L4-L5)
sx- pain in dermatomal pattern (inc w/ cough, strain, bend, sit), sciatica
exam- pos straight leg raise +/- pos crossover test,
spondylolysis
pars interarticularis defect from either failure of fusion or stress fracture (often from repetitive hyperextension trauma i.e. football, gymnastics)
- often 1st step to spondylolisthesis
- MC back pain in children and adolescents
- MC at L5/S1
- tx- sx relief, activity restrict, PT, brace
SPONDYLOLISTHESIS - FORWARD SLLIP OF VERTEBRAE (MC 10-15Y)
compartment syndrome
inc intracompartmental pressure >30-45 mmHg
ewing sarcoma
giant cell tumor mc in children (mc males 5-25y)
-FEMUR MC and pelvis mc sites (bone also mc site of metastasis)
-dx- lytic lesion, layered periosteal rx “onion skin” on xray
+/- codman’s triangle
paget disease (osteitis deformans)
abnormal bone remodeling + disorganized osteoid formation –> larger, weaker, less compact bones, more vascular and prone to fractures
-lytic phase (inc osteoclast) –> mixed phase –> sclerotic phase (inc osteoblast)
- sx- HIGH ALK PHOS on labs
- skull involvement, deafness (seen in up to 50% due to compression of CN8)
- dx- “blade of grass/flame-shaped” lucency, coarsened trabeculae; skull = cotton wool appearance
- tx- BISPHOSPHONATES
polymyalgia rheumatica
idiopathic inflam condition causing synovitis, bursitis + tenosynovitis –> pain/stiffness of the proximal joints
-closely related to GIANT CELL ARTERITIS
polymyositis + dermatomyositis
idiopathic inflam muscle dz of proximal limbs, neck, pharynx; may affect heart, lungs +; GI
PROGRESSIVE SYMMETRICAL PROXIMAL MUSCLE WEAKNESS (usually painless)
-dysphagia, skin rash, polyarthralgias, muscle atrophy
+ANTI-JO 1 AB, GOTTRON’S PAPULES - raised violaceous scaly knuckle eruptions
+ANTI-SRP AB (signal recognition particle ab) - almost exclusively seen with PM
+ANTI-MI-2-AB (specific for dermatomyositis)
-muscle biopsy
DERMATOMYOSITIS
-HELIOTROPE (blue/purple) EYELIDS, GOTTRON’S PAPULES (raised, purple eruptions on knuckles), poikiloderma, alopecia, malar rash includes nasal labial f
OA v RA
OA
- EVENING STIFFNESS -worsens throughout day
- HARD BONY JOINTS = osteophytes
- HEBERDEN’S NODE (palpable osteophytes @ DIP jt)
- BOUCHARD’S NODE - PIP osteophytes
RA
- SMALL JOINT STIFFNESS - MCP, wrist, PIP, knee, MTP, shoulder, ankle
- MORNING JOINT STIFFNESS > 60 MIN after mvmt
- SYMMETRIC ARTHRITIS - swollen, tender, red, boggy
- BOUTONNIERE deformity, SWAN NECK deformity, ULNAR DEVIATION at MCP jt
behcet’s
multisystemic autoimmune disorder char by RECURRENT, PAINFUL ORAL AND GENITAL ULCERS (aphthous), erythema nodosum, eye (uveitis, conjunctivitis), arthritis + CNS involvement
eosinophilic granulomatosis w/ polyangiitis (EGPA-CHURG-STRAUSS)
granulomatosis w/ polyangiitis (GPA - WEGNER’S)
small vasculitis of arteries + veins w/: ASTHMA HYPEREOSINOPHILIA CHRONIC RHINOSINUSISITS \+P-ANCA
small vessel vasculitis w/ granulomatous inflam
-UPPER RESP TRACT/NOSE SX, saddle-nose deformity, refractory sinusitis
-LOWER RESP TRACT/LUNG SX
-RENAL: GLOMERULONEPHRITIS
+C-ANCA
boerhaave syndrome
FULL THICKNESS RUPTURE OF DISTAL ESOPHAGUS, assoc w/ REPEATED, FORCEFUL VOMITING or perf during endoscopy
- sx-RETROSTERNAL CHEST PAIN WORSE W/ DEEP BREATHING OR SWALLOWING, hematemesis
- CREPITUS ON CHEST AUSCULTATION due to PNEUMOMEDIASTINUM
PLUMMER-VINSON SYNDROME
dysphagia, esophageal webs, iron def anemia, atrophic glossitis
bilirubin metabolism
prehepatic:
- bilirubin produced from heme metabolism (80% old RBC, 20% turnover immature RBC, myoglobin)
- heme degraded by macrophages in liver + spleen
- heme –> biliverdin (green) –> bilirubin (red-orange) –> sent to liver for conjugation and excretion
- uncongjugated (indirect) bilirubin isn’t soluble in water
intrahepatic phase:
- unconjugated/indirect bilirubin is conjugated w/ a sugar in hepatocytes via enzyme GLUCURONOSYLTRANSFERASE (UGT)
- conjugated (direct) bilirubin is now water soluble (for bile excretion)
posthepatic phase:
- once soluble in bile, transported and stored in GB
- in intestine, conj bili is converted to urobilinogen which can go through 3 main pathways:
1. oxidized by intestinal bacteria into stercobilin (gives stool brown color)
2. small amount converted in kidney to urobilin and excreted (gives urine yellow color)
3. some recycled back to liver & bile for reuse - in dz where excess direct bilirubin –> excreted into urine (why dark urine and light stools are seen in elevated direct/conj bilirubin)
- in hemolysis (inc unconj/indirect bilirubin,) urine may be dark due to hemoglobinuria not bilirubinemia
dubin-johnson syndrome
"Dubin", "Direct bilirubinemia" "Dark liver" hereditary conjugaed (direct) hyperbilirubinemia due to dec hepatocyte excretion
crigler-najjar syndrome
hereditary unconjugated hyperbilirubinemia (0.6-1.0/million)
- glucuronosyltransferase (UGT) is enzyme needed to convert indrect to direct
- Type I: no UGT activity (auto recessive)
- Type II: very little UGT activity <10% normal
-sx- neonatal jaundice w/ severe progression in the 2nd week leading to kernicterus (bili-induced encephalopathy) –> hypotonia, deafness, oculomotor palsy + death by 15 mo
GILBERT’S SYNDROME
hereditary unconjugated hyperbilirubinemia (relatively common 5-10% pop)
-reduced UGT activity –> dec bili uptake –> inc indirect bili
-sx- TRANSIENT EPISODES OF JAUNDICE DURING STRESS, FASTING, ETOH OR ILLNESS
meckel’s diverticulum
persistent portion of embryonic vitteline duct (yolk stalk)
-rule of 2’s: 2% of pop, 2 feet from ileocecal valve, 2% symptomatic, 2” length, 2 types of ectopic tissue, 2 years MC age at presentation, 2x mc boys
- ectopic pancreatic or gastric tissue may secrete digestive hormones –> bleeding
- usually asymptomatic; PAINLESS RECTAL BLEED OR ULCERATION; may cause intussusception, volvulus or obst
- dx- Meckel’s scan looks for ectopic gastric tissue in ileal area
- tx- surgical excision if symptomatic
vit c (ascorbic acid) deficiency
- SCURVY: 3 “H”s
- Hyperkeratosis: hyperkeratotic follicular papules
- Hemorrhage: vascular fragility (abn collagen) w/ recurrent hemorrhages in gums, skin (perifollicular) and joints; impaired wound healing
- Hematologic: anemia, inc bleeding time
vit B2 (riboflavin) deficiency
ORAL-OCULAR-GENITAL SYNDROME
- oral: lesions, MAGENTA COLORED TONGUE, ANGULAR CHEILITIS
- ocular: photophobia, corneal lesions
- genital: scrotal dermatitis
B12 (cobalmin) deficiency
animal foods primary source; binds to IF in stomach for later absorption in terminal ileum
- PERNICIOUS ANEMIA: AUTOIMMUNE DESTRUCTION OF GASTRIC PARIETAL CELLS that secrete IF = B12 def
- STRICT VEGANS (B12 must be supplemented)
- MALABSORPTION: ETOH-ISM, CELIACS, CROHN’S
- dec IF production: acid-reducing drugs, bypass
- sx- NEURO: PARESTHESIAS, GAIT ABNORMAL, MEMORY LOSS, DEMENTIA, GI SX
- tx- IM B12 for pernicious (won’t absorb oral)
diarrhea
PROTOZOAN
GIARDIA LAMBLIA
- remote streams/wells “backpacker’s diarrhea”
- FROTHY, GREASY, FOUL DIARRHEA
- fluids and metronidazole, FURAZOLIDONE KIDS
AMEBIASIS
- entamoeba histolytica transmitted by fecal soil/water
- AMEBIC LIVER ABSCESSES
- metronidazole
BACTERIAL
TROPHERYMA WHIPPELII (whipples dz) overgrowth
- mc farmers around contaminated soil, osmotic
- MALABSORPTION - RHYTHMIC MOTION OF EYE MUSCLES WHILE CHEWING
- PCN or tetracycline for 1-2 years
YERSINIA ENTEROCOLITICA
- contaminated pork, milk, water, tofu
- MIMIC ACUTE APPENDICITIS
- FLUIDS, if severe –> FQ, bactrim
SALMONELLA
- poultry products, exotic pets (turtles)
- SICKLE CELL
- MUCUS + BLOODY DIARRHEA
- TYPHOID -PEA SOUP STOOLS, INTRACTABLE FEVER,
- FLUIDS +/- FLUOROQUINOLONES, ceftriaxone, bactrim
SHIGELLA
- LOWER ABD PAIN, EXPLOSIVE WATERY D –> BLOODY/MUCUS -may lead to toxic megacolon, complications include reactive arthritis +/- FEBRILE SEIZURES IN CHILDREN
- FLUIDS; severe –> BACTRIM 1ST LINE, FQ
CAMPYLOBACTER ENTERITIS
MC BACTERIAL ENTERITIS in US - contaminated food
MC ANTECEDENT EVENT IN POST-INFX GUILLAIN-BARRE SYNDROME. -diarrhea watery –> bloody
-S, COMMA, OR SEAGULL SHAPED
-ERYTHROMYCIN 1ST LINE, fq, doxy
ENTEROTOXIGENIC E.COLI
MC cause TRAVELER’S DIARRHEA –> unsanitary H2O/fruit
-FLUIDS, +/-BISMUTHS; severe –> FQ
VIBRIO CHOLERAE
diarrhea: contaminated food/water; poor sanitation, overcrowding conditions (esp abroad)
- RICE WATER STOOLS -gray, no fecal odor or pus
- fluid replacement +/- TETRACYCLINES, FQ
CHA2DS2 - VASc Criteria
(anti-coag risk stratification in nonvalvular a-fib)
2+ = moderate to high risk - chronic oral anti-coag rec
congestive heart failure - 1 hypertension - 1 age 75+ - 2 diabetes - 1 stroke, tia, thrombus - 2 vascular disease (prior mi, aortic plaque, pad) - 1 age 65-74 - 1 sex female - 1
angiogram
GOLD STANDARD / definitive dx for:
- coronary artery dz
- peripheral arterial dz
- renal artery stenosis
- abdominal aortic aneurysms
pharmacologic stress test
MPI: Vasodilators w/ MPI: ADENOSINE OR DIPYRIDAMOLE (dilate normal vessels, not diseased)
- C/I IN BRONCHOSPASTIC DZ (asthma and copd), 2/3rd degree heart block or sick sinus syndrome
- AVOID VASOCONSTRICTORS 24 HR BEFORE (caffeine)
Stress ECHO: DOBUTAMINE
acute coronary syndrome
SX OF ACUTE MYOCARDIAL ISCHEMIA 2RY TO ACUTE PLAQUE RUPTURE AND VARYING DEGREES OF CORONARY ARTERY THROMBOSIS (OCCLUSION)
-Includes: UNSTABLE ANGINA, NSTEMI AND STEMI
Unstable Angina
- angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
- thrombosis: subtotal occlusion
- ECG: ST DEPRESSION and/or T-wave inversions
- cardiac enzymes: NEG
NSTEMI
- angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
- thrombosis: subtotal occlusion
- ECG: ST DEPRESSION and/or T-wave inversions
- cardiac enzymes: POS (cell death)
STEMI
- angina that is new, crescendo, or at rest >30 min (90% occlusion can cause sx at rest)
- thrombosis: TOTAL occlusion
- ECG: ST ELEVATIONS
- cardiac enzymes: POS
etiologies:
- ATHEROSCLEROSIS (MC CAUSE) –> PLAQUE RUPTURE
- CORONARY ARTERY VASOSPASM: cocaine, variant (prinzmetal angina)
symptoms:
- angina pain (>30 min), not relieved w/ rest or nitro
- SYMPATHETIC STIMULATION - tachy/palp, n/v, dizzy
- silent MI - about 25%, esp women, elderly, dm, obese
- PE usually normal +/- S4
diagnostic:
-ECG
-CARDIAC MARKERS - STD 3 SETS q8
-troponin most sensitive and specific
CK/CK-MB: appears 4-6 h, peaks 12-24 h, returns 3-4 d
TROP I + T: appears 4-8 h, peaks 12-24 h, returns 7-10 d
*trop may be falsely elevated in pt w/ renal failure, advanced HF, acute PE, CVA
thrombolytics/fibrinolytic contraindications ACS
Absolute:
- PREVIOUS INTRACRANIAL HEMORRHAGE
- NON-HEMORRHAGIC STROKE W/IN 6 MONTHS OR CLOSED HEAD/FACIAL TRAUMA W/IN 3 MONTHS
- intracranial neoplasm, aneurysm, AVM
- active internal bleeding
- suspected aortic dissection
Relative:
- SBP > 180 on presentation
- INR >2 or known bleeding diathesis
- trauma/major surgery in last 2 weeks
- recent internal bleed w/in 2 weeks
- prior streptokinase exposure, pregnancy
acute pericarditis
constrictive pericarditis
pericardial tamponade
MC ARE IDiOPATHIC (maybe viral related) AND VIRAL (ESP ENTEROVIRUSES: COXSACKIE AND ECHOVIRUS)
-tx:
-ANTI-INFLAMMATORIES: ASA or NSAIDS x 7-14d, colchicine 2nd line
+/- CORTICO if sx >48h and refractory
THICKENED, FIBROTIC, CALCIFIED PERICARDIUM
- RIGHT-SIDE HF SIGNS: jvd, peripheral edema, n/v, hepatojugular reflux
- KUSSMAU’LS SIGN: INC JVD W/ RESPIRATION
- PERICARDIAL KNOCK - HIGH PITCHED 3RD HEART SOUND
- tx: PERICARIECTOMY DEFINITIVE, diuretics for sx
BAD PERICARDIAL EFFUSION –> RESTRICTS VENTRICULAR FILLING –> DECREASED OUTPUT
- BECK’S TRIAD: DISTANT/MUFFLED HEART SOUNDS, INC JVP, SYSTEMIC HYPOTENSION
- PULSUS PARADOXUS (>10mmHG decrease w/ inspir)
- PERICADIOCENTESIS (IMMEDIATE)
myocarditis
INFLAMMATION OF HEART MUSCLE -MC DUE TO VIRAL - ENTEROVIRUSES (ESP COXSACKIE) adenovirus, parvo19, hhv6, ebv, hiv, vzv -VIRAL PRODROME --> HF SX, MEGACOLON \+/-CONCURRENT PERICARDITIS -supportive, standard hf tx
rheumatic fever
ACUTE AUTOIMMUNE INFLAMMATORY MULTI-SYSTEM ILLNESS
-MAINLY CHILDREN 5-15y, strep infx 2-6 wks prior
-RHEUMATIC VALVE DZ: MITRAL 75%, AORTIC 25%
JONES CRITERIA (2 MAJOR; 1 MAJOR + 2 MINOR)
- JOINT - MIGRATORY POLYARTHRITIS, MED/LAR MC
- oh my heart - ACTIVE CARDITIS - mitral and aortic valves
- NODULES - SUBCUTANEOUS over joints, scalp, spine
- ERYTHEMA MARGINATUM - macular, red, annular
- SYDENHAM’S CHOREA - invol movement, jerky, purposeless
MINOR: 101.3+ fever, arthralgia, inc ESR, CRP, leukocytosis, prolonged PR interval
- tx:
- ANTI-INFLAM: ASA +/- CORTICO in severe or cardio
- PCN G (or erythromycin)
JVP ddx
increased JVP + crackles/rales in lungs
CONGESTIVE HEART FAILURE
increased JVP + normal pulm exam
PERICARDIAL (EX TAMPONADE OR CONSTRICTIVE PERICARDITIS)
increased JVP + decreased breath sounds
TENSION PNEUMOTHORAX
peripheral VENOUS vs ARTERIAL disease
VENOUS
- worse w/ standing, sitting, leg dependency
- better w/ walking, elevation
- cyanotic leg when dependent
ARTERIAL
- better when resting, leg dependent
- worse with walking, elevation, cold
- redness w/ dependency and cyanotic w/ elevation
HTN treatment
Initial in uncomplicated and non AA, any of folllowing: THIAZIDE DIURETICS ACE INHIB ARBs CCBs
a-fib (rate control) –> BB or CCB (non-dihyd)
angina –> BB, CCB
post-MI –> BB, ACEi
systolic HF –> ACEi, ARB, BB, diuretics
DM, CKD –> ACEi, arb
isolated HTN in elderly –> diuretics +/- CCB
osteoporosis –> thiazides
BPH –> a-blockers
AA non-diabetic –> thiazides, CCB
young, caucasian male –> thiazides –> ACEi/ARB –> BB
gout –> CCB, LOSARTAN ONLY ARB THAT DOESN’T CAUSE HYPERURICEMIA
infective endocarditis
- MITRAL VALVE MC (m > a > t > p)
- TRICUSPID VALVE MC IN IV DRUG USERS
ACUTE: STAPH AUREUS MC
SUBACUTE: STREP VIRIDANS MC, ORAL FLORA AS SOURCE
IV DRUG USER: STAPH AUREUS MC, ESP MRSA, candida
PROSTHETIC VALVE: w/in 60 days –> STAPH EPI MC
*ENTEROCOCCI MC MEN 50Y W/ HISTORY OF GI/GU PROCEDURES, others: fungi, yeast, gnr
- JANEWAY LESIONS - red, painless on palms/soles
- ROTH SPOTS - retinal hemorrhages w/ pale center
- PETECHIAE - conjunctiva, palate
- OSLER’S NODES - tender nodules on pads of digits
- SPLINTER HEMORRHAGES of proximal nail bed
VANC FOR GRAM +, GENT FOR GRAM -
Acute = NAFCILLIN + GENTAMICIN 4-6WKS; VANC + GENTAMICIN (if suspected mrsa or pcn allergic)
Subacute = PCN OR AMP + GENTAMICIN; VANC IN IVDA
Prosthetic = VANC + GENT + RIFAMPIN (for s.aureus)
Fungal = AMPHO B
*DURATION USUALLY 4-6 WKS, AMINOGLYCOSIDES ONLY FOR 2 WKS
AAA
- ABD US: initial study of choice, used to monitor
- CT: test of choice for thoracic and eval known AAA
- ANGIOGRAPHY GOLD STANDARD
- MRI/MRA
- abdominal xray - may show calcified aorta
-tx: 3cm = aneurysm
-SURGICAL REPAIR DEFINITIVE
>5.5 cm or >0.5 cm expansion in 6 mo –> IMMED SX
>4.5 cm –> vascular referral
4-4.5 cm –> monitor US q 6 mo
3-4 cm –> monitor US yearly
-B-BLOCKERS REDUCE SHEARING FORCES, DEC EXPANSION AND RUPTURE RISK
thromboangitis obliterans (Buerger’s Disease)
NONARHEROSCLEROTIC INFLAMMATORY DISEASE OF SMALL AND MEDIUM ARTERIES AND VEINS
-STRONGLY ASSOC W/ TOBACCO - suspect in young smokers/tobacco w/ distal extremity ischemia/ulcers or gangrene of digits
- sx: TRIAD
- SUPERFICIAL MIGRATORY THROMBOPHLEBITIS
- DISTAL EXTREMITY ISCHEMIA
- RAYNAUD’S
- AORTOGRPAHY GOLD STD: segmental, occlusive lesions of small/med vessels with CORKSCREW COLLATERALS
- ABNORMAL ALLEN TEST - tests patency of radial and ulnar arteries (dec patency and delayed reperfusion)
- TOBACCO CESSATION - ONLY DEFINITIVE
- CCBs for Raynauds (dihydropyridines)
TROUSSEAU’S SYNDROME - MIGRATORY THROMBOPHLEBITIS IS ASSOC W/ MALIGNANCY
asthma
Intermittent - SABA prn sx: 0-2x /day 0-2x/week SABA use: 0-2x /day 0-2x/week nighttime awakening: <2x/month interference w/ activity: none exacerbations req steroids: 0-1/yr
Mild Persistent - SABA prn + LOW-DOSE ICS sx: >2 days/week SABA use: >2 days/week nighttime awakening: 3-4x/month interference w/ activity: minor exacerbations req steroids: 2+/yr
Moderate Persistent - SABA prn + MED-DOSE ICS OR LOW ICS + LABA, add LTRA sx: daily SABA use: daily nighttime awakening: >1x/week interference w/ activity: some exacerbations req steroids: 2+/yr
Severe Persistent - HIGH-DOSE ICS + LABA, +/-OMALIZUMAB
sx: throughout day
SABA use: several times/day
nighttime awakening: often, usually nightly
interference w/ activity: extreme
exacerbations req steroids: 2+/yr
*step-wise –> step down if sx controlled for 3+ months
asthma meds
INHALED CORTICOSTEROIDS
- DRUG OF CHOICE FOR LONG-TERM MAINTENANCE
- BECLOMETHASONE, FLUNISOLIDE, TRIAMCINOLONE
- cytokine and inflam inhibition
LONG-ACTING B2 AGONISTS (LABA)
- SALMEROL, FORMOTEROL
- bronchodilator, prevents sx
MAST CELL MODIFIERS
- CHROMOLYN, NEDOCROMIL
- inhibits mast cell and leukotrien-mediated degranulation; inhibits acute phase response to cold air, exercise, etc
LEUKOTRIENE MODIFIERS/RECEPTOR ANTAGONISTS
- MONTELUKAST, ZAFIRLUKAST, ZILEUTON
- blocks leukotriene-mediated neutrophil migration, smooth muscle contraction
THEOPHYLLINE
- methylxanthine, a bronchodilator that improves respiratory muscle endurance
- higher dose needed for smokers
- narrow therapeutic index - arrhythmias, seizures
OMALIZUMAB
-anti-IgE antibody - used in severe, uncontrolled
management of COPD
BRONCHODILATORS
-COMBO w/ anticholinergics + B2 agonists better
- Anticholinergics: IPRATROPIUM, TIOTROPIUM (preferred over B2 agonists w/ copd)
- B2 Agonists: ALBUTEROL, TERBUTALINE, SALMETEROL
- Theophylline - only used in refractory cases (narrow therapeutic index, monitor levels –> arrhythmias and seizures)
CORTICOSTEROIDS
-may be added to long-acting bronchodilators
OXYGEN
-only med tx proven to dec mortality (dec pulmonary htn and cor pulmonale)
bronchiectasis
IRREVERSIBLE BROCNHIATL DILATION 2RY TO TRANSMURAL INFLAMMATION –> OBSTX AND IMPAIRED CLEARANCE OF MUCUS –> LUNG INFX
Etiologies:
- Recurrent/chronic lung infx
- H.INFLUENZA MC IF NOT CYSTIC FIBROSIS
- PSEUDOMONAS MC IF CYSTIC FIBROSIS
- Hereditary - CF mc cause in US, a-1 antitrypsin deficiency
- DAILY CHRONIC COUGH W/ THICK, MUCOPURULENT, FOUL-SMELLING SPUTUM, chest pain, pnm recurrs
- HEMOPTYSIS (50-70%)
bronchogenic carcinoma
MC CAUSE OF CANCER DEATHS IN MEN AND WOMEN
- SMOKING MC CAUSE (includes 2nd hand), asbestosis
- METS MC TO BRAIN, BONE, LIVER, LYMPHS, ADRENAL
TYPES NON SMALL CELL CARCINOMA (85%):
ADENOCARCINOMA 35%
- MC IN SMOKERS, WOMEN AND NONSMOERS, typically PERIPHERAL, Bronchioalveolar (rare subtype w/ good prognosis)
- sx: GYNECOMASTIA
SQUAMOUS CELL 20%
-CENTRALLY LOCATED, CAVITARY LESIONS (central necrosis), HYPERCALCEMIA, PANCOAST SYNDROME
LARGE CELL (ANAPLASTIC) CARCINOMA 10% -VERY AGGRESSIVE
SMALL CELL (OAT CELL) CARCINOMA (13%)
- METS EARLY –> usually found on presentation, central, aggressive, SX NOT TX OF CHOICE
- sx: SIADH/Hyponatremia, CUSHING SYNDROME, LAMBERT-EATON SYNDROME (muscle weakness improves w/ continued use)
- SVC SYNDROME - dilated neck veins, facial plethora, prominent chest veins
- sx:
- asymptomatic, cough, hemoptysis, dyspnea, wl
- PANCOAST SYNDROME - TUMORS AT SUPERIOR SULCUS = SHOULDER PAIN, HORNER’S SYNDROME, ATROPHY OF HAND/ARM MUSCLES
- dx:
- CXR (incidental) and CT for staging
- SPUTUM CYTOLOGY for central lesions
- BRONCHOSCOPY for central lesions
- pleural fluid analysis
- NEEDLE BX for peripheral lesions
- tx:
- NON SMALL CELL - SX RESECTION TX OF CHOICE ESP IF LOCALIZED TO CHEST
- SMALL CELL - CHEMO TX OF CHOICE +/-radiation
pulmonary hypertension
mean pulm arterial pressure >25mmHg at rest (normal <20) or >30 during exercise
- INC PULM VASC RESISTANCE –> RVH –> R-SIDED HF
- SIGNS OF R-SIDED HEART FAILURE (INC JVP, PERIPH EDEMA, ASCITES)
- ECG: COR PULMONALE, RVH, RIGHT AXIS DEVIATION, right atrial enlargement, right bundle branch block
- R-SIDED HEART CATH - DEFINITIVE DX - GOLD STD: mean pulm artery pressure 25+mmHg at rest
IF VASOREACTIVE –> CCB 1ST LINE FOR PRIMARY
-heart-lung transplant definitive
brain tumors/cancer
meningiomas
- NEUROFIBROMATOSIS (2)
- BX: SPINDLE-CELLS concentrically arranged in WHORLED PATTERN; PSAMMOMA BODIES: concentric round calcifications
oligodendoglioma (glial tissue)
-BX: soft, gray-ish, pink CALCIFIED tumors, areas of hemorrhage and or cystic; CHICKEN-WIRE CAPILLARY PATTERN W/ FRIED EGG SHAPED tumor cells
ependyoma
- MC IN CHILDREN, MC IN 4TH VENTRICLE, +/- medulla,
- BX: PERIVASCULAR PSEUDOROSETTES (tumor cells surrounding a blood vessel)
hemangiomas
- HEMANGIOBLASTOMA: arises from blood vessel lining; benign, slow-growing well-definited tumors
- mc found in BRAINSTEM AND CEREBELLUM
- RETINAL HEMANGIOMAS ASSOC W/ VON HIPPEL-LINDAU SYNDROME
- BX: well-defined borders, FOAM CELLS W/ HIGH VASCULARITY
spinal cord
ANTERIOR cord syndrome
-MC after blowout vertebral body burst fracture (flexion)
-LOWER EXTREMITY DAMAGE > UPPER (corticospinal)
-DEC SENSORY: pain, temp (spinothalamic), light touch, may devo BLADDER DYSFUNCTION (incontinence, retention)
Preserved:
-proprioception, vibration, pressure (dorsal column spared)
CENTRAL cord syndrome
-hyperextension injures (50% w/ mva), falls in elderly, gsw, tumors, cervical spinal stenosis, syringomyelia
-UPPER EXTREMITY DAMAGE > LOWER (distal portion more severe involvement from corticospinal involvement)
-DEC SENSORY: pain, temp (spinothalamic) deficit greater in upper extremity –> SHAWL DISTRIBUTION
Preserved:
-proprioception, vibration, pressure (dorsal column spared)
POSTERIOR cord syndrome
-LOSS OF PROPRIOCEPTION AND VIBRATORY ONLY
Preserved:
-pain, light touch; no motor deficits
BROWN SEQUARD
IPSILATERAL DEFICITS
-MOTOR: lateral corticospinal tract, VIBRATION AND PROPRIOCEPTION (dorsal column)
CONTRALATERAL DEFICITS
-PAIN AND TEMP (lateral spinothalamic tract) usually 2 levels below injury
ischemic stroke
-MC 80% d/t TROMBOTIC 49%, EMBOLI 31%,
- LACUNAR STROKE:
- SMALL VESSEL DZ atheroembolic stroke, penetrating arteries providing blood to the brain’s deep structures is occluded
- PURE MOTOR MC, ATAXIC HEMIPARESIS, DYSARTHRIA, HX OF HTN 80%
- CT: SMALL PUNCHED OUT HYPODENSE AREAS
- tx: ASA, control risk factors
MIDDLE CEREBRAL ARTERY - MC 70%
- contralateral sensory/motor loss/hemiparesis: GREATER IN FACE, ARM > leg/foot
- GAZE PREFERENCE TOWARDS SIDE OF LESION
- LEFT SIDE –> APHASIA: BROCA, WERNICKE, MATH COMPREHENSION, AGRAPHIA
- RIGHT SIDE –> SPATIAL DEFECTS, DYSARTHRIA, LEF-SIDE NEGLECT, ANOSOGNOSIA, APRAXIA
ANTERIOR CEREBRAL ARTERY
- contralateral sensory/motor loss/hemiparesis: GREATER IN LEG/FOOT –> ABN GAIT
- FACE SPARED, speech preserved, slow response
- frontal lobe and mental status impairment: IMPAIRED JUDGMENT, CONFUSION, PERSONALITY CHANGES (FLAT AFFECT)
- URINARY INCONTINENCE, upper motor neuron weak
- gaze pref towards side of lesion
POSTERIOR CEREBRAL ARTERY
-VISUAL HALLUCINATIONS, CONTRALATERAL HOMONYMOUS HEMIANOPSIA, “CROSSED SX” (ipsilateral cranial nerve deficits, contralateral muscle weakness), coma, drop attacks
BASILAR ARTERY
-cerebral dysfx, CN palsies, dec vision, dec bilateral sensory
VERTEBRAL ARTERY
-VERTIGO, NYSTAGMUS, N/V, DIPLOPIA, ipsilateral ataxia
- dx:
- NON-CONTRAST CT: r/o hemorrhage (may be normal first 6-24h)
- tx:
- THROMBOLYTICS W/IN 3 HOURS of onset
- ALTEPLASE (tissue plasminogen activator TPA) given if no evidence of hemorrhage (c/i BP >185/110, recent bleed/trauma, bleeding disorder)
- antiplatelet: asa, clopidogrel, dipyridamole, +/- anticoag if cardioembolic
- only lower BP if >185/110 for thrombolytics or >220/120 if no thrombolytic use
- STROKES W/ FACIAL INVOLVEMENT INVOLVES LOWER HALF OF FACE (WILL STILL BE ABLE TO RAISE EYEBROW)
bacterial meningitis
-DON’T WAIT FOR LP RESULTS - START EMPIRIC
<1 mo –> GROUP B STREP (STREP AGALACTIAE) MC
-AMP (listeria) + CEFOTAXIME
1 mo - 18y –> N. MENINGITIDIS MC (ASSOC PETECHIAL RASH)
-CEFTRIAXONE (CEFOTAXIME) + VANC
18y - 50y –> S. PNEUMO MC, N. MENINGITIDIS
-CEFTRIAXONE (CEFOTAXIME) + VANC
> 50y –> S. PNEUMO, LISTERIA
-AMP + CEFTRIAXONE (CEFOTAXIME) +/-VANC
*DEXAMETHASONE RECOMMENDED IF KNOWN/SUSPECTED S.PNEUMO
absence (petit mal) generalized seizure
-ETHOSUXIMIDE 1ST LINE (only works for absence), Valproic acid 2nd line
cranial nerves
I. OLFACTORY
-smell
II. OPTIC
- visual acuity, visual fields, pupillary light reflex (swinging)
- OPTIC NEURITIS, MARCUS GUNN PUPIL
III. OCULOMOTOR
- inferior recuts, ciliary body
- DILATED PUPIL
IV. TROCHLEAR
-superior oblique rectus
V. TRIGEMINAL
- Motor: mastication, close jaw, move chin side to side
- Sensory: light touch on 3 divisions of nerve
- TRIGEMINAL NEURALGIA
VI. ABDUCENS
-lateral rectus (lateral gaze)
VII. FACIAL
- Motor: muscles of facial expression (blinking, raise eyebrows, frown/smile, close eyes tight, puff cheeks), tear glands
- Sensory: taste anterior 2/3, somatic fibers to external ear
- BELL’S PALSY, RAMSAY HUNT SYNDROME
VIII. VESTIBULOCOCHLEAR
- Hearing: speech, Weber/Rinne tests
- Vestibular: balance and proprioception
- ACOUSTIC NEUROMA
IX. GLOSSOPHARYNGEAL
- Motor: swallow, gag reflex
- Sensory: taste posterior 1/3
X. VAGUS
- Motor: voice, soft palate, gag reflex
- Sensory: relays to brain sensory info about organs (GI, pulm, heart)
XI. ACCESSORY
-shoulder shrug, turn head side to side
XII. HYPOGLOSSAL
-tongue - inspect for fasciculations and asymmetry
**motor, sensory or both: “Some Say Money Matters But My Brother Says Big Bucks Matter More”
nerves
C5
Motor: shoulder abduction, elbow flexion (palm up)
Muscles: deltoid, biceps
Sensory: lateral arm (below deltoid and above elbow), axillary nerve
Reflexes: loss of bicep jerk reflex
C6
Motor: elbow flexion (thumb up), wrist extension
Muscles: brachioradialis, extensor carpi radialis
Sensory: thumb, radial side of the hand
Reflexes: brachioradialis
C7 Motor: elbow extension, wrist flexion Muscles: triceps, flexor carpi radialis Sensory: radial side of fingers, fingers 2, 3, 4 Reflexes: triceps jerk reflex
C8
Motor: finger flexion
Muscles: flexor digitorum superficialis
Sensory: median nerve, +/-Horner’s syndrome
T1
Motor: finger abduction
Muscles: interossei
Sensory: medial elbow, ulnar nerve
S1-S2 - loss of ankle jerk
L3-L4 - loss of knee jerk
C5-C6 - loss of biceps jerk
C7-C8 - loss of triceps jerk
Peroneal nerve - innervates the peroneus longus, peroneus brevis, and the short head of the biceps femoris muscles –> injuries lead to FOOT DROP
neuroleptic malignant syndrome
- DEC DOPAMINE ACTIVITY (ESP D2)
- d/t dopamine antagonists (typical > atypical antipsych) ex. haldol, chlorpromazine, clozapine, risperidone
- d/t abrupt d/c of dopamine agonists
- NMS usually slow in onset occurs 1-2 wks after intitation or inc dose
- sx:
- AMS: delirium, coma
- AUTONOMIC INSTABILITY: tachy, bp fluctuations, +/- resp distress, HYPERSALIVATION, INCONTINENCE
- HYPERTHERMIA: fever d/t muscle rigidity, sweat
- MUSCLE RIGIDITY: extrapyramidal sx - BRADYKINESIA, “LEAD PIPE” RIGIDITY, HYPOREFLEXIA
- distinguishing features:
- INC CREATININE KINASE, LDH, LFTS (RHABDO), INC WBC, normal pupils
- HYPERTHERMIA
- diarrhea and mydriasis NOT assoc w/ NMS
- tx:
- DC DRUG MOST IMPORTANT (sx resolve 1-2wk)
- supportive: cooling blankets, vent, fluids
- DOAPMINE AGONISTS: BROMOCRIPTINE, amantadine
- DANTROLENE - SKELETAL MUSCLE RELAXER
serotonin syndrome
INC SEROTONIN (5-HT1) ACTIVITY D/T INC DOSE OF SEROTONERGIC DRUGS OR POTENTIATION BTW 2 SEROTONERGIC DRUGS
- usually occurs w/in 24 hours
- SSRI + MAOI
- SNRI OR SSRI + ST. JOHN’S WORT
- SSRI + PROMETHAZINE
- sx:
- AMS: mood change, foggy, AGITATION
- AUTONOMIC INSTABILITY: tachy, bp fluctuations
- HYPERTHERMIA: fever (from muscle contractions), sweat
- NEURO CHANGES: TREMOR, HYPERREFLEXIA, MYCOLONUS
- distinguishing features:
- MYDRIASIS (DILATED PUPILS)
- HYPERACTIVE GI TRACT: BOWEL SOUNDS, DIARRHEA, CRAMPS
- AGITATION
- tx:
- PROMPT DC OF DRUG (sx resolve 1 wk)
- supportive: fluids, cardiac monitor, O2
- BENZOS FOR HYPOTHERMIA (dec muscle contraction) or agitation
- SEROTONIN ANTAGONISTS - CYPROHEPTADINE if above unsuccessful
glutamate
MOST ABUNDANT EXCITATORY NT IN CNS
- released by UMN in synapse to LMN
- activates NMDA receptor
INCREASED:
-ALZHEIMER-assoc excess glutamate causes excitotoxicity and cell death (NMDA antagonists / Memantine is sometimes used in Alzheimer’s)
DECREASED:
-PHENYLKETONURIA
GABA
MOST ABUNDANT INHIBITORY NT IN CNS
-regulates muscle tone, protects against overexcitation (seizure)
INCREASED:
-ETOH mimics GABA at receptor site
DECREASED:
- UMN LESIONS DEVO HYPERTONIA (SPASTIC ) muscles no longer respond to gaba
- ANXIETY, HUNTINGTONS
- meds that inc gaba can be used for anxiety and seizures
acetylcholine
ACTIVATES THE MUSCLE AT NT JX from LMN to effector cell, regulating movement
INCREASED:
- PARKINSONS DZ (relative inc d/t dec dopamine)
- black widow spider venom, mushroom toxicity, ORGANOPHOSPHATE POISONING - PESTICIDES AND SARIN GAS
DECREASED:
- Alzheimer, Huntington, MDD
- botulism toxin (blocks AcH release leading to paralysis)
dopamine
INHIBITORY CNS NT, ALLOWS FOR COORDINATED MVMT
- w/out dopamine, movements jerky and rigid
- MOTIVATED BX (DRUG ADDICTION)
- endocrine control, sexual bx
INCREASED:
-SCHIZOPHRENIA (dopa antagonists used to tx)
DECREASED:
- PARKINSON DISEASE (dopa agonists levo-dopa 1st line)
- depression
- NEUROLEPTIC MALIGNANT SYNDROME (tx w/ Bromocriptine - dopa agonist
- Bromocriptine also used to treat prolactinemia and acromegaly (inhibits anterior pituitary prolactin secrete)
norepi
EXCITATORY CNS NT
INCREASED:
-anxiety, arousal, selective attention
DECREASED:
-ADHD
serotonin
INVOLVED IN REGULATION OF MOOD, PAIN, HIGHER COGNITION, EMOTION
INCREASED:
-SEROTONIN SYNDROME
DECREASED:
-Depression
